Inverting Osteopathic Family Physicians Approach to Osteoporosis
By Robert Zaid, DO
This is the second place winner of the 2008 Namey/Burnett Writing Award.
The Namey/Burnett Writing Award is implemented by the ACOFP Preventive Medicine and Medical Preparedness Committee to honor the best preventive medicine papers submitted by osteopathic family practice residents, interns, and osteopathic medical students.
Introduction
Osteoporosis is responsible for 1.5 million life altering fractures a year in the United States.1 Hip fractures are among the most debilitating fracture related to osteoporosis and considerable resources are utilized in treating these patients. Typically, high risk patients including post-menopausal women are screened for Osteoporosis and treatment is geared towards prevention of bone loss. Often patients are diagnosed too late and would have benefited from earlier intervention.
Peak bone formation in males and females occurs around 25 years of age2, while women undergo accelerated bone loss at menopause. The amount of bone formed prior to 25 years of age has been shown to be directly relate to risk for complications from osteoporosis later in life. In fact, bone mass increases progressively during childhood and 40 percent of total bone mass is accumulated during later adolescence.3 Although most bone mass is accrued during adolescence, family physicians expend most of their energy towards preventing bone loss in patients who already have the disease. Children are capable of absorbing calcium from their diets more efficiently than the elderly. Instead of extracting calcium from their diet, the elderly will resorb calcium from their bones.2 These facts may cause family physicians to rethink their focus when approaching osteoporosis.
If family physicians implement measures targeting habits that promote bone growth in childhood, we may find that preventing bone loss in the future may be less imperative.
In considering treatment for osteoporosis, primary prevention is as much if not more important than secondary or tertiary prevention. Family physicians play a critical role in educating and promoting good lifestyle choices for youth while their bones are still forming and before bone loss begins.
Over the last several decades in the United States, children have been replacing caffeinated drinks for dairy drinks in their diets; playing video games instead of baseball, and many preteen children smoke cigarettes. All of these factors are contributing to decreased peak bone mass and studies have shown that bone mass in adolescents is related to risk of osteoporosis later in life.2 Family physicians should emphasize bone formation early on, rather than relying on efforts to preserve bone later in life.
Risk Factors (Modifiable)
In order to be successful in preventing osteoporosis family physicians must maintain a comprehensive understanding of the risk factors that cause osteoporosis, affording particular attention to those that can be altered. The modifiable risk factors for osteoporosis can be divided into those that are metabolic and those that are mechanical.
Metabolic Risk Factors
The use of tobacco, caffeine, and alcohol can all cause excretion of calcium from the urine. Additionally, excessive intake of protein and phosphate can cause a negative calcium balance.5 Inadequate nutrition coupled with low calcium intake early in life may result in a decreased peak bone mass.4 These factors may be negated if appropriate calcium intake or calcium supplementation is implemented.
In contemporary American society, increased consumption of soft drinks often replaces dairy beverages and this significantly affects bone structure. These drinks will cause dieresis and loss of calcium from the urine, while providing high amounts of phosphates that also promote calcium loss in the urine. Also, the absence of calcium rich dairy products in the diet compounds also contributes calcium deficiency.
Decreased exposure to the sun can decrease Vitamin D levels in the body that in turn can cause a decreased absorption of calcium in the blood. Parathyroid hormone is then secreted, and bone loss occurs to maintain calcium levels.5 Over time this can have deleterious effects on bone structure and can cause thinning of cortical bone.
Mechanical Risk Factors
Although bone metabolism relies on the total body calcium loads, bone formation depends on weight bearing exercise. Bone becomes stronger as demand and work load increases. Low loads allow for bone maintenance, high loads can cause bones to become stronger and very high loads can be deleterious. It is imperative that children exercise and stay active. Gaining insight of basic bone physiology, it becomes clear that the cultural shift towards enhanced and expanded video entertainment is likely to have significant impact on bone health.
Prevention
As explained earlier, children are much better handlers of calcium than are adults. Due to this fact, family physicians will obtain better results for bone health if they encourage calcium consumption at an early rather than later in life.
Current recommendations for calcium intake can be found in Table 1. Good sources of calcium can be found in yogurt, milk, cheese, sardines and salmon.1 If supplementation is needed, Calcium Citrate and Gluconate are more absorbable than Calcium Carbonate. A more comprehensive list of foods rich in calcium can be found in Table 2.
Required daily amounts of vitamin D can be attained with sun exposure for 10 – 15 minutes a day without sunscreen. Dietary sources of Vitamin D can be found in liver, fish, Swiss cheese, egg yolk and fortified milk.
Amounts of caffeine should be limited and children should avoid soft drinks.
Weight bearing exercises can be performed fairly easily and do not require much effort. Some examples of appropriate exercises include walking, jogging and dancing.
one is extremely sensitive to exercise and mechanical load. Low loads will maintain bone, while high loads will remodel bone to withstand the new loads.1 Exercise for 20 to 30 minutes a day, three days a week has been recommended for adults, although no formal recommendation is available for children.
Summary
Osteoporosis is quite debilitating to both the health of patients and with regard to the impact on the health care system. Patients lose quality of life and have decreased function. Osteopathic family physicians have a unique opportunity to examine patients and promote lifestyle choices early on that may benefit them before it is too late. Often, providers target elderly patients who have begun to show signs or have risk factors for acquiring osteoporosis. As educators, family physicians have the chance to teach patients good habits as children so that they develop the ability to make good health choices throughout their lives. Family physicians can encourage children to reduce the amount of caffeine, increase the amount of dairy products and to balance the amount of indoor activities with outdoor physical activities. By promoting bone growth in late adolescence, osteopathic family physicians may save patients from a debilitating fall or bone fracture in the future, improving the quality and length of their lives.
| Table 1. Recommended Daily Calcium Intake | |
| Patient Population | Mg |
| Children < 10 years | 700 |
| 10-25 years | 1,300 |
| Adults | 800 |
| Pregnant Women | 1,500 |
| Lactating Women | 2,000 |
Dr Zaid, a graduate of Michigan State University, is currently a resident at Genesys Regional Medical Center in Grand Blanc, Michigan. He will begin practicing in Novi, Michigan this August.
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