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"Medical Journeys" is a set of clinical resources reviewed by physicians, meant for the medical team as well as the patients they serve. Each episode of this journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.

Despite the multitude of items on the wellness checklist in a medical exam, it's important to help at-risk patients be aware of the seriousness of osteoporosis and the substantial impact of fragility fractures on quality of life, function, and even longevity.

"Doctors need to stress that this is a very prevalent disease, and that 1 in 2 women and 1 in 4 men over age 50 will have a fracture in their remaining lifetimes," said Meryl S. LeBoff, MD, chief of the Calcium and Bone Section and director of the Skeletal Health and Osteoporosis Center and the Bone Density Unit at Brigham and Women's Hospital and Harvard Medical School in Boston. "Primary care doctors play a critical role in ordering timely bone densitometry for both men and women."

Added Kendall F. Moseley, MD, clinical director of the Division of Endocrinology, Diabetes & Metabolism at Johns Hopkins Medicine in Baltimore: "My hope is that no matter how busy they are, primary care physicians will not put bone health at the bottom of the clinical agenda. It's as important as checking cholesterol and blood pressure levels."

The main goal is to prevent patients from breaking a bone, Moseley stressed. "A fragility fracture is like a heart attack of the bone. Just as cardiovascular risk factors such as high blood pressure and blood lipid levels are silent before a stroke or infarction, osteoporosis is also silent. People don't feel their bones thinning."

Bone Biology

It may be useful for patients to have a basic understanding of the biology of bone metabolism. "They should be aware of the dynamics of bone modeling and understand why their bone density is not as high as we would like it to be – and how they can use their body's own ability to their advantage," Moseley said.

"Many don't realize that bone metabolism is a dynamic process and that bone is not just an inert support for muscle and tissue," she added. "So they need to be made aware that bone is constantly renewing itself like skin, hair, and other organ systems."

Patients may be more engaged if they have a basic grasp of the ongoing balancing act between osteoblasts and osteoclasts and the disruption of this resorption/formation equilibrium by such factors as age, hormonal status, and other diseases. "The level of detail I give depends on the level of curiosity or education of the patient," Moseley said.

Nutrition and Lifestyle

Patients need to understand the importance of essential nutrients such as protein, calcium, and vitamin D that provide the dietary building blocks of bone formation. In some cases, supplements may be needed to correct dietary shortfalls. Conversely, patients need to know that sedentarism, smoking, excess alcohol intake, and possibly a high consumption of phosphorus-heavy soft drinks are inimical to bone health.

Male Patients

As for men at risk of osteoporosis, the biggest challenge is getting the broader medical community and the public at large to accept that older men are also vulnerable to low bone mass and are more likely than women to die after a hip fracture or be sent to an assisted-living facility.

"Even some of my women patients with osteoporosis don't realize their husbands can get osteoporosis, too," said Moseley. "A low-trauma fracture can signal low bone density in men as well as women and needs to be promptly investigated. The goal is to have a man diagnosed in primary care before a specialist is needed."

Contributing Diseases

Patients should also be aware that many other illnesses and their associated treatments foster low bone density and osteoporosis. These include cancer; inflammatory diseases such as rheumatoid arthritis, asthma, and Crohn's disease; liver and celiac disease; hypercalciuria; and thyroid disease.

Affected patients should be routinely encouraged to discuss conditions they may have had in this long list and the drugs they may have taken for them, LeBoff advised.

Fractures

Knowing the serious consequences of fragility fractures -- an estimated two million a year in the U.S. -- may incentivize at-risk patients to make bone health a priority. Fragility fractures can be lethal, and especially after hip fractures, patients may never return to their former level of independent living. Some may need to move to institutionalized care.

While hip fractures carry the greatest disability, fractures of the humerus, spine, and wrist can also be debilitating.

Specific Statistics

The Bone Health & Osteoporosis Foundation has some :

• A woman's fracture risk is equal to her combined risks of breast, uterine, and ovarian cancer

• A man is more likely to break a bone owing to osteoporosis than to get prostate cancer

• 24% of hip fracture patients age 50 and older die in the year following the fracture

• Six months after a hip fracture, only 15% of patients can walk across a room unaided

• Every year, of nearly 300,000 people in the U.S. who have hip fractures, 25% end up in nursing homes and 50% never regain their previous function

Side Effects

Osteoporosis medications are broadly divided into treatments that slow the breakdown of bone, allowing more time for bone rebuilding; and therapies that actively form bone (or do both).

Regarding the negative side effects known to be associated with use of oral bisphosphonates such as gastrointestinal problems, patients can be informed that the medications need not necessarily be taken orally, LeBoff explained. "These can be given intravenously once a year, and that works out especially well for people with an active lifestyle."

But patients are more likely to be concerned about the rare and disturbing consequences they read about on the Internet such as osteonecrosis of the jaw and atypical mid-thigh fractures of the femur. "Patients can be terrified when they see the images on Google," Moseley said.

Stress the infrequency of such side effects, LeBoff recommended. "In all my many years of practice, I can count on the fingers of one hand the number of these cases I've seen. They're incredibly rare occurrences, and the patients I've seen with them often had cancer or other contributing conditions."

It also may allay doubts to communicate that adverse side effects are usually due to extended duration of therapy, she added. "We're very careful nowadays about how long we keep a patient on a given treatment. We guide therapy based on duration to minimize risk."

Moseley noted that patients may need to be reminded that all medications, of course, have side effects, including vitamins and aspirin. "It's up to them to weigh the real risks and benefits," she advised. "Do patients want to have a one-in-a-million fracture that may never happen, or break a hip tomorrow? Talk it through with them and help them make peace with their concerns."

Fear and Anxiety About Activity

Another source of anxiety may be physical activity following a fragility fracture, after which some individuals may tend to catastrophize exercise as a fall and fracture waiting to happen, Moseley said. "Some patients may see themselves as Humpty Dumpties and continue to feel very vulnerable. They see themselves as permanently frail. But they don't need to stay covered in bubble wrap." Those who live alone can be particularly anxious about falling and not being able to get up, she added.

Physicians may want to stress that osteogenic exercise does not have to mean heavy training or pumping iron at the gym. "A brisk walk around the block or a session on a recumbent bike is good exercise," Moseley said.

If concern about refracture is overwhelming, a referral to physiotherapy for fall prevention and balance training may be in order, she advised. "That gives them the confidence they need to be proactive about their health," and some may benefit from a support group or even psychotherapy in overcoming an exaggerated fear of moving about.

Fall Prevention

An important part of the conversation is preventing fractures by preventing falls. That could mean installing better lighting, upgrading eyeglasses, eliminating loose rugs, fixing shaky railings, and using walking aids. In some cases it may mean moving to a one-level domicile without stairs.

The good news to deliver to patients is that there are many effective therapies that can be targeted to individuals according to their lifestyle, goals, and the severity of disease, said LeBoff. "We have the means to treat fractures and prevent them and improve longevity and quality of life."

Half the battle is getting people diagnosed. Yet of older Americans who have already suffered a bone break are not tested or treated for osteoporosis.

Read previous installments in this series:

Part 1: New Insights Into the Complex Biology of Osteoporosis

Part 2: The Latest on Osteoporosis Treatment and Diagnosis

Part 3: Osteoporotic Fragility Fractures

Part 4: Case Study: First-Time Mom's Severe Low Back Pain After Breastfeeding

Part 5: As Men Live Longer, Osteoporosis Looms Larger

Part 6: These Other Medical Conditions and Treatments Can Also Increase Osteoporosis Risk