Osteoporosis and prevention of fractures in the elderly.

A walk on the beach in Maui. (Dr. Noorali Bharwani)
A walk on the beach in Maui. (Dr. Noorali Bharwani)

Recently, I came across a good article on osteoporosis and prevention of fractures in the elderly written by Dr. Erika Dempsey, clinical assistant professor with the University of Calgary (MD Scope, March 7, 2019).

Osteoporosis is a condition in which there is loss of calcium and a gradual softening of the bones that make them fragile.

Osteoporosis leads to an increased incidence of fractures resulting from low impact injury. Sometimes no injury is involved in case of spontaneous fractures of vertebrae. Believe it or not, 80 per cent of all fractures in patients over the age of 50 are thought to be related to osteoporosis. Osteoporosis affects more women than men because of hormonal (estrogen) changes at menopause. This causes bone loss and softening.

There are several reasons why we should control osteoporosis. Osteoporosis is exceedingly costly, both for the patient and the health care system. Osteoporosis Canada estimates that acute care for patients with hip fractures alone will cost Alberta over $62 million in 2020. 

This does not include increased costs of care after discharge. Roughly a quarter of the patients with hip fractures will require institutional care on a long-term basis. A person with hip and spinal fracture may die from medical and/or surgical complications. One-year post-operative death for hip fracture patients is 25 to 30 per cent.

Should individuals over 50 be on vitamin D and calcium supplements?

Both calcium and physical activity are important to build and maintain strong bones. Ingesting the recommended daily amounts of calcium primarily through dietary sources and staying physically active appear to be the best approaches to limit your fracture risk.

Sometimes we forget how regular exercise builds strong bones.

We need vitamin D to absorb calcium. Vitamin D enhances absorption of calcium.

Vitamin D is necessary for building and maintaining healthy bones. That’s because calcium, the primary component of bone, can only be absorbed by your body when vitamin D is present. Your body makes vitamin D when direct sunlight converts a chemical in your skin into an active form of the vitamin.

Vitamin D isn’t found in many foods, but you can get it from fortified milk, fortified cereal, and fatty fish such as salmon, mackerel and sardines.

Dr. Dempsey suggests treatment of osteoporosis should be accompanied by vitamin D supplementation (800-2000 IU daily) and 1200 mg/day of (preferably dietary) calcium. Do not start these pills without consulting your family doctor.

If the osteoporosis begins before menopause then estrogen loss alone cannot account for the changes. Other causes of osteoporosis for men and women are: long-term use of cortisone, smoking, heavy drinking, sedentary lifestyle, low body weight and medical conditions that affect absorption, such as celiac disease. Diagnosis of osteoporosis is made by measuring bone mineral density.

The current national guidelines recommend the test for osteoporosis (measuring bone mineral density) should be done every two to three years.

How to prevent hip fractures?

All individuals over the age of 50 should consult their doctors and seek advice. General recommendations are: get enough calcium and vitamin D, do regular exercise to strengthen bones and improve balance. Do weight-bearing exercises, and do walking that helps you maintain peak bone density for more years. Avoid smoking or excessive drinking.

Walking has other advantages. “All truly great thoughts are conceived while walking,” says Friedrich Nietzsche. Let us walk and change the world!

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How much vitamin D do you need daily to prevent fractures?

A vitamin capsule. (iStockphoto/Thinkstock)
A vitamin capsule. (iStockphoto/Thinkstock)

Basking in the sun is one way to obtain vitamin D

Basking in the sun is one way to obtain vitamin D although the risk of skin cancer increases. Other sources of vitamin D are fortified dairy products, fatty fish and egg yolks.

Answer to this question appears in an article in the New England Journal of Medicine (NEJM) published in July, 2012. The authors examined the relationship between vitamin D supplementation and fracture reduction.

They looked at 11 double-blind, randomized, controlled trials of oral vitamin D supplementation (daily, weekly, or every 4 months), with or without calcium, in persons 65 years of age or older. The goal was to look for the incidence of hip and any nonspinal fractures.

The study included 31,022 persons (mean age, 76 years; 91 per cent women) with 1111 incident hip fractures and 3770 nonspinal fractures.

When they looked at a subgroup of participants by actual intake of vitamin D, they found reduction in the risk of fracture was shown only at the highest intake level (median, 800 IU daily; range, 792 to 2000), with a 30 per cent reduction in the risk of hip fracture and a 14 per cent reduction in the risk of any nonspinal fracture.

“Benefits at the highest level of vitamin D intake were fairly consistent across subgroups defined by age group, type of dwelling, baseline 25-hydroxyvitamin D level, and additional calcium intake,” says the NEJM paper.

The conclusion of the study was that high-dose vitamin D supplementation (≥800 IU daily) was somewhat favorable in the prevention of hip fracture and any nonspinal fracture in persons 65 years of age or older.

As we know, vitamin D is a nutrient that helps the body use calcium and phosphorous to build and maintain strong bones and teeth. Vitamin D is unique in that it can be synthesized by the body after exposure to ultraviolet rays from sunlight.

Too much vitamin D can cause too much calcium to be deposited in the body, which can lead to calcification of the kidney and other soft tissues including the heart, lungs and blood vessels. But it is hard to define what is too much. Some expert recommend daily intake of 1000 to 2000 IU of vitamin D to prevent certain types of cancers.

Health Canada’s recommendation for daily dietary intake of vitamin D in adults age 70 and over is 800 IU (20 mcg). This is based on the assumption that there is minimum of exposure to sunlight. The major sources of vitamin D are fortified foods. In Canada, cow’s milk and margarine must be fortified with vitamin D. The only natural sources of vitamin D in the Canadian food supply are fatty fish and egg yolks.

Many people meet at least some of their vitamin D needs through exposure to sunlight. Although there is some risk of skin cancer. But you never know how much vitamin D you are getting through sun exposure. It all depends on the season, time of day, cloud cover, smog, skin pigmentation, and sunscreen use.

Daily intake of vitamin D recommendation depends on a person’s age. Talk to your doctor or see Health Canada website for more details. But do not forget to drink your milk everyday.

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Safety of calcium supplements questioned – how much is enough?

One thing is beyond dispute – whatever the age, we all need calcium to make our teeth and bones strong. Calcium is also required to make our muscles and nerves function. Calcium is also a necessary factor for blood clotting.

Although these facts are well known, many people continue to be deficient in their calcium intake and hence in their body’s total calcium requirement. This leads to bad teeth and osteoporosis, bone fractures and its nasty complications.

On the other hand, studies have shown that too much calcium is not good for your health. But how much is enough? There is no agreement on that.

-In Britain, women over 50 are urged to consume 700 milligrams a day.
-In Scandinavia the level is set at 800 mg.
-In the United States and Canada it’s 1,200 mg.

-In Australia and New Zealand top the list with 1,300 mg.

A Swedish study published in the British Medical Journal found that women who consumed less than 700 mg of calcium a day had a higher risk of fractures than those who took in larger amounts. But an intake of more than 700 mg per day didn’t seem to provide any additional protection. The results suggest that there are no further benefits to taking more than 700 mg. of calcium every day.

Some studies have suggested that taking calcium supplements (but not calcium from food) may increase a woman’s chances of developing heart disease. Other studies have suggest that calcium may play an important role in the development of prostate cancer but evidence also shows calcium may lower the risk of colon cancer and age-related thinning of the bones.

Men are also prone to getting osteoporosis. In women, bone loss begins before menopause and is accelerated in old age. So prevention is better than cure.

One glass of milk contains 300 mg of calcium. About 175 ml of plain yogurt and 42 grams of cheese each contain about 300 mg of calcium. You can get enough calcium on a daily basis just by drinking milk and enjoying natural yogurt and cheese.

And don’t forget your vitamin D 1000 to 2000 IU per day especially in winter months. Vitamin D has an important role in preventing prostate cancer and other cancers.

A report published in the Journal of the American Geriatrics Society says vitamin D, taken in a high dose, may help prevent falls in the elderly. The study shows that nursing home residents who took a daily dose of 800 international units (IU) of vitamin D for five months were less likely to fall than those who took either lower doses or no vitamin D.

Another paper reviewed 29 observational studies and concluded that in North America, a projected 50 per cent reduction in colon and breast cancer incidence would require a universal intake of 2,000 to 3,500 IU per day of vitamin D.

A third report came out in the Archives of Internal Medicine. This review paper analyzed the results of 18 vitamin D studies says that taking vitamin D supplements may help people live longer. But it’s not yet clear exactly how vitamin D does that. But it appears to be a life extender.

Don’t be confused now. Eat a healthy balanced diet, take vitamin D and do regular exercise. Talk to your doctor to find out what is the best dose of calcium and vitamin D for you. Then sit on a recliner and enjoy a cold or hot glass of milk. Sounds like a good idea to me.

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