Editorial
Osteoporosis: The other interventions
Osteoporosis: Las otras intervenciones
Jorge Morales Torres
Corresponding author
Hospital Aranda de la Parra. Morales Vargas Centro de Investigación, Hidalgo 320-704, León, 37000, GTO, México
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Morales Vargas Centro de Investigación, Hidalgo 320-704, León, 37000, GTO, México" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author. Tel.: +52-477-714-5559; fax: +52-477-636-7382." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Osteoporosis: Las otras intervenciones" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">There is increased life expectancy worldwide, and the impact of osteoporosis and associated fractures is notably increasing, even in Latin America.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Practically all clinicians share similar views on the diagnostic (osteodensitometry) and therapeutic (antiresorptive drugs or bone formers) interventions. There are considerable evidence-based reviews and management guidelines regarding these interventions.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–8</span></a> They define who should be treated or undergo further studies, and all urge changes to certain lifestyle habits, such as smoking or excess alcohol consumption. All these guidelines recommend an adequate intake of calcium and vitamin D, and weight-bearing exercise. However, in daily practice, too many patients under treatment for osteoporosis do not receive calcium and vitamin D supplements, and the prescription for increased physical activity goes no further than a vague instruction to “take exercise”.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The WHO working definition of osteoporosis (a T-score based on osteodensitometry below -2.59) was a valuable step towards defining the epidemiology of the disease.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> This limit has even been used to define who should be treated, which is correct, but does not take into account that many fractures occur in patients above this limit, indicating the need to define bone fragility in a different way.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Today it is agreed that those requiring treatment are: a) people with a minimal trauma fracture, particularly of the hip; b) People with an osteodensitometry-based T-score of -2.5 of the femur, spine or forearm, and c) people with low bone mass, above this limit, with risk fractures defined by FRAX identifying those at elevated absolute risk for fracture for the thresholds of each country. This defines what is currently considered “osteoporosis” and who should be treated.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> This concept is included in the management guidelines cited.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–8</span></a>Three additional diagnostic interventions can improve certainties in identifying those who should be treated: 1) A systematic search of vertebral fractures. Their high prevalence<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and the fact that they are usually asymptomatic, require lateral spinal radiographies or assessment of the vertebral fracture using an osteodensitometer.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Finding a fracture will reclassify the individual's risk. 2) A search for causes of secondary osteoporosis. These are relatively frequent; it identifies relevant disorders (such as hyperparathyroidism) that can interfere in the response to treatment.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> This search only requires a clinical history and accessible laboratory tests. 3) A screening strategy to identify people most likely to have osteoporosis. There is limited access to osteodensitometry in many regions<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and certain tactics can fine-tune the decision as to who should be studied. Some authors have proposed the FRAX, a tool to evaluate absolute risk for fracture, but which, by identifying the most vulnerable, determines “thresholds” that define the individuals who should be treated and those who require further studies.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17</span></a> There are various screening tools to decide the individuals at most risk of osteoporosis.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Of these, OsteoRisk, validated in Latin America, comprising only age and weight, identifies people with low bone mass.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> It is easy to use, shows close correlation with more complex tools such as FRAX,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> and has no cost.</p><p id="par0015" class="elsevierStylePara elsevierViewall">It is essential to administer calcium and vitamin D for every individual with a deficiency in these nutrients and those receiving therapy with drugs against osteoporosis.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–8</span></a> Adherence to this widely accepted intervention is poor in 50%-70% of individuals.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21,22</span></a> Adequate calcium intake (from 1000<span class="elsevierStyleHsp" style=""></span>mg to 1200<span class="elsevierStyleHsp" style=""></span>mg/day) is required for bone health throughout life. This should ideally be from dietary sources, which can be complemented with supplements to ensure this intake.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Controversy about possible cardiovascular consequences with calcium supplements,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> has meant that some doctors and patients avoid them. However, many studies have demonstrated that calcium supplements in appropriate doses do not increase the risk of cardiovascular disorders.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,26</span></a> It is advisable not to exceed a total daily intake of 1500<span class="elsevierStyleHsp" style=""></span>mg calcium, including diet and supplements.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Other risks such as nephrolithiasis – discretely increased – can be prevented by monitoring hypercalciuria in susceptible individuals. Dyspepsia can be alleviated by changing calcium carbonate for calcium citrate.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Appropriate protein intake (.8 to 1.5<span class="elsevierStyleHsp" style=""></span>g/Kg of body weight/day) through the diet is essential for healthy bones and muscles.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> People of advanced age who consume more than .8<span class="elsevierStyleHsp" style=""></span>g/Kg of protein per day, have greater bone density, less bone loss, and lower risk of hip fracture.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23,27</span></a> Malnutrition is common in people of advanced age in Mexico, and increases with age.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> In people suffering hip fracture, protein deficiency causes adverse outcomes and higher mortality.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Protein supplementation improves malnutrition markers such as prealbumin and IGF-I and IgM levels. This apparent structural and immune improvement could explain the reduction in unfavourable outcomes and deaths.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23,27,29,30</span></a> Elderly people are advised to take a daily 1.0 to 1.2<span class="elsevierStyleHsp" style=""></span>g/protein per kg of body weight.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Dairy products provide more calcium and protein per calorie than any other food.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> A 200<span class="elsevierStyleHsp" style=""></span>ml glass of milk, a 180<span class="elsevierStyleHsp" style=""></span>g portion of yoghurt or 30<span class="elsevierStyleHsp" style=""></span>g of hard cheese provide 250<span class="elsevierStyleHsp" style=""></span>mg of calcium. The minimum daily requirement can be met with 3 or 4 portions. A litre of milk provides around 35<span class="elsevierStyleHsp" style=""></span>g of protein. Several studies have demonstrated that dairy products have positive effects on the biochemical and hormonal markers of bone remodelling, and a synergic effect with physical activity to improve bone structure and strength.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23,31</span></a> A diet rich in dairy products can provide some protection against hip fracture.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Increasing the consumption of dairy products could be an effective health strategy to reduce the impact of fractures.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23,31,32</span></a> Given the concern that dairy products can increase lipids and affect cardiovascular risk, a report on 136,384 subjects aged from 35 to 70 from 21 countries is reassuring. The report found that consumption of dairy products was associated with a <span class="elsevierStyleItalic">lower</span> risk of mortality and major cardiovascular events.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> And there are now alternatives available for people who are lactose intolerant.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Physical activity and exercise are interventions that can favourably change the outcomes of many chronic/degenerative diseases, and it is essential that they are actively promoted worldwide.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Exercise produces modest gains in bone density; a discrete reduction in new fractures, and a clear reduction in the number of falls.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35–37</span></a> The benefits of physical activity and exercise are acknowledged by the public at risk<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> and doctors and health professionals.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39,40</span></a> However, their perception is that their interventions lack sufficient impact on the population, which they attribute to insufficient training in this field and various aspects relating to the time available for patient care. There are several guidelines for increasing physical activity and exercise with a view to improving health in general<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41,42</span></a> as well as bone and muscle health. These are specific to the practice of safe and effective exercise and include a) progressive resistance training; b) impact and weight-bearing exercises and c) balance and mobility training.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43–45</span></a> The frequency and intensity of these activities will depend on the factors of each individual: bone health, comorbidities, functional status and clinical risk factors for fall and fracture.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Diagnosis screening interventions can improve the selection of individuals to be studied with the limited resource of osteodensitometry. An active search for vertebral fractures and causes of secondary osteoporosis will enable the risk of some individuals to be reclassified. Efforts in research and clinical practice have focused on the diagnosis and pharmacological treatment of osteoporosis, but general primary prevention measures based on modifiable risk factors should be a health priority to delay the onset of bone loss and skeletal fragility. The professional societies’ tasks in this field must include spreading this notion to the health authorities, the medical community and society in general.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> These recommendations are far from sufficient for patients at high fracture risk, but there is enough evidence to conclude that nutritional and lifestyle factors can have a positive effect on muscle and bone mass and function, and are reasonably cheap and safe. Ensuring adequate intake of protein, calcium and vitamin D, in combination with an individualised exercise programme for the susceptible population, will probably help to reduce the impact of osteoporosis and fractures. To contribute to this, we must develop the skills to form working teams with nutrition, rehabilitation and physical medicine professionals.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Sources of financing</span><p id="par0035" class="elsevierStylePara elsevierViewall">None</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Sources of financing" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-05-03" "fechaAceptado" => "2019-05-23" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Torres JM. Osteoporosis: Las otras intervenciones. Reumatol Clin. 2019;15:185–187.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:47 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Morales-Torres" 1 => "S. Gutiérrez-Ureña" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00198-004-1596-3" "Revista" => array:6 [ "tituloSerie" => "The burden of osteoporosis in Latin America. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 3 | 8 |
| 2024 October | 38 | 42 | 80 |
| 2024 September | 49 | 33 | 82 |
| 2024 August | 57 | 35 | 92 |
| 2024 July | 58 | 52 | 110 |
| 2024 June | 47 | 47 | 94 |
| 2024 May | 38 | 37 | 75 |
| 2024 April | 53 | 32 | 85 |
| 2024 March | 37 | 50 | 87 |
| 2024 February | 26 | 46 | 72 |
| 2024 January | 23 | 41 | 64 |
| 2023 December | 15 | 35 | 50 |
| 2023 November | 30 | 41 | 71 |
| 2023 October | 35 | 43 | 78 |
| 2023 September | 157 | 49 | 206 |
| 2023 August | 125 | 42 | 167 |
| 2023 July | 21 | 28 | 49 |
| 2023 June | 25 | 36 | 61 |
| 2023 May | 42 | 37 | 79 |
| 2023 April | 19 | 19 | 38 |
| 2023 March | 64 | 23 | 87 |
| 2023 February | 44 | 21 | 65 |
| 2023 January | 22 | 16 | 38 |
| 2022 December | 76 | 23 | 99 |
| 2022 November | 61 | 33 | 94 |
| 2022 October | 59 | 29 | 88 |
| 2022 September | 32 | 30 | 62 |
| 2022 August | 23 | 32 | 55 |
| 2022 July | 28 | 35 | 63 |
| 2022 June | 29 | 39 | 68 |
| 2022 May | 34 | 35 | 69 |
| 2022 April | 39 | 44 | 83 |
| 2022 March | 54 | 72 | 126 |
| 2022 February | 41 | 32 | 73 |
| 2022 January | 51 | 42 | 93 |
| 2021 December | 31 | 38 | 69 |
| 2021 November | 40 | 32 | 72 |
| 2021 October | 85 | 49 | 134 |
| 2021 September | 42 | 30 | 72 |
| 2021 August | 31 | 24 | 55 |
| 2021 July | 26 | 26 | 52 |
| 2021 June | 25 | 34 | 59 |
| 2021 May | 31 | 39 | 70 |
| 2021 April | 147 | 114 | 261 |
| 2021 March | 89 | 19 | 108 |
| 2021 February | 51 | 29 | 80 |
| 2021 January | 23 | 23 | 46 |
| 2020 December | 30 | 15 | 45 |
| 2020 November | 22 | 20 | 42 |
| 2020 October | 15 | 16 | 31 |
| 2020 September | 25 | 16 | 41 |
| 2020 August | 22 | 16 | 38 |
| 2020 July | 9 | 16 | 25 |
| 2020 June | 8 | 11 | 19 |
| 2020 May | 19 | 10 | 29 |
| 2020 April | 12 | 8 | 20 |
| 2020 March | 2 | 0 | 2 |
| 2019 November | 1 | 0 | 1 |
| 2019 September | 1 | 0 | 1 |
| 2019 July | 1 | 0 | 1 |
| 2019 June | 1 | 2 | 3 |
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