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Osteoporosis

Osteoporosis literally means ‘porous bones’. Your bones become weak, brittle and more likely to break (fracture), and you’ll usually lose bone density.

Osteoporosis is very common. In the UK, about one in five men and half of women over 50 will fracture a bone because of osteoporosis. Osteoporosis can affect all age groups but it becomes more likely the older you get. It’s most common in post-menopausal women. Having osteoporosis doesn’t mean that your bones will definitely fracture; it just means that it’s more likely.

Osteoporosis is sometimes confused with osteoarthritis because their names are similar. However, they are different conditions.

How osteoporosis develops
Osteoporosis is a condition where your bones become brittle and weak and are more likely to break

Details

  • Symptoms Symptoms of osteoporosis

    You can’t see or feel your bones getting thinner, and you may only become aware of osteoporosis when you fracture a bone. Osteoporosis itself doesn’t cause symptoms until you fracture a bone. Fractures are most likely to happen in your back (vertebrae), hip and wrist. They can also happen in your arm, pelvis, ribs and other bones.

    Fractures in your hip and wrist usually follow a fall and will probably be painful. If you’ve broken your hip you’ll find it hard to bear weight, and to move your leg normally. If osteoporosis causes a fracture in the bones in your back a sign to look out for is severe back pain. Other signs include your spine becoming curved and some reduction in your height. However, only one in three people with a fracture of the bones in the back have any symptoms at all.

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  • Diagnosis Diagnosis of osteoporosis

    If you’re at risk of having osteoporosis, your doctor will carry out an assessment. They’ll examine you, and ask you questions about your lifestyle and family medical history. You may have a DXA scan (dual energy X-ray absorptiometry scan). This measures the density of your bones. The scan is painless and takes 10 to 20 minutes.

    Osteoporosis is diagnosed if your bone density as measured by a DXA scan is found to be well below average. If your bone density is slightly lower than average, it’s known as osteopenia.

    Osteoporosis is sometimes diagnosed after a fracture has happened, possibly after a trip or a fall. If this happens, your doctor may recommend you have a DXA scan. You may also have some blood tests to rule out underlying conditions.

    If your doctor diagnoses osteoporosis, they can put the results of your DXA scan alongside other information into an online risk assessment tool. The other information will include such things as your age, sex, whether you smoke and whether other people in your family have osteoporosis. Your doctor can then say what your chance is of having a fracture over the next 10 years.

  • Treatment Treatment of osteoporosis

    The aim of treatment for osteoporosis is to strengthen bones and prevent fractures.

    If you’ve been diagnosed with osteoporosis your GP will probably advise you to make some healthy changes to your diet and lifestyle. They may also suggest changes to your home to help reduce the risk that you might fall. See our sections on prevention of osteoporosis and living with osteoporosis below for more details.

    They may also recommend you take supplements of calcium and vitamin D as these may help to prevent fractures. It’s important to follow your GP’s advice on which supplements to take and how many.

    Medicines

    If you have osteoporosis, your GP may offer you medicine to reduce your risk of fractures and increase your bone density. If the medicine your GP offers doesn’t work, or has too many side-effects they may refer you to a rheumatologist. A rheumatologist is a doctor who specialises in treating arthritis and other diseases of the joints, muscles and bones. See below for more information about the individual medicines.

    There are a number of different medicines that are used to treat osteoporosis. What medicines you are offered, if any, will depend upon:

    • your age
    • your sex
    • the risk that you’ll have a fracture
    • whether you’ve had a fracture due to osteoporosis before

    Some of the medicines used for osteoporosis are only prescribed by hospital specialists and/or in special circumstances. Your doctor will discuss with you which treatment is best for you. The main medicines used for osteoporosis are listed here.

    • Bisphosphonates – these work by slowing down bone loss. Examples include alendronate and risedronate. Bisphosphonates are the mainstay of treatment for osteoporosis. This is the medicine your GP is most likely to offer you.
    • Denosumab – this is a treatment that works by blocking the formation of the cells that break down bone.
    • Teriparatide – a form of the hormone which regulates calcium levels in your body (parathyroid hormone). This stimulates formation of bone.
    • Raloxifene – this is an artificial hormone that works by copying the effects of oestrogen on your bones.

    Some men will have osteoporosis due to low levels of testosterone. If this is found, your doctor may suggest testosterone replacement therapy.

    Always read the patient information leaflet that comes with your medicine carefully. If you have queries about taking your medicines you can ask your pharmacist.

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  • Causes Causes of osteoporosis

    Healthy bone consists of a strong mesh made of protein and minerals (particularly calcium) surrounded by a thick outer layer. This mesh is living tissue that is constantly being renewed by two types of cells which work in balance with each other. One type of cell (osteoblasts) builds up new bone and the other (osteoclasts) breaks down old bone. Your bones are at their most dense in your early to mid 20s. After the age of about 35, your bones gradually lose their density as a natural part of ageing. This happens slowly at first, but the rate increases in women after they have been through the menopause.

    An image showing the structure of bone and bone affected by osteoporosis 

    Although the genes you inherit from your parents play an important role in how healthy your bones are, other factors can affect your risk.

    • Age – the risk of getting osteoporosis increases as you get older.
    • Gender – women are more likely to get osteoporosis than men.
    • Race – white or Asian people are at greater risk than African-Caribbean people.
    • Menopause/hysterectomy. If you’ve had the menopause or if your ovaries were removed in a total hysterectomy, this increases your risk because you have less oestrogen.
    • Long-term immobility – bones and muscles become weak if your body isn’t active and using them regularly.
    • Weight – if you’re underweight or you’ve lost weight in recent years, you have an increased risk of osteoporosis.
    • Poor diet – low levels of vitamin D or calcium mean your body can’t repair bones and keep them strong.
    • Smoking and alcohol – if you smoke and/or drink excessive amounts of alcohol you’re more likely to get osteoporosis.

    Other medical conditions can increase your risk of osteoporosis. These include:

    • an overactive thyroid gland (hyperthyroidism) or overactive parathyroid glands (hyperparathyroidism)
    • rheumatoid arthritis
    • low level of testosterone – caused by a condition in which your testicles don’t function properly (hypogonadism)
    • digestive disorders – for example Crohn’s disease or any other condition that decreases absorption from your digestive system

    Some medicines can increase your risk of osteoporosis. These include long-term steroids, anti-epilepsy medicines and some cancer treatments. Ask your doctor to explain the risks and benefits of taking these medicines. Don’t stop taking medicines without discussing it first with your doctor.

  • Complications Complications of osteoporosis

    The main complication of osteoporosis is getting a fracture (break) in one of your bones.

    If you have osteoporosis, you’re more likely to fracture bones after quite minor accidents like falling or tripping, or even bending and lifting. Your bones fracture much more easily than you’d expect. You’re most likely to fracture bones in your spine, wrists and hip. However, you can fracture any bone in your body. Fractures are often painful and can lead to a loss of independence and long-term disability in older people.

  • Prevention Prevention of osteoporosis

    Making some changes to your lifestyle could help to reduce your risk of developing osteoporosis. A healthy diet and regular exercise can increase bone mass in youth, and slow down the rate of bone loss in later life.

    Exercise

    Being physically active should start in childhood and be lifelong. Experts recommend regular weight-bearing and muscle-strengthening exercise. This can improve strength and balance and reduce falls and fractures. Exercise may also increase bone density.

    Weight-bearing exercise includes brisk walking, jogging, tennis, dancing and Tai Chi. Pilates and weight training are examples of muscle-strengthening exercises. If you aren’t used to exercising, start slowly and build up your exercise routine gradually.

    Quit smoking

    Smoking can have a harmful effect on your bone strength and can also cause an early menopause in women. If you smoke, try to give up. Also, if you drink alcohol keep to sensible amounts rather than drinking excessively. Doctors recommend that you shouldn’t drink more than 14 units a week, and that these should be spread over the course of the week. To find out more about what this means for you see our topic on sensible drinking.

    Walk to run training programme 

    Healthy diet

    It’s important to eat a healthy balanced diet to make sure you get all the vitamins and minerals you need to keep your bones healthy. It’s particularly important to eat a diet that’s rich in calcium. Adults should aim to have 700mg to 1000mg of calcium every day, which you should be able to get through healthy eating. Good sources of calcium include milk, cheese and yogurt, oily fish, and some green leafy vegetables, such as broccoli. See our FAQs for more information about getting enough calcium.

    Vitamin D

    Making sure you get enough vitamin D is also important for healthy bones as your body needs this to absorb calcium properly. Vitamin D is produced naturally by your body when your skin is exposed to sunlight. You can also get it from some foods, such as oily fish, eggs and some breakfast cereals. You may get enough vitamin D by spending frequent short spells in the sun without wearing sunscreen. You need around 15 minutes in the middle of the day, two to three times a week from April to September. Be careful not to let your skin redden. Apply sunscreen if you’ll be in the sun for longer than this. See our FAQ below for more information about getting enough vitamin D.

  • Living with osteoporosis Living with osteoporosis

    If you’re living with osteoporosis remember that you’re not alone. There are many people going through the same ups and downs as you. There’s a lot you can do to keep yourself healthy and reduce the chance that you’ll have a fracture. Some aspects of your life may need to change, but it’s important that you keep active and continue to enjoy life as normal.

    Some people find it helpful to talk to other people who have osteoporosis, either in local groups or in online forums.

    Falls

    Many people with osteoporosis worry about falling and breaking a bone, especially as they get older. There are lots of very practical, simple ways to help prevent falls. These may include home modifications, better fitting footwear, improving diet and physical activity levels and changing medications. Ask your GP if there’s a specialist NHS falls prevention service local to you which can give advice. You may also be able to get help with home aids or modifications from social services. Various charitable organisations also offer a lot of very helpful advice. See our ‘other helpful websites’ section below for contact details.

    Being active

    If you have osteoporosis it’s important to try and keep active. Regular weight-bearing and muscle-strengthening exercises reduce the risk of falls and fractures. It’s important to start exercise slowly and build it up over time. If you have osteoporosis and other medical problems you should check with your GP before starting vigorous activities. See our section on prevention of osteoporosis above for more information.

    Fractures

    If you have a fracture it should heal within the usual time of six to 12 weeks, as osteoporosis doesn’t affect the healing process. Your treatment and recovery will depend upon the type of fracture you have.

    If you have a fracture you may wish to take medicines for pain-relief. Over-the-counter painkillers such as paracetamol or ibuprofen may help with this. Some people with osteoporosis have long-term pain after fractures. Your pharmacist will be able to help you find the right type of pain relief for your circumstances. Always read the patient information leaflet that comes with your medicine. If you’re finding it hard to control the pain see your GP. See our FAQs for more information about pain in your back.

    Older people with hip fractures may need extra help from healthcare specialists such as physiotherapists and occupational therapists to help them get back their independence. Most people with fractures recover and return to active lives.

  • FAQ: Calcium and vitamin D How much calcium and vitamin D should I be getting?

    For healthy bones an adult needs between 700 and 1000mg of calcium a day, on average. Calcium comes from your diet. You also need vitamin D. Most of the vitamin D you need is made in your skin when it’s exposed to sunlight, but some comes from your diet too.

    If you’re not getting enough calcium and vitamin D you can take supplements to make the levels up to the recommended amount. If you have osteoporosis your doctor will discuss with you what supplements you may need.

    If you have osteoporosis your GP will want to make sure you’re getting enough calcium and vitamin D.

    If they don’t think you’re getting enough calcium in your diet your GP will recommend you take a daily supplement of calcium. To give you some idea about how to get enough calcium in your diet, here’s the amount in some everyday foods.

    • A 200ml glass of semi-skimmed milk contains 240mg calcium.
    • A 150g pot of fruit yogurt contains 240mg calcium.
    • Cheddar cheese (matchbox size) contains 240mg calcium.
    • Four slices of white bread contain 240mg calcium.
    • Four slices of wholemeal bread contain 120mg calcium.
    • Tinned salmon (half a tin) contains 60mg calcium.
    • Baked beans (small tin, 220g) contains 120mg calcium.

    Vitamin D comes mainly from exposing your skin to sunlight. See our section on prevention of osteoporosis above for guidance. You may not be getting enough vitamin D if:

    • you’re over 65, as your skin isn’t so good at making vitamin D
    • you have dark skin and live in the UK or other northern countries
    • you cover most of your skin when outdoors
    • you’re housebound, or spend most of your time indoors
    • you’re pregnant or breastfeeding

    If you have osteoporosis and you may not be getting enough vitamin D, your GP may recommend that you take vitamin D supplements.

    It can be confusing knowing what vitamins and minerals you need – your GP will discuss with you what’s best for you personally. It’s important to follow your GP’s advice when taking supplements for osteoporosis.

  • FAQ: Calcium in dairy-free diets I can’t eat dairy foods so how can I get enough calcium?

    Even if you don’t eat milk or dairy food, there are plenty of non-dairy foods that contain calcium. You should still be able to get enough from your diet.

    Good sources of calcium include:

    • oily fish such as canned sardines and pilchards
    • soya beans and tofu
    • bread (white has more calcium in it than wholemeal), pitta bread, chapatti
    • certain green vegetables including broccoli and spring greens

    You may also want to include in your diet foods with added calcium. Examples are calcium-enriched milk alternatives (soya, oat, nut), orange juice and some breakfast cereals.

  • FAQ: Calcium in low fat diets How can I get enough calcium if I have to limit cheese and milk?

    It’s good to eat some dairy foods each day as they are good sources of calcium. You can try either switching to lower fat options or using a little less of high-fat foods such as hard cheese. There are many low-fat dairy products available and these contain calcium as well as those with full fat.

    Try changing from:

    • whole milk to semi-skimmed or skimmed milk
    • Cheddar or Edam cheese to cottage cheese
    • cream to yoghurt or low-fat crème fraîche
  • FAQ: Pain from spine fracture How can I deal with the pain from a broken bone in my back?

    If you have osteoporosis you’re at risk of getting an osteoporotic spinal compression fracture. This is when pressure on weakened bones in your spine (vertebrae) causes them to crack and fracture. This type of fracture usually heals without leaving problems but it can unfortunately be painful.

    There is a range of options to help with any pain you have. Your GP will work with you to find the right solution.

    You may or may not feel any immediate pain when the fracture occurs. However, if you do have pain, it can be very severe. You may also have chronic pain even after your bone has healed. Chronic means that it lasts a long time. Ongoing pain after a fracture can make your day-to-day life more difficult and leave you feeling low in spirits. It’s important to let your GP know if you are in pain, or if you feel you might be becoming depressed.

    Your GP is likely to suggest trying either over-the-counter or stronger, prescription painkillers. They may recommend a short period of bed rest (24 to 48 hours). However, if these don’t help control your pain, there are other options to consider. Some examples are listed below.

    • You may find that physiotherapy, hydrotherapy (exercise in water), acupuncture or using a TENS (transcutaneous electrical nerve stimulation) machine may help to relieve your pain.
    • Surgical treatments that include injecting cement into the fracture are available. These methods are called vertebroplasty and kyphoplasty.

    It’s important that your GP helps you to find an approach that works for you. It’s possible that you may need to be referred to a specialist pain clinic. You may also find helpful advice on coping with pain from charitable organisations like the National Osteoporosis Society. See our section on ‘other helpful websites’ below for contact details.

  • FAQ: Spinach and calcium Why isn’t spinach a good source of calcium?

    The calcium content of spinach is quite high compared with other foods. For example, 100g of boiled spinach contains around 160mg of calcium compared with 75mg in the same amount of spring greens. However, spinach isn’t recommended as a calcium-rich source of food because the calcium is bound to a substance called oxalate. This stops your body from absorbing it. So, although spinach is a good source of other vitamins and minerals it isn’t a good source of calcium.

  • FAQ: Calcium supplements and heart attack Can calcium supplements increase the risk of having a heart attack?

    There is some evidence that calcium supplements may increase the risk of heart attacks in women who have gone through the menopause. However, as other studies have reported different findings, more research is needed before we know for sure. If your GP has recommended that you take calcium supplements because you’re at risk of osteoporosis, don’t stop them without talking to him or her.

    Calcium supplements are sometimes advised for women who have gone through the menopause to keep their bones healthy. A 2011 study found that heart attacks were more common in women taking calcium supplements than in women taking a placebo (dummy pills). Scientists don’t yet know why calcium supplements could cause this effect. Perhaps high calcium levels could lead to a build-up of calcium in the blood vessels. However, since other studies don’t show the same results, experts really don’t know yet whether taking calcium supplements can cause heart attacks. We’ll have to wait for the results of more studies to be sure.

    If your GP has recommended that you take calcium supplements, it may be because they think that you’re at risk of osteoporosis. If you get enough calcium from your diet, you may not need calcium supplements. If your GP prescribes a calcium supplement, it will be to take in combination with a vitamin D supplement. Calcium that you get in your diet doesn’t appear to lead to an increased risk of heart attack.

    Always talk to your GP before stopping any medicine or supplement that has been recommended or prescribed for you. Any risks associated with taking calcium supplements must be balanced against the risk of osteoporosis and fractures that may happen if you don’t take them.

  • Other helpful websites Other helpful websites

    Further information

    Sources

    • Osteoporosis. BMJ Best Practice. www.bestpractice.bmj.com, last updated 21 August 2015
    • Osteoporotic spinal compression fractures. BMJ Best Practice. www.bestpractice.bmj.com, last updated 29 January 2016
    • Osteoporosis. Medscape. www.emedicine.medscape.com, updated 16 June 2016
    • Osteoporosis. PatientPlus. patient.info/patientplus, last checked 12 October 2015
    • Osteoporosis – prevention of fragility fractures. NICE Clinical Knowledge Summaries. cks.nice.org.uk, last revised March 2016
    • Osteoporosis: assessing the risk of fragility fracture. National Institute for Health and Care Excellence (NICE), August 2012. www.nice.org.uk
    • Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. National Institute for Health and Care Excellence (NICE), 2008 (amended 2011). www.nice.org.uk
    • Map of Medicine. Osteoporosis. International View. London: Map of Medicine; 2016 (Issue 1)
    • Avenell A, Mak J and O’Connell D. Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men. Cochrane Database of Systematic Reviews 2014, Issue 4. doi: 10.1002/14651858.CD000227.pub4.
    • What is osteoporosis? National Osteoporosis Society. www.nos.org.uk, accessed 12 July 2016
    • Scans and tests and osteoporosis. National Osteoporosis Society, 2014. www.nos.org.uk
    • Risk factors for osteoporosis and fractures. National Osteoporosis Society. www.nos.org.uk, accessed 12 July 2016
    • Living with osteoporosis. National Osteoporosis Society. www.nos.org.uk, accessed 12 July 2016
    • All about osteoporosis. National Osteoporosis Society, 2014. www.nos.org.uk
    • Osteoporosis – help and support. Age UK. www.ageuk.org.uk, accessed 12 July 2016
    • Osteoporosis: Food fact sheet. BDA. The Association of UK Dietitians, 2016. www.bda.uk.com
    • Vitamin D: Food fact sheet. BDA. The Association of UK Dietitians, 2016. www.bda.uk.com
    • Calcium: Food fact sheet. BDA. The Association of UK Dietitians, 2014. www.bda.uk.com
    • Osteoporosis. International Osteoporosis Foundation. www.iofbonehealth.org, accessed 12 July 2016
    • Cosman F, de Beur S, LeBoff M, et al. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int 2014; 25:2359. doi:10.1007/s00198-014-2794-2
    • Nutrition. National Osteoporosis Foundation. www.nof.org, accessed 12 July 2016
    • Bone health for life: health information basics for you and your family. NIH Osteoporosis and Related Bone Diseases – National Resource Center. www.niams.nih.gov, published July 2014
    • Theobald H. Briefing paper: dietary calcium and health. British Nutrition Foundation. Nutrition Bulletin 2005; 30(3):237–77. doi:10.1111/j.1467-3010.2005.00514.x
    • Bolland MJ, Grey A, Avenell A, et al. Calcium supplements with or without vitamin D and risk of cardiovascular events: reanalysis of the Women’s Health Initiative limited access dataset and meta-analysis. BMJ 2011; 342:d2040. doi:10.1136/bmj.d2040
    • Lewis, J, Calver J, Zhu K et al. Calcium supplementation and the risks of atherosclerotic vascular disease in older women: results of a 5-year RCT and a 4.5-year follow-up. J Bone Miner Res 2011; 26:35–41. doi:10.1002/jbmr.176
    • Li K, Kaaks R, Linseisen J, et al. Associations of dietary calcium intake and calcium supplementation with myocardial infarction and stroke risk and overall cardiovascular mortality in the Heidelberg cohort of the European prospective investigation into cancer and nutrition study (EPIC-Heidelberg). Heart 2012; 98:920–25. doi:10.1136/heartjnl-2011-301345
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    Reviewed by Dr Kristina Routh, Freelance Health Editor, Bupa Health Content Team, August 2016
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