Osteoporosis is a menacing yet silent disease affecting more than a million Australians, writes Leanne Philpott

This year alone the total annual cost of bone fractures from osteoporosis and osteopenia is estimated to be $2.075 billion and as our population ages, the number of people suffering from osteoporosis and the associated healthcare costs are set to rise.

Despite the general belief that osteoporosis affects mainly women, men will account for up to 30 per cent of all fractures related to osteopenia and osteoporosis.

In line with this commonly held misconception, a couple of years ago Osteoporosis Australia carried out an attitudinal survey of 1,000 Australian men, which revealed that around 60 per cent of the men surveyed did not think they were at risk of osteoporosis.

“It’s time that men cared about their bone health. We know nearly 25 per cent of people with osteoporosis are men and that men account for almost 30 per cent of all fractures in adults over 50 years of age. It’s important that health professionals, including pharmacists, identify risk factors in men and raise the issue of their bone health,” says Osteoporosis Australia CEO, Greg Lyubomirsky.

Driving change

“Risk factors for osteoporosis are generally the same for men and women. Additional risk factors in men include low testosterone levels and treatments for prostate cancer. In addition any minimal trauma fracture in a man over 50 should be investigated, as this is generally considered to be osteoporosis unless proven otherwise.”

Recognising that men are not being adequately diagnosed or treated for osteoporosis is the first step in taking action. Brenda Davy, strategy manager – complementary medicines at Australian Self Medication Industry (ASMI) acknowledges that pharmacists are in a prime position to talk to men about the risks of osteoporosis and offer useful tips.

Key advice includes:

  • Recommending they talk to their doctor, know your risk factors and take early action
  • Ensuring they’re getting enough calcium, vitamin D and exercise – the three essential ingredients for strong bones
  • Offering general health tips such as stopping smoking, drinking moderately, maintaining a healthy weight and staying active in their daily life. Suggest they visit: http://www.osteoporosis.org.au/men

Back in 2004 the Third Community Pharmacy Agreement Research and Development Program looked at an osteoporosis prevention program in pharmacy and found that there was a very low uptake of referral and advice overall by those deemed to be at high risk.

Lyubomirsky says, “People do not take their bone health seriously enough and that is something we need to change. Osteoporosis Australia’s Medical Director Professor Peter Ebeling considers any type of broken bone occurring with minimal trauma as a very serious incident and we know the major impact these breaks can have on people’s lives and their ability to live from day to day.
“Fractures can result in pain, surgery, hospital stays and disrupt work, driving, shopping and caring for children or grandchildren. In extreme cases, these fractures can lead to premature death or an inability to continue living in your own home. This is an important message pharmacy can convey effectively – early investigation can prevent serious fractures.”

Prevention over cure

Lyubomirsky stresses that prevention is the main focus, whether that’s stopping a first fracture from occurring or subsequent fractures. “Preventing fractures is not only important for the patient and their family but represents a cost-saving to the healthcare system as fractures are expensive to repair.”

Yet prevention messages should not be aimed solely at older patients; the importance of bone health should be made clear to the young and middle aged too.

Davey says, “The key message is to build strong bones while you are young, then maintain your bone strength as you get older. We achieve our Peak Bone Mass (the point at which our bones are at their highest density) in our twenties. Nearly 40 per cent of our Peak Bone Mass is acquired during puberty. Achieving a high Peak Bone Mass during these younger years can help maintain better bone health throughout life, and an adequate calcium intake is therefore essential for children and teenagers.

“Childhood and teenage years are an important time for bone growth, so diet and exercise during these years are valuable for building healthy bones. Pharmacists can help to inform parents about nutrition and lifestyle behaviours that can build stronger bones for children.

“Bone mass can keep growing throughout a person’s twenties, so pharmacists could also consider talking with young adults about the key factors that keep bones strong as they get into adulthood (calcium, vitamin D and exercise). Young women and men may be particularly susceptible to inadequate dietary intake of calcium if they’re following restrictive diets, and this can impact on bone development.”

Yet Davey points out that while calcium is important, healthy bones rely on more than just calcium intake.

“Other nutrients like vitamin D are essential for bone strength. Vitamin D is primarily produced in the body from exposure to sunlight. Insufficient vitamin D is a particular risk for people who are largely indoors, vegans, those who have dark skin or who limit their sun exposure. Due to the importance of vitamin D for utilising calcium, this nutrient is often included in calcium supplements.

“Exercise, particularly weight-bearing exercises, is important for building and retaining bone density. In children exercise helps growing bones to become as strong as possible to help minimise the impact of bone loss as we age. Exercise also maintains bone health in adulthood, helps to prevent or slow bone loss after menopause and helps to improve balance and co-ordination in the elderly to reduce the risk of falls. Exercise can also help speed rehabilitation following a fracture. Other lifestyle factors such as smoking, alcohol consumption, caffeine intake and fizzy drinks, all impact on rates of calcium loss from bones, so contribution of these factors should also be considered when discussing osteoporosis prevention strategies,” she advises.

Lyubomirsky says there’s a very strong link between managing bone health and pharmacy.  Pharmacists are in the ideal position to advise on calcium and vitamin supplementation when assisting patients recovering from fractures.

According to Osteoporosis Australia, the recommended daily calcium requirements for men and women aged 19+ years is 1,000 mg. For women over the age of 50 and men over 70 years, this recommendation increases to 1,00 mg per day.

“Dietary intake is recommended and when this is not achievable a supplement in the order for 500–600 mg per day may be required,” says Lyubomirsky.

With 30 per cent of adults having some sort of Vitamin D deficiency, pharmacists can emphasise optimal Vitamin D levels: 60-70nmol/L during summer and at least 50 nmol/L at the end of winter.

Given that sun exposure remains the main source of Vitamin D, pharmacists can ensure patients are familiar with the recommended sun exposure times and realise that these will change based on the season, location in Australia, skin type and area of the skin exposed.

“Many patients do not understand why these factors are important for their bone health and many misunderstand what supplementation is trying to achieve. It is important pharmacists explain the role of diet, sunshine and exercise in protecting bone health,” Lyubomirsky adds.

Medication management

Alongside educating patients on the positive steps they can take to help support their bone health, Lyubomirsky says pharmacists are ideally placed to ensure patients understand the positive role their medication is playing and to re-assure worried patients that thousands of people take osteoporosis medication without incident over many years.

According to NPS Medicinewise, poor adherence to osteoporosis medicines is directly linked to notably higher risk of fracture and hospitalisation, as well as increased medical costs.

It’s believed that more than 40 per cent of people taking osteoporosis medication are not taking it sufficiently to obtain the full clinical benefits, with those who take less than half of their prescribed medicines at the same risk of fracture as people who are untreated.

With poor adherence attributed to gaps in knowledge of the risk factors and concerns over the effectiveness and safety of osteoporosis medicines, pharmacists can play a viol role in educating patients on the benefits of taking the medications as advised as well as helping to alleviate concerns over side effects.

“Like other chronic diseases it is important for patients to understand they need to care for their bone health and this requires a combination of medication and these other important factors,” says Lyubomirsky.

What’s new?

New scientific advances are challenging our understanding of osteoporosis and creating new hope that there will be many game-changing osteoporosis treatments to come in the not too distant future.

“There’s a lot of positive activity in the bone space. There are new treatments on the horizon for osteoporosis but we are waiting patiently as they are a few years away at this stage,” says Lyubomirsky.

“There is also exciting research work being undertaken to advance the diagnosis of osteoporosis by looking at other facets of the micro-architecture of bone, and research into genetics is ongoing. But we have recently advanced in the area of risk assessment of fracture using online assessment tools.”

In June this year Osteoporosis Australia and the Garvan Institute of Medical Research launched Know Your Bones, an Australian-first bone health self-assessment.

The online tool is based on key findings from Garvan’s 26-year Osteoporosis Epidemiology Study, the world’s longest running osteoporosis study. The self-assessment reviews risk of fracture over five years and 10 years for users 50 years plus and provides a general report showing results and risk factors for all users (aged 18 and over) for further discussion with their doctor.

Pharmacists can recommend patients visit the website www.knowyourbones.org.au to take the test and better understand their bone health. This is particularly useful for patients with obvious risk factors for poor bone health.

Lyubomirsky says, “Pharmacy has a key role to play in these important messages and in flagging osteoporosis in those at-risk. As trusted healthcare professionals, advice from a pharmacist can help prevent fractures in Australia. So we encourage everyone to help make bone health a higher priority.”

You may also be interested in reading:

Clinical tips: osteoporosis