A recent research finding that more than one in five seemingly healthy adults had fractured a bone since turning 40 is a red flag about the state of bone health in Ireland. The particular concern is that over a third of those bone breaks were described as “fragility fractures”, in other words they had occurred after minimal impact, such as falling from standing height or less.
“It’s what we see in osteoporosis,” says endocrinologist Dr Miriam Delaney, a specialist in osteoporosis, metabolic bone disorders and calcium metabolism at the Galway Clinic. People call osteoporosis, which weakens bones, a “silent disease”, but there is nothing silent about a fracture, she says.
For her the surprise outcome of this research – it was commissioned by Athena Pharmaceuticals – is not only the significant number of fragility fractures reported in the 40 to 55 age group but also the high number of men affected in the over 40 group. (1,000 people were surveyed, 600 of whom were over 40.)
“Men are very much undertreated and under-recognised; we know about 20 per cent of men have osteoporosis and when men have osteoporosis and have a fracture they do worse than women,” she says. While one in two women over 50 are expected to have a fragility fracture in their remaining lifetime, the effect of menopause being a significant factor, the corresponding figure for men is one in four.
With the International Osteoporosis Foundation (IOF) predicting that Ireland, out of 27 EU countries plus the UK and Switzerland, will have the biggest increase in fragility fractures between 2019-2034, it is clearly a growing health problem in this country, primarily due to the ageing population. The IOF’s Scope 2021 report says “Ireland represents one of the high-burden, high-provision countries” and it ranks the burden of this disease here currently as seventh highest out of the 29 countries surveyed.
“It is not just the ageing population; also I think worrisome is that we are seeing these younger people with fractures because it is not what we see internationally,” says Delaney, who is a spokeswoman for Athena Pharmaceuticals. While the research also indicates that most people are unaware of how much calcium and vitamin D they should be consuming for optimum bone health, “we don’t know that’s what is causing the fractures”.
The IOF puts the annual cost of osteoporotic fractures for the Irish healthcare system at €464 million but this figure is way out of date and much higher now, says Delaney. She believes there needs to be a “huge public health education message” if we are to improve bone health as a nation.
Here are seven things individuals need to know:
Bone health needs attention over our whole lifespan
Our skeleton starts developing in the womb a few weeks after conception and will continue to develop until up to age 20. But the bones that make up our skeleton are alive to the day we die. “When you have reached your peak height you fill in your bones with mineralised bone on top of the scaffolding,” explains Delaney. Nutrition and weight-bearing exercise will contribute to the density of the bone and you can expect your bone bank to be at its peak around age 25 or soon after.
From then on the continual process of bone formation will start to be outstripped by the rate it is breaking down, resulting in gradual bone loss for men and women. But menopause accelerates the speed of bone loss.
Women go from 1-2 per cent per year to 3-5 per cent [loss] per year during menopause, says Delaney. But that rate of loss will slow down again about five years after menopause. “For men the decline is more consistent. If you go down far enough, everybody gets osteoporosis.”
While we can do nothing about ageing, optimising peak bone bank in young adulthood and then maintaining as much of it as we can for longer will prevent, or at least delay, osteoporosis.
We need bone-building blocks every day
To maintain our normal bone skeleton we must have calcium and vitamin D every day. The body needs enough calcium to keep bones strong and adequate vitamin D is essential for sufficient absorption of calcium. But vitamin D deficiency is common in Ireland. For instance, one in eight of older adults is not getting enough vitamin D in summer and this increases to one in five during the winter, according to the Irish Longitudinal Study on Ageing, known as Tilda.
Earlier this year the Food Safety Authority of Ireland (FSAI) published its Vitamin D recommendations for the age group five to 65. It has now issued guidelines for the whole population, as three previous reports focused on infants, on children aged one to five and on adults aged 65 and over. In addition to food sources, varying levels of vitamin D supplements are recommended for everyone – at least from October to March – with all-year-round use recommended for those at highest risk of vitamin D deficiency, including pregnant women, people of dark-skinned ethnicity and housebound adults over 65.
“We consider the prevention of vitamin D deficiency to be a public health nutrition priority and this report outlines how we can combat this deficiency through using both natural food sources of vitamin D and fortified foods along with appropriate doses of vitamin D supplements,” said Dr Pamela Byrne, CEO of the FSAI on publication of these latest recommendations in February.
Vitamin D is found in a small range of foods including oily fish, egg yolks and fortified foods such as some milks, yoghurts, breakfast cereals and infant formula. Offal meats, such as liver and kidney, are a good source of vitamin D but are not suitable for infants and pregnant women because they provide too much vitamin A.
Although 20 minutes of sun exposure a day during the summer months in Ireland is considered to provide sufficient vitamin D for low-risk categories, you need to have a significant amount of your body exposed, says Delaney, also pointing out that dermatologists do not recommend going out without using sunscreen on skin.
Vitamin D needs vary with life stage
The Scientific Committee of the FSAI has provided specific details on the range of dietary intake recommended for vitamin D across all age groups and also what doses of supplements are advisable for whom and when.
Delaney is concerned that the latest study she is commenting on shows a widespread lack of knowledge about recommended daily allowances of both Vitamin D and calcium. Just over half (54 per cent) had no idea how much vitamin D they should be taking and only 10 per cent got it right.
For the general population, the daily amount recommended ranges from 400-800 international units (IU) depending on age. Yet some people are taking exceedingly high doses, which she attributes to the suggestion, later discredited, that up to 3,000 IUs daily would help prevent Covid.
“The problem is now we are seeing patients coming in with very high levels of vitamin D,” she reports. This could cause you to absorb more calcium than needed, resulting in problematically high levels in the blood.
Some 60 per cent of respondents had no idea about the recommended intake of calcium; 25 per cent estimated too much and 15 per cent got it right.
Delaney also notes that of the 60 per cent surveyed who take a supplement of some kind, only one in four (26 per cent) is getting it from a pharmacy. “In a pharmacy they can get some sort of direction around what they’re doing but the people who are buying them in supermarkets, online etc have no possibility of getting guidance.”
When a visit to the GP is advised
Anybody who is treated for a fracture should go to their GP afterwards to be checked, says Delaney, “especially younger people breaking an ankle or a wrist. You might be able to prevent more debilitating fractures in the future.”
There are many different factors that could contribute to fragility fractures, including inadequate levels of vitamin D and/or calcium; an over-active thyroid; low testosterone; absence of periods and medications being taken, she says. The action required could be treating those underlying causes rather than giving you a medicine for osteoporosis.
Vitamin D deficiency causes osteomalacia, which is soft bones and a different disease, she says. “Bone cells are making bones, but if they can’t fill it in and mineralise it, it is called osteomalacia.”
Lifestyle changes can improve bone density
In addition to eating a calcium-rich diet and ensuring you are getting enough vitamin D (as outlined above), not smoking and keeping alcohol consumption low will help. Excess caffeine can also be detrimental to bones, which is one more reason why children and teenagers should not regularly consume fizzy drinks and energy drinks, while adults should avoid drinking too much coffee and tea.
Regular weight-bearing exercise is also crucial at all ages. A minimum of 60 minutes a day for children and 30 minutes daily for adults. Michele O’Brien, CEO of the Irish Osteoporosis Society – which runs a national helpline at (01) 637 5050 – says research has shown that weight-bearing exercise just before puberty starts in children – on average between eight and 12 years of age – can significantly reduce a child’s chances of developing osteoporosis in later life, not to mention other conditions such as heart disease, obesity etc. While the need for exercise is lifelong, she is concerned that people with osteoporosis who attend exercise classes for older people are at risk of breaking bones in their back if the instructor is not aware of the risks of, for example, forward stretches from a sitting position. “It has to be appropriate exercise and unfortunately it is not always the case,” she says.
“We don’t recommend anyone with bone loss start an exercise programme without being assessed to see what is safe for them to do. They can contact us on that, no problem.”
The society regards a vegan diet as a higher risk for osteoporosis. “It’s not healthy for anyone to have such a limited diet, that’s the issue,” says O’Brien. It is not the lack of dairy she singles out, as many non-dairy milks are fortified with calcium and vitamin D, but rather the detrimental effect of excessive fibre on the absorption of nutrients.
The argument for screening
The Irish Osteoporosis Society, which was founded by Prof Moira O’Brien in 1995, estimates that only 19 per cent of people with the condition are actually diagnosed.
Among the ageing population it is educated patients, says Delaney, who come forward for a DXA scan to check their bone density, while those unaware don’t. She believes all men and women with certain criteria, including age, should have a DXA scan and then be assessed for osteoporosis. Family history, medications being taken and very low BMI are just a few of the other reasons somebody should have a scan. However there is more to bone strength than density, she says. “We can’t treat on the basis of DXA, it’s just a number – it’s a good number but you have to use it wisely.” A broader assessment is needed in looking at fracture risk.
“If we treat everybody with low bone density we will end up treating a lot of people who will never have a fracture anyway,” she says. “We need to think about who we are giving these medicines to; long-use of these medicines can have side-effects.
“Bone health is an important part of how I counsel patients who are at low risk of fracture. They don’t necessarily need a medicine; they need bone health regimen to protect and to maintain and even to maybe improve their bone density.”
However, if we had a screening programme, she says, for everyone over the age of 55, even over the age of 65, which involved a DXA scan, then follow-up assessment and medication if necessary, a huge number of debilitating fractures could be prevented.
O’Brien believes all cancer patients should be given a DXA scan after treatment because chemotherapy and radiation can cause significant bone loss. Yet, she says, many are left unaware of the impact of this side-effect.
Don’t underestimate the impact of a fracture
“People don’t realise the consequences of broken bones,” says O’Brien. It’s the secondary effects that can be fatal, with many older people dying after a hip fracture because they develop a blood clot, pneumonia or infection. The death cert is never going to say it was the secondary effect of untreated, undiagnosed osteoporosis, she says. “We know 30 per cent of patients with a hip fracture die within the first year; 30 per cent never become independent again and only 30 per cent recover,” says Delaney. The burden of lack of mobility and chronic pain after a hip or spine fracture affects not only the individual but also their family and carers.
“A lot of people do all the right things and still get osteoporosis,” she adds, “so what you have to say is that they probably would have been worst if they hadn’t”.
