Bone Fracture Prevention: Medical Silence Gives Us an Opportunity

There is a disease about which the medical profession is considerably mute, yet this disease contributes to death rates that are greater than 25% in the first year after a fall. The disease is osteoporosis.

Overall, medical physicians give a low priority to osteoporosis and think their patients share this view. But patients want information and guidance. Patients are very interested in a discussion about osteoporosis, but only 44% of medical doctors actually have this discussion with those patients who are interested.

This failure of the medical profession gives doctors of chiropractic an open door. May is National Osteoporosis Awareness and Prevention Month, and a patient handout has been created for you to share with your patients.

You have permission to distribute the below information to your patients in printed or digital form (you are restricted from posting the information on the internet). This type of effort can positively enhance our cultural authority. Preface the information with the following or similar introduction:

Dear Patient,

Osteoporosis is the most common bone disease. It is often called a “silent disease” because it can progress without any symptoms until a fracture occurs. May is National Osteoporosis Awareness and Prevention Month, which provides us with an opportunity to share some information about osteoporosis and how to prevent it.

Best regards,

Dr. [Your full name]

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A Nonpharmacological Approach to Bone Fracture Prevention

Significant bone loss and decreased bone strength are signals of osteoporosis, which can increase the risk of fracture. Osteoporosis affects people of all races and ethnicities and both sexes. In the United States, an estimated 10 million people age 50 and older have osteoporosis. Most of these people are women, but about 2 million are men.²⁶

What Is the Relationship Between Osteoporosis and Bone Fractures?

It has been known for decades that low bone mineral density (BMD) is an important indicator of fracture risk.^4,7,13 However, it has become apparent that a majority of fractures occur in non-osteoporotic people.^{10-11,14,18,21,25} The National Osteoporosis Risk Assessment observed that more than two-thirds of patients with fractures did not have osteoporosis.²⁰

Overall, most fractures occur in those with BMD above the “osteoporotic” cutoff point. The majority of fractures are a result of previous fractures, falls, and advancing age (such as loss of muscle with advancing age and balance issues). Thus, the issue is not just low BMD, but also falls and advancing age.

Enhancing Skeletal Health and Improving Advancing-Age Issues

A major goal is to prevent falls and, by extension, fractures. The following recommendations are aimed at enhancing skeletal health and improving advancing age issues:

Exercise: High-quality evidence from two scientific reviews shows that cardio, resistance and weight training, and supervised balance training in adults can reduce the number of falls and fall-related fractures.^15,19

Nutrition: A research team examined the relationship between the Mediterranean diet and the risk of falling in older adults.² Participants with the highest adherence to the Mediterranean diet showed a 28% lower frequency of falling compared with those with the lowest adherence. Multiple systematic reviews have reported that higher adherence to the Mediterranean diet is associated with an 18% decreased risk of fracture.^5,8,12

Smoking: Numerous peer-reviewed studies have found a link between smoking, reduced BMD values, and an increased incidence of fractures.¹ The Surgeon General’s report causally linked tobacco smoking with several skeletal system disorders.²³

Alcohol: Excess alcohol consumption is known to be detrimental to human health. Compared to non-drinkers, a 33% higher risk of fractures was found in those who consume three drinks of alcohol per day and a 41% higher risk with four alcoholic drinks per day.⁶ Interestingly, having one or two drinks a day was associated with a lower risk of osteoporosis.

Vitamin & Mineral Supplements: A review of six quality clinical trials using vitamin D and calcium supplements demonstrated a 16% reduced risk of fracture.²⁷ In another high-quality study, the rate of injurious falls and injured fallers more than halved with strength and supervised balance training and vitamin D.²⁴

Research teams have shown that inappropriate dosages (low and high) of vitamin D and calcium do not reduce fracture or fall rates.^9,16,22,28 It also has been discovered that osteoporosis is linked to reduced magnesium levels.¹⁷ In a long-term study of over 48,000 participants, supplemental calcium and magnesium were associated with about a 40% reduction in fracture risk.³

The most effective and digestible form of vitamin D, calcium, and magnesium is cholecalciferol (vitamin D₃), calcium citrate, and magnesium oxide, respectively. Recommended dietary allowances for adults are 800-1,200 units/day of vitamin D, 1,000-1,200 mg/day of calcium, and 400 mg/day of magnesium.

Before starting any of the above recommendations, consult with your doctor. References supporting the above information are available upon request from the clinic director.

References

1. Al-Bashaireh AM, Haddad LG, Weaver M, et al. The effect of tobacco smoking on bone mass: an overview of pathophysiologic mechanisms. J Osteoporos, 2018;2018:1206235.
2. Ballesteros JM, Struijk EA, Rodríguez-Artalejo F, López-García E. Mediterranean diet and risk of falling in community-dwelling older adults. Clin Nutr, 2020;39(1):276-281.
3. Cui Y, Cai H, Gao Y, et al. Associations of dietary intakes of calcium, magnesium and soy isoflavones with osteoporotic fracture risk in postmenopausal women: a prospective study. J Nutr Sci, 2022;11:e62.
4. Cummings SR, Melton LJ. Epidemiology and outcomes of osteoporotic fractures. Lancet, 2002;359(9319):1761-1767.
5. Estruch R, Ros E, Salas-Salvadó J, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. NEJM, 2013;368:1279-1290.
6. Godos J, Giampieri F, Chisari E, et al. Alcohol consumption, bone mineral density, and risk of osteoporotic fractures: a dose-response meta-analysis. Int J Environ Res Public Health, 2022;19(3):1515.
7. Kanis JA, et al. An update on the diagnosis and assessment of osteoporosis with densitometry. Committee of Scientific Advisors, International Osteoporosis Foundation. Osteoporos Int, 2000; 11(3):192-202.
8. Kunutsor SK, Laukkanen JA, Whitehouse MR, Blom AW. Adherence to a Mediterranean-style diet and incident fractures: pooled analysis of observational evidence. Eur J Nutr, 2018;57(4):1687-1700.
9. LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int, 2022 Oct;33(10):2049-2102.
10. Lespessailles E, Cortet B, Legrand E, et al. Low- trauma fractures without osteoporosis. Osteoporos Int, 2017;28(6):1771-1778.
11. Mai HT, Tran TS, Ho-Le TP, et al. Two-thirds of all fractures are not attributable to osteoporosis and advancing age: implications for fracture prevention. J Clin Endocrinol Metab, 2019;104(8):3514-3520.
12. Malmir H, Saneei P, Larijani B, Esmaillzadeh A. Adherence to Mediterranean diet in relation to bone mineral density and risk of fracture: a systematic review and meta-analysis of observational studies. Eur J Nutr, 2018;57:2147-2160.
13. Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ, 1996;312(7041):1254-1259.
14. Nguyen ND, Eisman JA, Center JR, Nguyen TV. Risk factors for fracture in nonosteoporotic men and women. J Clin Endocrinol Metab, 2007;92(3):955-962.
15. Ponzano M, Rodrigues IB, Hosseini Z, et al. Progressive resistance training for improving health-related outcomes in people at risk of fracture: a systematic review and meta-analysis of randomized controlled trials. Phys Ther, 2021;101:pzaa221.
16. Reid IR, Bolland MJ, Grey A. Effects of vitamin D supplements on bone mineral density: a systematic review and meta-analysis. Lancet, 2014;383(9912):146-55.
17. Rondanelli M, Faliva MA, Tartara A, et al. An update on magnesium and bone health. Biometals, 2021;34(4):715-736.
18. Sanders KM, Nicholson GC, Watts JJ, et al. Half the burden of fragility fractures in the community occur in women without osteoporosis. When is fracture prevention cost-effective? Bone, 2006;38(5):694-700.
19. Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev, 2019;1:CD012424.
20. Siris ES, Miller PD, Barrett-Connor E, et al. Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment. JAMA, 2001;286(22):2815-2822.
21. Stone KL, Seeley DG, Lui LY, et al; Osteoporotic Fractures Research Group. BMD at multiple sites and risk of fracture of multiple types: long-term results from the Study of Osteoporotic Fractures. J Bone Miner Res, 2003;18(11):1947-1954.
22. Tobias DK, Luttmann-Gibson H, Mora S, et al. Association of body weight with response to vitamin D supplementation and metabolism. JAMA Netw Open, 2023;6(1):e2250681.
23. The Health Consequences of Smoking - 50 Years of Progress: A Report of The Surgeon General. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
24. Uusi-Rasi K, Patil R, Karinkanta S, et al. Exercise and vitamin D in fall prevention among older women: a randomized clinical trial. JAMA Intern Med, 2015;175:703-711.
25. Wainwright SA, Marshall LM, Ensrud KE, et al; Study of Osteoporotic Fractures Research Group. Hip fracture in women without osteoporosis. J Clin Endocrinol Metab, 2005;90(5):2787-2793.
26. Wright NC, et al. The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res, 2014;29(11):2520-252.
27. Yao P, Bennett D, Mafham M, et al. Vitamin D and calcium for the prevention of fracture: a systematic review and meta-analysis. JAMA Netw Open, 2019;2(12):e1917789.
28. Zhao R, Zhang M, Zhang Q. The effectiveness of combined exercise interventions for preventing postmenopausal bone loss: a systematic review and meta-analysis. J Orthop Sports Phys Ther, 2017;47(4):241-251.