OSTOEOPOROSIS:OSTOEOPOROSIS:

You CAN Do You CAN Do Something About It!Something About It!

Lisa Z. Killinger, DCLisa Z. Killinger, DC

What do we know about OP?What do we know about OP?

• Now affects 25 million AmericansNow affects 25 million Americans

• 1/3 of women > 75 are osteoporotic*1/3 of women > 75 are osteoporotic*

• 94% of women > 75 have low bone mass94% of women > 75 have low bone mass

• 1.5 million OP-related fractures/year1.5 million OP-related fractures/year

• 700,000 vertebral fx/year700,000 vertebral fx/year*2.5 *2.5

standard deviations below the mean of a standard deviations below the mean of a young adult reference popul.young adult reference popul.

So, what can WE do?So, what can WE do?

Primary PreventionPrimary Prevention::(Prevent OP from ever happening)(Prevent OP from ever happening)

• Counsel pts about diet and physical Counsel pts about diet and physical activity at all ages, to maximize bone activity at all ages, to maximize bone density in the third decade of life and density in the third decade of life and slow the rate of bone loss after that.slow the rate of bone loss after that.– Most important factor = physical Most important factor = physical

activity!!!! activity!!!! (National Osteoporosis (National Osteoporosis

Foundation and Clinician’s Handbook of Foundation and Clinician’s Handbook of Preventive Services recommendations)Preventive Services recommendations)

Secondary PreventionSecondary Prevention: : (Early detection)(Early detection)

1. Screen all patients: OP checklist1. Screen all patients: OP checklist

2. Identify preventable risks2. Identify preventable risks

3. Get baseline bone mineral density 3. Get baseline bone mineral density test (Dexa scan of the hip is the gold test (Dexa scan of the hip is the gold standard)standard)

4. Design a prevention plan suited to 4. Design a prevention plan suited to patient’s risk factorspatient’s risk factors

BMD testing: The DEXA BMD testing: The DEXA ScanScan

• Recommended for:Recommended for:– Women with risk factorsWomen with risk factors– Women whe have had a fracture (as an Women whe have had a fracture (as an

adult)adult)– Those 65 and olderThose 65 and older– Those who are considering OP therapiesThose who are considering OP therapies– Those who have been on or are starting Those who have been on or are starting

HRTHRT

But, what does it all But, what does it all mean?!!mean?!!• Normal = BD within 1 Standard deviation Normal = BD within 1 Standard deviation

of a young healthy adultof a young healthy adult

• Low Bone Mass = BD is 1-2.5 SD below Low Bone Mass = BD is 1-2.5 SD below meanmean

• Osteoporosis = BD is >2.5 SD below Osteoporosis = BD is >2.5 SD below meanmean

• Your Z score = compares your BD to Your Z score = compares your BD to people your size, age and gender (careful)people your size, age and gender (careful)

Tertiary PreventionTertiary Prevention::(Minimizing osteoporosis’ impact and (Minimizing osteoporosis’ impact and disability/slowing progression)disability/slowing progression)

• Employ safe chiropractic adjusting Employ safe chiropractic adjusting strategiesstrategies

• Keep patients physically activeKeep patients physically active

• Monitor lifestyle and behaviors, Monitor lifestyle and behaviors, encouraging healthy choicesencouraging healthy choices

So, what do we tell our So, what do we tell our patients?patients?

• Physical activity-Weight bearing Physical activity-Weight bearing (axial loading) activities are best(axial loading) activities are best– Stair climbingStair climbing– WalkingWalking– Step aerobicsStep aerobics– JazzerciseJazzercise– 3 times a week for 15-20 minutes3 times a week for 15-20 minutes– Find a friend to be active with!Find a friend to be active with!

Pumping IronPumping Iron

• Free weights work wonders!Free weights work wonders!

• Focus on lifting weights with muscles Focus on lifting weights with muscles that tug against the spine (traps, that tug against the spine (traps, rhomboids, lats, etc)rhomboids, lats, etc)

• Start small and work up to more weightStart small and work up to more weight

• Can be done while watching TV, etc.Can be done while watching TV, etc.

• Lower body?Lower body?(Jette, Exercise-It’s never too late; AJPH)(Jette, Exercise-It’s never too late; AJPH)

Later years: Fall preventionLater years: Fall prevention

• Strengthen lower bodyStrengthen lower body

• Proprioceptive trainingProprioceptive training

• Balance/gait focusBalance/gait focus

• Home safety checklistHome safety checklist

• Modify unsafe surroundingsModify unsafe surroundings

• Assess and monitor medsAssess and monitor meds

• Regular chiropractic care-IMPORTANT!Regular chiropractic care-IMPORTANT!

Risks for hip fractures/fallsRisks for hip fractures/falls• older ageolder age

• history of fxhistory of fx

• low weightlow weight

• caffeine intake (>2 cups coffee/day)caffeine intake (>2 cups coffee/day)

• alcohol usealcohol use

• lack of walking/exerciselack of walking/exercise

• vision impairmentvision impairment• meds that have dizziness or bone loss as meds that have dizziness or bone loss as

a side effect a side effect (steroids, anticonvulsives, BP (steroids, anticonvulsives, BP meds)meds)

What about nutrition?What about nutrition?

• Recommendation =1,200-1,500 mg/day of Recommendation =1,200-1,500 mg/day of calcium (hard to get in diet) calcium (hard to get in diet)

• Vitamin D=400 - 800 IU/dayVitamin D=400 - 800 IU/day

• Other bone helpers = magnesium, boron, Vit Other bone helpers = magnesium, boron, Vit C (collagen), etc.C (collagen), etc.

• Choosing where the calcium deposits… Choosing where the calcium deposits… through physical activities through physical activities

• Watch out for calcium thieves: phosphorus, Watch out for calcium thieves: phosphorus, caffeine, alcohol, smoking, oxalic acids, etc.caffeine, alcohol, smoking, oxalic acids, etc.

But what kind of Calcium?But what kind of Calcium?

• Calcium citrate-most easily digested Calcium citrate-most easily digested (expensive) 22% usable Ca++/big pills(expensive) 22% usable Ca++/big pills

• Calcium carbonate-needs acidic gastric Calcium carbonate-needs acidic gastric envir (but cheaper!) 40% elemental or envir (but cheaper!) 40% elemental or usable Ca++/smaller pills)usable Ca++/smaller pills)

• Dairy-yogurt and lowfat milk are the gold Dairy-yogurt and lowfat milk are the gold standard calcium sources (all other standard calcium sources (all other sources are viewed in comparison to sources are viewed in comparison to these)these)

The Acid TestThe Acid Test

• Tablet should dissolve completely in Tablet should dissolve completely in a small glass of vinegar in 30 a small glass of vinegar in 30 minutes or lessminutes or less

• Beware of coated, compressed Beware of coated, compressed supplements with a shelf life of a supplements with a shelf life of a zillion years!zillion years!

• Don’t take more than 500 mg at a Don’t take more than 500 mg at a timetime

Foods for CalciumFoods for Calcium

• Yogurt/milkYogurt/milk

• Ca++ fortified JuiceCa++ fortified Juice

• Fortified cerealsFortified cereals

• Acidophillus milkAcidophillus milk

• Fortified soy milk/cheese, etcFortified soy milk/cheese, etc

• Canned sardines with bonesCanned sardines with bones

• Legumes-soak the phylates out first!Legumes-soak the phylates out first!

Calcium InterferenceCalcium Interference

• Oxalates and phylatesOxalates and phylates

• High protein diets (esp. meat-based)High protein diets (esp. meat-based)

• High sodium diets (causes kidneys to High sodium diets (causes kidneys to dump Ca++)dump Ca++)

• Wheat bran-phylateWheat bran-phylate

• High iron intakeHigh iron intake

• High phosphorus intakeHigh phosphorus intake

• Alcohol, smoking, etcAlcohol, smoking, etc

Know the medical options...Know the medical options...

• HRT, ERT, etcHRT, ERT, etc

• Alendronate Alendronate (bisphosphonate)-”Fosomax”-decreases (bisphosphonate)-”Fosomax”-decreases osteoclastic activity, arrests bone loss, osteoclastic activity, arrests bone loss, may increase bone density, reduces may increase bone density, reduces fractures (EXPENSIVE)fractures (EXPENSIVE)

• Calcitonin-oral or nasal spray (hormone): Calcitonin-oral or nasal spray (hormone): increases bone density in increases bone density in postmenopausal womenpostmenopausal women

Resources related to OP:Resources related to OP:

• Article: Management considerations for Article: Management considerations for patients with OA and OP: A chiropractic patients with OA and OP: A chiropractic perspective on what’s working. TICC perspective on what’s working. TICC 2002;9(1):48-60.2002;9(1):48-60.

• National OP foundation: 1(800) 624-National OP foundation: 1(800) 624-BONE or “www.nof.org”BONE or “www.nof.org”– info on prevention, patient pamphlets info on prevention, patient pamphlets

(free!), bone density tests, research, (free!), bone density tests, research, causes, etc.causes, etc.

Take Home Messages...Take Home Messages...

• Counsel patients on diet/physical activityCounsel patients on diet/physical activity

• Screen patients for risksScreen patients for risks

• Assess bone density before designing Assess bone density before designing interventionintervention

• Develop prevention/health promotion Develop prevention/health promotion strategies based on patient’s clinical strategies based on patient’s clinical scenarioscenario

• Offer good, sound, safe chiropractic careOffer good, sound, safe chiropractic care