Osteoporosis is a quietly prevalent chronic disease, and today, when diabetes, coronary heart disease and cancer are commonly taken seriously, only patients who experience fragility fractures and orthopaedic surgeons who encounter difficulties with internal fixation on the operating table can appreciate how tricky and frightening this disease can be. The consequences of fragility fractures, especially hip fractures, are not promising, with mortality rates as high as 15-20% in the first year after the fracture.
A “Ninth Five-Year Plan” project led by the Institute of Geriatrics of Beijing Hospital conducted an epidemiological study on more than 5,000 people and found that the proportion of people over 40 years old suffering from osteoporosis in China was 16%, and the proportion of people over 60 years old was as high as 30% to 50%, but the proportion of these people receiving standardized treatment was very small, while the clinical Studies have shown that the risk of osteoporosis-related nonviolent fractures can be greatly reduced if early standardized treatment measures are actively taken.
I. What are the risk factors for osteoporosis?
The Chinese Osteoporosis Prevention and Control Guidelines developed by the Chinese Medical Association’s Osteoporosis and Bone Mineral Diseases Branch in 2005 summarized the risk factors associated with osteoporosis in the following table.
Clinical risk factors for osteoporotic fractures
Genetic/unselectable factors
Associated disease factors
Life related factors
Aging
Female
Asian/Caucasian
Low BMD
High bone turnover (perimenopausal)
Family history of nonviolent fracture
Past history of nonviolent fracture
Premature menopause
Hypogonadism
Long-term glucocorticoid therapy
Diseases affecting bone metabolism
Low body weight
Restricted vision
Neuromuscular disorders
Ongoing smoking
Excessive alcohol consumption
Carbonated drinks, coffee
Chronic physical inactivity
Low calcium intake
Vitamin D deficiency
Lack of sunlight
As can be seen from the table above, the risk factors located in the genetic column are not selectable or modifiable by each of our patients, and none of us can choose our race, age, or gender. It is noteworthy that individuals with a prior history or family history of nonviolent fractures are far more likely to have another nonviolent fracture than the normal population, and these factors are extremely important in the development of osteoporosis.
Among these factors, the identification of secondary osteoporosis factors is emphasized, and a significant proportion of primary osteoporosis can be cured or avoided by eliminating the primary disease, such as hyperparathyroidism. On the other hand, prevention of falls in the elderly is also placed in an extremely important position, which is often easily overlooked by our families and clinical doctors. Life related bad habits are something that we can overcome and change, and are often overlooked by us.
Second, a brief analysis of the resistance to diagnosis and treatment of osteoporosis
Comparing the connotations of the 1994 World Health Organization (WHO) and the 2001 National Institutes of Health (NIH) definition of osteoporosis, it is clear that the latter emphasizes the significance and status of bone quality, which is due to the fact that some cases of fragility fractures occurring despite not having low bone density are noted in clinical practice, and therefore the diagnostic criteria are not perfect.
The reason for the passivity of the diagnosis and treatment of osteoporotic diseases is mainly due to the following reasons.
1. Most patients with osteoporosis are asymptomatic until a fragility fracture occurs. Less than 60% have symptoms of bone pain, which is often confused with the pain of degenerative osteoarthrosis and is easily overlooked, hence the term “silent epidemic”.
2. Although dual-energy X-ray (DEXA) bone density test is the gold standard for diagnosing osteoporosis, it is not convenient for census and screening due to the large and expensive equipment. It is an advantage in quantitative examination but cannot show the internal structure of bones and the effect of osteophytes on bone density.
3.Most people are only interested in the prevention and treatment of osteoporosis at the level of calcium supplementation, and they do not know which kind of calcium is good, thinking that bone soup or shells are the best calcium, however, calcium supplementation is far from enough.
4, the reduction and growth of bone density is slow, even if the treatment is very standardized, the increase of bone density is quarterly or even yearly, which is detrimental to the establishment of self-confidence and treatment compliance of patients.
Third, the basic process of screening patients with osteoporosis
Given that it is impossible for every individual to get a bone density test, asymptomatic patients with osteoporosis should first be targeted for early diagnosis and treatment in a high-risk group. All individuals and families with the above risk factors are the target of bone density screening and follow-up. The following groups are summarized.
① Females over 65 years old / Males over 70 years old;
②Postmenopausal women under 65 years of age with one or more risk factors for osteoporosis;
③Older men under 70 years of age with one or more risk factors for osteoporosis;
④Adults of both sexes with a history of fragility fracture;
⑤Adults of both sexes with low sex hormone levels for various reasons;
(6) Those who have osteoporotic changes on X-ray;
(vii) Those who are being monitored for the efficacy of osteoporosis treatment;
(viii) Diseases affecting bone mineral metabolism and drug applications;
⑨ Perimenopausal women.
The basic process of screening is shown in the figure below.
Grasp the risk factors – Target the risk group – Bone density screening:
Outcome I: reduced bone mass but no history of fragility fracture – Primary prevention: life interventions including calcium + Vit D
Outcome II: meets diagnostic criteria for osteoporotic BMD Outcome III: normal BMD but history of fragility fracture
Both Outcome II and III should be treated medically according to the guidelines; calcium supplementation alone is not sufficient.
This shows that risk factors are the entry point of the osteoporosis diagnosis and treatment procedure, not bone density. Risk factors determine the population at risk and those groups that need to be screened for bone density. It is worth mentioning that a history of previous fragility fractures is extremely important, and even if the bone density is normal, it should be treated as osteoporosis, and it is severe osteoporosis. It can be seen that risk factors run through the whole process of osteoporosis prevention and treatment, and the correct and appropriate grasp of these risk factors has an extremely important impact on osteoporosis diagnosis and treatment strategy and prognosis.