Osteoporosis is a skeletal disease characterized by low bone mass and deterioration of the microarchitecture of bone tissue.1 This loss results in an increase in bone fragility and subsequent risk for fracture.1 The vertebrae, hip and wrist are the most common fracture sites associated with the disease.
Considered a clinically silent disease, osteoporosis often is not detected until a fracture occurs, an event that alerts the provider to an underlying pathologic process.1 Data collected from 2005 to 2008 show the prevalence of osteoporosis ranged from 7% to 35% among women and 3% to 10% among men 50 and older.2 Nine percent of people older than 50 have been diagnosed with osteoporosis at the femur neck or lumbar spine, and an estimated 49% have low bone mass at either site.2 Much of the damage to the microarchitecture is irreversible, and emphasis on prevention of osteoporosis and maintenance of healthy bone should be the healthcare focus.1
A 2004 report released by the Office of the Surgeon General estimated the average cost of bone fracture care in the United States at $18 billion a year. Approximately 1.5 million fractures are caused by osteoporosis annually, leading to 2.6 million office visits, 500,000 hospitalizations and 180,000 nursing home placements.3
Risk Factors
Certain risk factors increase the likelihood of developing osteoporosis. Unmodifiable factors include advanced age, female gender, white or Asian race, personal fracture history, family fracture history and diagnosis of dementia.1
The target of prevention is a reduction in the number of modifiable risk factors. Such factors include current cigarette smoking, excessive alcohol use, low calcium intake, low body weight, low physical activity, poor health, frequent falls, long-term steroid or anticonvulsant therapy, and hypogonadism.1
Prevention of osteoporosis is the mainstay of treatment and can be affected by diet, activity, and lifestyle changes. Though treatment options are available to stabilize or even increase bone density, they are not able to completely restore bone strength and density.
People build bone mass starting in childhood and until the third decade of life.1 After this age, peak bone mass has occurred and maximization of that state throughout the lifesup is the goal. Between 30% and 40% of variability in peak bone mass is related to environmental factors largely adjustable by lifestyle (e.g., diet, exercise, smoking, alcohol habits, disease states, and medications). This statistic is encouraging for providers when motivating patients to alter their lifestyle to improve bone health.
Strategies
Lifelong adequate intake of calcium and vitamin D is an influential factor in building and maintaining strong bones. The 2013 National Osteoporosis Foundation’s Clinician Guide recommends men ages 50 to 70 should aim for a dietary calcium intake of 1,000 mg per day while women 51 and older and men 71 and older should consume 1,200 mg daily. It is estimated the average intake of dietary calcium in adults 50 and older is only 600 mg to 700 mg a day.4 To reach the goal, providers should recommend oral calcium supplements and encourage patients to select foods that are rich in calcium.
The recommendation for vitamin D intake by adults older than 50 is 800 to 1,000 international units a day.4 Supplementation with vitamin D is appropriate for patients at high risk for vitamin D deficiency, like the elderly. Supplementation should take place to keep serum vitamin D levels over 30 ng/mL.4
Regular weight-bearing and muscle strengthening activity can help improve bone density and prevent fractures and falls. Regular exercise also helps improve posture, strength, balance, and agility. It is recommended adults get 30 minutes of physical activity daily and strength training two to three times a week.3
Tobacco products have harmful effects on bone health and cessation should be encouraged and reinforced often. Although use of alcohol has no detrimental effects on bone integrity when consumed as less than three servings a day, excessive use places people at high risk for injury and falls. Those who drink in excess should be counseled about practicing moderation.4
Outreach
The public requires more information about the prevention of osteoporosis via weight, exercise and nutrition choices. Access to primary care and continuity ofcare are two important factors in gaining access to the public.
In the New York City metropolitan area, specifically the neighborhood of the South Bronx, a deficit exists in the information provided about osteoporosis prevention. The South Bronx presents multiple challenges stemming from its demographics: ethnicity, poverty, lack of access to primary care providers, high percentage of uninsured, and lack of continuous care and preventive medicine.
In the South Bronx in 2005, Latinos made up 72% of the population, making them the predominant ethnicity in the community.5 A 2007 report released by the New York City Department of Health and Mental Hygiene on healthcare access among adults in New York City showed Hisupic residents have the highest rate of uninsured at a ratio of 1:4. In addition, Hisupics have the highest proportion of being both uninsured (25%) and not having a regular healthcare provider (31%).6
Lack of a regular care provider means this community is not able to fully access the healthcare system. Adults who lack a regular provider are four times more likely to utilize the emergency department (ED) for medical services as a source of care.6 Use of the ED also varies with ethnicity. The rate is lowest among white people; black people and Hisupic people are three times more likely to utilize the ED for their regular care regardless of their insurance status.6
Often, the ED provides no opportunity for preventive medicine education. This means the South Bronx residents who seek care through the ED are missing out on establishing a relationship with a healthcare provider who has the time to counsel them about preventing disease states like osteoporosis and can track their bone density over time, altering their healthcare plan as needed.
SEE ALSO: Earn CE: Vitamin D
The National Osteoporosis Foundation recommends bone mineral density (BMD) testing should be performed on women 65 and older and men older than 70. For postmenopausal women and men ages 50 to 69, BMD testing should be based on calculated risk factors.4
It is unlikely these recommendations can be implemented in people who do not establish a healthcare provider or seek care from an ED. This can lead to delayed diagnosis and treatment of osteoporosis and an increased risk of fractures for this patient population.
Smoking is one of the modifiable risk factors for osteoporosis. In 2011, 20.6% of people in the South Bronx were smokers compared to the 14.1% average for the rest of the city.7 This heightened prevalence of smoking in the South Bronx increases the risk for developing osteoporosis and makes encouraging tobacco cessation of utmost importance.
Healthcare providers in the South Bronx and similar communities have an obligation to provide information to their patients and members of the community on ways they can prevent the development of osteoporosis. Reinforcement of the importance of routine exams and establishment of care is a critical step in creating public outreach about preventable health conditions.
References for this article can be accessed online at www.advanceweb.com/nurses. Click on Resources, then References.
Kelly A. Radtke is a family nurse practitioner at the Hospital for Special Surgery in New York City.
