Osteoporosis Prevention: Reducing Risk Factors

Excerpted from
What Your Doctor May Not Tell You About Osteoporosis: Help Prevent-and Even Reverse-the Disease That Burdens Millions of Women
By Felicia Cosman, M.D.

One of the most important factors in preventing osteoporosis is eliminating or reducing risk factors. This chapter describes the measures-including lifestyle choices, safety practices, and medication that can be modified to reduce the risk of osteoporosis.

Smoking

First and foremost on the list of habits offensive to the skeleton is smoking. Smoking increases the risk of hip fracture by 100 percent. For example, if the lifetime risk of hip fracture on average is 15 percent, a smoker has an average lifetime risk of 30 percent. Smoking has direct toxic effects on the cells that make bone. It also reduces estrogen levels and can result in an earlier menopause. Smokers are overall less physically active, and a sedentary lifestyle is another risk for the development of osteoporosis. Furthermore, there is evidence that quitting smoking is an important way to reduce fracture risk. Women who stop smoking can cut their hip fracture risk in half after five years. This is similar to the impact of smoking on heart disease: Again, cessation can reduce the risk substantially within five years. Preventing osteoporosis is just another of the myriad reasons why people should quit smoking.

Medications

A large group of medicines can influence bone health, reduce acquisition of peak bone mass, or increase the amount of bone loss. These include, most importantly, steroids and thyroid hormone. Sometimes these medicines are started with questionable indications. In some cases, it may not be possible to eliminate these medications; still, any reduction in the dose might help benefit bone.

Steroids (also called glucocorticoids or corticosteroids) are medications such as prednisone, cortisone, and medrol. They are usually taken by mouth as pills but also come in forms for intravenous use and in inhalers for use in patients with asthma and other chronic lung diseases. Besides lung diseases, these sometimes lifesaving medications are used for a variety of autoimmune diseases-those in which the body attacks itself because it mistakenly perceives itself as something foreign. Some of the most common conditions for which they are used besides asthma and emphysema (chronic obstructive lung disease) are rheumatoid arthritis, lupus, polymyalgia rheumatica, multiple sclerosis, inflammatory bowel disease (ulcerative colitis, Crohn's disease), and certain cancers. Unfortunately, there are often no alternative treatments for some of these illnesses. Where there are alternatives that can be tried safely, they should be. The doses of steroid should be the lowest possible to control the illness, and they should be stopped as soon as your doctor believes possible. The inhalers should be used instead of pills, when possible, since these have less of a detrimental effect on bone and other organ systems.

With thyroid hormone, there is one rare indication for use in which large doses are required: among people who have had thyroid cancer. Here the hormone is used to shut down the releasing hormone from the pituitary gland. Normally, the pituitary gland produces a small amount of the hormone to stimulate the thyroid gland. In people who have had thyroid cancer, however, it may be important to prevent any stimulation of the remaining thyroid tissue. Some patients are treated with thyroid hormone to try co suppress the growth of small benign tumors called nodules. This makes sense in some individuals, but many times the thyroid medication is started and the nodule is never reassessed. It would not be reasonable to remain on a high dose of thyroid hormone forever to prevent growth of a benign nodule. It is important to discuss the pros and cons with your doctor every six months.

Most people are actually started on thyroid medicine to replace what their own glands are not making, a condition called hypothyroidism. This may occur as a result of prior surgery or treatment of the overactive condition (Graves' disease) or be due to an autoimmune disease called Hashimoto's disease. Endocrinologists who specialize in treatment of this condition usually perform a blood test called the TSH level every three to six months to determine very carefully the dose of thyroid hormone needed to replace what the patient's thyroid is not making. This is very important for two reasons: The dose needed can vary, and overdose can cause serious complications for the skeleton and elsewhere. In bone, excessive amounts of thyroid hormone can accelerate bone loss and increase the risk of fractures.