Brittle bones

Like a silent stalker, osteoporosis can creep up unawares. The workplace
presents an ideal opportunity to catch this potentially crippling condition
before it strikes.  By Dr Alison Graham

Osteoporosis, regrettably, is all too often a story of lost opportunities.
It is not an understatement to say that the preventable is not being prevented,
the diagnosable diagnosed, nor the treatable treated. It is not someone else’s
problem, we all have chances to prevent, diagnose and treat it if only we
recognised them. Osteoporosis is not a new disease. It has, until recently,
been dismissed as an inevitable consequence of ageing. It is not – and it is
never too late to treat it. Nor is it a disease confined to old ladies as my
two patients in their thirties will testify.

How important is osteoporosis?

Osteoporosis affects one in three women and one in 12 men, and causes more
deaths than cancer of the ovary, uterus and cervix combined. It causes a
fracture every three minutes in the UK alone, and costs the NHS £1,500m per
year1. The hidden costs in terms of human suffering are incalculable – in a
recent survey, women said they would rather die than suffer a hip fracture2.
Fractures caused by osteoporosis are responsible for more days of
hospitalisation in women over 45 than any other disease3, and the outcome after
a fractured hip is poor. One in five patients dies, and half the survivors
never regain their former level of independence.

What has this got to do with the workplace?

Occupational health is largely about prevention and recognition of the
relationship between work and health and vice versa. The workplace provides a
valuable opportunity to educate people about health matters. For example, the
majority of wrist fractures occur in women in their 50s and 60s. They cause
debility, pain, absence from work and often long-term functional difficulties.
If the public and professionals were more aware of osteoporosis, many of its
complications could be prevented. Once one fracture has occurred, we should
heed the warning and try hard to prevent another.

Osteoporosis can affect the workplace in other ways. Consider, for example,
the impact on a working daughter when her elderly mother fractures her hip. The
worker affected may not necessarily be the patient for osteoporosis to have a
social and a financial cost.

What causes osteoporosis?

Osteoporosis literally means porous bone, and is caused by a reduction in
bone mass and a micro-architectural deterioration in the bone structure. These
two abnormalities result in a fragile skeleton and an increased risk of
fracture. Osteoporosis has been called the "silent thief", because
the patient often has no symptoms until a fracture occurs.

Our 206 bones are not simply lifeless coat hangers on which we carry our
bodies. They are a living, responsive tissue, which continues to remodel itself
until the day we die. Old bone is taken away by cells called osteoclasts, and
new bone laid down by other cells called osteoblasts – a little like repairing
a worn out motorway. In healthy bone, there is a balance between the two

In osteoporosis, there is either too much bone removed, or too little being
laid down.

The bone that is present is normal, but there is not enough of it, and some
of its supporting internal structures have been broken down. Consider a
cardboard box: if it is made of thick material and has internal supports like
in a case of wine, it is strong, but if the card is thin and/or the internal
supports are removed, it becomes weak and can be crushed more easily.

What increases the risk of developing osteoporosis?

Bone is laid down during childhood and adolescence, with a peak bone mass
reached in the Thirties. After that, we lose bone gradually as we age. Women
achieve a lower peak bone mass than men, and lose it faster at the menopause,
thus explaining their greater risk of fractures. The graph in Figure 1 can be
used to explain to patients what happens to their bones and how they weaken
over the years until they cross the theoretical threshold at which fractures

Bone mass is affected by many different factors

Many diseases and lifestyle factors affect the peak bone mass (or the amount
in our bone deposit account), and others affect the rate of loss. It is
important to understand that the presence of risk factors does not mean that
osteoporosis or a fracture is inevitable. Likewise, healthy bones are not
guaranteed just because risk factors are absent. The presence of risk factors
merely highlights those people we need to look at more closely.

Osteoporosis has been defined by the World Health Organisation in terms of
bone density and how it differs from the young adult mean. Bone density can be
measured in a variety of ways and the gold standard method is DXA (dual X-ray
absorptiometry). Measurements can be taken at the hip, spine or wrist,
depending on the device used. Most DXA machines are hospital based and not all
patients have access to a local service.

Bone quality can also be assessed using ultrasound of the heel, known as
QUS. This measures different features of bone to DXA and has been shown to
predict fractures in post-menopausal4 and elderly women5. It does not diagnose
osteoporosis, it assesses fracture risk. Similarly, a cholesterol measurement
can predict the risk of heart disease but does not diagnose it. When asked,
women wish to know what their risk of fracture is, as this is the clinically
important outcome. However, the answer is not straightforward since many people
with osteoporosis will not fracture.

What assessments are practical?

Ultrasound is safe, painless, portable and quick and can be taken to the
patient. It is therefore ideal to be used in the community setting. It is vital
that the technology is used appropriately and unfortunately heel scanning is
not suitable for pre-menopausal women or for men. This is because a lack of
data in these groups makes interpretation of the results in terms of fracture
risk impossible.

It is also essential that the heel scan is not judged in isolation. It is a
piece in the jigsaw puzzle that we build for each individual. It is very
important to assess other risk factors that may have already caused bone loss
or that may cause problems in the future and the result needs to be interpreted
by a trained professional. Similarly with cholesterol, the result should be
interpreted in the context of the whole patient.

What can be done?

It is never too late to take action, but clearly the choice of action
changes with age. The key message is that if a woman establishes her risk, she
can then take action to reduce the rate of bone loss, and thus prolong the time
before she becomes vulnerable to fracture.

Many interventions lie within the control of the individual and do not
necessarily need prescribed medication. A lifestyle that is good for bones is
good for hearts as well. There is no such thing as bad news with a risk
assessment as the advance warning it provides allows intervention before
disaster strikes and it has been shown that compliance with treatment is better
in women who have a test result to motivate them6.

The issue of bone health could be raised in the workplace by displaying a
poster asking about risk factors such as those in the box. This could help
identify women at increased risk.

Occupational health nurses should be vigilant, for these high-risk groups
will be present in most workplaces and there are ample opportunities to educate
about the benefits of hormone replacement therapy, exercise, not smoking and
eating healthily.

As long as we are all suspicious about osteoporosis, know how to recognise
it when it is already established and know how to identify those at high risk
of developing it in later life, we will contribute to the enormous task that
faces us. Preventing 200,000 fractures a year in the UK is a task that will not
be achieved by GPs and their prescribing budgets alone. The opportunities
presented in the workplace mean that it too must play its part.

Dr Alison Graham, MBBS, MRCGP, D.Occ.Med. is medical director of Scancare


1. Torgerson DJ et al. (1999) The economics of fracture prevention in
primary care. UK Key Advance Series: Key advances in the effective management
of osteoporosis. In Press.

2. Salkeld G et al. (2000) Quality of life related to fear of falling and
hip fracture in older women: a time trade off study.  British Medical Journal,320:341-346.

3. Kanis JA et al. (1997) Osteoporosis International,7:390-406.

4. Stewart A, Torgerson DJ, Reid DM (1996) Prediction of fractures in
perimenopausal women: A comparison of dual energy X-ray absorptiometry (DXA)
and broadband ultrasound attenuation (BUA). Annals of Rheumatic Disease, 55:

5. Bauer DC, Gluer CC, Cauley JA, et al. (1997) Broadband ultrasound
attenuation predicts fractures strongly and independently of densitometry in
older women. A prospective study. Archives of Internal Medicine; 629-634.

6. Bone and Tooth Society and National Osteoporosis Society (2000) How
fragile is her future? A report investigating the current attitudes towards and
management of osteoporosis in the UK.

Risk factors

Have you had any of the following:

– An early menopause?

– A previous fracture after a minor trip or fall?

– Height loss of more than two inches?

– A mother who has broken her hip?

– Steroid tablets for more than six months?

Ultraso und checklist

– Ultrasound can be used to
investigate the full range of risk factors

– It must be carried out by trained personnel (preferably

– There must be an auditable set of procedures that are managed
by a trained and qualified physician

– Practitioners should keep up to date in the subject area, and
be capable of changing as evidence emerges

– The best equipment available should be used and operated to
strict quality control standards

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