Surgeon general targets bone health

Fractures after age 45 that come from moderate trauma should serve as red flags that a patient is at risk for additional breaks.

By Susan J. Landers — Posted Nov. 8, 2004

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Washington -- The U.S. surgeon general has asked the nation's physicians to join in a collective effort to help Americans maintain healthy bones by being alert to early indications of bone loss among their patients.

Osteoporosis and other bone diseases, such as Paget's disease and osteogenesis imperfecta, can lead to a downward spiral in physical health and quality of life and even premature death, according to a new surgeon general's report on bone health and osteoporosis released Oct. 14.

"Osteoporosis isn't just your grandmother's disease. We all need to take better care of our bones," said Surgeon General Richard H. Carmona, MD, MPH.

"The good news is that you are never too old or too young to improve your bone health."

Poor bone health is implicated in 1.5 million fractures each year in the United States among both men and women, according to the report, and the nation's aging population virtually ensures that millions more will be at increased risk for fractures from osteoporosis and low bone mass unless they take preventive action.

Although primary care physicians are always having to deal with "the problem of the moment," said Laura Tosi, MD, an orthopedic surgeon and board member of the American Academy of Orthopaedic Surgeons, the evaluation of bone health should be made a routine part of an annual physicals.

"We now know that bone density is a better predictor of longevity than is cholesterol level," she said.

The report urges physicians to be particularly alert to fractures from a moderate trauma, such as falling from a standing height or less, that occur in patients older than 45. Such fractures are red flags that warrant further assessment for osteoporosis or other bone disease.

"A fracture is not a normal part of aging," said Dr. Tosi. "If you are over 45 or 50 and you have a fracture, your body is telling you, 'You are in trouble.' "

Additional red flags signaling the possibility of poor bone health include treatment with drugs that affect bone metabolism, such as glucocorticoids, and such medical conditions as hyperthyroidism and multiple sclerosis.

The report recommends testing for bone mineral density in all women older than 65 and for any man or woman who has even a minor fracture after age 50. BMD testing for women younger than 65 is also recommended if there are additional risk factors such as a family history of osteoporosis, low body weight and cigarette smoking.

BMD testing serves as the "gold standard" diagnostic test for identifying osteoporosis and fracture risk, notes the report, because it relates strongly to bone strength and is a good independent predictor of fracture risk.

Dual x-ray absorptiometry, or DXA, is the most widely accepted method for measuring BMD, said the report, and measurements taken in the spine and hip are most appropriate for monitoring the effectiveness of therapy.

As part of its wide-ranging policies on bone health, the AMA also advocates the use of bone densitometry to assess fracture risk and in the diagnosis of osteoporosis.

Treatments both old and new

Prevention plays a large role in bone health, and it is intertwined with treatment "since the major goal of treatment is the prevention of fractures," notes the report.

"We know that osteoporosis is a largely preventable disease, but we also know that very few people are doing what they can to prevent it," said Miriam E. Nelson, PhD, associate professor of nutrition at the Friedman School of Nutrition Science and Policy at Tufts University in Boston.

The basic prevention message must still be hammered home: Consume the recommended amounts of calcium and vitamin D or take a supplement, be physically active, quit smoking and remove items that may cause falls.

Vitamin D deficiency is particularly common among elderly patients living at northern latitudes because they may not be outdoors long enough to gain sufficient exposure to the sun, according to the report.

Although most individuals do not meet either their vitamin D or calcium requirements, said Dr. Nelson, "these nutrients are the two in which there is the largest gap between usual intake and requirement. We need to focus more on vitamins and getting at least three servings of calcium-rich, low-fat dairy foods a day and, if necessary, taking a calcium/vitamin D supplement."

This tried-and-true recipe for bone health has been joined over the past decades by effective medications. "The great thing is, this isn't 30 years ago when we had nothing to offer except calcium, vitamin D and exercise," said Dr. Tosi. "We have medications that can turn [bone loss] around and substantially reduce fracture risk."

The introduction of bisphosphonates and selective estrogen receptor modulators, which act as antiresorptive agents to reduce bone loss, and anabolic agents that build bones have provided physicians with powerful tools to prevent and treat bone loss. Additional drugs are in development, according to the report.

The report also provides advice on the use of T scores, which are standards developed by the World Health Organization that compare the results of an individual's DXA scan with the bone density levels of healthy, 30-year-old women who are thought to be at peak bone density.

The report encouraged physicians using a patient's T score results to consider initiating drug treatment for patients with scores -1 to -2.5, which is 25% below the reference level, while patients who receive a score below -2.5 should be treated.

Physicians are cautioned, however, that the risk of bone fracture increases continuously and there is no precipitous change in risk at each level. In addition the data apply only to DXA scan results, and research validating the scores has been conducted primarily among postmenopausal women with only limited data available for other groups.

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Fracture forecast

The surgeon general's report, "Bone Health and Osteoporosis," identifies the following risk factors for fracture:

  • Age 65 and older
  • Amenorrhea
  • Current tobacco use
  • Excess alcohol consumption
  • Falls
  • Fractures after age 45
  • First-degree female relative who had a fracture in adulthood
  • Lifelong low calcium intake
  • Medical conditions such as hyperthyroidism, chronic lung disease, endometriosis and malignancy
  • Medications such as oral glucocorticoids, excess thyroxine replacement, antiepileptic medications, gonadal hormone suppression and immunosuppressive agents
  • Menopause before age 45
  • Minimal weight-bearing exercise
  • Poor vision despite correction
  • Self-report of "fair" or "poor" health
  • Weight less than 127 lbs.

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External links

U.S. surgeon general's report on bone health and osteoporosis, October (link)

Resources from the National Osteoporosis Foundation (link)

American Academy of Orthopaedic Surgeons' statement on the surgeon general's report on bone health (link)

National Institute of Arthritis and Musculoskeletal and Skin Diseases on bone diseases (link)

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