Central  South  Dakota Medical News
The Clinical View
By: Phillip E. Hoffsten, M.D.
15  FEB  2001

Osteoporosis - The Hip Fracture Problem  

    One hundred years ago, life on the prairies of South Dakota was very different than it is now. The labor-saving devices we have now were not invented then; farm work was strenuous and in addition the life expectancy was slightly less than 60 years of age. The hard strenuous work required then tended to maintain bone strength and the infrequency of aging limited the incidence of hip fractures. Today, a woman's average lifespan is 77 years of age and increasing with each decade. The strenuous physical labor that was required 100 years ago has been replaced by many of our labor saving devices. Thus, now women and men live to a much older age with less strain on their bones and therefore a weakening process that has made hip fractures a major health consideration in our society.

    To understand osteoporosis (softening of the bones) it needs to be understood that everyday a small amount of bone all over the body is melted away and replaced by new bone When a child is growing up, new bone formation exceeds the rate of bone breakdown and the skeleton gets bigger and stronger until around 22 years of age. At that point, the total amount of bone in the body stays relatively stable for about 10 to 15 years. However, at about age 35, the bone absorbing process begins to exceed the bony lay down reparative process and there is a net loss of bone mineral for the rest of the person's life. It is estimated that approximately 30% of bone mineral will be lost by age 60 and progressively more after that. The critical part of this bone loss occurs on the middle inside of the bone and once lost does not grow back.

    There are multiple factors that lead to the bone loss. How strong a person's bones will be when they are 60 years old is partially related to how strong their bones were when they were 22. Thus, the better the diet in the childhood and teenage years, the better will be the person's bone mineral when they are 60. In today's society where Coca-Cola seems to be more consumed than milk, osteoporosis is going to be a problem. The recommendation of one quart of milk a day for children still applies. The next factor that helps preserve bony integrity is adequate loading and stress on the bones. As mentioned above, prior to our labor-saving devices, people worked much harder and bones were much better maintained because they were strained. It is known that astronauts who go up in a spacecraft for several months come home with horrible osteoporosis because they are not weight bearing and their bones dissolve like ice in the summer. Weightbearing exercise is a critical part of maintaining bony integrity over the long run. Perhaps the one advantage of being overweight is that your bones have a built in exercise program. Every place a heavy person walks, they are carrying more weight and therefore staining their bones more than the thinner person. This helps maintain bony integrity. Thus, adequate exercise is an important part of maintaining bony integrity. This needs to be weight- bearing exercise such as walking.

    Several other practices in our society contribute to early occurrence of osteoporosis. One of these is cigarette smokingwhich interferes with vitamin D metabolism and prevents normal calcium absorption. Several medications such as Dilantin used to treat seizures interfere with vitamin D metabolism and can cause early osteoporosis. The use of cortisone to treat arthritis or other conditions also leads to increased bone loss and early osteoporosis.

    One of the very controversial topics in the past 20 years has been hormone replacement therapy for women and for men. It was shown early that hormone replacement therapy leads to a decreased rate of hip fractures and to maintenance the bone mineral density. However, the concerns over estrogen replacement in women or testosterone replacement in men has to do with side effects from these two hormones. Estrogen replacement in women may contribute to breast cancer. Testosterone replacement in men may contribute to prostate cancer. To our general society, cancer is much scarier than osteoporosis and the use of hormone replacement therapy is not as acceptable as would be beneficial for osteoporosis treatment.

    Medications available to treat osteoporosis have advanced substantially in the past 10 years. There are now medications that will prevent the rapid breakdown of bone. These are best used when people are in their 50s and after as opposed to waiting until age 70 or 80 when osteoporosis has already developed. Medications for this purpose include Fosamax (alendronate), Actonel (Risedronate), Evista (Raloxifene), Miacalcin nasal spray (Calcitonin), and lastly large doses of vitamin D. Which of these various medications may be helpful is a complex consideration.

    Your healthcare providers at your local clinic are available to deal with osteoporotic considerations on an individual basis. The benefits of treating osteoporosis include avoiding hip fractures, avoiding back fractures and avoiding wrist fractures. Of those individuals who have a fractured hip, approximately one-half will be in a nursing home for the rest of their life. Avoiding the hip fracture is an important part of healthcare in the elderly population in South Dakota.