by Stephen M. Pribut, D.P.M., F.A.C.F.A.S.
American Podiatric Medical Association News, February 1998
Women's health issues have historically been either neglected or superficially studied. Insufficient effort to make many studies relevant to women was the rule. While the Women's Health Initiative has recently recognized the importance of women's health issues, Podiatric Medicine has always recognized the needs of women, since a typical podiatric practice has over 70% female patients.
A knowledge of Women's health issues is of tremendous importance to us. This month, we will take an in depth look at osteoporosis. To keep up with rapidly changing information we again turn to the web. Osteoporosis is a major public health threat for 28 million Americans. While osteoporosis can affect both men and women, women make up the vast majority of the sufferers of this disease. The dramatic fall in the level of estrogen produced following menopause has a dramatic impact on the amount of bone replacement that occurs. Testosterone which does not fall as dramatically in men until they are in their 70's, protects men from having the same occurrence rate of this disorder.
February, the month of Ground Hogs and Valentines, is also a month of ice, snow and falls. For many these falls result in broken hips, in which up to 30 percent of the elderly affected can die within one year. In the United States, two thirds of those injured are women with osteoporosis playing a major role. Osteoporosis affects our surgical planning, the healing of fractures, and can dramatically impacts our patients' lives. Over 1.5 million fractures each year result from Osteoporosis. The direct expenditures on care for Osteoporosis are over $14 billion dollars per year.
Etiology and Risk Factors:
The postmenopausal drop in estrogen production is the most frequent cause of osteoporosis. While it is never too late to take action against osteoporosis, prevention must begin at a young age. Osteoporosis has been called a disease of adolescence that is manifested in the golden years. The teenage years are a time of much increase in density of bones and bone growth . It is important that ample calcium be supplied to the body. Health and Human Services has sponsored the "Why Milk?" web site (http://www.whymilk.com/). This ShockwaveÔ enhanced site has a dietary calcium calculator, images from the milk moustache campaign, facts on milk, and a quiz contest. In an entertaining manner this "crash course on calcium" attempts to prevent the next generation from the devastating effects of osteoporosis.
Risk factors that heighten the chances of developing osteoporosis include: early menopause, white or Asian race, lack of exercise, use of corticosteroids, slight build, inadequate dietary calcium, thyroid or renal disease, and excessive alcohol use. These risk factors are reviewed at ORBD-NRC (http://www.osteo.org/).
Our bones reach their peak density between the ages of 25 - 35 and then start gradually losing density at the rate of .1% - .3% each year. This rate of bone loss may accelerate to 1% - 3% in the initial years after menopause, before slowing again. It is important to continue getting adequate dietary calcium at all stages of life and to perform both weight bearing exercise and strength training. Weight bearing exercise is an excellent means of improving the density of the weight bearing bone structures, while strength training helps the upper extremity and also improves balance.
Falls are the primary cause of osteoporosis related injury. A recent article in the New England Journal of Medicine demonstrated that falls were an important cause of admission to nursing homes. Fall avoidance training is another means of reducing injury from osteoporosis. Tips on fall avoidance may be found at: Priocal (http://www.priocal.se/fall.html) and at ORBD-NRC (http://www.osteo.org/newsfalls.html).
A diet rich in calcium and also containing Vitamin D is an important component of an osteoporosis prevention program. The best sources of calcium include milk (300mg per cup), tofu (258mg per cup), yogurt (250mg per cup), Calcium fortified orange juice (240 mg per 8 oz.), part skim mozzarella chesse (183 mg per 1 oz), canned salmon with bones (181 mg per 3 oz) , collards (179 mg per ½ cup), turnips (125 mg per ½ cup) and Broccoli (94 mg per 1 cup). An excellent web based source of information is the FDAs "Bone up on Calcium Page at http://www.fda.gov/fdac/features/796_bone.html .
Hormone Replacement Therapy:
A critical time frame in which to take action is the perimenopausal years. The manner in which both estrogen and testosterone protect bone from calcium is not known. Much research is being done on estrogen receptors, with the recent discovery of a second estrogen receptor which is now being targeted during therapy. Hormone Replacement Therapy (HRT) is an important component of postmenopausal osteoporosis prevention. Recent research is clarifying the risks and benefits of this therapy. While many women wonder about its safety, a recent study in the Annals of Internal Medicine showed that twice as many physicians as the general population use HRT and that gynecologists were three times as likely to use HRT.
HRT can take many forms. Estrogen alone or in combination with a Progestin is most frequently used. A nasal spray of Salmon Calcitonin is also occasionally used. In an attempt to look at drugs with fewer side-effects than estrogen, recent research is investigating a new family of drugs called "Selective Estrogen Receptor Modulators" (SERMs). These drugs came out of cancer research on estrogen receptors and with anti-estrogen drugs. These drugs bind to only certain receptors and activate only some of the nearly 100 genes that estrogen can activate. Raloxifene is the most recent of these drugs, it seems to offer about 1/2 of the protection that estrogen does against Osteoporosis, but might lower the risk of uterine and breast cancer. Because of their specific effects SERMs are also known as designer estrogens.
A variety of medical strategies can be used to prevent or slow down the process of osteoporosis. The current literature suggests that there are a variety of ways to minimize the risks, which do not seem to be as great as was believed as recently as 3 years ago. The current literature on the medical treatment of osteoporosis is well covered at the web site of Osteovision ( http://www.osteovision.ch/ ) which contains a series of lectures on Osteoporosis, literature reviews in "Advances In Osteoporosis", and a series of slide lectures on current drug therapy. Another category of drugs used are the Bisphosphonates of which Alendronate (Fosamax) is an example.
Just for fun & Valentine's Day: Empty's chocolate page - http://hp5.econ.cbs.dk/people/toha96ad/chocolate/index2.html
The Osteoporosis and Related Bone Diseases~National Resource Center (ORBD-NRC) at http://www.osteo.org/
The National Osteoporsis Foundation at http://www.nof.org/
The Priocal Home Page at http://www.priocal.se/
Osteovision Home Page at http://www.osteovision.ch/