Osteoporosis risk factors

Some osteoporosis risk factors (see Table 53-1) are non-modifiable, including family history, age, ethnicity, sex, and concomitant disease states. However, certain risk factors for bone loss may be minimized or prevented by early intervention, including smoking, low calcium intake, poor nutrition, inactivity, heavy alcohol use, and vitamin D deficiency. 

Review bone densitometry (i.e., central DXA) for the presence of low bone mass (i.e., T-score below -2.5 in the spine or hip for osteoporosis or T-score below -1.5 with presence of other significant osteoporosis risk factors). 

Pentti, K., Tuppurainen, M. T., Honkanen, R., Sandini, L., Kroger, H., Alhava, E., and Saarikoski, S. (2009). Hormone therapy protects from diabetes The Kuopio osteoporosis risk factor and prevention study. Eur. J. Endocrinol. 160, 979-983. 

Identify risk factors that predispose patients to osteoporosis. 

All postmenopausal women with a personal history of osteoporotic fracture and/or low bone mineral density with risk factors for osteoporosis should receive treatment for osteoporosis. 

Many of the risk factors for osteoporosis and osteoporotic fractures are predictors of low bone mineral density, such as age and ethnicity (Table 53-1). The most important risk factors for fracture are low bone mineral density, personal history of adult fracture, age, and family history of osteoporotic fracture. Other important risk factors for osteoporosis and osteoporotic fractures include menopausal status, smoking status, and low body weight. As bone mineral density decreases, the risk of fracture increases. However, the threshold at which individual patients develop a fracture varies, and other factors may play a role in fracture susceptibility. One such factor that can influence the development of fracture is falling. 

What risk factors for osteoporosis does this patient have ... 

In order to prevent certain risk factors and maximize peak bone mass, efforts must be directed toward osteoporosis prevention at an early age. 

Although most fragility fractures in women occur after age 50, certain groups of premenopausal women are at high risk for osteoporosis. The NOF recommends measuring bone mineral density in premenopausal women with risk factors in addition to sex and race, in whom treatment would be considered.1 Premenopausal women at risk for osteoporosis should follow all nonpharmacologic recommendations for exercise and adequate calcium and vitamin D intake. Currently, no good data... 

Assess patient risk factors for osteoporosis, with special attention to age, menopausal status, previous history of osteoporotic fracture, smoking status, low body weight, family history of osteoporotic fracture in first-degree relatives, and presence of secondary causes of osteoporosis. 

A number of dietary and nondietary variables have been proposed as risk factors for osteoporosis. Among dietary factors, the relation between caffeine intake and bone health has been studied extensively. Although proof that caffeine adversely affects calcium metabolism and is detrimen-... 

A patient history should be obtained to identify history of adult fractures, comorbidities, surgeries, falls, and the presence of risk factors for osteoporosis. 

Major risk factors include current smoker, low body weight (<127 lb in postmenopausal women), history of osteoporotic fracture in a first-degree relative, and personal history of low-trauma fracture as an adult. Other independent risk factors include age, high bone turnover, low body mass index (<19 kg/m2), rheumatoid arthritis, and glucocorticoid use. Decision tools may help identify individuals who should undergo BMD testing, such as the Osteoporosis Risk Assessment Instrument and the Simple Calculated Osteoporosis Risk Estimation. 

Bone mineral density should be measured in women older than 65 years and in women younger than 65 years with risk factors for osteoporosis. Repeat testing should be done as clinically indicated. 

Osteoporosis is in many ways a silent disease and osteoporotic fractures occurs mainly in women, the ratio being 1.6 females to 1 male. There are many risk factors that have been identified as increasing the development of osteoporosis and age, sex and life styles factors are some (Box 5.13)... 

The clinical problems that arise in the menopause are hot flushes, sweating, depression, decreased libido, increased risk of cardiovascular disease and osteoporosis. The latter results in increased incidence of hip, radial and vertebral fractures. Oestrogen is one factor controlling synthesis of active vitamin D and osteoporosis is in part due to a deficiency of vitamin D. Not surprisingly, to reduce these problems, administration of oestrogen is recommended (known as hormone replacement therapy or HRT). HRT reduces some of the risk factors for coronary artery disease since it reduces blood pressure and decreases the blood level of LDL-cholesterol and increases that of HDL-cholesterol. However, there is considerable debate about whether HRT increases the risk of breast or endometrial cancer. 

Chronic exposure to high levels of cadmium in food has caused bone disorders including osteoporosis and osteomalacia. Long-term ingestion of water, beans, and rice contaminated with cadmium by a Japanese population was associated with a crippling condition, Itai-Itai disease. The affliction is characterized by pain in the back and joints, osteomalacia, bone fractures, and occasional renal failure, and it most often affected women with multiple risk factors such as multiparity and poor nutrition. ... 

Bone mineral density changes Use of medroxyprogesterone may be considered among the risk factors for development of osteoporosis. The rate of bone loss is greatest in the early years of use and then subsequently approaches the normal rate of age-related fall. 

The etiologies of the autoimmune inflammatory diseases, OA, osteoporosis and crystal-deposition disease are still not known in exact details. This is in contrast with impressive molecular insights gained recently. However, there is consensus that manifestations of autoimmune diseases are precipitated by either acute and/or chronic interactions of genetic and environmental risk factors. 

Porteous, L., Nutritional and Dietary Risk Factors for Osteoporosis An Investigation of Association Between Diet and Indices of Bone Health in Young British Women Aged 25-30 Years, BSc Thesis, University of Surrey, 2001. 

Consumption of soy foods (providing 60mg/day isoflavones) for 12 weeks by postmenopausal women has been found to significantly decrease clinical risk factors for osteoporosis (short-term markers of bone turnover) including decreased urinary M-telopeptide excretion (bone resorption marker) and increased serum osteocalcin (bone formation marker). Furthermore, consumption of a soy isoflavone supplement containing 61.8 mg of isoflavones for 4 weeks by postmenopausal Japanese women significantly decreased excretion of bone resorption markers. ... 

Scheiber MD, Liu, JH, Subbiah, MTR, Rebar RW, Setchell KDR. Dietary inclusion of whole soy foods results in significant reductions in clinical risk factors for osteoporosis and cardiovascular disease in normal postmenopausal women. Menopause 8, 384-392, 2001. 

The role of estrogens in the prevention and treatment of osteoporosis has been carefully studied (see Chapter 42). The amount of bone present in the body is maximal in the young active adult in the third decade of life and begins to decline more rapidly in middle age in both men and women. The development of osteoporosis also depends on the amount of bone present at the start of this process, on vitamin D and calcium intake, and on the degree of physical activity. The risk of osteoporosis is highest in smokers who are thin, Caucasian, and inactive and have a low calcium intake and a strong family history of osteoporosis. Depression also is a major risk factor for development of osteoporosis in women. 

Gastrointestinal complaints (eg, nausea, diarrhea, vomiting, flatulence) are the most common adverse effects but rarely require discontinuation of therapy. Other potential adverse effects include headache and asthenia. Tenofbvir-associated proximal renal tubulopathy causes excessive renal phosphate and calcium losses and 1-hydroxylation defects of vitamin D, and preclinical studies in several animal species have demonstrated bone toxicity (eg, osteomalacia). Monitoring of bone mineral density should be considered with long-term use in those with risk factors for or with known osteoporosis, as well as in children. Reduction of renal function over time, as well as cases of acute renal failure and Fanconi s syndrome, have been reported in patients receiving tenofovir alone or in combination with emtricitabine. For this reason, tenofovir should be used with caution in patients at risk for renal dysfunction. Tenofovir may compete with other drugs that are actively secreted by the kidneys, such as cidofovir, acyclovir, and ganciclovir. 

While biochemical markers of bone metabolism may be sensitive to the effects of glucocorticoids in the short term, the relation between changes in these markers and intermediate measures, such as bone mineral density, and the more important clinical outcomes of fractures, is unknown. In a random stratified sample of 3222 women in the perimenopausal age range (47-56 years), including 119 women with asthma, bone mineral density was measured to determine whether asthma was a risk factor of osteoporosis and to investigate the effect of inhaled glucocorticoids (102). The subjects had predominantly adult-onset asthma, as the age at diagnosis was over 40 years. There were 26 patients who were treated mainly with... 

Diamond TH, Bucci J, Kersley JH, Aslan P, Lynch WB, Bryant C. Osteoporosis and spinal fractures in men with prostate cancer risk factors and effects of androgen deprivation therapy. J Urol 2004 172 529-32. 

Ten patients who had taken lithium for less than 1 year and 13 who had taken it for more than 3 years were assessed for alterations in bone metabolism and parathyroid function (654). There were no differences in bone mineral density, serum calcium concentration, or PTH concentration, but both groups had increased bone turnover and the longterm group had nonsignificantly higher calcium and PTH concentrations (including one hyperparathyroid patient who had an adenoma excised). The authors conclusion that lithium therapy is not a risk factor for osteoporosis needs to be tempered by the small sample size, the case of adenoma, and the blood concentration trends. 

Cohen O, Rais T, Lepkifker E, Vered I. Lithium carbonate therapy is not a risk factor for osteoporosis. Horm Metab Res 1998 30(9) 594-7. 

O Keane V, Meaney AM. A new risk factor for osteoporosis in young women with schizophrenia J Clin Psychopharmacol 2005 25 26-31. 

OSTEOPOROSIS A loss in total bone density that may be the result of a chronic calcium deficiency, early menopause, certain endocrine diseases, advanced age, endocrine diseases, certain medications, or other risk factors. 

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