Prevention of osteoporotic fractures is of major importance from a public health perspective. Despite the large burden the disease exacts on individuals and society, not all patients with osteoporosis receive optimal treatment. Since only 1 in 3 patients with osteoporosis is diagnosed, clinicians need to improve their ability to identify patients who are candidates for bone mineral density (BMD) screening. Although limited data exist about the direct correlation between effective screening and fracture morbidity and mortality, it has been proved that increases in fractures are associated with increases in morbidity and mortality. Therefore, identifying patients at risk, making a timely diagnosis, implementing prevention measures (ie, calcium, vitamin D, exercise, fall precautions, etc), and initiating pharmacologic therapy for appropriate patients can all help to minimize fracture risk.
(Am J Manag Care. 2011;17:S170-S176)
Underdiagnosis and Undertreatment
Osteoporosis continues to be a growing problem in the United States, due in part to the aging population.1 Despite increased awareness of the magnitude and consequences of osteoporosis and the availability of recommendations for screening and treatment from multiple organizations, osteoporosis is still underdiagnosed and inadequately managed in the United States.2-4 Contributing factors include2-6:
It is estimated that 50% of all women and 25% of all men will have an osteoporosis-related fracture in their lifetime.1 Fragility and low impact fractures may lead to disability and impaired quality of life for patients. In addition, individuals who suffer hip and vertebral fractures may have excess mortality.7 Hip fractures have been shown to result in 10 to 20 percent excess mortality within 1 year, and also lead to a 2.5-fold increase in risk of future fractures.5 Vertebral fractures have been shown to be associated with significant complications such as back pain, height loss, and hyphosis.5 Vertebral fractures have also been shown to be associated with excess mortality (~10%).5 Given the morbidity and mortality associated with fractures, osteoporosis management needs to focus on fracture prevention, and it is imperative that attention be given to primary prevention in individuals who are at high risk for initial fracture. However, the asymptomatic nature of osteoporosis makes recognition difficult, and unfortunately, the disease often goes undiagnosed until a fragility fracture actually occurs. More concerning is that even after a fracture is evident, osteoporosis often remains undiagnosed and untreated.8-10
Potential Benefits of Screening and Early Treatment
Limited data exist that directly evaluate the correlation between effective osteoporosis screening and rates of fracture, or between effective osteoporosis screening and fracture-related morbidity or mortality under controlled conditions. However, there are abundant data that demonstrate the negative health repercussions related to untreated osteoporosis and osteoporosis-related fractures, including initial and recurrent fracture, as well as associated increases in morbidity and mortality. Therefore it may be fair to infer that effective screening for, diagnosis of, and early management of osteopenia (more appropriately termed low bone mass), osteoporosis, and related fractures may prevent potential negative health-related outcomes of the disease. The potential economic consequences of osteoporosis and osteoporosis-related fracture, estimated to be $17 billion in 2005, are anticipated to exceed $25 billion by 2025 with the aging population.5,6 Earlier identification and management of osteoporosis, and improved prevention of related fractures, may help curb the impending societal burden and costs of the disease.
The potential impact of fracture prevention is clear. Fracture prevention is now possible with the availability of a number of safe and effective medications that, combined with universal prevention measures (calcium, vitamin D, weight-bearing exercise, smoking cessation, moderation of alcohol consumption, and fall precautions), can significantly reduce the risk of fractures and related health issues. The USPSTF found convincing evidence for use of appropriate pharmacotherapy to reduce the risk of fractures in postmenopausal women who have no previous osteoporosis-related fractures, and found moderate evidence for the treatment of screening-detected osteoporosis in women 65 years or older, and in younger women whose fracture risk is equal to or greater than that of a 65-year-old woman with no additional risk factors.11
Assessing Fracture Risk
Optimal management of patients with osteoporosis and osteoporosis-related fractures cannot be achieved until these patients are appropriately identified and their risk of fracture is determined.12 Estimating fracture risk and understanding the impact of fractures can help patients, clinicians, and caregivers better understand the severity and significance of the underlying disease. It may also improve patient adherence and persistence with long-term intake of osteoporosis medication, even though the disease is largely asymptomatic and no immediate effect of nonadherence will be noticed if several doses are missed.
Clinical evaluation should be used to assess risk factors for osteoporosis and identify patients who require additional testing or preventive interventions. Many factors influence the risk of osteoporosis (see the article by Dempster in this supplement13), including those that are considered to be modifiable (eg, alcohol use, smoking, poor nutrition, low intake of dietary calcium, vitamin D deficiency) and those that are fixed (eg, age, ethnicity, family history of fractures).14 Osteoporosis is a complex disorder that depends on interactions between environmental and patient-specific factors. A positive family history for fracture is one of the most important clinical risk factors for osteoporosis and fracture risk, emphasizing the potential significance of genetics on the pathogenesis of the disease.15,16 Studies on the genetic basis of osteoporosis are ongoing and have potential implications for clinical practice, including improvements in predicting fracture risk and the prospect of identifying novel targets for the development of effective pharmacologic agents.16
Assessment of bone mineral density (BMD) is a vital component of the diagnosis, management, and monitoring of osteoporosis, as it has been shown to correlate with bone strength and is a sound predictor of future fracture risk. However, BMD should be used in combination with assessment of clinical factors to determine a patient’s risk of fracture. A number of risk factor assessment tools and algorithms have been developed to aid clinicians in estimating fracture risk, such as the Fracture Risk Assessment Tool (FRAX), a Web-based algorithm available at www.shef.ac.uk/FRAX.17-21 The purpose of FRAX is to assess patients with low bone mass to determine if they are candidates for pharmacologic therapy, based on their individualized absolute risk for a major fracture (>20%) or hip fracture (>3%).21 Risk assessment scores may be used to inform the appropriate use of both BMD testing and treatment, thereby allowing healthcare providers to use resources more judiciously.14
Bone Mineral Density
Accurate assessment of bone strength through the use of BMD testing is a critical element that guides osteoporosis diagnosis, prediction of future fractures, identification of patients in whom to initiate therapy, and treatment efficacy. Bone densitometry, as determined by central DXA performed on the spine and hip, is the current gold standard for the diagnosis of osteoporosis, and a good correlation exists between BMD and fracture risk.15 BMD is calculated by dividing the assessed mineral content of the scanned bone by its surface area, and is compared with young healthy adults of the same gender to ascertain the T-score.22 It is also matched to an age- and sex-matched population to derive the Z-score.22 T-scores and Z-scores represent the number of standard deviations (SD) of the subject’s BMD from that of the respective reference population.22
The World Health Organization (WHO) guidelines for the diagnosis of osteoporosis are universally accepted (Table 1). According to these guidelines, a T-score of greater than -1.0 is considered normal, a T-score of -2.5 or lower is considered to be indicative of osteoporosis, and a T-score between these 2 values (-1.0 and -2.5) is considered to be osteopenia (low bone density).20 This classification is only relevant to BMD assessments of the spine, hip, or forearm, and cannot be applied to BMD assessments of peripheral bones.22
Several national and international organizations have developed BMD screening guidelines, including the NOF, the USPSTF, and the AACE (Table 2).5,6,11 Recommendations within these screening guidelines may vary, potentially leading to confusion upon implementation among healthcare providers. The NOF recommends BMD testing in women 65 years and older, and for men 70 years and older, regardless of the presence of other clinical risk factors.5 BMD testing is also recommended in younger postmenopausal women and in men 50 years to 69 years of age when there is concern based on their risk factor profile, as well as in patients who have suffered a fracture.5 BMD assessment is not recommended in children or adolescents, and is not routinely indicated in healthy young men or premenopausal women.5
Risk Assessment Models
While BMD assessment is correlated with fracture risk, it may not be sufficient to identify all patients at risk for osteoporosis or related fractures.12 In addition, many patients may not have ready access to BMD measurement equipment.12 As a result, risk factor assessment scores have been developed to help clinicians identify those who would most benefit from BMD testing and those who are at high risk that would benefit from therapy.12 Risk assessment algorithms and tools are being used in a variety of ways in the identification and management of osteoporosis. More simplistic assessments are being used as prescreening tools in an attempt to identify patients who may have low bone density and might be candidates for BMD testing, while other, more comprehensive instruments are being used to confirm fracture risk and determine if treatment should be initiated.18,23
One of the most recent and well known risk assessment algorithms (FRAX) was developed by the WHO. FRAX calculates a patient’s 10-year probability of hip fracture and the 10-year probability of a major osteoporotic fracture (spine, forearm, hip, or shoulder).21 The FRAX tool allows clinicians to enter patient demographic information, select from a number of clinical risk factors, and include femoral neck BMD or T-score, all of which are used to calculate fracture risk (Table 3).21 While there are limitations to the use of FRAX—including the fact that risk of fracture increases progressively with the number of prior fractures and that the evaluation of risk factors is limited and not all inclusive—it still represents a major step forward in the estimation of fracture risk because it considers factors beyond just age, gender, and BMD.21 The use of FRAX is included in several clinical guidelines, including those developed by the NOF. Considerations for the application of FRAX in clinical practice include the following5:
While several treatment options for osteoporosis are available, prevention of the disease and associated fractures should remain a priority. There are several strategies for reducing the risk of osteoporosis and related fractures that can be utilized by the general population. These preventive strategies primarily focus on maximizing BMD, and should include ensuring an adequate intake of calcium and vitamin D and promoting lifelong participation in regular exercise (weight-bearing and muscle-building). Other overall strategies include fostering avoidance of tobacco use, identifying and treating alcoholism, and assessing and managing other fracture-related risk factors related to falls, such as impaired vision.
Prevention Early in Life
While osteoporosis and osteoporosis-related fractures are considered to be conditions of the elderly and are of particular concern later in life, it is important to remember that in addition to genetics, physical activity and appropriate nutrition during childhood and adolescence are critical determinants of bone density and mass.24 Although efforts in prevention are focused on decreasing bone resorption in the aging population, there is a clear opportunity to intervene earlier to help maximize peak bone mass development.25 Data regarding when peak bone mass is achieved vary; however, it is hypothesized that peak bone mass is attained between late adolescence and the third decade of life.24,25 Computer modeling has demonstrated that development of osteoporosis may be delayed by up to 13 years if peak bone mass of a young adult is 10% higher than the mean BMD for that age group.25 These findings demonstrate a real opportunity to prevent osteoporosis and osteoporosis-related fractures if appropriate lifestyle and dietary interventions are implemented early in life. Strategies for osteoporosis prevention early in life begin with assessing and ensuring adequate calcium and vitamin D intake and should include counseling regarding the importance of physical activity.25
It is also critical to remember that peak bone mass is achieved in young adulthood, and therefore the preventive strategies that are recommended for children are just as important to maintain in young adults. Young women may not be aware of the serious long-term impact of osteoporosis on their health and many may doubt they will develop osteoporosis as they age. Studies demonstrate that this population of young women may not achieve recommended levels of exercise and calcium intake to obtain optimal peak bone mass.26 As such, adolescence and young adulthood remains a critical window of opportunity to continue or introduce health habits that promote continual bone growth and development, and may ultimately serve to prevent osteoporosis and related fractures.
Nutrition and Dietary Considerations
Adult patients, especially postmenopausal women as well as men over the age of 50, should receive counseling on interventions to prevent osteoporosis and reduce fracture risk. From a dietary perspective, adequate intake of calcium and vitamin D should be monitored and supplemented as needed.
It is important to note that recent guidance from the Institute of Medicine (IOM) has different recommendations for vitamin D supplementation. Their suggestion is 600 IU to 800 IU of vitamin D for most healthy adults, which will achieve a serum 25-hydroxyvitamin D level of 20 ng/mL.28 Previous evidence has suggested that this level is not suitable for optimal bone health with respect to hip bone density or fracture reduction,29 but despite this evidence, the IOM reports that there is inconsistent evidence on vitamin D and fall prevention.28
In addition, consumption of a balanced diet throughout life is important for bone health. While definitive correlations related to protein intake in the elderly and fracture risk may not be confirmed, recent data suggest that adequate protein intake in the elderly may be important for reducing risk of hip fracture.30 While findings indicate that associations between protein intake and fracture risk may not be mediated through effects on BMD in elderly patients, they may be associated with the possibility that greater protein intake results in greater lower extremity muscle mass and strength, which may help prevent fracture-causing falls.30
Exercise and Lifestyle-Based Recommendations
Exercise is also an important aspect of osteoporosis prevention, and adequate physical activity is an essential element of managing bone health. Recommendations from the NOF advise that patients regularly engage in both weight-bearing and muscle-strengthening exercise to reduce the risk of falls and fractures. Regular exercise, 2 to 3 times per week, may also modestly increase bone density.5 Weight-bearing activities, in which bones and muscles work against gravity as the lower body bears the body’s weight, may include walking, jogging, and dancing, while muscle-strengthening exercise includes weight training and other resistance-type activities.5 Regardless of the type of activity, it should be something the individual enjoys doing, as consistency of exercise is key to reaping maximum benefit.
Other important lifestyle considerations for the prevention of osteoporosis include avoidance of tobacco use and excessive alcohol intake (≥3 drinks [units] per day). The use of tobacco products has been shown to be detrimental to the skeleton, most notably related to fracture of the hip, affecting BMD as well as overall health and well-being.25 Clinicians should also take care to recognize and effectively manage patients who excessively use alcohol. While moderate alcohol intake has not demonstrated a negative effect on bone, and may even be associated with a positive effect on BMD, excessive alcohol intake is detrimental to bone health and increases the risk of falling.5,25
As the majority of osteoporosis-related fractures are a result of falls, it is important to evaluate and address risk factors for falling. Risk factors for falling include, but are not limited to, a history of falls, age, muscle weakness, deficits in gait or balance, visual impairment, arthritis, the use of psychotropic medications, and dehydration.5,25 Patients frequently fail to mention or discuss falls with clinicians; therefore it is important for providers to take an accurate history of falls.25 Fall prevention strategies should be discussed with patients, including the importance of engaging in exercise and maintaining adequate vitamin D levels, as well as checking and correcting vision and hearing as appropriate. Clinicians should provide education for improving safety at home (ie, handrails, non-skid carpeting, proper lighting, etc), as this is where the majority of hip fractures occur.5
Appropriate identification and prevention are imperative to reducing the risk of osteoporosis and osteoporosis-related fractures. While understanding what needs to be done is important, knowing how to deliver optimal care is even more crucial. Patients need to be educated on the crucial role they play in minimizing their own fracture risk, including the importance of good nutrition, adequate intake of calcium and vitamin D, and regular physical activity. In addition, the development and implementation of effective strategies for routinely assessing risk for osteoporosis and fracture in patients is imperative to improving the identification of patients that need to be targeted for screening and initiation of preventive measures.
Author Affiliation: Department of Family Medicine and Community Health, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ.
Funding Source: This activity is supported by an educational donation provided by Amgen.
Author Disclosure: Dr Levine reports serving as an advisory board member for Amgen, a consultant for Bayer, and a member of the speakers’ bureau for Merck.
Authorship Information: Concept and design; drafting of manuscript; supervision; and critical revision of the manuscript for important intellectual content.
Address correspondence to: Jeffrey P. Levine, MD, MPH, Department of Family Medicine and Community Health, UMDNJ-Robert Wood Johnson Medical School, One Robert Wood Johnson Place, CN 19, New Brunswick, NJ 08903-0019. E-mail: firstname.lastname@example.org
1. National Osteoporosis Foundation. Fast facts. http://www.nof.org/node/40. Accessed February 22, 2001.
2. Kiebzak GM, Beinart GA, Perser K, et al. Undertreatment of osteoporosis in men with hip fracture. Arch Intern Med. 2002;162:2217-2222.
3. Wilkins CH, Goldfeder JS. Osteoporosis screening is unjustifiably low in older African American women. J Natl Med Assoc. 2004;96(4):461-467.
4. Morris CA, Cabral D, Cheng H, et al. Patterns of bone mineral density testing: current guidelines, testing rates, and interventions. J Gen Intern Med. 2004;19(7):783-790.
5. National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis. Washington, DC: National Osteoporosis Foundation; 2010. http://www.nof.org/sites/default/files/pdfs/NOF_ClinicianGuide2009_v7.pdf. Accessed February 22, 2011.
6. Watts NB, Bilezekian JP, Camacho PM, et al. American association of clinical endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of postmenopausal osteoporosis. Endo Pract. 2010;16(suppl 3):1-37.
7. Johnell O, Kanis JA, Oden A, et al. Mortality after osteoporotic fractures. Osteoporos Int. 2004;15(1):38-42.
8. Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE. Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int. 2004;15:767-778.
9. Andrade SE, Majumdar SR, Chan KA, et al. Low frequency of treatment of osteoporosis among postmenopausal women following fracture. Arch Intern Med. 2003;163:2052-2057.
10. Feldstein A, Elmer PJ, Orwoll E, et al. Bone mineral density measurement and treatment for osteoporosis in older individuals with fractures: a gap in evidence-based practice guideline implementation. Arch Intern Med. 2003;163:2165-2172.
11. US Preventive Services Task Force. Screening for osteoporosis: US preventive services task force recommendation statement. Ann Intern Med. 2011;154:356-364.
12. Silverman S. Selecting patients for osteoporosis therapy. J Bone Miner Res. 2009;24:765-767.
13. Dempster DW. Osteoporosis and the burden of osteoporosis-related fractures. Am J Manag Care. 2011;17:S164-S169.
14. Marini F, Brandi ML. Genetic determinants of osteoporosis: common bases to cardiovascular diseases? Int J Hypertens. Published March 25, 2010. doi: 10.4061/2010/394579.
15. US Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Office of the Surgeon General; 2004. http://www.surgeongeneral.gov/library/bonehealth/docs/full_report.pdf. Accessed on February 22, 2011.
16. Ralston SH, Uitterlinden AG. Genetics of osteoporosis. Endocr Rev. 2010;31:629-662.
17. Pluijim SM, Koes B, Laet C, et al. A simple risk score for the assessment of absolute fracture risk in general practice based on two longitudinal studies. J Bone Miner Res. 2009;24:768-774.
18. Diez-Perez A, Gonzalez-Macia J, Marin F, et al. Prediction of absolute risk of non-spinal fractures using clinical risk factors and heel quantitative ultrasound. Osteoporos Int. 2007;18:629-639.
19. Klotzbuecher CM, Ross PD, Landsman PB, et al. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res. 2000;15:721-739.
20. Robbins J, Aragaki AK, Kooperberg C, et al. Factors associated with 5-year risk of hip fracture in postmenopausal women. JAMA. 2007;298:2389-2398.
21. Kanis JA, Oden A, Johansson H, et al. FRAX and its application to clinical practice. Bone. 2009;44:732-743.
22. Kanis JA, Melton LJ III, Christiansen C, et al. The diagnosis of osteoporosis. J Bone Miner Res. 1994;9(8):1137-1141.
23. Schwartz EN, Steinberg DM. Prescreening tools to determine who needs DXA. Curr Osteoporos Rep. 2006;4:148-152.
24. Ondrak KS, Morgan DW. Physical activity, calcium intake and bone health in children and adolescents. Sports Med. 2007;37(7):587-600.
25. Grossman JM. Osteoporosis prevention. Curr Opin Rheumatol. 2011;23:203-210.
26. Kasper MJ, Peterson MGE, Allegrante JP, et al. Knowledge, beliefs, and behaviors among college women concerning the prevention of osteoporosis. Arch Fam Med. 1994;3:696-702.
27. Dawson-Hughes B, Heaney RP, Holick MF, et al. Estimates of optimal vitamin D status. Osteoporos Int. 2005;16:713-716.
28. Dawson-Hughes B, Mithal A, Bonjour JP, et al. IOF position statement: vitamin D recommendations for older adults. Osteoporos Int. 2010;21:1151-1154.
29. Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, et al. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. BMJ. 2009;339:b3692.
30. Misra D, Berry SD, Broe ke, et al. Does dietary protein reduce hip fracture risk in elders? the Framingham osteoporosis study. Osteoporos Int. 2011;22(1):345-349.