With 1.2 million Australians affected by osteoporosis, pharmacists can play a key role in encouraging people to make bone health a higher priority, writes Leanne Philpott

Osteoporosis is a common, chronic and debilitating disease that can lead to premature death without proper treatment and management. Yet osteoporosis is preventable, providing people realise the risk factors and recognise the importance of bone health.

“Osteoporosis is often called the silent disease because people commonly don’t know they have it until they fracture. If people with osteoporosis don’t get diagnosed and treated following a first fracture they have an increased risk of future fractures,” explains Greg Lyubomirsky CEO, Osteoporosis Australia.

This is referred to as the ‘cascade effect’ and one of the key ways to address and prevent multiple bone fractures is to take every opportunity available to discuss bone health and the importance of taking action to reduce the impact of osteoporosis.

“People do not take their bone health seriously enough and that is something we need to change. Fractures can result in pain, surgery, and 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,” says Lyubomirsky.

Preventing poor bone health

“Pharmacy has an important role to play in bone health. The initial step is to raise the issue of bone health with appropriate patients. In particular patients who are recovering from a fracture, have a condition or take medications that impact on bone health,” says Lyubomirsky. 

“Pharmacy can also play a part in raising awareness of bone health in those people who are at-risk of osteoporosis.”

According to Osteoporosis Australia, the risk factors for osteoporosis include:

  • family history of low bone density;
  • low calcium levels;
  • inadequate vitamin D levels;
  • low hormone levels (such as low testosterone in men and cases of; early menopause for women);
  • using corticosteroids for longer than three months; and
  • chronic diseases such as rheumatoid arthritis, chronic liver or kidney disease

Lyubomirsky says, “The practical advice that pharmacy staff can give customers is that preventative measures, such as calcium, exercise and vitamin D, are essential to maintaining bone health. The best way to achieve this is by sustaining a healthy lifestyle and by avoiding lifestyle risk factors, such as smoking, alcohol and low levels of physical activity.

“There are plenty of positive steps people can take to help support their bone health, but one of the most important is ensuring adequate calcium intake. Calcium is the major building block for bones; it gives them their strength.

“However, a range of factors can result in low daily calcium intake, especially when people don’t realise the recommended levels to maintain healthy bones, or believe they consume enough calcium when actually they are falling short.

“The recommended amount of calcium is dependent on your age and gender. In adults the RDI is 1000mg and this increases to 1300mg per day for women aged over 50 and men older than 70.

“When dietary intake is not sufficient, a supplement in the range of 500-600 mg per day may be required to boost calcium levels.”

Lyubomirsky points out that many consumers are confused about adequate calcium intake, they also don’t realise that that the calcium content in food varies.

Nicole Dynan, accredited practising dietitian and founder of The Good Nutrition Company, advises, “Dairy foods (milk, yoghurt, cheese) are an excellent source of calcium. If dairy isn’t tolerated, choosing alternative milks with ‘added calcium’ is recommended.”

Other non-dairy foods high in calcium include:

  • tofu;
  • canned salmon with bones, oysters and sardines;
  • blackstrap molasses;
  • almonds;
  • brewer’s yeast;
  • broccoli and dark green leafy vegetables;
  • dried figs; and
  • fortified foods such as juices, soy milk, rice milk, and cereals.

“Vitamin D is important as it increases the amount of calcium that is absorbed in the body,” explains Lyubomirsky.

“It’s difficult to get the vitamin D that is required from diet, so the best way to achieve this is through getting enough sunshine.

“For people who don’t get adequate incidental sun exposure, a supplement may be required. Pharmacy staff can play a role in recommending patients to check their vitamin D levels with their doctor or by explaining the vitamin D doses available.

“Some factors to consider when discussing vitamin D and sunshine include the location in Australia, the season and skin type. People should be encouraged to have some limited sunshine for vitamin D most days.

“This will vary depending on the person. For example, fair people only require 5 – 10 minutes in summer (outside peak UV time), with arms exposed.  In winter slightly longer exposure is needed and around midday. Osteoporosis Australia recommends vitamin D levels should not be lower than 50 nmol/L at the end of winter (and it is understood levels are generally higher during summer). 

“For sun avoiders or people at risk of vitamin D deficiency a supplement may be required in doses of 1,000 -2,000 IU per day. For people with moderate to severe vitamin D deficiency, as determined by their doctor, higher doses may be required (for example, 3,000 – 5,000IU per day for 6-12 weeks followed by a lower maintenance dose).”

Lyubomirsky says, “Exercise helps build strong bones and muscles, but your bones respond better to ‘particular’ types of exercises. This includes weight-bearing exercise, such as jogging, running, brisk walking, tennis, basketball or volleyball.”

At least 30 minutes of moderate to high intensity weight-bearing exercises is recommended 3-5 days a week.

“Other exercises, which create an impact for your bones, are resistance training and balance training (assists in falls prevention). Muscle-strengthening or resistance exercises should be performed at least twice a week. This includes weight lifting, holding your own body weight and calf raises.”

Pharmacist Moegamat Gaffoor from Jindalee, QLD, says “Information is power. We know the more cigarettes you consume, the greater your risk of fracture in old age. We know smokers who fracture may take longer to heal than non-smokers and may experience more complications during the healing process. We also know significant bone loss has been found in older women and men who smoke.

“We have the knowledge but it is essential that we ensure our customers are also aware of the health risks that are relevant to them so they may make informed decisions.

“Providing people with the tools they need to understand their broader health position can be a catalyst for great change. In this case that might include a fact sheet on the risks associated with smoking and the factors that could lead to osteoporosis. It offers a starting point for discussion about an individual’s particular health status.”

Bone density screening

A growing role for pharmacists lies in bone density screening, a non-invasive procedure that tests bone density and strength. Aimed at people at-risk of osteoporosis or osteopenia, it provides a way of identifying poor bone health before a fracture or broken bone occurs.

Lyubomirsky says, “Currently only approximately 20% of patients who come to medical attention with a minimal trauma fracture are then investigated for osteoporosis. We are repairing tens of thousands of fractures but not actively checking the status of patient bone health following a fracture. That is something we need to change and we recommend the expansion of ‘re-fracture prevention services’ around Australia to capture patients post-fracture. Osteoporosis Australia has released state reports demonstrating the prevalence and cost of osteoporosis. The reports clearly demonstrate that approximately 70% of the overall cost of the disease relates to fracture costs. So we need active intervention to reduce fracture numbers.”

Gaffoor has previously hosted an in-pharmacy bone density clinic. He says, “This service was conducted by a registered nurse who used foot scanning to measure bone density. She interpreted the results and provided patients with supporting information to increase their understanding. The service was well received, particularly by those people who discovered they might have had significant bone loss.

“Anyone who showed signs of significant bone loss (T Scores between  -1 and -2.5 as a result of our screening) was referred to their GP.

“Generally we target bone health conversations to those patients aged 40 years plus, post-menopausal women, those people who have had a previous fracture or people concerned about osteoporosis.

“However, people who have identifiable risk factors are also targeted, particularly those patients receiving medications that are likely to decrease their bone density, for example anti-diabetic (glitazones), anti-oestrogen or anti-androgenic drugs.”

Managing osteoporosis

While we know that many patients at high-risk of bone fracture are not identified for treatment, the second gap in osteoporosis management is suboptimal adherence to osteoporosis pharmacotherapy.

Lyubomirsky tells The AJP, “We know many patients are reluctant to take osteoporosis medication as directed. It’s essential that pharmacists take the opportunity to explain to patients their medication can reduce their fracture risk over time, but must be taken as advised.

“Many new patients are simply not aware how common osteoporosis is in the community and how medication is taken without incident over many years. This information may help patients to take their bone health more seriously and receive the full benefit of their medication. It’s really important to mention that managing osteoporosis takes time and, like other chronic conditions, medications play an important role in protecting patient bone health.   

“Pharmacists are also ideally placed to advise patients on supplementation and medication.”

Gaffoor advises, “in regards to low calcium levels, it’s important first of all to identify the level of deficiency and to make sure similar conditions are excluded by recommending the customer gets a thorough check by their GP.

“Calcium in isolation may be insufficient. Vitamin D can be equally important when dealing with osteoporosis. A supportive supplement is often best as it’s not always possible or cost effective to check all the possible deficiencies that are present.

“Drawing attention to the importance of calcium and vitamin D supplementation is just as vital as addressing other risk factors, such as obesity and smoking.

“I find that more often than not patients are simply unaware that in order for bisphosphates to work optimally they need sufficient vitamin D and calcium.

“We had a patient who had been on Alendronate for at least eight months and was completely unaware that she should be on calcium and vitamin D. What was worrying about this was the patient was also lactose intolerant and therefore, unlikely to be getting enough calcium and vitamin D. She was in disbelief when I mentioned the need for supplementation and perhaps thought I was up-selling. Once I drew her attention to the consumer medicines information she was quite shocked that I had been the first to mention it but also very grateful for making her aware.”

The other nutrient consideration in regards to bone health is vitamin K. Vitamin K2, in particular, has an important role in the process of bone mineralisation. Vitamin K2 activates osteocalcin, a protein in bone cells that helps the bone cells bind calcium to the bones assisting bone formation, strength and repair.

“Recent studies have shown that high calcium consumption may increase skeletal strength, but it also increases the risk of arterial calcification,” advises Gaffoor.

“If at least 32 mcg of vitamin K2 is present in the diet, then the risks for blood-vessel calcification and heart problems are significantly lowered and the elasticity of the vessel wall is increased.

“An adequate intake of vitamin K2 has been shown to lower the risk of vascular damage because it activates matrix GLA protein (MGP), which inhibits the deposits of calcium on the walls.

“In light of the two-fold benefit of K2, several companies have included it in their bone formulations, and this should be a first line recommendation for patients for whom K2 is not contraindicated, as is the case for warfarin patients.”