WOMEN’S HEALTH

Learn from our elders: Prevent osteoporosis

By Penelope Morrison Bosarge, RNC, CRNP, MSN

Women’s Health Nurse Practitioner

Teaching Faculty, Graduate Programs

University of Alabama School of Nursing

Birmingham

Examine this case history: Susan is a 76-year-old Caucasian woman who presents at the emergency department via ambulance after falling in her yard. Tests reveal a severe fracture of the left wrist, which requires placement of a metal plate. Since Susan already has limited use of her right hand, she is placed in a short-term, skilled nursing facility for three weeks, where she receives physical and occupational therapy.

A review of Susan’s medical history reveals a relatively sedentary lifestyle for the past 25 years. A longtime heavy smoker, she began hormone therapy after a total hysterectomy at age 45, only to abandon the course when she noted a weight gain. She has taken calcium replacements for the past 10 years, but the type and dose have varied.

This story is played out across the United States every day, with medical costs mounting as the number of bone fractures due to osteoporosis grows. What can providers do? Lifestyle changes are the answer — and they are among the most difficult to initiate in patients.

An age-old condition

Osteoporosis is not a new disease. It has been described throughout the ages as a problem of the elderly that resulted in fractures and, in many cases, disability. Hippocrates may have seen its association with nutrition when he said, "Let thy food be thy medicine and thy medicine be food."

It is said that osteoporosis is a disease that begins in adolescence. Providers can begin early prevention with education and support to young women to instill healthy eating habits that last a lifetime.

But what can be done for mid-life and mature women? Providers who are now treating members of the "baby boom" generation need to pay attention to Susan’s case history because every patient who has poor eating habits, smokes, drinks alcohol, and reports a sedentary lifestyle, while steering away from long-term hormone therapy, is in for a challenging time.

The gold standard for prevention and stopping the progression of bone loss includes:

• balanced diet;

• calcium and vitamin D supplementation;

• exercise;

• hormone therapy for postmenopausal women.

Menopausal women who are at high risk of fractures still can benefit from calcium supplementation, as well as hormone therapy. While this benefit is not great and does not occur right away, most women can see a 50% reduction in the incidence of fractures associated with osteoporosis if exposed to estrogen for seven to 10 years. The effects of estrogen are seen only while therapy is given, and bone is lost after estrogen is discontinued.1

In one study, women older than 70 who had taken estrogen for less than five years, then discontinued treatment, were evaluated for skeletal mass. Researchers found no remaining evidence of the effects of the hormones.2 Conclusion: Estrogens should be administered long-term, probably for a lifetime.

Create a lasting plan

Providers should help patients design a lifetime program to optimize bone mass and preserve skeletal integrity:3

• Promote good nutrition and a diet with adequate calcium. Milk and other low-fat dairy products, leafy green vegetables, soybeans, and tofu are good calcium sources.

• Advocate regular weight-bearing exercise. Brisk walking, running, aerobics, weight training, cross-country skiing, dancing, and tennis can help the bones and improve the heart function, muscle tone, and balance.

• Strongly discourage use of tobacco and intake of large amounts of alcohol. Both can interfere with bone health.

• Consider other preventive measures such as pharmacological therapy with bisphosphonates, calcitonin, or selective estrogen receptor modulators.4,5,6

An adequate calcium intake must be consumed to prevent further demineralization of bone, which may compromise the usefulness of any therapeutic or preventive plan. New national dietary guidelines specify 1,000 mg daily for all women younger than 65 who are premenopausal or taking estrogen. Women who are menopausal and not on estrogen or older than 65 should take 1,500 mg.7

Give careful instructions for choosing a calcium supplement and its proper administration. Make sure the supplement not only provides adequate elemental calcium but also is bioavailable.

Start the dialogue now

A recent Gallup survey of U.S. women ages 45 to 75 reveals that three out of four have never spoken with their health care providers about osteoporosis.

Start the dialogue now with your patients. Remind them that although every woman’s body goes through bone loss, especially in the years after menopause, not every woman will devel op osteoporosis. Osteoporosis is generally preventable.

As the adage says, "Aging happens, but good health is planned."

References

1. Lindsay R. The burden of osteoporosis: cost. Am J Med 1995; 98:9S-11S.

2. Felson DT, Zhang Y, Hannan MT, et al. The effect of postmenopausal estrogen therapy on bone density in elderly women. N Engl J Med 1993; 329:1,141-1,146.

3. Civitelli R. Osteoporosis: screening and treatment issues. Syllabus material from the Advances in Health Care for Women over 40: Contemporary Forums Conference, Washington, DC; June 1998, 24-30.

4. Liberman UA, Weiss SR, Broll J, et al. Effect of oral alendronate on bone mineral density and the incidence of fractures in postmenopausal osteoporosis. The Alendronate Phase III Osteoporosis Treatment Study Group. N Engl J Med 1995; 333:1,437-1,443.

5. Civitelli R, Gonnelli S, Zacchei F, et al. Bone turnover in postmenopausal osteoporosis. Effect of calcitonin treatment. J Clin Invest 1988; 82:1,268-1,274

6. Delmas PD, Bjarnason NH, Mitlak BH, et al. Effects of raloxifene on bone mineral density, serum cholesterol concentrations, and uterine endometrium in postmenopausal women. N Engl J Med 1997; 337:1,641-1,647

7. Consensus Development Conference: Prophylaxis and Treatment of Osteoporosis. Am J Med 1991; 90:107-110.