People with rheumatoid arthritis (RA) have a greater-than-average risk of developing osteoporosis. Learn about the relationship between RA and osteoporosis, as well as ways to mitigate your own risks.
Rheumatoid arthritis (RA) is a chronic systemic illness. It affects the whole body, especially the joints. RA is also an autoimmune disease, which means that the immune system in the body, usually responsible for fighting off infections, instead begins to attack healthy tissue.
RA affects just over one million people in the United States; about 70% of them are women. Most people are between the ages of 30 and 50 when they are diagnosed with RA.
Inflammation, which is a major feature of rheumatoid arthritis contributes to joint pain and swelling, and cartilage damage, which then leads to erosion into the bone around the around the joint. Inflammation also affects bones, including contributing to the loss of bone mineralization. Bone mineralization is the ongoing process of absorption of minerals, and requires adequate intake of vitamin D, calcium and other nutrients – including iron, phosphorus and zinc – which are needed to build and maintain healthy bones. Inflammatory processes in the bone near the joints – as well as in bone erosions and large cysts around the joint – can decrease the mineral content of the bone. This can lead to the development of osteopenia (moderately low bone density) as well as osteoporosis (significantly low bone density).
Osteoporosis is a “silent” skeletal disorder caused by the loss of bone mineral content. It is marked by low bone mass and density, microscopic deterioration within the bone, an increase in bone fragility, and increasing risk of fracture. Osteoporosis occurs when your body makes too little bone (formation), loses too much bone (resorption), or a combination of both of these factors.
Bone is living tissue and even as adults, we are constantly remodeling our whole skeleton! In the normal bone growth cycle, our bodies continually:
The body tries to replace old bone that it has removed. However, the amount of bone replaced is reduced as we age and in people with certain diseases such as rheumatoid arthritis.
The good news is that we can do things to make bones healthier, stimulate bone formation and slow down bone remodeling. Bone remodeling is the body’s way of breaking down weak bone and rebuilding stronger bone. At around age 27 to 30, our bones are strongest and at peak mineral density. However, after this age, there is a slow and steady decline in bone strength, accompanied by an increased risk of developing osteopenia and osteoporosis.
According to estimates of the US Department of Health and Human Services (HHS) Healthy People 2020 Initiative:
At the same time, some young persons in their teens and twenties (particularly those with a history of bone fracture, eating disorders or excessive use of corticosteroid drugs), are also diagnosed with osteopenia and osteoporosis.
Although you can’t change the risk factors above, you can have some control over other risk factors. There are several bone-healthy lifestyle choices that can have a significant, positive impact.
For people with RA, the main treatment approach emphasizes controlling inflammation and preventing joint damage. There are other things you can do to reduce your risk of developing osteoporosis. These include:
The preferred approach now favors obtaining the calcium one needs through eating a healthy, well-balanced diet, and adding calcium supplements if needed to make up for any shortfalls. For postmenopausal women (who are most at risk for developing osteoporosis and fractures), the recommendations are for 1,200 mg per day of calcium. For premenopausal women and men, the recommendation is for 1,000 mg per day.
Good calcium-rich food sources include:
Below are daily requirements of calcium and vitamin D3 – from both diet (food sources) and dietary supplements.
Women
Premenopausal
1,000 mg calcium
600 international units vitamin D3
Postmenopausal
1,200 mg calcium
800 international units vitamin D3
Men
Up to age 70
1,000 mg calcium
600 international units vitamin D3
Over Age 71
1,200 mg calcium
800 international units vitamin D3
Supplemental calcium is best absorbed when taken in amounts of 500 mg to 600 mg or less, preferably with a meal.
It tends to be difficult to receive enough vitamin D through exposure to sunlight or food. Recommendations for vitamin D intake range from 600/800 international units to 1,000 international units per day. It is a good idea to have your doctor check your vitamin D level with annual blood tests.
Good sources of vitamin D-rich foods include:
Numerous studies have shown that bones like to be mechanically “loaded,” that is, engaged in weight-bearing activities that help the bones get stronger. Any activity that places force on the bone may increase your bone mineral density in your hip and spine.
Bone-loading/weight-bearing exercises include:
Studies have shown the benefits of exercise in the prevention of hip fracture in older women, and reduced overall occurrence of fractures in older adults. (Kemmler, 2013, Feskanish, 2002, Greg, 1998.)
Resistance exercises are also beneficial. Examples include resistance using stretch bands or light weights with multiple repetitions. Pilates is another example of a type of exercise that uses resistance of gravity. And practices such as yoga and T’ai chi have been shown to improve balance – helping to prevent falls and fractures.*
Individuals with RA are at increased risk of developing osteoporosis. Chronic inflammation associated with RA, medications used to treat the disease, particularly prednisone and other corticosteroid (“steroids”) drugs, all contribute to this risk.
In addition, inadequate intake or absorption of bone-building calcium, and less exercise due to fatigue and pain, may contribute to reduction in bone formation, bone mineral density loss – and increased risk of fractures. People with RA have a 30% higher rate of fractures due to osteoporosis than the average population, as well as a 40% increase in hip fractures, as well as loss of height and periodontal bone loss (loss of bone around the teeth in the jaw and skull).
Rheumatoid arthritis has an impact on bone mineralization. This is the body’s ability to absorb and make use of bone-building minerals, including calcium and phosphorous. People with RA may experience the following:
Since osteoporosis is a silent disease and is not associated with pain until you fracture a bone, it is important to have screening tests performed to look at the quality or mineralization of the bone.
Once one is diagnosed with osteoporosis or osteopenia, taking calcium alone is not adequate to restore bone density. Discussions with your healthcare provider will likely identify treatment options which include:
Loss of bone mineral density occurs naturally with the normal aging process. Rheumatoid arthritis and its treatment with corticosteroids can increase an individual’s chance of developing a low bone mineral state such as osteopenia or osteoporosis.
Screening tests to identify poor bone mineralization are important along with treatment with medications, if indicated. Conservative measures such as diet, supplements, exercises and fall prevention are all important to include in a bone-healthy lifestyle.
Original presentation date December 18, 2017, by Patricia Donohue, then the nurse practitioner in the HSS Osteoporosis and Metabolic Bone Health Center