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Focus on…
Osteoporosis
– and the importance of Vitamin D

What is Osteoporosis?

Osteoporosis is a disease that affects the bones.¹ It is often referred to as a "silent disease" because there may be no signs or symptoms until a bone breaks. In fact, a fracture following a minor fall in women over 60 may be the first indication of osteoporosis; the only other sign may be a loss in height.

Osteoporosis literally means "bone that has many holes" which makes the bone weak and more likely to break. This weakening process is increased in women after the menopause when their ovaries produce less oestrogen which helps to protect bones. ¹

Osteoporosis affects the whole skeleton but fractures most commonly occur to the wrist, hip and spine. From the age of 50 onwards, half of all women and 1 in 5 men will suffer a fracture. ² After the menopause, women who have had one fracture are at least twice as likely to suffer another. ³

One hundred and eighty thousand bones are broken in the UK every year as a result of osteoporosis – the equivalent of one fracture every three minutes. ¹ Although osteoporosis is not a life-threatening disease in itself, the after-effects of fractures can have a devastating effect on a person's quality of life. One year after a hip fracture, 40% of people are unable to walk unaided, and 80% are restricted in such routine activities as driving and shopping. ⁴ On average, a patient will make 14 additional visits to their GP in the year following their fracture. ⁵

Fracture sites in the body

Osteoporosis affects the whole of the skeleton. ¹ People with osteoporosis are at risk of fragility fractures. ¹ Osteoporotic fragility fractures occur most commonly in the spine, hips and wrist. ¹

Of an estimated 180,000 osteoporotic fragility fractures in England and Wales, 70,000 are hip fractures, 25,000 fractures of the spine, and 41,000 are wrist fractures. ¹

What are the risk factors for osteoporosis?

Everyone is at risk of developing osteoporosis as they grow older – age is one of the major risk factors for this silent disease. ¹

Osteoporosis affects both sexes but post-menopausal women are at greatest risk because bone loss is accelerated to varying degrees after the menopause due to reduced oestrogen which helps protect the bones. ¹

There are a number of other risk factors for osteoporosis including:

The role of vitamin D and calcium

Most people recognise that getting the right amount of calcium in your diet is important to help protect your bones. It is less well known that vitamin D plays a vital role in allowing the body to absorb calcium in the intestine ¹⁰ so that you can build and maintain strong healthy bones. ¹¹ A lack of vitamin D means that you are not be able to make use of calcium,¹⁰ regardless of how much you eat. Moreover, if you have an adequate intake of vitamin D, your body will adapt the way it uses calcium to help ensure that the right amount is available to help ensure healthy bones. ¹²

Calcium

The recommended daily dose of calcium is 700mg. ¹³ Although many older women's calcium intake falls with age, it is relatively easy to increase your calcium intake, e.g. by drinking a half pint of milk a day. ¹⁴ The best sources of calcium are milk, cheese and other diary products. ¹³

Vitamin D

Vitamin D, often referred to as the "sunshine" vitamin, ¹⁰ is actually a hormone ¹² and essential for healthy bones. ¹¹ The recommended daily intake of vitamin D for people over 65 years is 400 IU (10µg). ¹⁵

A 2005 survey of households and institutions in England showed that a lack of vitamin D is extremely common in people over the age of 65, especially in those people living in institutions. ¹⁶ This lack of vitamin D is increased in women in the autumn and winter. ¹⁶

Most people rely on their exposure to sunlight to satisfy their body's requirements for vitamin D. ¹⁰ People with darker skin colour require longer exposure to sunlight to make the same amount of vitamin D as those with lighter skin.11 Where you live, time of day and season of the year can dramatically affect the production of vitamin D in the skin. As you grow older, your skin's ability to use sunlight to synthesise vitamin D decreases. ¹¹ This inability to make sufficient vitamin D may be aggravated in the elderly and frail who are housebound and in those ethnic groups who cover their skin for religious reasons. ¹⁷

Unlike calcium, vitamin D is not so readily available from the diet. ¹⁰ Only a few foods (e.g. oily fish, cod liver oil and irradiated mushrooms) contain sufficient amounts of vitamin D to have a significant effect. ¹⁰ It is therefore difficult to achieve the recommended intake through diet alone, e.g. you would need to eat 9 eggs a day or a kilo of butter. ¹⁵,¹⁷

Vitamin D and/ or calcium supplementation is recommended for post-menopausal women receiving treatment for osteoporosis following a fracture unless doctors are confident that they already have an adequate calcium intake and/or are vitamin D replete. ¹

What can you do to guard against osteoporosis?

There are a number of things that everyone can do to guard against osteoporosis.

Regular exercise

There is evidence that weight-bearing exercise strengthens bones and protects against fragility fractures and osteoporosis. Children and adults should be encouraged to exercise regularly. Low-impact weight-bearing exercise such as walking or running is of most benefit. ¹,¹⁴

Ensure a healthy diet

A diet rich in calcium and vitamin D is necessary to protect against osteoporosis and strengthen bones. The UK recommended daily dose of calcium for adults is 700mg. ¹³ The recommended daily intake of vitamin D for people over 65 years is 400 IU (10μg). ¹⁵

Ensuring you have sufficient vitamin D is essential. Vitamin D plays a vital role in allowing the body to absorb calcium in the intestine so that you can build and maintain strong healthy bones. ¹⁰ Most people depend on their exposure to sunlight to satisfy their requirements for vitamin D. ¹⁰

Avoid smoking

Smoking can have an effect on hormones in men and women. Tobacco lowers oestrogen levels in women which helps guard against bone loss. In men, tobacco lowers testosterone levels which again can lead to weaker bones. Women who smoke have been shown to have a greater risk of hip fracture than non-smokers, with the risk increasing in line with cigarette consumption. ¹⁸

Avoid alcohol

Regular consumption of more than 2 to 3 units a day of alcohol may be damaging to the skeleton, even in young women and men. ¹⁴,¹⁹

What treatment options are available for osteoporosis?

In addition to lifestyle changes, sensible steps can be taken to prevent falling and hip fractures. These include simple things such as wearing flat, well fitting shoes, avoiding mats and polished floors, and ensuring that vision is not restricted through dirty or out of date prescription glasses. ²⁰

Absorbing the impact of a fall with the use of hip protectors (cotton mix pants which have a shell of made of polypropylene fitted to each side) may help to avoid fractures as well.²⁰

There are also a number of different medicines available for the treatment of post-menopausal osteoporosis. The main objective of medical treatment is to prevent further fractures.

Treatments include non-hormonal treatments such as bisphosphonates (alendronate, etidronate and risedronate). These work by slowing down the cells that break down bone, allowing bone density to increase. ¹,¹⁴

Other treatments include selective estrogen receptor modulators or SERMs (raloxifene), parathyroid hormone (teripatide), and a naturally occurring hormone to improve the action of bone building cells (calcitonin). ¹,¹⁴

Unless doctors are confident that post-menopausal women receiving osteoporosis treatment following a fracture have an adequate calcium intake and/or are vitamin D replete, calcium and/or vitamin D supplementation should be provided. ¹

Strong and healthy bones – a nutritional guide

The bone in your skeleton is a living structure which is constantly renewed. To ensure healthy bones a good supply of essential vitamins and minerals, particularly vitamin D and calcium, is important.

Calcium

Getting enough calcium in your diet ¹⁸, ²²,²³

Portion size / weight		Food	Calcium (mg)	Calcium content per 100g (mg)
Imperial	metric
1/3 pt	190 ml glass	Semi-skimmed milk	231	684 per pint
1/3 pt	190 ml glass	Full fat milk	224	684 per pint
1/3 pt	190 ml glass	Soya milk	25	75 per pint
1/3 pt	190 ml glass	Concentrated orange juice (unsweetened)	67	200 per pint
3 oz	84g pot	Yoghurt, low-fat fruit	126	150
1 oz	28g	Cheddar cheese	202	720
7 oz	200g	Macaroni cheese	340	170
3 oz	84g	Cheese omelette (1 egg, 1oz Cheddar)	235	280
3 oz	84g	Cheese and egg quiche	219	261
2 oz	56g	Sardines, canned in tomato sauce	258	460
2 oz	56g	Milk chocolate	123	220
3 oz	90g	Spinach, boiled	144	160
4 oz	112g	Broccoli, boiled	45	40
4 oz	112g	Baked beans	59	53
4 oz	112g	Red kidney beans, cooked	80	71
3oz	84g	Soya bean curd, steamed	428	510
2 oz	56g	Brazil nuts	95	170
2 oz	56g	Swiss style muesli	62	111
1 oz	28g	Dried figs	70	250
1 slice	30g	Bread, white	33	110
1 slice	30g	Bread, wholemeal	16	53

Vitamin D

Getting enough vitamin D in your diet ¹⁷

Food 17	Serving 17	Vitamin D (mg) 17	Number of servings required to achieve daily recommended intake in persons aged over 65 years 15
Margarine	10 g	0.8	12.5
Eggs	1	1.1	9
Cheese	60 g	0.2	50
Milk	0.15 litres	0.05	200
Butter	10 g	0.1	100
Herrings	100 g	16.5	0.61
Tuna	100 g	4	2.5
Mackerel	100 g	8	1.25
Kippers	100 g	13.5	0.74
Sardines	100 g	7.5	1.33

References

¹ Bisphosphonates (alendronate, etidronate, risedronate), selective oestrogen receptor modulators (raloxifene) and parathyroid hormone (teriparatide) for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. Technology Appraisal 87. January 2005. National Institute for Clinical Excellence (NICE). ISBN 1-84257-872-3

² Van Staa TP, Dennison EM, Leufkens HGm et al. Epidemiology of fractures in England and Wales. Bone 2001;517-522

³ Klotzbuecher C M et al. Patients with prior fractures have an increased risk of future fractures. A summary of the literature and statistical synthesis. Journal of Bone & Mineral Research 2000; 15 (4): 721-727.

⁴ Cooper C. The crippling consequences of fractures and their impact on quality of life. Am J Med 1997; 103 (2A): 304 – 435.

⁵ Dolan P et al. The cost of treating osteoporotic fractures in the United Kingdom female population. Osteoporos Int 2005;8:611-617

⁶ Brankin E. Closing the osteoporosis management gap in primary care. Curr Med Res Opin 2005; 21(4): 475-482

⁷ Hosking D, Holick MD, Lips P Turpin J et al. Postmenopausal osteoporotic women around the world are at high risk for vitamin D inadequacy. Presented at: Annual European Congress of Rheumatology (EULAR), 8-11 June 2005, Vienna Austria

⁸ Holick MF, Ethel SS et al. Prevalence of vitamin D inadequacy among postmenopausal North American women receiving osteoporosis therapy. J Clin End & Met. 2005 90(6)3215-3224.

⁹ Daisy Network.
www.daisynetwork.org.uk/whatisit.html#Premature+Menopause. Accessed 15 August 2005.

¹⁰ Holick MF, Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers and cardiovascular disease. Am J Clin Nutr 2004;80(suppl):1678s-88s

¹¹ Holick MF. Vitamin D: Photobiology, metabolism, mechanism of action and clinical applications. In: Primer on metabolic bone diseases and disorders of mineral metabolism. 1996, 5th ed. Philadelphia: Lippincott;92-98.

¹² West JB. Best and Taylor's Physiological Basis of Medical Practice. 1985 11th Edition Williams and Wilkins. Baltimore London

¹³ Food Standards Agency Expert Review Group Secretariat on Vitamins and Minerals. Review of calcium (2002).
www.food.gov.uk

¹⁴ Arthritis Research Campaign. Osteoporosis – an information booklet. Accessed on 10 August 2005 at:
www.arc.org.uk/about_arth/booklets/6058/6058.htm

¹⁵ Commission of the European Communities. Report of the scientific committee for food. (31st series), 1993.

¹⁶ Hirani V et al. Vitamin D concentrations among people aged 65 years and over living in private households and institutions in England: population survey. Age and Ageing, July 2005

¹⁷ Arthritis Research Campaign. Osteomalacia – an information booklet. Accessed on 10 August 2005 at:
www.arc.org.uk/about_arth/booklets/6028/6028.htm

¹⁸ Scottish Intercollegiate Guidelines Network (2003). Management of osteoporosis: National clinical guideline 71.
www.sign.ac.uk

¹⁹ National Osteoporosis Society.
www.nos.org.uk/osteo3.asp. Accessed on 10 August 2005.

²⁰ National Osteoporosis Society. Hip Protectors – an information leaflet. Accessed on 16th August at:
www.nos.org.uk/InfoSheets/HIPPROTECTORS.pdf

²¹ The Vegan Society at:
www.vegsoc.org/info/calcium.html. Accessed on 10 August 2005.

²² National Osteoporosis Society factsheet – Calcium Rich foods and bone health. December 2003

²³ Arthitis Care Inforamation sheet – Recommended daily calcium intake. March 2004

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