Osteoporosis

When you hear the word “osteoporosis," you may think of a little old Caucasian lady, feeble and hunched over a walker. But osteoporosis doesn't only happen to older Caucasian women. Osteoporosis occurs in women and men from all backgrounds. It can even happen when people are younger, if they have certain risk factors. We should all be concerned about osteoporosis and mindful of the things we can do to prevent it throughout our lives. After all, what we do today affects our bones today and tomorrow.

Osteoporosis means “porous bones." The disease occurs when the body makes too little or loses too much bone. Some bone cells deposit osteoid (called bone formation), and other bone cells begin to dissolve bone (called bone resorption). This process of making and losing bone cells is called bone remodeling and is a normal process designed to remove and replace bone damaged with day-to-day activities.

In people with osteoporosis, bone is lost faster than it is created. As a result, bones become weaker and break more easily. In extreme cases, bones can break with a force as light as a minor bump or sneeze.

Osteoporosis is common. According to the National Osteoporosis Foundation, about 54 million Americans have osteoporosis or low bone density that puts them at risk for the disease.

• One in two women and one in four men over 50 will break a bone due to osteoporosis.
• Breaks can occur in any bones, but the most common places for fractures are in the hips, spine, and wrist. These fractures can be serious.
• One in five older people die within one year of a hip break, with a higher rate of death among men than among women, usually from complications related to other pre-existing health conditions.

People who have osteoporosis of bones in the spine can experience loss of height, stooped posture, and chronic back and abdominal pain. Osteoporosis or low bone mass doesn't hurt, unless a person experiences a fracture, which makes early diagnosis difficult without specific testing.

Because it can limit mobility, osteoporosis can also lead to feelings of isolation and depression. Many people limit their activities after a break to try to prevent a future one.

Understanding your bones

You may think of your bones as hard and inactive, but they are important living tissues that are constantly adapting. Bones support your muscles and protect your organs. They also store 99 percent of your body's calcium.

At their healthiest, your bones are strong and dense, with many components. Bones are mostly made of collagen and hydroxyapatite.

• Collagen is a protein that provides the soft part of the framework.
• Hydroxyapatite is made up of the minerals calcium and phosphate, which make bones hard.

This combination of hard and soft makes bones strong yet flexible.

The process of bone remodeling happens throughout your life but changes as you age. From the time you are born until age 25 or 30, you make more bone than you break down. Your bones reach their peak density at age 30--called peak bone mass. Your peak bone mass happens as a result of your nutrition, physical activity, genetics, and hormones. The more you can do to boost bone health in these younger years, the healthier your bones will be later in life.

Around age 30, the rate of bone formation starts to slow down. During perimenopause and for a few years after menopause, you lose bone quickly. In fact, you can lose up to 20 percent of your bone mass in the first five to seven years after menopause. Bone loss may slow a little after this point. Certain lifestyle factors, such as diet, lack of exercise, smoking, and alcohol consumption, as well as some health conditions or their treatments can increase the rate of bone loss.

Risk factors for osteoporosis

There are several risk factors for osteoporosis, some within your control and some not.

• Cigarette smoking
• Age over 65
• Weight under 127 pounds
• Personal history of fracture as an adult
• Family history of osteoporosis
• Caucasian or Asian ethnic backgrounds, but African Americans and Hispanic Americans are also at risk
• Early menopause (before age 45), either spontaneous or due to surgical removal or ovaries
• Estrogen loss caused by menopause, certain medical conditions such as athlete energy imbalance or anorexia nervosa, and treatment with medications that lower estrogen levels (such as to treat breast cancer)
• Chronic health conditions
• Medications such as oral steroids, chemotherapy, seizure medicine, heparin, lithium, and thyroid replacement therapy
• Going one year without a period in the pre-menopausal years
• Excess alcohol consumption. ("Moderate drinking" for women and older people is defined by the National Institute on Alcohol Abuse and Alcoholism as one drink per day—one drink equals: a 12-ounce bottle of beer (5 percent alcohol), one 5-ounce glass of wine (12 percent alcohol), or 1.5 ounces of 80-proof distilled spirits. Moderate drinking may be considered safe. Drinking more can harm your health.)
• Low calcium or vitamin D intake
• Sedentary lifestyle

Menopause is one risk factor for osteoporosis that affects all women. The hormone estrogen helps keep bones healthy and strong by helping to control the cells that remove bone. When estrogen levels drop due to natural or surgical menopause or related to medications or some health conditions, women lose bone density faster than they did before. In fact, in the five to 10 years following menopause, women can lose up to one-third of their bone density. This age-related bone density decline happens to men, too, also primarily related to loss of sex hormones.

As mentioned earlier, certain medical conditions can also put you at increased risk for osteoporosis, including:

• Autoimmune/inflammatory disorders, such as rheumatoid arthritis or inflammatory bowel disease
• Digestive problems
• Certain blood disorders
• Cancer
• Type 1 diabetes and other endocrine disorders
• Eating disorders
• Chronic kidney disease
• Adrenal disease
• Liver disease
• Thyroid problems
• Pituitary tumor

Symptoms

Because people with osteoporosis cannot feel their bones weakening, it is often called a “silent disease." Some people with osteoporosis don't know they have it until they break a bone or notice they are getting shorter or have a more hunched posture. If you experience loss in height or notice new back pain that does not improve, speak with your health care professional. If you are treated for a broken bone, make sure that your primary care provider is aware, so he or she can assess your bone health.

While a bone break that occurs with minimal or no trauma may cause concern about osteoporosis, the diagnosis can only be confirmed with a bone mineral density (BMD) test. A BMD test should be obtained after a break or if you have symptoms of bone loss in your spine, such as loss of height.

Even if you have not broken a bone, the National Osteoporosis Foundation (NOF) also recommends a BMD test if:

• You are a woman and are 65 years old or older (70 or older for men)
• You are menopausal and have other risk factors for osteoporosis
• You are post-menopausal, younger than 65, and have other risk factors
• You have rheumatoid arthritis
• You are taking corticosteroids

Also called a bone mass measurement test, a BMD test is painless and safe. It uses a special machine called a dual energy x-ray absorptiometry (DXA) to examine bone density and exposes you to radiation at the level of a chest x-ray. The test takes less than 15 minutes and is painless and non-invasive. The NOF recommends a DXA scan of the hip and spine (or the wrist if needed). These are the areas that lose bone mass more quickly, and bone loss in these areas can be early indicators of the development of osteoporosis.

The BMD test measures the amount of mineral present in certain areas of the bones and compares that to the amount of mineral that is estimated to be present during a period of peak bone mass. The result of the test is called a "T-score." It is important for you to ask your health care professional what your T-score is, just as you know your most recent weight or blood pressure. The T-score is determined based on your sex, as men and women have different levels of peak bone mass. If you are transgender, it is important for your bone density measurement to be calculated based on your sex at birth, rather than your current gender, as that gives the most accurate view of your bone health.

Here are the current treatment guidelines based on T-scores for women and men age 50 or older:

• -0.1 or above (normal bone density): you probably don't need to take medication
• Between -1.0 and -2.5 (low bone density or ostopenia): you should think about taking an osteoporosis medication, especially if you have certain risk factors
• -2.5 or below (osteoporosis): you should consider taking an osteoporosis medication.

You don't have to have osteoporosis to be at higher risk of a broken bone. People with osteopenia can still fracture a bone with minimal or no trauma.

In addition, there are screening tests – called peripheral bone density tests - that look at bone density in the wrist, finger, heel, and lower arm. These tests can help determine if you may benefit from a BMD test. These tests include:

• pDXA: Peripheral dual energy x-ray absorptiometry
• QUS: Quantitative ultrasound
• pQCT: Peripheral quantitative computed tomography

QUS is sometimes done at health fairs. Peripheral bone density tests cannot accurately diagnose osteoporosis or help guide treatment. If you have one of these tests, follow up with your health care provider to see if you will need additional tests.

In addition to a BMD test, your healthcare professional may order laboratory tests to rule out other conditions that may be contributing to bone loss. The most common test is 25-hydroxyvitamin D, which determines if the body has enough vitamin D. If your bone loss does not seem to be related to loss of sex hormones, other health conditions, or low vitamin D level, your provider may order additional tests such as:

• Complete blood cell count
• Blood chemistries to assess kidney and liver function
• Blood and urine calcium levels
• Thyroid function tests
• Parathyroid hormone levels
• Biochemical marker tests, such as CTX and NTX
• Serum immune or protein electrophoresis

With the results of your BMD test and any labs, your provider will make suggestions on what you can do to keep your bones as healthy as possible. When choosing the right treatment, your provider will look at your risk factors for low bone mass, your medical history, your current health, and the likelihood that you will break a bone.

To help you and your health care provider make the best decision about your treatment, there is an online risk assessment tool that can help. Called FRAX, the tool calculates your absolute fracture risk and estimates your chances of breaking a bone in the next 10 years.

Preventing osteoporosis starts in childhood, when physical activity and a healthy diet rich in calcium, vitamin D, and sufficient calories build strong bones. These need to be continued throughout life, while also avoiding smoking and limiting alcohol intake.

Lifestyle approaches

A healthy lifestyle goes a long way in preventing and helping to treat osteoporosis. Here are some things you can do:

Calcium and vitamin D. Calcium provides the strength to bone. Your body's supply of calcium, needed in all areas of the body, is primarily stored in bone. If your calcium intake is low, your body may remove it from bone so it can get to other areas where it is needed. If you can, it's always best to get most of your calcium from food, because it decreases the risk of calcium building up in the arteries in your heart. Good sources of calcium include:

• Dairy products (including low fat or nonfat), such as milk, yogurt and cheese. Three eight-ounce glasses of milk plus calcium from a normal diet will meet daily calcium needs.
• Dark green, leafy vegetables such as broccoli, collard greens, bok choy and spinach
• Sardines and salmon with bones
• Soymilk that is supplemented with calcium
• Almonds
• Calcium-fortified foods and beverages such as orange juice, cereals and breads
• Non-fat dried milk (add a tablespoon to recipes for an instant 50 mg of calcium)

You can add more calcium with supplements, which come in pills, chewable tablets, and liquid. Calcium citrate and calcium carbonate are the best forms. Talk to your health care provider about the best form for you. Calcium carbonate is best absorbed when taken with food. Aim for 1,000 mg calcium, depending on your age, in food and supplements each day.

Vitamin D helps your body absorb calcium and strengthens your muscles so you can avoid falls. You can get vitamin D from food, supplements, and the sun. It's harder to get vitamin D from food or the sun (especially if you are over the age of 50 or you use sunscreen), so you will likely have to take a supplement to get the amount you need. Food sources include:

• wild-caught tuna, mackerel, and salmon
• fortified orange juice
• fortified soy or almond milk
• fortified cereals

In terms of supplements, check the other drugs and supplements you take to see if they contain vitamin D, and if so, how much. Then dose any extra vitamin D supplements based on this amount. Both of the vitamin D supplements available—vitamin D 2 (ergocalciferol) and vitamin D3 (cholecalciferol)--are good for bone health.

• If you are under age 50, you need 400 to 800 IUs of vitamin D per day.
• If you are 50 or older, aim for 800 to 1,000 IU.

If you have kidney or liver disease, you may not be able to metabolize vitamin D appropriately. Talk with your healthcare professional about options to maintain your vitamin D levels.

Get your bones moving. Regular exercise helps strengthen your muscles and your bones. Research shows children and young adults who exercise achieve a greater peak bone mass than adults who are not active. Continuing to exercise when you are older will help maintain your bone mass.

In a 2014 study published in Osteoporosis International, researchers looked at the relationship between regular physical activity and hip bone density in middle-aged women. They found women who regularly walked or were physically active had higher density in their hip bones compared to women who were not active.

By exercising, you'll also boost your endurance and agility, which helps prevent falls.

The two most important types of exercise for bone health are muscle-strengthening and weight-bearing exercises.

Weight-bearing exercises include those you do upright against gravity, such as:

• Walking
• Running
• Dancing
• Hiking
• Aerobics
• Jumping rope
• Tennis
• Climbing stairs.

Lower impact weight-bearing activities, such as walking on a treadmill or using an elliptical machine, also help. Swimming or water exercises and riding a bike maintain muscle strength and heart and lung conditioning, but they do not impact bone strength as much as weight-bearing exercises.

Muscle-strengthening exercises, also known as resistance exercise, include:

• Weight-lifting, using weight machines
• Engaging in body weight exercises, where you use your own body weight as resistance
• Using elastic exercise bands.

Stronger muscles help to prevent the falls that lead to broken bones in people with low bone mass. Functional movements, like standing and rising up on your toes and tai chi also help maintain your strength and balance and decrease the risk of falls.

Talk to your health care professional before you start any exercise program, especially if you've already been diagnosed with osteoporosis. Once you get the green light, aim for 30 minutes of moderate-intensity exercise (walking, light jogging, swimming) on most days of the week. Try to add muscle strength training two to three days a week.

Other things you can do:

Make your surroundings safer. Most fractures in older adults result from falls. So, by preventing falls, you may help to prevent fractures. To prevent falls, get rid of all tripping hazards, such as loose rugs, cords, and clutter. Install grab-bars in the bathroom and use a rubber mat in the shower. Put brighter lightbulbs in lamps and fixtures so you can see clearly. And avoid walking in socks.

Go for a garden. In one study of 3,310 women age 50 and older, gardening and other activities--raking, shoveling, and moving dirt and weeds with a wheelbarrow—helped reduce risk of osteoporosis. If gardening isn't your thing, try another active hobby, like rowing, hiking, or dancing, to help get your 30 minutes of activity per day.

Communicate with your provider. If you feel dizzy, confused, or anything else that makes you feel less steady on your feet, tell your health care provider right away. Keep in mind that some medicines, taken alone or with other medicines, can cause dizziness; be prepared to talk about the drugs you are taking with your provider or pharmacist.

Don't party like it's 1999. Avoid smoking and excess alcohol. The National Institute on Alcohol Abuse and Alcoholism defines "moderate drinking" for women and older people as one drink per day—one drink equals: 12-ounce bottle of beer (5 percent alcohol) , one 5-ounce glass of wine (12 percent alcohol) or 1.5 ounces of 80-proof distilled spirits. Moderate drinking is considered safe.

Medications

If your BMD test reveals you have low bone density or osteoporosis, work with your health care provider to come up with the best treatment plan for you. Treatment may include lifestyle changes and/or medication.

The overall goal of osteoporosis medicine is to restore a healthy balance between bone loss and bone building and ultimately, to prevent bones from breaking. There are two main categories of osteoporosis medicines—those that slow bone loss (antiresportives) and those that promote building of new bone (anabolics). Some medications are only approved for use in women after menopause.

Antiresorptives: Antiresorptive drugs work by slowing down the breakdown of bone. They include the bisphosphonates alendronate (Fosamax), Zoledronic acid (Reclast), and risedronate (Actonel and Atelvia); SERMs or estrogen agonist/antagonist (Raloxifene); and denosumab (Prolia and Xgeva). Estrogen is no longer used for the prevention or treatment of osteoporosis due to the risk of side effects and because more effective medication is available.

Anabolics: These drugs work on building bone so that the body builds more bone than it breaks down. The result is stronger bones that are less likely to fracture. Anabolic medications include teriparatide (Forteo), abaloparatide (Tymlos), and romosozumab-aqqg (Evenity).

The length of time you take osteoporosis medication depends on the drug. Some osteoporosis drugs stay in your bones after you stop taking them and others leave the body quickly. Your health care provider will recommend the most effective medication and treatment length for your individual needs. Discuss possible side effects of each drug with your health care professional, and weigh the risks of side effects compared with the risk of complications of a fracture related to low bone mass.

For some drugs, your health care provider may recommend a "drug holiday," where you take a break from treatment. When risk of fracture rises, you start taking the medicine once again or change to a different type of medication.

In extreme cases of bones affected by osteoporosis in the spine, a surgery called balloon kyphoplasty may be an option. This surgery involves injecting bone cement into the fractured bone to stabilize it and relieve pain. It has not been shown to decrease back pain in the long term, however.

1. The National Osteoporosis Foundation estimates as many as 54 million Americans have osteoporosis and low bone mass. Research shows about half of women and one-quarter of men will break a bone due to osteoporosis.
2. The number of fractures due to osteoporosis is expected to rise to more than three million by 2025, according to the National Osteoporosis Foundation.
3. An estimated 9 million osteoporosis-related fractures occur each year worldwide.
4. Fractures of the hip and spine increase mortality rate by 10 to 20 percent.
5. According to the International Osteoporosis Foundation, osteoporosis affects about 200 million women worldwide - approximately one-tenth of women aged 60, one-fifth of women aged 70, two-fifths of women aged 80 and two-thirds of women aged 90.
6. Menopause increases your risk for developing osteoporosis because your body's natural production of the hormone estrogen declines, and estrogen helps keep bones strong.
7. Smoking, drinking too much alcohol, and a having low body weight increase your risk for developing osteoporosis. Your risk for developing osteoporosis also rises if you don't exercise or if you exercise too much.
8. The combined lifetime risk for vertebral, hip, or forearm fractures is about 40 percent, the same as the risk for cardiovascular disease.
9. Fractures may limit mobility and lead to loss of independence, depression, and chronic pain.
10. There is no cure for osteoporosis. However, it is preventable and treatable. You can help prevent bone loss and fractures from osteoporosis with proper diet, exercise and when necessary, medication.

Review the following Questions to Ask about osteoporosis so you're prepared to discuss this important health issue with your health care professional.

1. Am I at risk for osteoporosis?
2. Do any of my medications increase my risk for developing osteoporosis?
3. What options are available to prevent or treat osteoporosis?
4. How can I tell if I have fractured a bone in my spine?
5. When and how often should I have a bone density scan?
6. How much calcium should I consume each day? How much vitamin D?
7. Do any of my medications interfere with calcium absorption?
8. Can I get my daily calcium needs from my diet?
9. If I have osteoporosis or low bone mass, is there anything I can do to help improve my bone health?
10. What kinds of exercise are best for me and how often should I exercise?

For information and support on coping with Osteoporosis, please see the recommended organizations, books and Spanish-language resources listed below.

American Academy of Orthopaedic Surgeons (AAOS)
Website: https://www.aaos.org
Address: 6300 North River Road
Rosemont, IL 60018
Phone: 847-823-7186

American Society for Bone and Mineral Research (ASBMR)
Website: https://www.asbmr.org
Address: 2025 M Street, NW, Suite 800
Washington, DC 20036
Phone: 202-367-1161
Email: asbmr@asbmr.org

Bone and Joint Decade
Website: https://www.usbjd.org/index.cfm
Address: 6300 North River Road
Rosemont, IL 60018
Phone: 847-384-4010
Email: usbjd@usbjd.org

International Osteoporosis Foundation
Osteoporosis Risk Check: https://www.iofbonehealth.org/whos-risk

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Website: https://www.niams.nih.gov
Address: National Institutes of Health
Bldg. 31, Room 4C02 31 Center Dr. - MSC 2350
Bethesda, MD 20892
Hotline: 1-877-22-NIAMS (1-877-226-4267)
Phone: 301-496-8190
Email: niamsinfo@mail.nih.gov

National Osteoporosis Foundation (NOF)
Website: https://www.nof.org
Address: 1232 22nd Street N.W.
Washington, DC 20037
Hotline: 1-800-231-4222
Phone: 202-223-2226

NIH Osteoporosis and Related Bone Diseases National Resource Center
Website: https://www.niams.nih.gov/Health_Info/bone/default.asp
Address: 2 AMS Circle
Bethesda, MD 20892
Hotline: 1-800-624-BONE
Phone: 202-223-0344
Email: niamsboneinfo@mail.nih.gov

Orthopaedic Research and Education Foundation (OREF)
Website: https://www.oref.org
Address: 6300 N. River Rd., Suite 700
Rosemont, IL 60018
Phone: 847-698-9980
Email: communications@oref.org

Books

Mind Over Menopause: The Complete Mind/Body Approach to Coping With Menopause
by Leslee Kagan, Herbert Benson, and Bruce Kessel

Osteoporosis Handbook: Every Woman's Guide To Prevention & Treatment
by Sydney Lou Bonnick

Better Bones, Better Body: Beyond Estrogen and Calcium
by Susan Brown, Susan E. Brown PhD, and Russell Jaffe MD

The Whole-Body Approach to Osteoporosis: How to Improve Bone Strength and Reduce Your Fracture Risk
by Keith Mccormick

Outwitting Osteoporosis: The Smart Woman's Guide To Bone Health
by Ronda Gates and Beverly Whipple

Smart Women, Strong Bones
by Ronda Gates and Dr. Beverly Whipple

Strong Women Stay Young
by Miriam Nelson and Sarah Wernick Ph.D.

Strong Women, Strong Bones: Everything You Need to Know to Prevent, Treat, and Beat Osteoporosis
by Miriam E. Nelson and Sarah Wernick

Walk Tall! An Exercise Program for the Prevention & Treatment of Osteoporosis
by Sara Meeks

Spanish-language resources

Medline Plus: Osteoporosis
Website: https://www.nlm.nih.gov/medlineplus/spanish/osteoporosis.html
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

National Osteoporosis Foundation
Website: https://huesosanos.org/
Address: 1150 17th Street NW, Suite 850
Washington, D.C. 20036
Hotline: 1-800-231-4222
Phone: 202-223-2226