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Osteoporosis: Blowing the Whistle on the Epidemic<o:p></o:p>

We are told that osteoporosis now afflicts half of all women over the age of 50, making it more widespread than breast cancer, AIDS and heart disease combined. How do we get to such figures, and are they true? Surely our hospital beds should be full of people with fractures, and most elderly women afflicted by a dowager’s hump? Some years ago I began looking into the facts around the epidemic of osteoporosis that was affecting the lives of so many well women.Months of digging through medical journals, asking questions of international experts and investigating the known effects of prescription treatments revealed a very different story from the one we had all accepted.

The main reason for the ‘epidemic�?turns out to be quite simply a change in the definition of the disease. Traditionally osteoporosis had been known as a condition where bones fracture as a result of little impact or trauma because they have become thin, brittle, and have lost tensile strength. But in 1994 the World Health Organisation changed the definition to a measure of low bone density (BMD) because new technology was available to measure this aspect of bone. Bone mineral density relates to the quantity not the quality of bone. It reveals nothing about the strength, micro-architecture, rate of remodelling, size or shape of bone �?all factors which contribute to fragility.

Everyone naturally loses bone density as they age, but the new definition does not account for that. The standard reference norm on the bone density machines is that of a young woman, making it almost impossible for an older woman to have a normal diagnosis. Although extensive reviews of the evidence in the US, Canada, Sweden, Australia and the UK concluded that bone density testing does not accurately identify those people who will go on to break bones, the new definitions remains. In reality, the vast majority of the population never break their bones, and remarkably, people with higher bone density go on to have 63 percent of all fractures!

When it is characterized by fragile bones osteoporosis is a serious disease. But it is uncommon, even rare in women under the age of 80. The majority of older women who have spinal compression ‘fractures�?are unaware of the fact and have no symptoms, and debilitating hip fractures are most likely to occur as a result of dangerous home environments, immobility, dementia, medication such as corticosteroids, low levels of vitamin D, and existing conditions such as hyperthyroidism, Crohn’s disease and celiac disease. The older a person is, and the more unwell they are, the greater the risk of falling and breaking a hip.

Osteoporosis is now diagnosed as a disease when in most cases it isn’t. Like Ann, people are diagnosed with osteoporosis because they have low bone density, not because they have fractured. Magazine ads, articles, and fact sheets in doctors�?waiting rooms greatly exaggerate the impact that osteoporosis can have on our lives. Even the experts agree. Dr Mark Helfand, a member of the U.S. National Institutes of Health osteoporosis consensus panel comments: "I think even people who agree that osteoporosis is a serious health problem can still say it is being hyped. It is hyped. Most of what you could do to prevent osteoporosis later in life has nothing to with getting a test or taking a drug."

The new definition has created massive ‘osteoporosis-preventing�?pharmaceutical, bone testing, dairy and calcium industries. Worldwide, sales of osteoporosis drugs reached US$3.98 billion in 2002 although most of these drugs act only on slowing bone density loss and offer virtually no benefit in terms of preventing fracture in people diagnosed with low bone density alone.

Millions of women world-wide took hormone replacement therapy (HRT) believing it was preventing osteoporosis. Since it has been deemed too dangerous for long-term use because of breast cancer, stroke, and heart attack risk, these women are left confused and worried about their bone health. Finding accurate unbiased information is extremely difficult and many are being steered into new treatment regimes that bring new risks and few benefits.

Even the old bone-basics calcium and dairy are controversial. Although calcium intake is essential, bones are complex and dynamic and have a wide range of nutritional needs. Taking a calcium pill does not guarantee that it will end up in your bones and it does not appear to prevent fractures. Too much supplemental calcium can even be harmful.

And what about the instructions to drink lots of milk, particularly while young? Ironically, osteoporosis incidence is highest in those countries where most dairy products are consumed �?USA, Australia, New Zealand, Switzerland, the UK and Northern Europe. Most Chinese people eat no dairy products and get all their calcium from vegetables. Yet while they consume only half the calcium of most Westerners they have one of the lowest rates of hip fracture in the world. A recent review of 57 studies looking at dairy food and bone health concluded that "…the body of scientific evidence appears inadequate to support a recommendation for daily intake of dairy foods to promote bone health in the general US population." The famous Nurses Health Study in the U.S. followed the dietary calcium intake of 77,000 women over a 12 year period and found that those with the highest consumption of dairy products had the highest rate of fracture.

So what to do if you are worried about your bones?

�?Educate yourself about bone health. Understand that a diagnosis of low bone density (osteopenia) or osteoporosis is not sufficient reason to embark on a treatment regime. There are many other risk factors for osteoporosis such as previous fragility fracture, smoking, corticosteroid use and so on which need to be considered when a diagnosis is made. If you are worried, make sure you are tested for secondary causes of osteoporosis and other rare conditions that your doctor will know about.

�?Exercise and a nutrient-rich diet are the most effective strategies to avoid osteoporosis. A diet that covers the diverse nutritional needs of bone including calcium, magnesium, vitamin K, boron, manganese, zinc, copper, silicon and others nutrients is ideal. Fresh vegetables, fruits, nuts and seeds are good sources of these foods. Limit heavy protein and salt intake, reduce alcohol, don’t smoke, and for essential vitamin D, get sunlight on your skin at safe times of the day.

�?Exercise often! The force of muscles pulling against bone stimulates bone remodelling and formation. Higher impact activities like running, jumping and jogging are very effective, but regular aerobic exercise such as walking is also beneficial. Weight bearing exercises, resistance training, and flexibility and balancing exercises like Pilates, Tai Chi and yoga are also important. Research has demonstrated that we can benefit from exercise at any age �?even centenarians will experience an increase in strength, stamina and muscle mass. Exercise programs have been found to reduce the frequency of falls in high risk older people.

�?Don’t rush into taking drugs that may influence bone density but at present have little known benefit in terms of reducing fractures. Remember that all drugs have side-effects, and the risks and benefits have to be carefully considered.

�?Read more in The Myth of Osteoporosis.

Genant HK et al. Interim report and recommendations of the World health Organisation Task-force for osteoporosis. Osteoporosis International 1999;10:259-264

Bone Mineral Testing: Does the evidence support its selective use in well women? B.C. Office of Health Technology Assessment. Dec 1997. www.chspr.ubc.ca

Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women

Principal Results From the Women's Health Initiative Randomized Controlled Trial. JAMA 2002;288:321-333

http://washingtonpost.com/wp-dyn/articles/A14106-2000Sep25.html

Heaney, R.P. Bone mass, bone fragility and the decision to treat. Editorial. JAMA 1998: (280) 24; 2119-2120

Bone densitometry is not a good predictor of hip fracture. Education and Debate. BMJ 2001:323 795-799

Dawson-Hughes B. Calcium supplementation and bone loss: a review of clinical trials. American Journal of Clinical Nutrition. 1991; 54:274S-80S