Managing Osteoporosis in the New Millennium

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Managing Osteoporosis in the New Millennium

• Elena Barengolts, MD
• Associate Professor of Medicine
• University of Illinois at Chicago College of
  Medicine

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Osteoporosis
A disease of women, occasionally men, and
rarely men who dress
like women
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Case 1

• Mrs. White is an 82 year old female, nursing home
  resident who has just returned to the nursing
  home following repair of a hip fracture she
  sustained during a fall. She has mild dementia
  (follows instructions) and a history of breast
  cancer.

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Osteoporosis Epidemiology

• 1.3 million fractures per year
• Osteoporosis is 3 times more common than
  breast cancer
• Cost - 10 - 12 billion in 1990 - 50 billion
  in 2040

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Case 2

• Miss Scarlett is a 92 year old woman who has
  recently suffered a painful vertebral fracture.
  She is in a wheelchair due to a stroke she
  suffered 4 years ago. Her creatinine is 2.4.
  She is frail with significant kyphosis.

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Osteoporosis More Common than Heart Attack in
Women
Annual Incidence of Common Disease
Osteoporotic Fracture gt 1,000,000 Heart
Attack 513,000 Stroke
228,000 Breast Cancer 182,000 Uterine
Cancer 32,800 Ovarian Cancer
26,600 Cervical Cancer
15,800 1993 estimated all ages 1991
estimated, women 30 1991 estimated, women
29 1995 new cases, all women
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Case 3

• Colonel Mustard who has suffered with
  symptomatic GERD for the last 10 years, falls and
  breaks a hip. He is 65 years old and has no
  apparent risk for osteoporosis.

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Hip Fracture Outcomes

• 24 mortality within first year1
• 50 of hip fracture sufferers unable to walk
  without assistance2
• 33 totally dependent3
• 7.8 need long-term nursing home care for an
  average of 7.6 years4

1 Ray, NF et al. J Bone Miner Res 1997
1224-35 2 Riggs, BL, Melton LJ III. Bone 1995
17 (Suppl) 505S-511S 3 Kannus, P et al. Bone
199618 (Suppl) 57S-63S 4 Chrischilles EA et
al. Arch Intern Med 1991 151 2026-32
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Case 4

• Professor Plum who is an expert on
  osteoporosis, is worried about his 50 yo
  daughter. Her mother, the professors wife,
  recently had a hip fracture due to severe
  osteoporosis. Ms. Plum is of small build, smokes
  cigarettes 1 ppd x 25 y, drinks lots of coffee
  and is a self-admitted couch potato. She refuses
  HRT but agrees to a DEXA. Her T-score is -1.7 at
  the L spine and -1.8 at the hip.

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Modifiable Risk Factors

• Behavioral Inactivity Alcohol abuse Cigarette
  smoking
• Nutritional Low calcium intake Low vitamin D
  intake Caffeine excess
• Drugs
• Low BMD

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Case 5

• Mr. Green is a 70 year old man with a recent
  history of prednisone use to manage temporal
  arteritis. He recently sustained a fracture of
  the left wrist after falling down his stairs. A
  DEXA scan reveals a T-score of -2.6 at the hip
  and -2.0 at the lumbar spine.

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Drugs

• Glucocorticoids
• Thyroid hormone excess
• Anticonvulsants
• Heparin, warfarin
• Cyclosporin A
• Methotrexate
• GnRH analogs

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Case 7

• Sorry, no chance to help Mr. Body. He was
  found dead, in the hall, after tripping over the
  candlestick, falling down the stairs and breaking
  both hips! If only his doctor had identified his
  advanced osteoporosis.

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Osteoporosis Evaluation

• Bone mass measurement devices
• Central
• Peripheral
• Bone turnover

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Osteoporosis Diagnosis and Evaluation

• Central DXA (Dual Energy X-ray Absorptiometry)
  remains the state-of-the-art diagnostic standard
• Bone density is the most important predictor
  offracture risk

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World Health Organization (WHO) Osteoporosis
Guidelines
T - Score
WHO, Guidelines for Preclinical Evaluation and
Clinical Trials in Osteoporosis, 1998.
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Osteoporosis prevention and screening

• Increased dietary calcium Vit. D
• Exercise - weight bearing (walking, dancing,
  some exercise classes)
• Recommend a BMD test

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Calcium absorption

• Adult average 30 (20-70)
• Most efficient-Duodenum, proximal jejunum
• Largest amount- distal jejunum, ileum
• Mechanism
• Cellularactive in vesicles and bound to
  calbindin
• Paracellularpassive diffusion
• Vitamin D increased synthesis of calbindin
• Other factors
• Estrogen via increased vit D synthesis
• Glucocort via reduced paracellular diffusion
• Thyrotoxicosis acidosis via decreased vit D
  syn Alcohol direct toxic effect on enterocytes

Endocrinology Ed. L. DeGroot Saunders Co 2001,
pp.1030-1033
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Calcium bioavailability RDA for Ca 1000 mg/day

• Increased growth spurt, pregnancy
• intestinal pH 4-6 after a meal
• bile salts
• lactose milk
• Decreased Aging
• dietary high fiber impair bile reabsorption
• Phytates/ cellulose wheat bran cereal
• oxalate spinach, rhubarb, tea
• Neutral or negligible effect
• Protein, fat, magnesium, phosporus, caffeine

Heaney RP et al, Consensus Opinion, Menopause
2001884-95 Endocrinology Ed. L. DeGroot
Saunders Co 2001, pp.1030-1033
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Normal response to varying Ca intake
Endocrinology Ed. L. DeGroot Saunders Co 2001,
pp.1030-1033

• Calcium mg/day
• Dietary intake Ca 220 850 2100
• Absorbed Ca 150 340 490
• Efficiency, 68 4 23
• Renal Ca excretion 150 210 260
• Skeletal Ca uptake 420 420 420
• Skeletal Ca release 530 420 350
• Total Ca balance -110 0 70
• diet-fecal calcium correcrted for endgns fecal
  Ca
• values calculated with compartmental model

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Calcium intake- the best source of Ca is food

• Total calcium intake most important
• With higher intake absrbed dcrs but total
  amount absorbed increased
• Absorptive efficiency individualized
• Is not completely understood
• Relates to nutrition, hormonal status, physical
  activity, drugs, alcohol

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Calcium absorption

• From milk 30
• From vegetables and grains same as milk or
  slightly better
• Less than milk
• high phytic acid wheat bran cereal, soy bean
• High oxalate spinach (5 vs 30 milk)

RP Heaney J Int Med 1992231169-180 RP Heaney,
CM Weaver Am J Clin Nutr 199153745-47
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Practical Approach to Dietary Ca
Dietary intake estimation
Total dairy Ca 250 for all nondairy
Heaney RP et al, Consensus Opinion, Menopause
2001884-95
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Dietary Changes for Vegetarians
FOOD CA, mg Baked beans, 1/2 c.
cooked 154 Almonds, 1/4 cup 100 Sesame
seeds, Tbsp 33 Broccoli, fresh, cooked, 1
c 150 Bok choy, 1 c cooked/raw 150/200
Collards, fresh, cooked, 1 c 350 Turnip
greens, 1 c 200 Figs, dried, 10 figs 270
Soybean curd (tofu), 4 oz 150
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Practical Approach to Dietary Ca

• Fortified foods CA, mg
• Soy milk, 1c 100-300
• Milk, 1c 500
• Cereal, w/o milk, 1c 100-1000
• Fruit juice, 1c 300
• Breakfast bars, 1 bar 200-500

Heaney RP et al, Consensus Opinion, Menopause
2001884-95
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Practical Approach to Ca supplement

• Which is the best?
• When to take?
• With or between meal, bed time
• Once a day or divided doses?

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Calcium absorption

• Coingestion with food - 20-25 improved
  absorbtion of both food and supplented Ca
  compared to empty stomach
• Improved absorbtion Chewable, effervescent
• Divided doses but worse compliance
• Bed time - prevents PTH-mediated bone resorption
  during the fasting at night

RP Heaney et al. Am J Clin Nutr 198949372-6 RP
Heaney J Int Med 1992231169-80
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Ca supplement - absorption

• Preparation Fractional absorption
• Hydroxyapatite 0.203 0.110
• Tricalcium phosphate 0.252 0.13
• Carbonate 0.296 0.054
• Citrate 0.296 0.060
• Bone meal/oyster shell 0.333 0.113
• Bisglycinocalcium 0.440 0.104
• Chelated to amino acids

Carr CJ, Shangraw RF Am pharm 1987NS2749-57
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Ca absorption from food

• Food Fractional absorption
• Milk 0.339 0.095
• Spinach 0.012 0.007
• Low phytate soybeans 0.306 0.054
• Kale 0.405 0.101
• Mean value SD measured under standard meal
  conditions

RP Heaney J Int Med 1992231169-80
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Risk Factors for vitamin D deficiency

• Lack of sunlight exposure
• Dietary lack
• Malabsorption
• Liver disease
• Renal disease
• Anticonvulsants

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Vitamin D Considerations

• Casual exposure to sunlight provides most of
  our Vitamin D requirements
• At latitude 42º N (Chicago), ultraviolet
  exposure is inadequate for producing
  sufficient Vit D in the skin between November
  and February

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Lifestyle Approach to Vit D

• Vitamin D fortified milk (8 oz 50 IU)
• Egg yolk
• Liver of salt water fish cod liver
• Fortified cereal (Total 1 cup 40 IU)
• 15 min. of daily sun exposure provides about
  400 IU of Vit D

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Practical Approach to Vit D

• Most multivitamins (200 - 400 IU)
• Cholecalciferol (D3) 400 IU in combination
  with Calcium (OTC)
• Ergocalciferol (D2) 50,000 IU or 8,000 IU/ml
  drops (Calciferol)
• Calcifediol (25 OH D3) 20, 50 mcg (Calderol)
• Calcitriol 1,25 (OH)2 D 0.25 - 0.5 mcg
  (Rocaltrol)

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Chinese Vegetable Stir-Fry
Thickener1/4 cup water,2 Tbsp light soy sauce,
1/8 tsp pepper, 1 tsp olive oil. Tofu Mixture1
packet firm tofu, cut into 1/2 inch cubes and
drained, 3/4 cup onion, cubed, 2 large cloves
garlic, minced. Veggie Chopped1/2 bunch
broccoli, 1 small zucchini, 1 cup green/red bell
pepper, 1 cup collard, kale or bok choy, 2 large
tomatoes, 1/2 cup vegetable broth. Method In wok
add oil Tofu Mixture, stir-fry for 3-4 min.
Onion and tofu should begin to brown. Add broth
Veggie and simmer for 10 min. Add tomatoes,
cover and cook for 5 min. Add thickener and cook,
stirring for 3 min. Serve over rice or
noodles. Yield 8 servings, per serving cal 126
Kcal, carb 12 gm, protein 10 gm, fat 4 gm,
calcium 200 mg
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Busy poor hungry student

• 2 cups 1 milk
• 2 cups cereal Total
• Mix in a bowl, stir for 30 sec
• Yield 2 serving, per serving
• calories 150, fat 8 g,
• carb 12 g, protein 8 g,
• calcium 800 mg

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