New bone-loss research on how to beat fractures, height loss and Dowager's humpby Nicky Pellegrino
An approaching “tsunami” of osteoporosis is likely to profoundly affect quality of life for New Zealanders. Here’s what to do about it.
Being highly active wasn’t the only reason for all those fractures. When she was 47, a surgeon told her she had the bones of a 60- or 70-year-old.
“I was pretty shocked at the time,” says Welten, now 52. “It felt like a bolt from the blue.”
She tried to strengthen her skeleton through diet, eating lots of calcium-rich sardines and dairy, but it didn’t prevent her going on to a diagnosis of the brittle-bone condition osteoporosis. After the last fracture, she was sent for an intravenous infusion of zoledronate, a bisphosphonate drug that increases bone density.
Welten isn’t certain why her bones were so weak at such a young age, although she is slight in build, had a period of illness in her twenties and her mother also suffers from osteoporosis, all of which, potentially, increased her risk. She is grateful for the medication that means she can continue to lead an active life of gardening, walking her dogs and riding her new e-bike.
“For a while, I was terrified to do anything because I didn’t want to trip over and break another bone. I do feel a lot stronger now.”
Our bones may seem solid things, but, as with any living tissue, they are in a constant state of flux. Cells called osteoclasts break down the bone’s matrix of collagen and minerals, releasing calcium into the bloodstream for reuse in other parts of the body. And another set of cells, osteoblasts, balance this out by forming new bone. The entire skeleton renews itself within eight to 10 years.
With age, things change. For the first 20 years of life, our bodies build new bone more quickly than the old bone is removed. By age 25, most of us have reached our genetic peak bone mass. Then, later in life, the process is reversed and bone is broken down more quickly than it is formed.
Osteoporosis isn’t inevitable, but a host of factors increase the likelihood of developing it, such as poor diet, a sedentary lifestyle, smoking, drinking too much alcohol, taking certain medications such as the glucocorticoids used to treat asthma, family history and being underweight.
However, the two most important factors are age and gender. Women lose bone as oestrogen levels start to dip during menopause; in men, hormonal changes take place more slowly and later. Plus, women tend to have smaller, thinner bones in the first place, putting them at higher risk. Half of all women will have a fracture between menopause and the time they die. Once we are elderly, the risk of a fracture increases steeply for both men and women.
A massive rise in hip fractures
Since more of us are living longer, there are dire warnings of an approaching “tsunami” of osteoporosis. Ian Reid doesn’t think the word “tsunami” is an exaggeration. A professor of medicine and endocrinology at the University of Auckland and a prominent figure in international bone research, he fears the growing size of our elderly population will lead to many more fractures unless we do a better job of prevention.
“When I was a young doctor, you’d have a small number of women who would get spine fractures in their fifties and sixties,” he says. “They had pain and got bent backs, but they weren’t a big issue in terms of proportion of the population.”
A massive rise in hip fractures is the biggest concern. Falling and sustaining one can be a game changer for the elderly, with 40% left unable to walk properly, many not returning to their previous level of independence and a significant number dying within a year.
“Hip fractures have a profound influence on your quality of life,” says Reid. “If you’re a 75-year-old and you break your hip, it’s quite a different deal to how you were yesterday. If you were living on your own before, you wind up in a rest home. If you were in a rest home, you wind up in hospital.”
Calcium has long been seen as the key to keeping bones strong. The prescription involves eating and drinking plenty of calcium-rich foods such as cheese, milk, yogurt, sardines, sesame seeds and almonds throughout your life, and getting enough vitamin D – produced by the body when skin is exposed to sunshine – to aid absorption. Then, the conventional wisdom says, in older age you should increase your intake of both, possibly with supplements.
A team of Reid’s colleagues at the University of Auckland decided to look at the evidence underpinning this advice. Two studies, published in the British Medical Journal in 2015, shook things up when they found that increasing calcium through diet or supplements was unlikely to improve bone health or prevent fractures in older people. Not only is a high calcium intake not a sure-fire winner, but excessive supplementation has been associated with gastrointestinal side effects and may even be detrimental to cardiovascular health.
The same team followed this up with research to show that vitamin D supplements don’t boost bone-mineral density or prevent fractures, either, except in rare cases where lack of sunlight is a factor (such as elderly people who don’t get outside much, or covered women).
So, if cheese and sunshine aren’t the answer later in life, what is? Reid believes we could be using the medications we have to better effect. He has been looking at bisphosphonates since he started working in bone mineral metabolism in the early 1980s. At that time, it was an experimental medicine used to treat the bone disorder Paget’s disease, by inhibiting the activity of osteoclasts, which are resorbing bone cells.
Reid was involved with research to prove this class of drugs could also be effective for those with osteoporosis. Since then, he has focused much of his work on zoledronate. And he has identified a problem. Among older women suffering fractures, only 20% actually meet the bone-density definition of osteoporosis.
“So, even if you had a drug that was 100% successful at preventing fractures, which of course nothing is, you would still reduce the total number by only 20%. The tsunami is being driven by the ageing of the population and you need to do better than 20% if it’s going to be worth the effort,” he says.
Taking your medicine
About a decade ago, Reid decided to do some research with older women who didn’t have osteoporosis. Instead, they were classed as having osteopenia – their bones were weakened, but not considered fragile enough to warrant drug intervention. It is likely that most women aged 65 and over fall into this category.
“It’s interesting because, in the 10 years it took us to do the study, people have gradually started treating women who don’t have osteoporosis and they’ve been doing it without any evidence it was worthwhile,” Reid says.
His study, funded by the Health Research Council, suggests those bending the rules were doing the right thing. Receiving an infusion of zoledronate every 18 months resulted in a 37% lower chance of a broken bone, and the drug also halved the risk of a vertebral fracture in which the bone compression causes part of the spine to collapse.
“I’m not campaigning that every woman aged 65 and over should have an infusion of zoledronate,” says Reid, “but that’s what our study suggests.”
There are signs the drug may have other benefits. In the same study, the number of heart attacks and cancers was reduced by a third as well, something Reid is looking into further.
Osteoporosis is often called the silent disease, since bone loss occurs gradually over a number of years without any symptoms. As Bonnie Welten says, “You can’t see it until it’s on you.” By the time you get the height loss and hunched posture, or the fractures, the skeleton is already considerably weakened. But getting people to take any drug when they are feeling perfectly healthy is a big ask. That is where zoledronate has an advantage over oral bisphosphonates. The effect of an infusion is long-lasting and currently there is research looking at whether it would be feasible to give it at five-yearly intervals.
“That may be a bridge too far, but we’ll see,” says Reid.
Even those who have had bone scans and been diagnosed can be reluctant to take medication. A large study, by the US National Osteoporosis Foundation, found that 43% of people thought the risks of these drugs outweighed the benefits. Worrying them, at least in part, are rare but alarming side effects, including atypical femoral fractures in long-term users. Why a drug designed to strengthen bones should cause breaks is unclear, but the incidence is low and, for those with a fragile skeleton, the benefits outweigh the risks. Some patients are advised to take a short “drug holiday” after five years on the oral version of the drug.
“But if people have horrendously low bone density and appalling fracture history, you don’t take them off the drugs, because the risk of them having a preventable fracture is much, much higher,” says Reid.
He isn’t advocating drugs over lifestyle, stressing that it is important to maintain a healthy body weight and eat a balanced diet. But, given that we are living so much longer, those things may not be enough to maintain a strong skeleton in our later years.
Jump to it
At Griffith University in Queensland, bone expert Belinda Beck is taking a different approach. She is interested in the power of exercise to strengthen bones and prevent falls and fractures.
Until Beck came along, most of the available evidence was that exercise delivered modest benefits, perhaps only preventing bone loss or giving just a 1% gain. “Deep in my gut, I knew exercise had more to give,” she says.
There was a catch-22 situation. Animal studies had shown that to strengthen bone, high-intensity loading was required – lifting heavy weights or jumping exercises – but that put those with brittle bones at greater risk of fracture, so researchers had been very conservative.
“All the exercise studies were reporting very vanilla kinds of results because they weren’t doing the kinds of exercise that bone needs to adapt,” says Beck.
Anecdotal evidence from a personal trainer, whose clients were seeing evidence of bone growth on their scans, encouraged Beck to go ahead with more-ambitious research. She signed up post-menopausal women who had osteoporosis or were in the osteopenia category to her Lifting Intervention For Training Muscle and Osteoporosis Rehabilitation (Liftmor) study, aiming to prove that bone-targeted, high-intensity training could be both safe and effective.
“For years I’d been wanting to do this, but hadn’t because I didn’t know whether we were putting people at risk. And, honestly, we were terrified to begin with,” admits Beck. “We did twice-weekly fully supervised exercise with these women. Over the course of the eight-month intervention, we had one injury, just a mild back strain, which resolved quite quickly. And the vast majority of these women started growing bone like crazy. Plus, we got all these functional improvements – they were getting stronger, their balance was better, they were standing straighter and their kyphosis [also known as dowager’s hump] was improving because the back muscles were stronger. Exercise has this fantastic multidimensional benefit for bone.”
By the end of the study, the women doing high-intensity resistance and impact training had increased bone-mineral density in their spines by about 3% and in their hips by 2.2%.
Beck has now opened bone clinics in Queensland and is licensing her Onero [Latin for overload] programme to physiotherapists and exercise physiologists in a bid to spread it around Australia and, ultimately, the world.
“You can’t just give this programme to people and tell them to do it at their local gym. It has to be supervised by experts who know what they’re doing,” she says.
Results from her bone clinics continue to be good. The latest data shows people getting a 4% bone-mineral density increase in the spine and a 30% improvement in back extensor muscle strength. Those clinics attract a range of people, some elderly and frail, but increasingly younger women who have gone through menopause early and are looking at a longer stretch of life with low bone mass and a greater risk of fracture.
The programme has to be highly individualised. There are fragile people who are treated with kid gloves and others pushed out of their comfort zone for maximum benefit.
“Some will say they’ve never lifted anything heavier than their handbag before, so how can we possibly expect them to lift a weight? Well, if you want to grow bone, your handbag’s not cutting it for you,” says Beck.
She is working on a Liftmor study for men that incorporates testing a device, known as a bioDensity system, touted as being a solution for building bone density. Plus, in a separate study, she is looking at whether whole-body vibration training is an effective intervention.
“Bone likes two things, heavy loads or loads that are applied fast,” she explains. “And the speed it likes things loaded is faster than we can apply physically, so that’s why there is a suggestion there may be a benefit from whole-body vibration. My feeling is it’s not going to be as good as exercise, so I’ve decided to put them head-to-head. Give me three years and I’ll answer that one for you.”
Be hard on yourself
Beck wrote the Exercise and Sports Science Australia position statement on exercise for osteoporosis, which includes a prescription for the ideal range of activities. This includes balance training such as tai chi, weight training targeting major muscle groups and impact loading such as jumping, skipping rope, hopping and bench stepping.
Team sports such as netball, volleyball and basketball are great for impact loading. Going for a walk is not so effective unless you make it harder for yourself.
“Incorporate some jumps, make sure you include hills or stairs. Or do something that’s going to load you up, such as putting on a backpack,” Beck says.
Resistance training is ideally done standing and with free weights, rather than on seated machines. “But anything that keeps you active is better than doing nothing,” says Beck. “Ideally, you will maintain as much of your mobility and functionality from the point you want to be at for the rest of your life. So, if 30 is how you want to be, then you have to be as active as you were when you were 30.”
A large part of the problem is that osteoporosis has always been thought of as an old woman’s problem and younger people really didn’t want to think about it. There is more work being put into changing that misconception.
In the UK, Camilla, Duchess of Cornwall, whose mother and grandmother suffered from the disease, has been campaigning to raise awareness of the importance of considering bone health at all ages. And in this country, Osteoporosis NZ is trying to raise funds for a major rebrand as well as a schools programme.
Executive director Christine Gill says the organisation is especially concerned about younger women whose lifestyles might be hindering them from reaching their genetic peak bone mass.
“Instead of getting two to three servings of calcium a day, they’re drinking green smoothies,” she says. “And they’re sitting around with their phones rather than running about in the backyard like we used to.”
The popularity of fad diets means some are cutting out entire food groups, to the detriment of their health. Then there is a sector of sporty young women who simply aren’t getting enough energy to fuel their high level of activity, potentially leading to low body weight and the cessation of periods (amenorrhea).
“That’s like being in menopause; it has a huge effect on their future bone health as well as their fertility,” says Gill.
Osteoporosis NZ has been working to ensure New Zealanders older than 50 who have a significant fracture are followed up with an assessment to see if they require a bone-density scan and, potentially, medication. It also plans to change the organisation’s name to Bone Health NZ, so it can better target young people. “They don’t want to be talked at in medical terms and they’re in denial,” says Gill. “We need them to realise that what they do now, in terms of building up their bones, will have an effect for the rest of their life. Kids born today may live until they’re 100, but their skeletons will not.”
The pills cause spills
Reviewing medication can limit fractures.
Some of the latest research is by Hamish Jamieson of the University of Otago, Christchurch. He used data from international research network interRAI’s assessment of New Zealanders in rest homes and found that the more of these drugs people were taking, and the higher the dose, the greater the risk of falls and hip fractures.
“People on the most medication had a 52% increased risk of hip fracture,” says Jamieson.
A lot of elderly people take these kinds of medication – some use them to manage pain or health conditions, others may have been relying on sleeping pills for years.
“However, as people get older, their metabolism slows down, so drug levels are higher in the body. It’s a gradual change that happens over 10 years. So, a medication that was once right isn’t any more.”
Typically, what happens with sleeping pills is that people are drowsy and have a fall after getting up in the night to go to the toilet. Ideally, they would take sedative medications only for a short while, to get through a difficult period, then stop. Once habituated to them, it is not a good idea to try to give up cold turkey.
“There are withdrawal effects,” says Jamieson. “Often people don’t sleep as well and they become agitated and confused. Some drugs have to be withdrawn over six to nine months.”
He suggests that older people check in with their GPs regularly and review the types and doses of drugs they are taking.
“Do they need them all, or are they causing more harm than benefit? What they needed even a year ago, they may not need now.”
This article was first published in the May 11, 2019 issue of the New Zealand Listener.
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