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Osteoporosis, or porous bone, is not a natural part of the aging process, as so many believe. It is a preventable and highly treatable disease.
"As you get older, it is normal to lose some bone, but the severe bone loss associated with osteoporosis is not a normal condition," says Lynn Chard-Petrinjak, senior communications coordinator for the National Osteoporosis Foundation in Washington, DC.
Bone mass is built until approximately age 30. Then, as part of the natural aging process, bones begin to break down faster than new bone is formed. Therefore, a healthy lifestyle that builds strong bones before age 30 and keeps bones strong later in life is the best method for preventing osteoporosis. The Foundation recommends an across-the-life span approach to health that includes a well-balanced diet with at least 1200 mg of calcium and up to 800 IU of vitamin D daily, weight-bearing exercise, and avoiding tobacco and excessive alcohol.
Education about nutrition, activity, and lifestyle choices should target girls as young as 10 years old, says Felicia Cosman, MD, clinical director for the National Osteoporosis Foundation. Cosman also is an osteoporosis specialist at Helen Hayes Hospital in West Haverstraw, NY, and associate professor of medicine at Columbia University in New York City. While adult women need to know these same preventive measures, they also need to understand the risk factors and who should be tested. If women have the disease, they need to be taught the treatment options, says Cosman.
Who is at risk? Women are more at risk than men. In fact, 80% of those diagnosed with osteoporosis are women. In the United States, about eight million women and two million men have osteoporosis, according to the National Osteoporosis Foundation. Other risk factors include a thin or small frame, advanced age, a family history of osteoporosis, being postmenopausal, abnormal absence of menstrual periods, anorexia or bulimia, an inactive lifestyle, cigarette smoking, a diet low in calcium, use of certain medications such as steroids, and excessive alcohol use.
The only way to determine whether a person has osteoporosis is by administering a bone mineral density (BMD) test. There are several machines used for testing, but the two main types are central machines, which measure bone density in the hip, spine, and total body, and peripheral machines, which measure bone density in the finger, wrist, kneecap, shin, and heel. "Osteoporosis screening is exceedingly important. You can’t tell that you have the disease in its early stages unless you get a bone density test," says Cosman.
Women between the ages of 50 and 65 should get a BMD test if they have any of the known clinical risk factors for osteoporosis, and all women at age 65 and above should be tested. Those treated for osteoporosis should be re-tested every one to two years, and those in the normal range should consult their physician about when they should be re-tested, according to the National Osteoporosis Foundation. "It is important to uncover osteoporosis in the early stages of the disease, because there are no warning signs until someone breaks a bone. If it is diagnosed and treated early, a person may never break a bone," says Chard-Petrinjak.
Bone fractures can be debilitating, especially for seniors. The two most commonly occurring fractures for people with osteoporosis are of the hip and spine. Only 10% to 20% of seniors over the age of 65 who break their hip are able to resume their former lifestyle once the fracture has healed, says Cosman.
With spine fractures, the bone tends to compress in on itself. This means that people who have this injury not only lose height, but the shape of the spine and torso change, explains Cosman. People end up with their head pointing downward, which makes it difficult to walk and causes them to fall more often. They frequently have back pain, chronic neck pain, and abdominal discomfort, and are at greater risk for dying of pulmonary causes such as pneumonia. Osteoporotic spine fractures can occur spontaneously just by walking, reaching for a dish, or turning in bed. "The fractures have a big impact on the quality of life and also life span," says Cosman.
While Cosman advocates testing, she is not generally in favor of public screenings at health fairs. Peripheral machines are usually used to do the BMD tests at health fairs, and these are not as accurate as the central machines, she says. "There is no other test that is as good as the central DXA [Dual Energy X-ray Absorptiometry] test, and I think that sometimes people may be misled by the peripheral test. It is a good test if you don’t have access to the central test," explains Cosman.
Another problem Cosman sees with community osteoporosis screenings is that younger women are being tested. These tests are inappropriate, because there are no medications available for the young age group. Sometimes young women are traumatized if they find out they have very low bone density, even if it is within the normal range, because the bell curve includes people with both very low and very high bone density. Osteoporosis-related fracture occurs infrequently in the young age group, says Cosman.
"We shouldn’t routinely test premenopausal women. Some premenopausal women with certain underlying diseases or those taking specific drugs that can adversely affect the skeleton should be tested, but in general, we do not advocate testing in that young age group," says Cosman.
There is also the quality control issue. People who are tested at public screenings often are handed their results on a piece of paper, and they have no idea what to do with it. There isn’t good follow-up, says Cosman. Yet, she does concede that some health fairs are well-run.
While people who are not always appropriate candidates due to their age or risk factors take advantage of the screenings at health fairs, their presence provides great opportunities for education, says Brenda Covert, RNC, women’s services coordinator at Sacred Heart Medical Center in Spokane, WA. "We really want to increase awareness in younger women that osteoporosis is something that you think about now," she says. It is especially important because many young women do not eat well and some have eating disorders. They also tend to drink a lot of soda, which has phosphorus that pulls calcium out of the bone, says Covert.
However, it is important to emphasize that the screenings are a service rather than a diagnostic procedure and are meant to identify people that may be at risk for osteoporosis, says Covert.
The vital part of a community outreach screening is education. Ten to 15 minutes are spent with each individual for this purpose during the osteoporosis screenings conducted at the University of Missouri Health Care’s health information center located in Columbia (MO) Mall. "Registered nurses go over the medical history for each individual and their risk factors as well as current methods of prevention and treatment. We work with the state Osteoporosis Education Program and provide lots of handouts," says Janet Hale, RN, manager of the health information center in Columbia. People at risk are referred to their physicians for follow-up and are given the computer printout from the DXA heel scan.
Education during the osteoporosis screenings conducted by women’s services at Sacred Heart Medical Center is both verbal and written, says Covert. Many pharmaceutical companies produce pamphlets on osteoporosis; these are distributed, as well as materials produced by the health care facility in conjunction with its orthopedic department and physicians within the community. These materials cover risk factors and ways to prevent osteoporosis focusing on diet and lifestyle. There is some mention of medications that build bone or prevent bone loss, but people are told to ask their pharmacist or health care provider for this information.
If it is a large event and 200 people are being screened each day, there’s little time for individual education, says Covert. Written materials are always given to people who receive screening. The results of the screening are explained, and people are told if they need to follow up with their physician, says Covert. However, participants at most screenings are asked to fill out a brief history that includes questions about their diet and lifestyle, medications they are taking that might put them at risk for osteoporosis (such as steroids), and whether or not they have a physician. The information helps with education and follow-up. Those who don’t have a physician are given a list of clinics they can go to.
Women’s services at Sacred Heart Medical Center conducts the screenings wherever they are asked to. Screening locations typically include senior wellness conferences, retirement facilities, schools, and corporate health fairs. They also carry the DXA scan machine on the coach they use for medical outreach so they can do an osteoporosis screening at other times as well.
When screenings are offered at the health information center in Columbia Mall, the promotions recommend that women entering menopause and men over 65 be screened, but anyone can participate. The first time the screenings were offered, 400 people took advantage of them. Now they are offered at the center every three months.
If a person is diagnosed with osteoporosis, the education at the physician’s office should include a review of all the available medications, says Cosman. The education process should help the patient make an informed decision by determining what is appropriate based on the individual’s personal history, family history, other medical conditions, and personal preferences, she says.
While there are pros and cons to community outreach osteoporosis screening, it does provide an opportunity to draw attention to a disease that is often misunderstood, says Hale. "One pro is that we have people’s attention to discuss prevention of osteoporosis and promote healthy lifestyles. The screening brings in people who may not just come in for health teaching," she says.