Osteoporosis is a disease in which bones become fragile and can easily break. It has no symptoms in its early stages and is a public health threat to more than 44 million Americans. In this community lecture given live on our Berkeley Heights, NJ campus, Dr. Toscano-Zukor, explains how to identify your risk factors for osteoporosis as well as prevent and treat this disease.

1. Osteoporosis
Dr. Amy Toscano-Zukor, DO
Summit Medical Group
Berkeley Heights, New Jersey
(908) 273.4300

2. What is bone?
• It’s living, growing tissue made up of
collagen, a protein that provides a soft
framework, and calcium phosphate, a
mineral that adds strength and hardens
the framework.
• The combination of collagen and
calcium makes bone strong yet flexible
to withstand stress.

3. Bone is constantly active!
• Your bone health is maintained by a process
know as “remodeling:” replacement of old
bone with new bone.
• Throughout your lifetime, cells called
osteoclasts remove old bone (resorption),
while cells called osteoblasts produce a new
bone matrix (formation).
• Bone loss occurs when resorption exceeds
formation.
• Bone formation occurs at a fast pace until
your peak bone mass is attained at about age
30.

4. More facts about BMD
• On average, BMD is higher in men (who
reach a higher peak BMD) than in women,
and higher in blacks than in whites.
• Age-related bone loss occurs at about 0.5-1%
per year.
• With menopause, bone loss accelerate to
about 1-2% loss per year; this phase last 5-
10 years.
• Age-related bone loss continues for the rest
of life, with bone density going down to pre-
adolescent levels.

5. What is osteoporosis?
• It occurs when bone resorption occurs
too quickly or if replacement occurs too
slowly.
• It is more likely to develop if you did not
reach your peak bone mass during your
developing years.
• It can strike at any age.
• Often called “the silent disease”
because bone loss occurs without
symptoms (until a fracture occurs).

6. •
Factsand lowFigures are
Osteoporosis
and bone mass
estimated to affect almost 44 million
US men and women over age 50.
• Of the 10 million Americans estimated
to have osteoporosis, eight million are
women and two million are men.
• It was responsible for approximately 2
million fractures in 2005.
Source:NOF.org

7. Facts and Figures
• Approximately one in two women and up to one in
four men over age 50 will have an osteoporosis-
related fracture in their remaining lifetime.
• A woman's risk of a hip fracture is equal to her
combined risk of breast, uterine and ovarian cancer.
• The rate of hip fractures is two to three times higher
in women than men; however, the one year mortality
following a hip fracture is nearly twice as high for men
as for women
Source: NOF.org

8. Where do fractures occur?
• Of the 2 million fractures that occurred in 2005:
 297,000 were hip fractures
 547,000 were vertebral (spine) fractures
 397,000 were wrist fractures
 135,000 were in the pelvis
 675,000 were at other sites
 The number of fractures due to osteoporosis is
expected to rise to more than 3 million by
2025.

9. Consequences of fractures
• Vertebral--back pain, height loss,
deformity, decreased lung function,
diminished quality of life, increased
mortality.
• Hip--increased mortality; immobility
leading to bed sores, pneumonia, blood
clots, urinary infections, and muscle
wasting; bone deformity; nerve injury;
non-healing fracture.

10. Risk Factors
• Certain factors are linked to the
development of disease. These are
known as “risk factors.”
• Many people with osteoporosis have
several risk factors, while other have no
identifiable risk factors.
• Some risk factors can be changed while
others cannot.

11. Risk factors you cannot change
• Gender--women have less bone tissue and
lose bone more rapidly
• Age--bones become less dense and weaker
as you age
• Body Size--small, thin women are at greater
risk (particularly those weighing less then
127 lbs).
• Ethnicity--Whites and Asians are at highest
risk.
• Family history--people with a parent who
fracture seem to have reduced bone mass
and higher fracture risk.
• Rheumatoid arthritis, liver disease, IBD

12. Risk factors you can change
• Sex hormones--abnormal absence of
menstrual periods, low estrogen
(menopause), and low testosterone in men.
• Anorexia
• Low calcium and Vitamin D diet
• Certain meds, such as glucocorticoids and
anticonvulsants
• Inactive lifestyle; extended bed rest
• Cigarette smoking
• Excessive alcohol use.

13. Prevention: Calcium
• Many studies show that low calcium
intake appears to be associated with
low bone mass, rapid bone loss, and
high fracture rates.
• Recommended adult Calcium intake
 Age 19-50 : 1000 mg/day
 Older than 50: 1200 mg/day
 Pregnant or lactating: 1000 mg/day.

14. Prevention: Calcium
• Sources of calcium:
 Low fat dairy (milk, yogurt, cheese, ice cream)
 Green, leafy vegetables (broccoli, collard greens,
bok choy, spinach)
 Sardines and salmon
 Tofu
 Almonds
 Fortified OJ
 There are 300 mg of Ca in 1 C milk, 1 C yogurt, 1
C fortified OJ, and 1.5 oz. cheese

15. Prevention: Vitamin D
• Vit D plays an important role in Ca absorption
and in bone health.
• It is made in the skin through sunlight
exposure and obtained in the diet.
• Vit D skin production is lower in elderly
people, sunscreen users, those who avoid
sunlight, housebound people, and during
winter months.
• Higher Vitamin D levels are associated with
lower risk of breast, prostate, colon cancer,
and multiple sclerosis.

16. Prevention: Vitamin D
• Recommended daily allowance of Vitamin D
(200 IU age 19-50; 400 IU age 51-70; 600 IU
age 70+) is probably too low.
• You should be getting 800-1200 IU per day,
depending on your sun exposure, dietary
intake, and race (darker skinned individuals
require more).
• Vit D containing foods: fortified milk, cereal, or
OJ; eggs; sardines; salmon; tuna.
• Should get 15 minutes sun exposure to arms
and leg three times a week

17. Prevention: Exercise
• It improves bone health, muscle strength,
coordination, and balance
• It should not be too strenuous as to put
sudden or excessive strain on your bones.
• Weight-bearing exercise is the best for your
bones because it forces you to work against
gravity.
• Examples include walking, hiking, stair
climbing, weight training, tennis, low-impact
aerobics, gardening, and dancing.

18. Prevention: Limit Alcohol
• Regular consumption of 2-3 oz. a day
may be damaging to bones.
• Those who drink excessively are at
higher fracture and bone loss due to
poor nutrition and increased risk of fall.

19. Prevention: Stop Smoking
• Women who smoke have lower
estrogen levels compared to
nonsmokers; they often go through
menopause sooner,
• Smokers absorb less calcium from the
diet.

20. Preventing Falls
• Keep floors free of clutter
• Wear supportive, low-heeled shoes
• Keep stairwells and hallways well-lit
• Don’t use area rugs
• Install grab bars on bathroom walls
• Keep a flashlight at your bedside
• Use a rubber bath mat in the shower
• Use a portable phone that can be carried
from room to room
• If you live alone, contract with a monitoring
company that will respond to you 24 hours

21. Detection: bone density measurement (DXA)
• A noninvasive and painless test
• Your doctor may order it if you’re:
 Females over 65 and males over 70.
 Under 65, postmenopausal, and have 1
or more risk factors
 Males 50-69 with risk factors.
 Postmenopausal and have had a fracture
 Are being monitored after starting
treatment for osteoporosis

22. DXA
• Normal T score >or = to -1
• Osteopenia: T score between -1 to -2.5
• Osteoporosis: T score < or = to -2.5
• The lower the T-score, the lower your
BMD, and the higher your fracture risk

23. Treatment
• Calcium
• Vitamin D
• exercise

24. •
Treatment: Estrogen
Reduces bone loss, increases bone density
in spine and hip, reduces risk of hip and
spinal fracture in post-menopausal women
• Given with progesterone to decrease risk of
endometrial cancer
• Relieves menopausal symptoms
• Especially recommended for women who
have had ovaries removed before age 50
• Benefits and risks must be discussed with
your doctor

25. Treatment: Raloxifene
(Evista®)
• Prevention and treatment
• Antagonizes estrogen in breast and
endometrium, but agonizes estrogen in
bone.
• Lowers risk of breast cancer
• Increases risk of blood clots
• Less effective than estrogen and
bisphosphonates

26. Treatment: Calcitonin
• A naturally occurring hormone available
as an injection or nasal spray
• A relative weak medication to prevent
fracture and only modest effect on BMD

27. Bisphosphonates: Actonel®, Fosamax®,
Boniva®, Reclast®, Atelvia®
• Increase bone mass and decrease
fracture risk
• Inhibit osteoclasts (bone resorption)
• Used for treatment and prevention
• Boniva® and Actonel® available in once
monthly
• Boniva® and Reclast® available in
intravenous

28. Bisphosphonates: Actonel®, Fosamax®,
Boniva®, Reclast®, Atelvia®
• GI side effects (nausea, heartburn, irritation of
esphagus) are uncommon if properly
administered
• Take on empty stomach first thing in AM with
4-8 oz plain H20, while upright. No food,
drink, meds for half hour (Fosamax, Actonel)
to 1 hour (Boniva). Remain upright at least 30
min.
• Avoid in patients with known esophageal
strictures or impaired esophageal motility.

29. Parathyroid Hormone: Forteo ®
• A daily under-the-skin injection available
for those with high fracture risk
• Unlike bisphosphonates and estrogen, it
stimulates new bone formation
(osteoblasts)
• Approved for use up to 24 months
• Not given with bisphosphonates

30. Prolia ®
• Twice a year injection given under the
skin in your doctor’s office
• For patients with history of osteoporosis
fracture, multiple fracture risk factors, or
who have failed other osteoporosis
treatments.

31. Summary
• Bone is an active organ, constantly being
formed and removed by cells.
• Bone density decreases as we age
• Osteoporosis occurs when bone resorption
exceeds formation
• There are factors that can increase your risk
of developing osteoporosis (low Ca/Vit D diet,
smoking, excessive alcohol, certain
medications, inactivity, anorexia)
• Fall prevention is KEY!!!
• Diagnosis involves a painless, noninvasive
test known as DXA.

32. Summary
• If you have or are at risk for
osteoporosis, your doctor can help you
determine the best medication, change
in lifestyle, or intervention for you by
weighing the risks and benefits of each
option.
• Always check with your doctor before
starting any exercise regimen.