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Vol. 15. Issue 4.
Pages 185-187 (July - August 2019)
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Vol. 15. Issue 4.
Pages 185-187 (July - August 2019)
DOI: 10.1016/j.reumae.2019.05.002
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Osteoporosis: The other interventions
Osteoporosis: Las otras intervenciones
Jorge Morales Torres
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Corresponding author. Tel.: +52-477-714-5559; fax: +52-477-636-7382.
Hospital Aranda de la Parra. Morales Vargas Centro de Investigación, Hidalgo 320-704, León, 37000, GTO, México
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There is increased life expectancy worldwide, and the impact of osteoporosis and associated fractures is notably increasing, even in Latin America.1,2 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.3–8 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”.

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.9 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.10 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.11 This concept is included in the management guidelines cited.3–8Three additional diagnostic interventions can improve certainties in identifying those who should be treated: 1) A systematic search of vertebral fractures. Their high prevalence12 and the fact that they are usually asymptomatic, require lateral spinal radiographies or assessment of the vertebral fracture using an osteodensitometer.13 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.14 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 regions15 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.16,17 There are various screening tools to decide the individuals at most risk of osteoporosis.18 Of these, OsteoRisk, validated in Latin America, comprising only age and weight, identifies people with low bone mass.19 It is easy to use, shows close correlation with more complex tools such as FRAX,20 and has no cost.

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.3–8 Adherence to this widely accepted intervention is poor in 50%-70% of individuals.21,22 Adequate calcium intake (from 1000mg to 1200mg/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.23 Controversy about possible cardiovascular consequences with calcium supplements,24 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.25,26 It is advisable not to exceed a total daily intake of 1500mg calcium, including diet and supplements.5 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.5

Appropriate protein intake (.8 to 1.5g/Kg of body weight/day) through the diet is essential for healthy bones and muscles.23 People of advanced age who consume more than .8g/Kg of protein per day, have greater bone density, less bone loss, and lower risk of hip fracture.23,27 Malnutrition is common in people of advanced age in Mexico, and increases with age.28 In people suffering hip fracture, protein deficiency causes adverse outcomes and higher mortality.29 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.23,27,29,30 Elderly people are advised to take a daily 1.0 to 1.2g/protein per kg of body weight.23 Dairy products provide more calcium and protein per calorie than any other food.23 A 200ml glass of milk, a 180g portion of yoghurt or 30g of hard cheese provide 250mg of calcium. The minimum daily requirement can be met with 3 or 4 portions. A litre of milk provides around 35g 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.23,31 A diet rich in dairy products can provide some protection against hip fracture.23 Increasing the consumption of dairy products could be an effective health strategy to reduce the impact of fractures.23,31,32 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 lower risk of mortality and major cardiovascular events.33 And there are now alternatives available for people who are lactose intolerant.

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.34 Exercise produces modest gains in bone density; a discrete reduction in new fractures, and a clear reduction in the number of falls.35–37 The benefits of physical activity and exercise are acknowledged by the public at risk38 and doctors and health professionals.39,40 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 general41,42 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.43–45 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.43

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.46 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.47

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Conflicts of interest

The authors have no conflicts of interest to declare

J. Morales-Torres, S. Gutiérrez-Ureña.
The burden of osteoporosis in Latin America. Osteoporos Int, 15 (2004), pp. 625-632
B.H. Albergaria, M. Chalem.
Clark Consensus statement: osteoporosis prevention and treatment in Latin America—current structure and future directions.
Arch Osteoporos, 13 (2018), pp. 90
Diagnóstico y tratamiento de osteoporosis en mujeres posmenopáusicas. Guía de evidencias y recomendaciones: Guía de práctica clínica. México, CENETEC 2018. http// Consultado el 5 Abril 2019.
D.H. Peña Ríos, F.A. Cisneros Dreinhofer, M.P. De la Peña Rodríguez, et al.
Consenso de diagnóstico y tratamiento de la osteoporosis en la mujer posmenopáusica mexicana.
Med Int Mex, 31 (2015), pp. 596-610
P.M. Camacho, S.M. Petak, N. Binkley, et al.
American Association of Clinical Endocrinologists and American College Of Endocrinology Clinical Practice Guidelines for the diagnosis and treatment of postmenopausal osteoporosis, 22 (2016), pp. 1-42
J.A. Kanis, C. Cooper, R. Rizzoli, J.Y. Reginster.
European guidance for the diagnosis and management of osteoporosis in postmenopausal women.
Osteoporos Int, 30 (2019), pp. 3-44
R. Eastell, C.J. Rosen, D.M. Black, et al.
Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Clinical Practice Guideline.
J Clin Endocrinol Metab, 104 (2019), pp. 1595-1622
J.E. Compston, M.R. McClung, D.W. Leslie.
Osteoporosis. Lancet, 393 (2019), pp. 364-376
WHO. WHO Study Group on Assessment of Fracture Risk and its Application to Screening for Postmenopausal Osteoporosis. Geneva, 1994.
A. Cranney, S.A. Jamal, J.F. sang, R.G. osse, W.D. Leslie.
Low bone mineral density and fracture burden in postmenopausal women.
CMAJ., 177 (2007), pp. 575-580
E.S. Siris, R. Adler, J. Bilezikian, et al.
The clinical diagnosis of osteoporosis: a position statement from the National Bone Health Alliance Working Group.
Osteoporos Int, 25 (2014), pp. 1439-1443
P. Clark, F. Cons-Molina, M. Deleze, et al.
The prevalence of radiographic vertebral fractures in Latin American countries: the Latin American vertebral osteoporosis study (LAVOS).
Osteoporos Int, 20 (2009), pp. 275-278
J.T. Schousboe, L.M. Lix, S.N. Morin, et al.
Prevalent vertebral fracture on bone density lateral spine (VFA) images in routine clinical practice predict incident fractures.
L. Colangelo, F. Biamonte, J. Pepe, C. Cipriani, S. Minisola.
Understanding and managing secondary osteoporosis.
Expert Rev Endocrinol Metab, 14 (2019), pp. 111-122
IOF (2012) The Latin American regional audit: epidemiology, costs & burden of osteoporosis in 2012. International Osteoporosis Foundation. ht**tps:// Consultado el 6 de Abril del 2019.
P. Clark, E. Ramírez-Pérez, A. Reyes-López.
Umbrales de intervención para la detección de casos en riesgo de osteoporosis (OP) y fracturas por fragilidad con FRAX en población mexicana para el primer nivel de salud.
Gac Med Mex, 152 (2016), pp. 22-31
P. Clark, E. Denova-Gutiérrez, C. Zerbini, et al.
FRAX-based intervention and assessment thresholds in seven Latin American countries.
Osteoporos Int, 29 (2018), pp. 707-715
S. Nayak, D.L. Edwards, A.A. Saleh, S.L. Greenspan.
Systematic review and meta-analysis of the performance of clinical risk assessment instruments for screening for osteoporosis or low bone density.
Osteoporos Int, 26 (2015), pp. 1543-1554
S.S. Sen, V.P. Rives, O.D. Messina, et al.
A risk assessment tool (OsteoRisk) for identifying Latin American women with osteoporosis.
J Gen Intern Med, 20 (2005), pp. 245-250
J. Morales-Torres, J. Morales-Vargas, C. Tinajero-Patiño.
Case finding in osteoporosis: Is there a role for OsteoRisk?.
Osteoporos Int, 28 (2017), pp. P1005
A.K. Pfister, C.A. Welch, J.T. WuLu, K.A. Hager, P.D. Saville.
An assessment of postmenopausal women's adherence to calcium with vitamin D supplements.
J Appl Res, 8 (2008), pp. 143-150
R.M. Al Adawi, Z. Jassim, I. Khanjar, M. Abdelgelil, I. Abdallah.
Assessment of Medication Adherence and Factors Contributing to Non- Adherence to Calcium and Vitamin D as Mainstay in Treatment and Prophylaxis of Osteoporosis.
J Basic Clin Pharma, 8 (2017), pp. S125-S128
R. Rizzoli.
Nutritional aspects of bone health.
Best Practice Res Clin Endocrin Metab, 28 (2014), pp. 795-808
M.J. Bolland, A. Avenell, J.A. Baron, et al.
Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis.
J.M. Paik, G.C. Curhan, Q. Sun, et al.
Calcium supplement intake and risk of cardiovascular disease in women.
Osteoporos Int., 25 (2014), pp. 2047-2056
M. Chung, A.M. Tang, Z. Fu, D.D. Wang, S.J. Newberry.
Calcium Intake and Cardiovascular Disease Risk.
Ann Intern Med, 165 (2016), pp. 856-866
R. Rizzoli, E. Biver, J.P. Bonjour, et al.
Benefits and safety of dietary protein for bone health-an expert consensus paper endorsed by the European Society for Clinical and Economical Aspects of Osteoarthritis, and Musculoskeletal Diseases and by the International Osteoporosis Foundation.
Osteoporos Int., 29 (2018), pp. 1933-1948
T. García Zenón, J.A. Villalobos Silva.
Malnutrición en el anciano Parte I: desnutrición, el viejo enemigo.
Med Int Mex, 28 (2012), pp. 57-64
V. Malafarina, J.Y. Reginster, S. Cabrerizo, et al.
Nutritional Status and Nutritional Treatment Are Related to Outcomes and Mortality in Older Adults with Hip Fracture.
Nutrients, 10 (2018), pp. E555
J. Bauer, G. Biolo, T. Cederholm, et al.
Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group.
J Am Med Assoc, 14 (2013), pp. 542-559
J.P. Bonjour, M. Kraenzlin, R. Levasseur, M. Warren, S. Whiting.
Dairy in Adulthood: From Foods to Nutrient Interactions on and Skeletal Muscle Health.
J Am Coll Nutr., 32 (2013), pp. 251-263
M. Hiligsmann, A. Neuprez, F. Buckinx, M. Locquet, J.Y. Reginster.
A scoping review of the public health impact of vitamin D-fortified dairy products for fracture prevention.
Arch Osteoporos, 12 (2017), pp. 57
M. Dehghan, A. Mente, S. Rangarajan, et al.
Association of dairy intake with cardiovascular disease and mortality in 21 countries from five continents (PURE): a prospective cohort study.
Lancet, 392 (2018), pp. 2288-2297
J.L. Durstine, B. Gordon, Z. Wang, X. Luo.
Chronic disease and the link to physical activity.
J Sport Health Sci, 2 (2013), pp. 3-11
T.E. Howe, B. Shea, L.J. Dawson, F. Downie, et al.
Exercise for preventing and treating osteoporosis in postmenopausal women.
Cochrane Database of Systematic Reviews, (2011),
W. Kemmler, L. Haberle, S. von Stengel.
Effects of exercise on fracture reduction in older adults: a systematic review and meta-analysis.
Osteoporos Int, 24 (2013), pp. 1937-1950
R. Zhao, F. Feng, X. Wang.
Exercise interventions and prevention of fall-related fractures in older people: a meta-analysis of randomized controlled trials.
Int J Epidemiol, 46 (2017), pp. 149-161
P.E. Pienaar, M. De Swardt, M. De Vries, H. Roos, G. Joubert.
Physical activity knowledge, attitudes and practices of the elderly in Bloemfontein old age homes.
SA Fam Pract, 46 (2004), pp. 17-19
D.A. Lawlor, S. Keen, R.D. Neal.
Increasing population levels of physical activity through primary care: GP's knowledge, attitudes and self-reported practice.
Family Practice, 16 (1999), pp. 250-254
O.M. Olutende, P.W. Bukhala, B. Wesonga.
Exercise Prescription: Practices of Healthcare Professionals in Hospital Setting.
Kenya. J Phys Act Res, 3 (2018), pp. 47-54
Prescripción de ejercicios con plan terapéutico en el adulto. México: Secretaría de Salud, 2013. Consultado el 6 de Abril del 2019.
U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. Washington, DC: U.S. Department of Health and Human Services; 2018.
B.R. Beck, R.M. Daly, M.A.F. Singh, D.R. Taaffe.
Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis.
J Sci Med Sport, 20 (2017), pp. 438-445
R.M. Daly, L. Giangregorio.
Exercise for osteoporotic fracture prevention and management.
Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism., 9th ed., pp. 517-525
R.M. Daly, J. Dalla Via, R.L. Duckham, S.F. Fraser, E.W. Helge.
Exercise for the prevention of osteoporosis postmenopausal women: an evidence-based guide to the optimal prescription.
Braz J Phys Ther., 23 (2019), pp. 170-180
R. Espinosa, P. Clark, E. Denova-Gutiérrez, et al.
Prevention of low bone mass to achieve high bone mineral density in Mexico Position of the Mexican Association for Bone and Mineral Metabolism.
Arch Osteoporos, 13 (2018), pp. 105
D. Agostini, S. Zeppa Donati, et al.
Muscle and Bone Health in Postmenopausal Women: Role of Protein and Vitamin D Supplementation Combined with Exercise Training.
Nutrients, (2018), pp. 10

Please cite this article as: Torres JM. Osteoporosis: Las otras intervenciones. Reumatol Clin. 2019;15:185–187.

Reumatología Clínica (English Edition)

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