How to help brittle bones

Her bones were the last things on Hilkka Hopearuoho’s mind when, in 2010, the Helsinki, Finland, native was diagnosed with breast cancer.

But because breast cancer is one of numerous conditions that can weaken the skeleton, her doctors ordered a bone density test. The test found that Hilkka, then 55, had osteoporosis in her spine, making her at increased risk for a fracture. Doctors also explained that the chemotherapy Hilkka was about to undergo would likely weaken her bones further. For now, as she underwent chemo, she was prescribed calcium and a synthetic form of vitamin D.

It wasn’t until 2016, with her cancer well behind her, that a second bone density test showed that the calcium and vitamin D hadn’t arrested her osteoporosis. Her doctor then prescribed Prolia, a biological osteoporosis drug designed to limit the breakdown of bone.

But as a researcher by profession, then 62-year-old Hilkka decided to find out more. She wanted to know what she could do to protect her bones from further degradation.

The term osteoporosis means, literally, “porous bone”. The inside of our bones resembles a honeycomb, a web of cells that break down and get replenished with new ones, just like the cells in other parts of our bodies.

But sometimes the spaces in that honeycomb-like structure become too great as the new bone cells are not replenished, making our bones more fragile—and easy to break.

It’s complicated and not an exact science figuring out who’s at danger of having fractures and who isn’t. WHO estimates that there are currently 22 million women and 5.5 million men aged 50 to 84 in the EU with osteoporosis. Among those, osteoporosis will be responsible for approximately 3.5 million fractures by the end of this year, primarily to the hip, back and forearm. It’s these fractures that are the danger to an ageing population and what the medical community is determined to reduce.

The sun hadn't yet risen that chilly morning of January 19, 2016, when Michèle Olivier of Le Havre, France, a 59-year old teacher, walked briskly to work, just as she did every day. This time, though, she tripped on the uneven sidewalk and fell. The pain in her right hip was excruciating.

Taken to the local hospital’s emergency room, x-rays of her hip showed she had a severe fracture— the kind that occurs when bone structure is impaired. Michèle was stunned to hear this news. She’d had a bone density test about two years before and was told her bones were in fine shape. How could this happen?

A closer look at her medical history, however, revealed that Michèle had other pre-existing risks for a serious break. She’d had two broken leg bones in 2014, a sign that her skeleton might be less robust, and the reason her doctor ordered a bone density test. Then in 2015, she was diagnosed with rheumatoid arthritis. That illness, and the corticosteroids she was prescribed to treat it, are known to weaken bones.

Her hip was replaced the day after the accident. Thanks to new, minimally invasive surgical techniques—and a healthy, active lifestyle prior to her accident— Michèle was able to walk again almost immediately. And she was prescribed Actonel, a drug that’s been shown to strengthen the skeleton. Michèle also follows an ambitious exercise regimen of swimming and stationary bike spinning.

But not all those with hip fractures are so lucky. “There’s a high mortality in the first 30 days particularly, but also in the first year after hip fracture,” says Dr Eugene McCloskey, professor in adult bone diseases at The University of Sheffield. The reasons aren’t well documented but he speculates that it’s due to many things: blood loss; the risk of inflammation and infection; the risk of anesthetic—and just the shock of the injury.

That’s why the focus is on preventing breaks in the first place.

There are definitely steps you can take to reduce your chance of developing osteoporosis as well as control it if you have it. You can’t change the genes you inherited; nor can you undo a history of illness such as rheumatoid arthritis, diabetes, or breast cancer— or the side effects of drugs prescribed for you. But if you smoke, stop. And you can limit the amount of alcohol you drink, eat a healthy diet, and exercise regularly.

Increasing physical activity is one of the most important lifestyle modifications that an individual can make. Exercise slows bone loss and reduces the risk of a fall. Strength training with elastic exercise bands, weight machines, or free weights can improve bone and muscle. “Weight bearing” exercise— anything that forces your body to “work against gravity” says the US National Institutes of Health, can help build bone and prevent bone loss. 

But if you already have osteoporosis or other signs of a compromised skeleton, your approach to exercise needs to begin with a consultation with a physical therapist or medical expert to ensure you don’t take on a programme that might actually cause a fracture. There are still plenty of options.

“Every time you take a step, you send a signal to your brain that something is happening and that stimulates bone turnover in a good way,” says Professor Kristina Akesson of Lund University and Skanes University Hospital in Malmo, Sweden.

Nutrition, too, plays an important role in prevention. Earlier this year a study in the Journal of Bone and Mineral Research showed that an anti-inflammatory diet (high in fruits, vegetables, whole grains and fish) was shown to preserve bone density and reduce the risk of hip fracture.

It’s also important to get enough calcium and vitamin D (which helps the body utilise calcium). A study published in the American Journal of Clinical Nutrition found that people without inherited risks for fractures benefit the most from calcium and vitamin D supplementation.

However, even if you’re diagnosed with osteoporosis through a bone density test, it doesn’t necessarily mean you’re as fragile as an eggshell. “Not everybody with a bone mineral density that puts them on the osteoporosis threshold will have a fracture,” explains Dr McCloskey.

And, when all is said and done, “What we’re really concerned about is the bad outcome of osteoporosis,” stresses Akesson. “The fracture.”

Often doctors will recommend preventive treatment if your FRAX assessment (a formula that takes into account different break factors) indicates a 20 per cent risk of any serious fracture in the next ten years, or a three per cent risk of hip fracture in that time frame. And, because breaking a bone is often a sign of a compromised skeleton, treatment might be recommended if you’ve suffered one fracture already, even if a bone density test or FRAX assessment suggests a lower risk.

The most frequently prescribed medications are bisphosphonates. “Bisphosphonates, in general, reduce your risk of fracture by 30 to 50 per cent, depending on fracture type,” says Akesson.

But there’s some controversy surrounding these medications. Although the risks are minute (between one and four in 10,000), bisphosphonates have been reported to cause jawbones to deteriorate and thigh bones to break. According to Akesson, these side effects are only likely to occur in people who have cancer or who have dental problems that involve the jaw.

More common is the side effect Michèle experienced with Actonel. After four months, she began having stomach pains so severe she had to discontinue the medication. The doctors then switched her to the biological drug, Prolia, which is working well for her.

Prolia, a biological agent, is given as an injection twice a year. “With Prolia, it looks like bone density progressively increases the longer you use it,” says Dr Eric Orwoll, professor of Medicine at Oregon Health and Science University in the US.

Teriparatide, another medication used for osteoporosis, actually builds bone, says Akesson. But it can only be used for 18 to 24 months due in part to concerns that its ability to grow bone might increase the risk for bone cancer (although there’s no human evidence of this). “It’s a very good way of getting a rapid increase in your bone density,” says Akesson.

Oestrogen-replacement therapy has also been shown to reduce the risk of fractures, in general by up to 29 per cent and of the hip by as much as 35 per cent, according to two large studies published in 2003 and 2006.

However, oestrogen has been implicated in increasing the risk of certain cancers, including breast. But now, thanks to a study published in March in The Journal of Clinical Endocrinology and Metabolism, we know which women are most likely to benefit from it, and for which women it isn’t worth the risk.

Researchers at the University at Buffalo in New York found that women with an inherited predisposition for fracture get a big boost in bone strength from oestrogen therapy. By contrast, women with no genetic risk got little benefit. Armed with this data, doctors are better able to “get the right drugs to the right person to ensure the most benefit and least harm,” says the study’s lead author, associate professor Heather Ochs-Balcom.

Another drug, raloxifene, offers some of the benefits of oestrogen without the breast cancer risk. In fact, says Dr Orwoll, “It probably protects against oestrogen-receptor-positive breast cancer.” But although it appears to offer protection against some breaks, there’s currently no evidence that it prevents hip fractures.

Hilkka was determined to be active despite her osteoporosis diagnosis

Lastly, physicians are likely to soon have a new drug called abaloparatide, in their arsenal. According to a 2016 paper in the Journal of the American Medical Association, abaloparatide, which acts in the same way as teriparitide, reduced fractures and increased bone density in women with osteoporosis more effectively than the older drug.

Abaloparatide has been approved by the US Food and Drug Administration and as of this writing, is undergoing regulatory review by the European Medicines Agency.

So osteoporosis needn't be a dire diagnosis. There are many treatment options, even if you already have a compromised skeleton, and research is ongoing. But just as important: you can take steps right now on your own to keep yourself strong, protect yourself from loss of bone mass and the risk of fracture, and stay active throughout your life.

When Hilkka decided to find out what she could do to prevent further degradation to her bones, her research led her to The Finnish Bone Society, where she took classes in topics such as bone-friendly nutrition and how to prevent falling.

She also joined an exercise group to learn what sorts of activities were safe and effective for building stronger bones. “I want to travel and to hike and live a good life as long as possible,” says Hilkka.