Differences
This shows you the differences between two versions of the page.
| Both sides previous revision Previous revision Next revision | Previous revision | ||
|
group_4_presentation_2_-_osteoporosis [2019/03/03 18:56] waliaa1 |
group_4_presentation_2_-_osteoporosis [2019/03/06 03:39] (current) dhaliwaa |
||
|---|---|---|---|
| Line 1: | Line 1: | ||
| ======= Osteoporosis ======= | ======= Osteoporosis ======= | ||
| - | {{ :bonecells.png?direct&500 |}} | ||
| - | |||
| - | {{:group_5_-osteoporosis.pptx|}} | ||
| - | ====== Introduction ====== | ||
| - | |||
| - | The adult human skeleton is composed of 206 bones, where there is continuous breaking down and replacing of these bones (Morrison, 2016). The remodeling of these bones occurs with the help of two special bone cells that include osteoclast and osteoblast (Morrison, 2016). Osteoclasts help break the bone down, while the osteoblasts help create the new bone (Morrison, 2016). The coordination between the osteoclast and osteoblast is really important for the well being of the human body (Morrison, 2016). Osteoporosis occurs when osteoclast starts to break down bones faster than the osteoblast can create (Morrison, 2016). | ||
| - | |||
| - | Osteoporosis is a common disorder that gets characterized by the deterioration of bone tissues and low bone density (Christodoulou and Cooper, 2003). This bone disease leads to an increase in fracture risks and a decrease in the strength of bones (Christodoulou and Cooper, 2003). Osteoporosis is most commonly associated with vertebral, wrist, and hip fractures and is seen to affect both male and females (Christodoulou and Cooper, 2003). | ||
| ====== History ====== | ====== History ====== | ||
| + | {{ :osteoporosis.png?300|}} | ||
| + | Osteoporosis is a medical condition characterized by low bone density and deterioration | ||
| + | of bone matrix in connective tissues (Melton, 2001). Osteoporosis usually occurs after 50 years of age and impacts millions of Canadians and people around the globe. Osteoporosis induced injuries can result in prolonged hospitalization, decreased independence, higher incidence of depression, and a reduced quality of life (Iqbal, 2000). Osteoporosis results in significant personal and economic damage, with estimated costs of a yearly $13.8 billion for direct medical treatment in the United States (Iqbal, 2000). | ||
| + | Research shows that approximately 20% of men over 50 years old are diagnosed with osteoporosis of the hip, spine or wrist. Furthermore, about 50% of women will suffer an osteoporotic fracture at some point in their life. The World Health Organization defines osteoporosis on the basis that an individual has a bone mineral density (BMD) of more than 2.5 standard deviations below the normal mean. Particularly, postmenopausal women have higher risks of developing osteoporosis due to declines in estrogen levels. A survey by the National Health and Nutrition institute in the United States, revealed that 20% of white postmenopausal women had osteoporosis of the femoral neck compared to 10% of Hispanic women and 5% of African-American women. In this same study, the prevalence of osteoporosis among white, Hispanic, and African-American men was 4%, 2%, and 3%, respectively (Melton, 2001). The following figure shows the annual incidence of common diseases in Canada and it is clearly evident that osteoporotic fractures are more common than heart attacks, stroke and breast cancer (Grant, 2015). | ||
| - | The discovery of the correlation between age-related deterioration in bone mass and density and the resulting risk in fractures can be dated back to the writings of 18th century British surgeon, Astley Cooper, who observed the “thin and spongy texture” of the bones of older patients (Grob, 2014). Furthermore, skeletal remains that have been studied by anthropologists have shown decreased bone density associated with chronic malnutrition, which is an identified risk factor of the bone disease (Grob, 2014). | + | ======Risk Factors ====== |
| - | + | ||
| - | ====== Epidemiology ====== | + | |
| - | + | ||
| - | Osteoporosis is one of the most common bone diseases among elderlies in Canada, affecting more than 2 million Canadians(Lyda, 2014); costing more than 456 million dollars annually (Government of Canada, 2016). However, since patients are usually not aware of this disease at early stages, this number may exclude ones not yet diagnosed. In 2002, the WHO found that osteoporosis has the 6th highest DALY (Disability-adjusted life years) in Europe and Americas. DALY is measures the cost of burdened disability compared to the regular life expectancy; calculated by total years of disability plus the difference in years of early death compared to the local life expectancy. In Canada, one in every three female and one in five male will be diagnosed with osteoporosis (Osteoporosis Canada, 2018). Osteoporosis may begin as early as in the the mid-30s, however it is usually not diagnosed until late in life. The most common sites of osteoporosis include the vertebrae, the hip and wrists (Masi, 2008). | + | |
| - | {{ :oestop1.png?500 |}} **Figure 2:** Disability-adjusted life year in thousands for varies chronic diseases. | + | |
| - | + | ||
| - | ==== Risk Factors ==== | + | |
| - | + | ||
| - | Risk factors for osteoporosis differ between individuals under and over the age of 50. | + | |
| - | + | ||
| - | Younger adults (age < 50 years): | + | |
| - | + | ||
| - | * Experience with bone fracture | + | |
| - | * Use of glucocorticoids (hormonal steroid as immune response suppressor) | + | |
| - | * Lack of hormone production | + | |
| - | Older adults (age > 50 years): | + | Osteoporosis can happen due to insufficient adolescent bone density, fluctuation in hormone levels leads to imbalances and an overall nutrient poor diet. During adolescence or puberty, bone density continuously increases and peak levels are reached when an individual is in their early 20’s. Following this age, osteoclast activity tends to surpass the osteoblast activity and rate of bone formation declines. Studies have revealed that a low peak bone density during puberty may induce a greater risk of developing osteoporosis when one is an adult (Schettler & Gustafson, 2004). Hormonal imbalances can occur because of an overactive or underactive thyroid and this phenomenon can in turn increase susceptibility to osteoporosis. Moreover, males who have low testosterone levels and females who have low estrogen levels, have a significantly greater risk of developing osteoporosis. A diet that is poor in Vitamin D or calcium can significantly decrease bone density (Larsen, Mosekilde & Foldspang, 2003). Calcium is deposited into trabecular bone during osteogenesis and without this essential element, bone growth occurs significantly slower and the overall structure may turn unstable. Vitamin D is essential for the small intestines as they use this vitamin to absorb calcium which is in turn supplied to the bones via the blood stream. Therefore, Vitamin D is vital to bone growth and insufficient amounts are indeed risk factors for osteoporosis. |
| - | * Older than 65 years old | + | {{ :incidence.png?300 |}} |
| - | * Smoking | + | |
| - | * Long term intake of large quantity of alcohol | + | |
| - | * Underweight or rapid weight loss | + | |
| - | * Having diseases that have complications leading to bone loss | + | |
| - | (Public health agency of Canada, 2008) | ||
| ====== Signs and Symptoms ====== | ====== Signs and Symptoms ====== | ||
| Line 46: | Line 22: | ||
| ====== Diagnosis ====== | ====== Diagnosis ====== | ||
| + | The diagnosis of osteoporosis is dependent on many factors such as the pathology and histology of the disease, the hormonal regulation of bone metabolism, bone mineral density (BMD), the type of fracture the individual had/has and the models for risk of fracture predictions (Lorentzon & Cummings, 2015). | ||
| - | The bone mass density, also known as BMD, is the primary test that can be used to determine the bone strength using a dual X-ray absorptiometry. The scanned bone from either the hip or spine from an individual can determine the bone density to determine the diagnosis as well as any future fracture risks (Sozen, Ozisik, and Calik 2017). The World Health Organization (WHO) presents that osteoporosis is determined when an individual has 2.5 standard deviation below the average using a T-score. This can be performed from knowing the difference between the patient’s BMD and the average to compare with the severity of the diagnosis (Sozen, Ozisik,and Calik 2017). The results are usually compared to a healthy 30-year old adult’s bone mineral density. Therefore, a lower BMD number will indicate a higher risk of a fracture (National Resource Center, 2015). | + | **Endocrine Regulation** |
| + | Riggs and Melton (1993), believed that the diagnosis of osteoporosis can be divided into two types of osteoporosis, this being so: | ||
| - | {{:screen_shot_2018-09-19_at_12.48.05_pm.png?700|}} | + | Type 1: this type of osteoporosis is due to low levels of oestradiol and the loss of trabecular bone following a few years after menopause in women |
| - | **Figure 5:** A table demonstrating the comparison of standard deviations created by the World Health Organization (WHO). | + | Type 2: this type of osteoporosis is due to ageing with dysfunctional calcium handling, which results in reduced levels of vitamin D, lead to hip/spine fractures. |
| + | After many other researchers tried to confirm this, it was found that this method of diagnosis was not correct. This was because osteoporosis and fractures tend to occur many years after menopause not in the first couple of years which, was claimed by, Riggs and Melton. Also, low levels of oestradiol were associated with hip/spine fractures but not low levels of Vitamin D. | ||
| + | **Bone mineral density** | ||
| - | ==== Screening & Measuring Tools ==== | + | Bone mineral density also known as BMD, can be used to measure the density of all bones in the body. Historically, single photon absorptiometry was used which, did not measure all bones in the body (Cameron, 1963). In present day, dual energy x-rays absorptiometry (DXA) is being used to measure the bone mineral density in peripheral/axial skeletal sites (Lorentzon & Cummings, 2015). This method is much more efficient, and accurate compared to the historical methods (Lorentzon & Cummings, 2015). It has been determined that if the patients femoral neck BMD is 2.5 SD below, the average young, healthy person has osteoporosis (Lorentzon & Cummings, 2015). The BMD tends to decrease because of age and other external factors. Research on the efficacy of DXA was tested on human cadavers via measuring the BMD of actual bones and it was seen to be a good proxy (Cheng et al., 1997). |
| - | Dual-energy x-ray absorptiometry (DEXA) is a method that can be performed on different areas to determine osteoporosis with a low radiation dose. This method consists of two energies where the x-ray goes across the desired area. Areas often included are the lumbar spine and proximal femur. However, if these areas are unavailable, the forearm can also be used to scan for BMD measurement (Ramos et al., 2011). | + | **Risk Models** |
| + | |||
| + | There are a lot of risk factors that are associated with osteoporosis. These factors include, age, previous fractures (low-trauma in adulthood), smoking, oral glucocorticoid usage, rheumatoid arthritis and alcohol use (WHO, 2007). Both smoking and alcohol are dosage dependent (WHO, 2007). These risk factors come together and make up the FRAX calculator (Lorentzon & Cummings, 2015). This is available online and is country specific since there are many geological variations (Lorentzon & Cummings, 2015). The FRAX model gives an approximate 10-year probability of any hip fracture or major fracture, that might occur in an individual (FRAX, n.d.). | ||
| - | Another method used to determine osteoporosis is determined using blood tests or bone biopsies. Blood tests are able to indicate certain proteins such as alkaline phosphatase. An individual with a higher amount of alkaline phosphatase has a higher indication with certain bone diseases. Calcium levels in the blood can also indicate if an individual has enough calcium intake (Institute for Quality and Efficiency in Health Care, 2017). | ||
| ====== Pathophysiology ====== | ====== Pathophysiology ====== | ||
| Osteoporosis is a systemic disease of the bones characterized by a low skeletal bone density and mass, as well as deterioration of bone tissues. Together, these cause an individual with osteoporosis to have an increased risk of bone fracture (Garnero, 2008). | Osteoporosis is a systemic disease of the bones characterized by a low skeletal bone density and mass, as well as deterioration of bone tissues. Together, these cause an individual with osteoporosis to have an increased risk of bone fracture (Garnero, 2008). | ||
| - | Around the ages between 40 and 50, bone mass starts to decrease in both men and women at a yearly rate of 0.3 to 0.5 percent. In fact, postmenopausal women experience an increase in the loss of bone mass by as much as 10 times. Similarly, this increased rate also occurs in men after castration, when there is loss of function of the testicles. | + | That being said, there are two classifications of osteoporosis identified; primary and secondary. Most commonly seen is primary osteoporosis which includes type 1 and type 2 which are postmenopausal osteoporosis and senile osteoporosis, respectively. On the other hand, secondary osteoporosis is characterized by bone mass loss from certain diseases. In addition, secondary osteoporosis is also caused from poor health choices like smoking and consumption of alcoholic beverages. Within primary osteoporosis, type 1 is associated with a loss of the hormones, estrogen and androgen, leading to increased bone turnover, bone resorption exceeds bone formation and dominant loss of trabecular bone rather than cortical bone. Type 2 osteoporosis is defined by predominant loss of cortical bone, and results from age related bone loss caused by systemic senescence and is induced by loss of stem-cell precursors (Dobbs, Buckwalter, & Saltzman, 1999). |
| - | ------------------------ | + | Around the ages between 40 and 50, bone mass starts to decrease in both men and women at a yearly rate of 0.3 to 0.5 percent. In fact, postmenopausal women experience an increase in the loss of bone mass by as much as 10 times. Similarly, this increased rate also occurs in men after castration, when there is loss of function of the testicles (Dobbs, Buckwalter, & Saltzman, 1999). |
| - | + | ||
| - | Osteoporosis is known defined as having a low bone mass and the deterioration of bone tissue which leads to a high incidence of bone fracture for individuals. The likelihood of obtaining osteoporosis usually increases with age. The mechanism and rate for which older individuals lose bone, positively correlates with calcium deficiency (NIH, 2018). | + | |
| - | + | ||
| - | There are two main types of osteoporosis; primary and secondary. Primary osteoporosis is caused by an age-related bone loss, typically occurring to men that are above the age of 70. Secondary osteoporosis is when bone mass is lost due to onset of certain diseases, bad lifestyle, etc. Some common causes of secondary osteoporosis include cigarette smoking, alcoholism, and low testosterone levels in men (NIH, 2018). | + | |
| - | + | ||
| - | This calcium deficiency leads to secondary hyperparathyroidism; elevated PTH levels in the blood. This stimulates osteoclast activity within the bone resulting in more bone resorption than normal. | + | |
| - | + | ||
| - | The reason for why osteoporosis is usually seen in older individuals is due to a couple of factors. Aging skin along with decreased sun exposure, reduces the conversion of a precursor of vitamin D (7-dehydrocholesterol) to Vitamin D3. Ultimately, this causes Vitamin D insufficiency which reduces the amount of calcium being absorbed (Kenny et al., 2000). | + | |
| - | + | ||
| - | + | ||
| - | In females, menopause usually leads to the loss of bone mass. When menopause occurs, the hormone progesterone is deficient. Some supporting data from 1990 suggests that progesterone plays the role of being a bone formation-stimulating hormone. Although supported, nothing is concrete as this hormone regulated by estrogen, thereby including multiple confounding variables (Wark, 1993). | + | |
| - | + | ||
| - | In males studies have been done linking bone mineral densities to testosterone levels. When comparing the estrogen level of males, the group of males with the highest levels had the highest bone mineral density, while the group of males with the lowest estrogen levels had the highest risk of a hip fracture. In contrast, when measuring levels of testosterone, there was no significant difference in hip fracture risk when looking at hypogonadal men versus eugonadal men. This supports the fact that the hormone estrogen plays more of a role in bone health in comparison to testosterone (Golds et al., 2017). | + | |
| ====== Treatments - Prevention & Management ====== | ====== Treatments - Prevention & Management ====== | ||
| Line 92: | Line 60: | ||
| Lastly, a healthy and physically active lifestyle is highly recommended for someone with osteoporosis, especially exercises involving the use of small weight. Some examples of exercises individuals can partake in are dancing, walking, jump rope, hiking, and stair climbing. These exercises can aid in increasing bone strength and stimulating bone growth. In addition, health practitioners recommend that individuals suffering from osteoporosis should avoid smoking and consume no more than two alcoholic drinks per day as both decrease bone density and increase fracture risk (NYU Langone Health, n.d.). | Lastly, a healthy and physically active lifestyle is highly recommended for someone with osteoporosis, especially exercises involving the use of small weight. Some examples of exercises individuals can partake in are dancing, walking, jump rope, hiking, and stair climbing. These exercises can aid in increasing bone strength and stimulating bone growth. In addition, health practitioners recommend that individuals suffering from osteoporosis should avoid smoking and consume no more than two alcoholic drinks per day as both decrease bone density and increase fracture risk (NYU Langone Health, n.d.). | ||
| + | |||
| + | ==== Methods of Prevention ==== | ||
| + | Beginning at a young age, it’s important to take steps to prevent osteoporosis. Some healthy practices/steps that can be taken include ("Osteoporosis", 2017): | ||
| + | * Healthy diet incorporating whole grain, fruits, and vegetables | ||
| + | * No smoking | ||
| + | * Avoiding the act of smoking can help maintain bone density, as non-smokers often have greater bone mineral density in comparison to smokers. | ||
| + | * Reducing caffeine consumption | ||
| + | * Calcium absorption can be negatively affected by excessive caffeine consumption. | ||
| + | * Reducing alcohol consumption | ||
| + | * The risk of developing osteoporosis can increase by drinking excessive amounts of alcohol. For this reason, alcohol consumption should be limited. | ||
| + | * Adequate intake of vitamin D | ||
| + | * Vitamin D is naturally obtained from sun exposure, but there are limits to intake as too much exposure to the sun is not safe. Vitamin D from sun exposure is also limited depending on geographical location, or an individuals skin type. However, Vitamin D aids in the absorption of calcium though diet, which is why it’s important to consume foods that have some quantity of Vitamin D, even if it’s a small amount. Some of these foods include eggs or fatty fish such as salmon. Vitamin D supplements can also be taken, as foods containing Vitamin D are often not enough to achieve the recommended intake. | ||
| + | * Eating food that’s rich in calcium | ||
| + | * Maintaining a diet rich in calc * Unordered List Itemium is vital to preserve bone density. This will ensure that the body is receiving calcium from the blood, rather than taking it away from bones, which will affect bone density. Some foods that are high in calcium include dairy products, almonds, spinach, and sardines. Calcium supplements are also an option if this is unattainable through diet. | ||
| + | * The recommended calcium intake for different age groups is: | ||
| + | * Children: 1,300 mg | ||
| + | * Adults: 1,000 mg | ||
| + | * Men or women over the age of 70: 1,300 mg | ||
| + | * Strength training and/or weight-bearing exercises | ||
| + | * Exercises that are weight bearing can help improve balance and reduce the likelihood of falls. Weight bearing exercises include dancing, jogging, walking or any activity that requires movement on your feet. Exercises that are not weight bearing include cycling or swimming. Strength (or resistance) training is also beneficial for bone health as they can help maintain bone mineral density. Muscle strength can also help with balance, posture, and coordination. | ||
| ====== Drugs and Medication ====== | ====== Drugs and Medication ====== | ||
| - | As of now, the most effective drugs for osteoporosis are antiresorptive agents, meaning they decrease the amount of calcium removed from bones. Since bones are dynamic and constantly being remodelled, and osteoporosis results when bone resorption is higher than bone rebuilding, these medications inhibit the removal of bone so bone rebuilding is favoured. Many antiresorptive agents are available including alendronate, risedronate, raloxifene and others (Lewiecki, 2004). | + | Osteoporosis used to be considered a sign of aging that was inevitable but can now be treated and prevented (Khosla & Hofbauer, 2017). Seeking treatment is recommended for individuals with osteoporosis as it can reduce the risk of fractures by almost 70% (Khosla & Hofbauer, 2017). Treatment is dependent on each individuals fracture risk and bone mineral density. To maximize positive outcomes, various forms of treatment are available that can be used in conjunction with healthy lifestyle and diet changes. |
| - | + | ||
| - | Bisphosphonates are a class of antiresorptive drugs that are used to decreases risks of fractures of hip, wrist, and spine. These class of drugs are all administered orally to reduce adverse side effects, and to enhance the absorption of the medicine. They are taken in the morning and are taken with water to increase absorption. They can also be administered intravenous to avoid possible stomach problems (Lewiecki, 2004). | + | Various treatment methods/drugs work to slow the naturally occurring process of bone loss by inhibiting osteoclast activity (Khosla & Hofbauer, 2017). These medications are considered **antiresorptive**: |
| - | + | * **Bisphosphonates** | |
| - | Alendronate (Fosamax) is an example of a bisphosphonate drug. It is effective treatment for postmenopausal osteoporosis as well as with glucocorticoid induced osteoporosis. This drug, similar to other bisphosphonates increases bone density and reduces various possible fractures. It is taken orally once a week for postmenopausal osteoporosis and is also the first drug used for increasing bone density in males with osteoporosis. This drug as all others does have a few side effects. This includes irritation of the esophagus or even inflammation of the esophagus. Differences in the chemical makeups of the other bisphosphonate drugs is what allows for certain side effects to be avoided (Gronholz, 2008). | + | * Examples: Alendronate, risedronate, ibandronate, zoledronic acid (Khosla & Hofbauer, 2017) |
| - | + | * Disadvantage: this drug can have rare side effects such as bone tissue death in the jaw area, atypical femur fractures, and atrial fibrillation (Khosla & Shane, 2016) | |
| - | Zoledronate (Reclast) is an intravenous administered bisphosphonate that is given once a year. It is able to effectively strengthen bones along with preventing both spinal and non-spinal fractures. As with all medications, side effects of this drug may result in muscle and joint aches, and so mild pain killers are given following treatment. This drug is used mainly to prevent postmenopausal osteoporosis and to increase bone mass in males suffering the disease (Gronholz, 2008). | + | * They are taken orally and are usually the first line of treatment. However they require users to take a break from treatment after 3-5 years of use to limit the risk of adverse effects (Khosla & Hofbauer, 2017) |
| + | * **Selective oestrogen receptor modulators (SERMs)** | ||
| + | * Raloxifene (Khosla & Hofbauer, 2017) | ||
| + | * **Denosumab** (Curtis, Moon, Dennison, Harvey, & Cooper, 2015) | ||
| + | * **Strontium ranelate** (Curtis et al., 2015) | ||
| + | There are also treatments that aid in bone formation, which are considered **anabolic** medications: | ||
| + | * **Teriparatide** | ||
| + | * Analogous to parathyroid hormone (PTH) which activates a pathway that is important to reduce the activation, proliferation, and maturation of osteoclasts (Khosla & Hofbauer, 2017) | ||
| + | * Treatment should be followed by the use of an antiresorptive to maintain bone density | ||
| ====== Conclusion ====== | ====== Conclusion ====== | ||
| - | Osteoporosis is set to become a major health concern with an ageing population. Scientists have identified human stem cells that develop into the bone, cartilage, and other tissues that make up the body’s skeleton (Price et al., 2018). This will one day help doctors repair or replace joint cartilage, heal broken bones more quickly, and build up bone in osteoporosis patients. Additionally, a new genetic screen may predict a person’s future risk of osteoporosis and bone fracture and may allow for more preventative measures (University of Stanford, 2018). | + | Although there are treatments available and preventative measures that can be taken, osteoporosis is still prevalent worldwide with severe health implications. With the course of aging, this condition results in significant bone loss that makes those at risk more susceptible to fractures and other negative health outcomes. There are treatment options available to help maintain or increase bone mineral density, while reducing the risk of fracture by minimizing bone loss. However, many of the most common forms of treatment can be associated with adverse side effects following prolonged use. Further research is required to determine more effective forms of treatment or therapy that would be beneficial in treating patients long-term, as well as minimizing side effects. |
| Line 114: | Line 110: | ||
| Christodoulou, C., & Cooper, C. (2003). What is osteoporosis?. Postgraduate medical journal, 79(929), 133-138. | Christodoulou, C., & Cooper, C. (2003). What is osteoporosis?. Postgraduate medical journal, 79(929), 133-138. | ||
| - | Garnero, P. (2008). Biomarkers for Osteoporosis Management. Molecular Diagnosis & Therapy, 12(3), 157–170. https://doi.org/10.1007/BF03256280 | + | Grant, S. (2015). November is Osteoporosis Month. Retrieved March 5, 2019, from http://www.proofofcare.com/2015/11/november-is-osteoporosis-month/ |
| - | Kling, J. M., Clarke, B. L., & Sandhu, N. P. (2014). Osteoporosis prevention, screening, and treatment: a review. Journal of Women’s Health (2002), 23(7), 563–572. https://doi.org/10.1089/jwh.2013.4611 | + | Iqbal, M. M. (2000). Osteoporosis: epidemiology, diagnosis, and treatment. Southern Medical Journal, 93(1), 2–18. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10653058 |
| + | |||
| + | Larsen, E. R., Mosekilde, L., & Foldspang, A. (2003). Vitamin D and Calcium Supplementation Prevents Osteoporotic Fractures in Elderly Community Dwelling Residents: A Pragmatic Population-Based 3-Year Intervention Study. Journal of Bone and Mineral Research, 19(3), 370–378. https://doi.org/10.1359/JBMR.0301240 | ||
| + | |||
| + | Melton, L. J. (2001). The Prevalence of Osteoporosis: Gender and Racial Comparison. https://doi.org/10.1007/s00223-001-1043-9 | ||
| + | Schettler, A. E., & Gustafson, E. M. (2004). Osteoporosis Prevention Starts in Adolescence. Journal of the American Academy of Nurse Practitioners, 16(7), 274–282. https://doi.org/10.1111/j.1745-7599.2004.tb00450.x | ||
| Minnis, G. (2016). Osteopeorosis Symptoms: Early and Late Stages. Retrieved from https://www.healthline.com/health/osteoporosis-symptoms#complications | Minnis, G. (2016). Osteopeorosis Symptoms: Early and Late Stages. Retrieved from https://www.healthline.com/health/osteoporosis-symptoms#complications | ||
| Morrison, W. (2016). Osteoporosis Causes: Remodeling, Balance, and Hormones. Retrieved from https://www.healthline.com/health/osteoporosis-causes | Morrison, W. (2016). Osteoporosis Causes: Remodeling, Balance, and Hormones. Retrieved from https://www.healthline.com/health/osteoporosis-causes | ||
| - | |||
| - | NYU Langone Health. (n.d.). Lifestyle Changes for Osteoporosis and Low Bone Mass. Retrieved March 3, 2019, from https://nyulangone.org/conditions/osteoporosis-low-bone-mass-in-adults/treatments/lifestyle-changes-for-osteoporosis-low-bone-mass | ||
| - | |||
| - | |||
