Uncovering the secret of the "silent killer" osteoporosis

Osteoporosis is a common aging disease, but it is easily overlooked in the early stages of the disease and is often discovered only when serious complications occur. In domestic and foreign news reports, many celebrities have also suffered from osteoporosis and osteoporotic fractures, such as the "Iron Lady" Margaret Thatcher, Hillary Clinton, President Biden, etc.

These celebrities have good living conditions and good medical insurance, but they still cannot completely avoid osteoporosis and its complications. Therefore, it is very necessary to popularize the science of osteoporosis to the middle-aged and elderly. Through this work, we introduce the disease characteristics of osteoporosis and understand its pathogenesis, which can help our middle-aged and elderly people to detect, prevent and effectively treat osteoporosis earlier and reduce the occurrence of fracture complications.

In the disease definition of the World Health Organization (WHO), osteoporosis refers to a systemic bone disease characterized by decreased bone mass and degeneration of bone microstructure, which ultimately leads to easy fractures. According to statistics from the IOF organization, one osteoporotic fracture occurs every three minutes worldwide. Therefore, all primary causes, such as aging, postmenopausal hormone disorders, etc., or secondary causes, such as parathyroid disease, kidney disease, etc., which lead to decreased bone mass and increased risk of fractures, are all within the scope of osteoporosis. As early as 1996, statistics from the American medical community found that the number of osteoporotic fractures had exceeded that of cardiovascular disease, stroke, and breast cancer. In my country, the large base of the elderly population, differences in regional distribution of medical conditions, and high prevalence of women have made the prevention and treatment of osteoporosis in the elderly severe. According to statistics, the incidence of osteoporosis in women over 65 years old in my country is as high as 51.8%.

Data from the "China Osteoporosis White Paper 2010" show that in 2006, more than 600,000 people aged 50 and over had osteoporotic hip fractures, and it is expected that this number will exceed 5 million by 2050. Therefore, the Chinese Medical Association and the Chinese Preventive Medicine Association and other departments have put forward the call for "paying attention to bone health throughout the life cycle" to comprehensively and systematically prevent and treat osteoporosis and reduce the risk of fractures. Osteoporosis is a long-term chronic metabolic disease, which is the result of an imbalance between bone absorption and bone formation. In the human body, osteoblasts are responsible for bone formation, while osteoclasts control bone absorption. The two are like the inlet and outlet of the bone mass reservoir, maintaining the stability of the overall bone mass. Once bone absorption exceeds bone formation, that is, the water output exceeds the water intake, the bone mass will gradually decrease, and the bone microstructure will be destroyed. Normal bone tissue has abundant and strong trabeculae, just like the beams and columns of a house structure, which can withstand stress and maintain stability. When bone mass decreases, trabeculae are destroyed, these beams and columns become thinner and more brittle, the spaces in the bones increase, the bones are unable to withstand stress, and are prone to fractures.

Osteoporosis has a variety of clinical manifestations and is extremely difficult to detect in the early stages, so it is called a "silent disease." As the disease progresses, bone pain, deformity, and fractures also occur. Many elderly people experience back pain, shortened height, and hunchbacks, which are actually caused by osteoporosis. The most vulnerable parts of osteoporosis fractures are spinal compression fractures, wrist fractures, and hip fractures. These fractures not only bring great pain to patients, but also seriously affect their ability to move, and even make them unable to sit up, causing complications related to long-term bed rest in the elderly, such as aspiration pneumonia, bedsores, and venous thrombosis. Among them, the mortality rate of hip fractures within one year of occurrence exceeds 30%. It is precisely because of the high incidence of the above complications that it is called "the last fracture in life." Therefore, the most important goal of osteoporosis prevention and treatment is to reduce the risk of fractures.

There are two ways to choose from for early screening of osteoporosis. One is the 1-minute osteoporosis risk test of the International Osteoporosis Foundation (IOF). If one of the questions is answered "yes", it indicates the risk of osteoporosis and reminds you to pay attention to it in your life. In addition, people with diabetes, hyperthyroidism or hormone treatment, family history of fragility fractures, too thin, postmenopausal women, and the elderly are all at high risk of osteoporosis. The other is the Asian Osteoporosis Self-Screening Tool (OSTA). The OSTA index = (weight kg-age) x0.2. The OSTA index between -1 and -4 is medium risk, and the OSTA index less than -4 is high risk. After the initial screening, medium and high-risk groups should undergo bone density testing as soon as possible, which is an important basis for the diagnosis of osteoporosis. Dual-energy X-ray absorptiometry (DXA) is currently an internationally recognized method for examining bone density. According to the diagnostic standards recommended by the WHO, a DXA-measured bone density value that is less than 1 standard deviation lower than the peak bone mass of healthy adults of the same gender and race is considered normal (T value ≥ -1.0 standard deviation); a decrease of 1 to 2.5 standard deviations indicates low bone mass, and a decrease of more than -2.5 standard deviations can be diagnosed as osteoporosis.

The treatment of osteoporosis is divided into three parts: basic treatment, drug treatment and rehabilitation treatment. Basic treatment emphasizes adjusting lifestyle, including strengthening nutrition, balanced diet; adequate sunshine, regular exercise; quitting smoking, limiting alcohol; avoiding excessive drinking of coffee, tea, and carbonated drinks; trying to avoid or use less drugs that affect bone metabolism, including glucocorticoids, anti-epileptic drugs such as phenytoin sodium, and proton pump inhibitors. The basis of drug treatment is calcium and vitamin D. The recommended daily calcium intake for ordinary adults is 800 mg, but most of our Chinese may not be able to reach this amount; for people over 50 years old, calcium intake needs to be 1000~1200 mg per day, and dietary supplements should be used as much as possible. When the diet is insufficient, calcium supplements can be considered. Vitamin D can promote the absorption of calcium and phosphorus in the small intestine, so that the ingested calcium can enter the blood circulation and be absorbed by the bones. The advanced drug treatment is drugs that inhibit bone absorption: estrogen, bisphosphonates (zoledronic acid, alendronic acid), calcitonin, denosumab; and drugs that promote bone formation: parathyroid hormone, etc. These need to be prescribed by endocrinology, orthopedics, or even specialized osteoporosis departments according to the situation. Rehabilitation therapy is an individualized rehabilitation program for osteoporosis patients or patients who have already experienced osteoporosis fractures, including exercise therapy, physical factor therapy, rehabilitation engineering, etc. These treatments can help osteoporosis patients recover their mobility and return to daily life as soon as possible. An aging society is an established trend of population characteristics in the next few decades, and aging diseases such as osteoporosis need to be paid attention to urgently. As a "silent killer", osteoporosis has an atypical and non-prominent onset, but it gradually weakens the mobility of the elderly, causing fractures, disability, and even death. Correctly understanding the occurrence and development of osteoporosis and mastering its preventable and treatable "life gate" can provide bone health protection for middle-aged and elderly people.

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Xu Yiyang, attending physician, doctor of joint surgery, is engaged in minimally invasive hip and knee replacement and sports medicine, and is committed to clinical and basic research on bone and cartilage degeneration and repair. He serves as a member of the Restoration and Reconstruction Committee of the Fujian Rehabilitation Medicine Association. He has presided over three research projects, including the Fujian Natural Science Foundation and the Science and Technology Plan Project of the Health Commission. In the past three years, more than ten research results have been published in journals such as Experimental & Molecular Medicine, Stem Cell Research & Therapy, Cell Death Discovery, Chinese Medical Journal, and Tissue Engineering Repair and Reconstruction. He won the third place in the southern division of the 9th Golden Hand Award Orthopedic Case Evaluation Competition. He has obtained four Chinese invention patents and utility model patents.