Patient History:
56-year-old Caucasian female
PMH: s/p fractures x 3. Right wrist fracture - after falling over a lamp cord in her single-level, carpeted home; 2 months later she fractured her left wrist after tripping and falling. Five years ago she fractured an ankle while making a (bad) landing while sky-diving for the first—and last—time.
s/p hysterectomy at age 45 for fibroids; the ovaries were not removed. Menopause onset age 51 without hormone therapy.
Medical Work-up: A review of the patient's previous medical records revealed that a spine x-ray had been done for persistent back pain about 4 months after her sky-diving accident. The x-ray revealed severe compression fractures at L1 and L2, with radiographic evidence of low BMD or osteopenia at other sites.
A BMD test was performed. Her total L1 - L4 T-score was -1.5. Her left hip bone density T-score was -2.5.
Family History: Her paternal aunt was diagnosed with osteoporosis after a hip fracture.
Nutrition History: Ht. 5’ 1” Wt. 105 lbs No recent weight loss.
Food frequency/24 hour recall reveals that patient consumes 1 cup of skim milk daily with 1 cup of Raisin Bran or other cereal; 1 cup of orange juice; ½ bagel with 1 T. cream cheese; green salad with 1 T. of cottage cheese; ½ peanut butter and jelly sandwich on whole wheat bread; 2-3 oz. of chicken breast; 1 c. rice with ½ c. broccoli and carrots; 1 c. yogurt.
Lifestyle history: She does not use any over-the-counter medications or supplements and does not smoke. She uses sunscreens to protect against skin cancer. Exercise is limited as she works in an office and does not like any sports.
All labs WNL.
1. Identify this client’s risk factors for osteoporosis.
Based on the client's medical history, she is at risk of getting osteoporosis. This is because of the compressed fractures in her back, low bone mineral density test report, and her paternal aunt who diagnosed with osteoporosis. But her chances of getting osteoporosis are reduced a little because her healthy weight and diet. It also helps that she does not smoke.
2. What is a bone mineral density test? How is this performed? When should a person have a BMD? How often?
The bone mineral density test is where the doctor is going to measure the amount of bone minerals that could be inside of a particular bone like the wrist, hip, or spine. Basically, the doctor will do an X-ray to look at the amount of calcium that is inside of the bone.
There are several circumstances when a person should get a BMD test:
- you are a woman age 65 or older
- you are a man age 70 or older
- you break a bone after age 50
- you are a woman of menopausal age with risk factors
- you are a postmenopausal woman under age 65 with risk factors
- you are a man age 50-69 with risk factors
- an X-ray of your spine showing a break or bone loss in your spine
- back pain with a possible break in your spine
- height loss of ½ inch or more within one year
- total height loss of 1½ inches from your original height
It is recommended that a person get a BMD test every two years.
3. What is a T-score - Interpret this patient’s scores.
The T-score is the part of your bone mineral density report that tells how your bone mass is going to compare to a healthy average 30 year old woman. There is a good chance that she has osteoporosis in her left hip.
4. Using the World Health Organization criteria for osteoporosis diagnosis, what is this patient’s diagnosis?
The patient does have a small case of osteoporosis but she should be able to reverse some of the symptoms if she takes care of herself and does everything that the doctor tells her to.
5. Explain the role (i.e. basic physiology) of calcium, Vitamin D and phosphorous in bone physiology.
Calcium is needed in the body so that a person can have healthy bones. But since calcium cannot be made inside of the body, it needs to be absorbed through the food that a person eats on a regular basis. Vitamin D helps a person to build up the strength in the bones. Plus the more Vitamin D in your body, the more calcium that your body is going to be able to absorb. Phosphorous also helps to build strong bones.
6. a. What is the recommended intake of each of these nutrients for the treatment
and prevention of osteoporosis?
If you are trying to prevent getting osteoporosis or treat osteoporosis, it is recommended that you take at least 1000 mg of calcium unless you are postmenopausal when you should take 1200 mg of calcium. It is very important that you do not take more than 2000 mg of calcium because of the serious side effects.
It is recommended that you have about 800 units of Vitamin D.
It is recommended that you have about 700 mg of phosphorous.
b. Using a computer dietary analysis, nutrition textbook, (or go to http://www.nal.usda.gov/fnic/foodcomp/search/ ) to get an estimate of this client’s average calcium intake.
This woman is going to need to take 1000 mg of calcium on a daily basis.
7. Explain the role of weight bearing exercise in the prevention and treatment of osteoporosis.
Exercises can help to prevent or reverse the amount of bone loss in a person who has osteoporosis. The most popular exercises to do to aid with the osteoporosis are going to include walking, running, aerobics, dancing, treadmills, and weightlifting.
8. Currently there are the following categories of drug therapies used for osteoporosis therapy: bisphosphonates, estrogen, selective estrogen receptor modulators (SERMs), and calcitonin. Explain the basic mechanism for each.
Bisphosphonates:
This is a group of different medications that are given by intravenous infusion that can slow down that rate in which the bone is going to dissolve. Therefore, the bone is going to have the ability to strength over time.
Estrogen:
Estrogen is given to a woman who has been through menopause through a series of shots.
Selective Estrogen Receptor Modulators (SERMs):
This is only going to be given to women to help make the bones thicker and slow down the thinning of the bones.
Calcitonin:
This is a hormone that your body is suppose to make naturally. It is given to help build in the bones in a person who is suffering from osteoporosis.
9. The recommendations for estrogen replacement therapy has been controversial. Why? What is the current recommendation?
It is because it increases the chances of a woman developing breast cancer, cancer in the lining of the womb, blood clots in the vein, stroke, and heart disease. The recommended amount of estrogen replacement therapy is 0.3 mg/d CEE and 2.5 mg/d MPA for someone who is suffering from osteoporosis.
10. What treatment strategies should be recommended for this patient?
In your discussion, please address:
a. dietary calcium intake, calcium supplementation, Vitamin D and any other nutrition recommendations.
It is recommended that a person has at least 1,000 mg of calcium on a daily basis. When you are taking a calcium supplement, you are only going to need 500 mg because it is going to absorb in your body a lot faster.
It is recommended that you have about 800 units of Vitamin D. It is recommended that you have about 700 mg of phosphorous.
b. medications:
- Bisphosphonates
- Raloxifene
- Calcitonin
- Parathyroid hormone
- Denosumab
- progestin
c. physical activity
- walking
- running
- stair climbing
- dancing
- weight lifting
- aerobics
- resistance exercises like weights or elastic bands
d. any other lifestyle issues
- limit the amount of alcohol you have on a regular basis
- limit the amount of caffeine you have on a regular basis
- quit smoking
References:
Begum, R.M. (2008). A Textbook of Foods, Nutrition, and Dietetics. Sterling Publishers Pvt. Ltd.: New Delhi.
Emory University Department of Human Resources. (2013). Computer Diet Analysis. Retrieved on October 15th, 2013, from http://genetics.emory.edu/clinical/index.php?assetID=303.
National Agricultural Library. (2013). Osteoporis. Retrieved on October 15th, 2013, from http://www.nal.usda.gov/fnic/foodcomp/search/.
