Let’s talk about bone health

Dr Abbie Laing

When talking about osteoporosis I find it helpful to describe it using the concept of chocolate. Healthy bone has a honeycombed appearance much like the Crunchie bar. In contrast bone that has developed osteoporosis contains larger holes with a softer middle and looks more like an Aero. This bone is weaker and vulnerable to breaking and, in some cases breaks even after mild knocks or bumps. People can be unaware that their bones are changing, there can be no symptoms at all until a break occurs. A broken wrist may well be the first warning sign of poor bone health and for people diagnosed with this, it can feel scary. Last week a patient told me that she no longer tried to change a light bulb for fear of what would happen to her bones if she fell.

People living with osteoporosis are not alone, even though they can feel it. In the UK an estimated 3.5 million people over 50 years are affected by it (1).  Women are more likely to develop it compared to men and one in two women will break a bone after the age of 50 years (1). There is a reason for this. At the time of the menopause women lose bone quickly, approximately 2% of bone density is lost each year and some lose bone faster than this (2). This is explained by dropping oestrogen levels (3) and the fastest rate of bone loss occurs in the year before and two years after the last period (2). However, osteoporosis does not need to be an inevitable consequence of female ageing and in my opinion by maximising peak bone mass in youth and minimising bone loss at the time of the menopause, osteoporosis could be prevented for many women.

Bone mass peaks at about the age of 30 years (2). The higher this peak the more protection a woman will have from the effects of bone loss at the menopause. A 10% increase of peak bone mass in children is thought to reduce the chance of breaking a bone from osteoporosis in adult life by 50% (2). I find this a remarkable statistic. There will always be a genetic blueprint to a persons’ skeleton, but our lifestyle choices can influence our peak bone mass by between 20-40% (8). As a woman enters the menopause HRT can be considered for minimising bone loss. There is lots of evidence demonstrating its bone protective effects (4,5) including at low doses (6). Even the addition of just a few years of treatment with HRT around the time of menopause, when bone loss is at its maximum, could have long-term positive effects on bone (7). This is recognised in guidance and HRT is recommended as a first line treatment option to prevent osteoporosis in menopausal women aged below 60 years, particularly in those with symptoms (9).

Lifestyle factors for everyone to consider include:

1. Eating a balanced diet containing plenty of calcium and protein. The recommended daily intake of calcium for post-menopausal women is 1000mg and for vitamin D is 1000IU (9). This can be obtained from diet alone, or supplements can be used where required.
2. Having enough exposure to sunlight for vitamin D formation. This is approximately 20-30 minutes of sunlight exposure at midday, 2-3 times a week in the summer.
3. Maintaining a body mass between 19-25 kg/m².
4. Undertaking regular varied exercise including from a young age, ideally 30 minutes on most days.
5. Avoiding smoking and excessive alcohol use. 14 Units of alcohol per week is the maximum recommended intake for both men and women. You can work out how many units there are in a drink by multiplying the ABV% by the total volume in mls and dividing this figure by 1000.

It is never too late or early to start thinking about our bones. Wherever you are in your journey positive steps can be made to take care of them and ‘Osteoporosis Awareness’ is a good reminder for us all to do this.

References:

• International Osteoporosis Foundation. Key Statistics per country. Last accessed May 2021.
• Hillard T, Abernethy K, Hamoda H, Shaw I, Everett M, Ayres J, Currie H. Management of the menopause. Sixth edition 2017. British Menopause Society.
• Baber R, Panay N, Fenton A and the IMS writing group. IMS Recommendations on women’s midlife health and menopause hormone therapy. Climacteric 2016 19,2 109-150.
• Stevenson J. NICE guideline-Menopause: diagnosis and management. Long-term benefits and risks of HRT (section 11): Osteoporosis. Post Report Health 2016 22(2) 92-94.
• Zhu L, Jiang X, Sun Y, Shu W. Effect of hormone therapy on the risk of bone fractures: a systematic review and meta-analysis of 470 Curr Osteoporos Rep (2019) 17:465–473 randomized controlled trials. Menopause. 2016;23(4):461–70 This meta-analysis documents that MHT is associated with a reduced risk of total, hip, and vertebral fractures, with a possible attenuation of this protection effect after it is stopped or when it is begun after 60 years.
• Abdi F, Mobedi H, Bayat F, Mosaffa N, Dolatian M, Ramezani Tehrani F. The effects of transdermal estrogen delivery on bone mineral density in postmenopausal women: a meta-analysis. Iran J Pharm Res. 2017;16(1):380–9.
• Bagger YZ, Tanko LB, Alexandersen P, et al. Two to three years of hormone replacement treatment in healthy women have long-term preventive effects on bone mass and osteoporotic fractures: the PERF study. Bone 2004; 34: 728–735.
• C Weaver, C Gordon, F Janz, h kalkwarf, J Lappe, R Lewis, M O’Karma, T Wallace, B Zemel, C Weaver, C Gordon. The National Osteoporosis Foundation’s position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations. Osteoporosis International 27, 1281-1386.
• Hamoda H, Panay N, Pedder H, Arya R, Savvas M. The British Menopause Society & Women’s Health Concern 2020 recommendations on hormone replacement therapy in menopausal women. Post Reprod Health 26(4) 181-208.