Preventive measures aim to ensure maximum accumulation of bone tissue during skeletal growth and maturation as well as reducing bone loss after the skeleton matures.
Approaches therefore differ during each life stage. Adolescence and young adulthood are the times to build skeletal reserve; midlife provides the opportunity to preserve bone mass and assure bone health in future years. In later life, those who may already have developed osteoporosis can take measures to prevent further bone loss and fractures.
Certain risk factors which predispose to the developing of osteoporosis cannot be altered- you cannot change your gender, race or age. You can still however do much to prevent further bone loss.
Lifestyle Changes
There are 4 main areas in which you can help maintain healthy bones:
Balanced diet rich in calcium/ calcium supplements
Regular weight-bearing exercise
Stop smoking
Decrease alcohol intake and avoid bone toxic drugs
Diet
A balanced diet containing adequate calories, minerals and vitamins is required to maintain bone health. Sufficient calories, protein, and vitamin C will ensure normal collagen synthesis.
An adequate Calcium intake is probably the most important bone building mineral.
It is a well-known fact that the diet of most individuals in western countries like South Africa, contain insufficient calcium to maintain a positive calcium balance.
Reasons for limited consumption include a distaste for dairy products, fear of calories and fats (although skim milk actually contains slightly more calcium than full cream milk), true milk allergy (rare in adults) and lactose intolerance which occurs frequently in the elderly, Blacks and Asians. Fermented lactose products like cheese and yoghurt are however tolerated by most.
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National Osteoporosis Foundation
of South Africa
Recommended daily allowance of calcium
Age group
Calcium per day (mg)
Infants
1 000
Children and adolescents
1 500
Young adults (pre-menopausal)
1 000
Pregnant and lactating females
1 500
Post-menopausal women:
on hormone (oestrogen) replacement (1 000)
not on hormone replacement (1 500_
Note:
Whereas calcium is an essential mineral required to build bone mass and to slow age-related bone loss, calcium alone will not protect against bone loss resulting from oestrogen deficiency in the post-menopausal female; it will also not provide protection against the bone loss cause by physical inactivity, smoking, alcohol abuse or bone toxic drugs. Sufficient calcium is just one of the many steps to ensure a healthy skeleton.
Calcium supplements should be considered when dietary intakes are insufficient. Calcium is not found free in nature and is usually bound to a salt (e.g. calcium carbonate, calcium citrate, calcium lactate etc). Since these salts all yield different amounts of elemental calcium (actual calcium that gets absorbed), it is important to know what the elemental calcium content of your supplement is, to know how much of it you should take per day.
Note:
Vitamin D enhances calcium absorption and is consumed in the diet and produced in the skin under the influence of sunlight. The recommended daily dose of vitamin D is 400 international units (IU) for individuals under 70 years and 800 IU for those over 70. Pharmacologic doses of vitamin D or vitamin D metabolites should be take under the supervision of a doctor. Excess vitamin D may cause kidney stones.
Calcium supplements are best absorbed if taken in small amounts throughout the day and with meals (calcium carbonate needs the presence of stomach acid to split from its salt, in order to get absorbed).
Avoid taking more than 500mg at one time.
Avoid taking calcium together with foods known to impair its absorption (e.g. fibre, oxalates, phytates, bulk-forming laxatives.).
Calcium supplementation is safe and generally free of side-effects- constipation can occur – increase your fluid and fiber intake, as well as exercise regularly.
There is no evidence, even in individuals with a personal or family history of kidney stones, that calcium supplementation causes kidney stones. If you take more than 2000mg per day and also in conjunction with Vitamin D, your urine calcium will increase and kidney stones may develop. Consult your doctor if this is the case and have your urine calcium levels monitored.
Exercise
Regular exercise is important at all ages as it is the only physiological way to stimulate bone formation. Individuals who exercise regularly tend to have higher peak bone mass and it also seems to slow down age-related bone loss. The exact mechanism of how exercise influences bone turnover is not known:
The muscle pull on bone generates pizo-electrical charges on bone surfaces which stimulate osteoblast activity and bone formation.
Exercise also causes the release of hormones that promotes bone formation.
Exercise stimulates blood flow within the bone.
Exercise improves balance, co-ordination and confidence- these help to prevent falls. It also strengthens muscles and flexibility, and protects against fractures even in the event of a fall.
Weight bearing exercise like brisk walking, stair climbing, jogging or dancing is better than non-weight bearing exercise like swimming or cycling. Although it is excellent to start with these if you have not exercised in a while.
A brisk 45 minute walk at least 3 times per week is recommended. Wear comfortable shoes with good arch and heel support.
Exercises to improve the posture and strengthen the pelvic floor, back and stomach muscles, are also very important.
Stop smoking, limit alcohol intake and avoid bone toxic drugs
The detrimental effects of tobacco and alcohol abuse on bone tissue have already been discussed. If you are serious about your health and want to prevent osteoporosis – don't abuse these bone toxic substances.
Pharmacologic Agents
Calcium and Vitamin
Already discussed
Hormone Replacement Therapy (HRT)
HRT is used to replace those hormones which decline during the menopause. Essentially the ovaries produce two hormones namely progesterone and oestrogen, although a small amount of male hormones (testosterone) are also produced.
In women who have had a hysterectomy, only oestrogen replacement is used. In women who still have a uterus, progesterone needs to be added to counteract the stimulating effect of oestrogen on the endometrium (inner lining of the uterus) which can lead to uterine cancer.
Benefits of HRT
HRT was originally developed to relieve the symptoms of the menopause ( hot flushes, night sweats, mood swings etc). It is now known that HRT also prevents the serious long-term complications of oestrogen deficiency (e.g. osteoporosis).
Osteoporotic fractures of the spine, hip and wrist are decreased by 50-70%.
Oestrogen has a beneficial effect on blood vessels and blood cholesterol.
HRT appears to improve cognitive function and may delay the onset of Alzheimer's disease although further research is required. It significantly decreases the incidence of colon cancer.
Potential risks of HRT
(Long-term use)
Cancer
Uterine Cancer
Endometrial cancer is increased in women who take only oestrogen therapy and still have their uterus intact. Progesterone should therefore be taken in conjunction with oestrogen. Combined HRT does not increase the risk of uterine cancer.
Breast Cancer
Long-term oestrogen therapy (more than 5 years) increases the risk of breast cancer. The risk seems to be insignificant in the short-term (less than5 years). Before initiating HRT, a baseline breast examination and mammogram should therefore be done.
Other cancers
The risk of other cancers is not increased.
Vascular problems
HRT is known to increase the incidence of deep vein thrombosis (DVT). HRT should be temporarily discontinued during periods of relative immobilisation (e.g. bed rest, long flights). Recent evidence has suggested that there may be an increased risk of cardiovascular disease during the first year of HRT. Known coronary artery disease and a recent myocardial infarction (heart attack) should be regarded as a contra-indication for HRT.
Short term side-effects
Vaginal bleeding
This usually occurs when HRT is given cyclically (10-14 days per month) and a monthly bleed follows. HRT can also be given continuously. Bleeding may occur for the first 6 months and should stop. If it continues, this needs to be investigated.
Breast discomfort
Breast discomfort and enlargement can be quite bothersome. It usually decreases with time and can be overcome by changing the hormone preparation or reducing its dose.
Fluid retention
This is more frequent in women who have been without oestrogen for many years and are started on too high a dose of HRT. These symptoms usually disappear after a while. Reduce salt intake and exercise. A different hormone preparation and the addition of a diuretic can also relieve symptoms.
HRT remains the only true effective way of treating the symptoms of menopause and is still one of the most cost-effective ways to prevent post-menopausal osteoporosis- it reduces fractures of the spine and hip by 50%.
It does, however, have side-effects and is not suitable for every woman. Decisions whether to start with HRT should be based on a thorough knowledge of the subject and open and honest discussion between the patient and her doctor. Every patient should be treated as an individual with specific needs.
Safe and effective alternatives to HRT exist to prevent osteoporosis.
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