•  Book Review: Strong Women, Strong Bones

If you thought that shrinking and stooped shoulders were an inevitable part of your golden years, there's good news. As it turns out, those phenomena are due to a bone disease called osteoporosis -- and it's preventable.

Osteoporosis is a thinning and weakening of the bones that strikes many women after menopause, as well as some elderly men. The disease makes your bones much more likely to break or fracture if you fall down or suffer an injury which otherwise would have been minor. An estimated 2 million fractures -- primarily of the hip, spine (vertebrae) and wrist -- occur in elderly people with osteoporosis each year.

According to the National Osteoporosis Foundation, around 44 million Americans either have osteoporosis or have low enough bone mass that they're at risk for the disease. For women, the disease usually begins to set in after menopause when estrogen production slows. Studies have shown that slender women as well as white and Asian women are at greater risk than others.

Your body has been breaking down and building up bone mass throughout your life. In this process of regeneration, your body creates a "new" skeleton every five years. As you get older, the building-up part of the process slows down, and after your mid-thirties it becomes easier to lose bone than to build it. Sometime in your 40s or 50s, you gradually start to lose more bone mass than your body produces. This is especially true if your body lacks enough calcium, Vitamin D, and sex hormones like estrogen, all necessary in the making of bones.

"Osteoporosis" means "porous bones" in Latin, so named because the loss of mass makes your bones porous, brittle, fragile, and less dense.

Even though osteoporosis is more common than breast cancer among American women, most people won't discover they have it until they take a small tumble in their living room and end up breaking a hip, or until they try to lift something heavy and fracture a vertebra. Breaks and fractures of the hip, spine, and wrists are the most common symptom of the disease, though they can occur in any bone. Hip fractures are the most serious since they tend to heal slowly, cause severe physical pain, and result in longlasting or permanent disability. While recovering, people may also fall prey to blood clots or pneumonia, and many older people also suffer psychologically due to the accompanying loss of independence.

Losing your height is one of the earliest signs of osteoporosis, though you may not even notice it at first. This shrinkage is caused by tiny (usually painless and undetected) fractures in the vertebrae. Extreme fractures may cause back pain and even kyphosis, the curvature of the spine that results in a "hump" back.

No, not necessarily. The discs between your vertebrae naturally shrink as you get older, so some height loss (about a half inch to one inch) is normal. If you've lost more than an inch, however, the culprit is probably osteoporosis and you should ask your doctor about getting a bone mineral density (BMD) test.

Sometimes. Back pain is often caused by some sort of muscle strain or arthritis. Osteoporosis, however, can cause vertebral fractures in the lower back that sometimes produce acute pain, typically lasting about a week, or a longer-lasting dull lower back pain.

According to the National Osteoporosis Foundation (NOF), women are considered at high risk for the disease if they have low body weight, a low calcium intake, poor health, or a history of osteoporosis in their immediate family.

Alcohol abuse, smoking, and high caffeine intake are also thought to significantly increase the risk of osteoporosis. Women who have had amenorrhea (absence of menstrual periods) and/or undergo early menopause can also be at higher risk, due to insufficient estrogen.

People who suffer from anorexia nervosa, an eating disorder that is most often found in young women, are at increased risk of osteoporosis due to low levels of estrogen (resulting from amenorrhea) and poor nutrition. Some young female athletes who exercise to excess and eat very little in order to keep their weight at a competitive level may develop Female Athlete Triad - a condition first recognized by the American College of Sports Medicine in the early 1990's. Female Athlete Triad is characterized by amenorrhea, disordered eating, and osteoporosis.

Risk factors specific to men include low testosterone levels or poor health, as well as those who take corticosteroid drugs. Diseases that prevent the body's ability to absorb calcium, like kidney or thyroid gland diseases (hyperthyroidism), can also lead to osteoporosis. Like women, men are more likely to have osteoporosis if they smoke, drink excessive amounts of alcohol, have a sedentary lifestyle, and are older. Of all men, white men are at greatest risk for the disease.

By a bone mineral density test, which will also tell your doctor how advanced the disease is. About 20 years ago doctors used regular X-rays to look for osteoporosis, but they could pick up changes only after a 25 to 40 percent drop in bone density -- by which time the disease is already far advanced. But today machines called densitometers, which expose you to only one fiftieth the radiation you'd get in a chest X-ray, can detect as little as a one percent bone loss.

The most accurate test for osteoporosis is called the dual-energy X-ray absorptiometry (DXA), which measures bone density in your spine and hip. The DXA test will produce a "T-score" for your bones: +1 to -1 is normal; -1 to -2.5 is considered low; and below -2.5 is regarded as osteoporosis. The National Osteoporosis Foundation recommends treatment for postmenopausal women and men age 50 and older with a T-score of -1 to -2.5 or below, who also have a fracture probability of 20 percent or greater (3 percent or greater for a hip fracture). The procedure can be expensive (up to $150) but is covered by Medicare and many insurance companies if certain criteria are met -- that is, if you're considered at high risk for osteoporosis.

Yes. Mini-versions of the densitometer, called pDXAs, measure bone density in the forearm, finger, and sometimes the heel of the foot. This and other tests that measure bone density at the heel are less expensive than the DXA, but they are also less accurate. They may not give the best indication of fracture risk at the hip and other sites, for example, so it's possible that you might get a false sense of security from a good reading.

In addition, heel ultrasounds, sometimes available in pharmacies, will not work for men because they don't use a male database. A man's score would be compared to a reference population consisting of women, so according to the Tufts University Health and Nutrition Letter, the measurement would be worthless. Because the less expensive tests may not give an accurate picture of overall bone density in men or women, your health provider is likely to recommend the DXA, which is considered the gold standard of osteoporosis testing.

Some physicians recommend that all women be screened at menopause, when bone loss rises sharply; if a woman's bones are healthy, they say, she should be screened again four years later. The US Preventive Task Force sys that women who weigh less than 154 pounds, or who don't take supplemental estrogen, should be screened for osteoporosis beginning at age 60. The task force also recommended that women who don't fit these descriptions should be screened regularly beginning at age 65.

The NOF recommends that the following people get a BMD test:

•All women over 65

•Postmenopausal women under 65 who present one or more risk factors for the disease

•Postmenopausal women under 65 who have broken or fractured a bone

Some physicians also recommend testing for elderly men if they have fractured a bone, are in poor health, or have low testosterone levels.

Prevention is key, but there's a great deal you can do to keep from losing more bone and to increase your low bone density.

Men with osteoporosis will be advised to exercise and increase calcium and Vitamin D in their diets (see below). Women, who are often more severely affected by the disease, will get the same advice, and one of the following drug treatments may be recommended as well.

•Bisphosphonates (brand names Fosomax, Actonel): These drugs reduce bone loss, increase bone density, and reduce the risk of fractures.

•Calcitonin (brand names Miacalcin, Calcimar, Fortical): These drugs are given to postmenopausal women to slow bone loss, increase spinal bone density and reduce the risk of spinal fractures.

•Raloxifene (brand name Evista): This drug offers estrogen-like benefits to bone.

•Parathyroid Hormone (Brand name Fortéo): This drug is given to postmenopausal women and men who are at high risk for a fracture. It stimulates new bone formation and increases bone density.

Be sure to talk to your doctor about the benefits and risks of each therapy, so that together you can choose the one that's best for you.

In three words: change your lifestyle. As with most health issues, diet and exercise are the key to getting and staying healthy. Here are some tips:

•Watch your weight. Try to put on some pounds if you're underweight.

•Diet. You need a diet rich in both calcium and Vitamin D, which helps your body absorb calcium and build strong bones. Experts recommend that men and women under 50 consume at least 1,000 mg (many say 1,200 mg) of calcium per day. People over 50 should consume 1,200 mg. The Institute of Medicine recommends that people older than 50 get 400 to 600 IU of vitamin D every day, but a 2005 statement by a US medical group says that's not enough. An expert panel convened by the American Medical Women's Association found that many older Americans are deficient in vitamin D. The panel recommends 800 to 1,000 IU of vitamin D for anyone over the age of 50. The best option is to get the nutrients naturally. For calcium, eat dairy products and green leafy vegetables; for vitamin D, seek out fortified products (like milk and cereal) or foods naturally rich in vitamin D like eggs and salmon.

•Get some sunshine. Sunlight also gives us vitamin D, so try to get at least 10 to 15 minutes of direct early morning or late afternoon sunlight on your face and arms three times a week. If you can't get all of the right nutrients naturally, you can take calcium and vitamin D supplements.

•Exercise. Experts recommend regular "weight-bearing" exercise (in which your feet and legs bear the weight of your body), such as walking, running, stair climbing, or dancing. This type of exercise can slightly improve your bone density and also gives you strength, agility and balance which will help you avoid falls. Nonweight-bearing exercises (like swimming or biking) will help build muscle but should be accompanied by a weight-bearing exercise for your bones as well. Weightlifting twice a week also helps prevent bone loss and may even increase bone density slightly, and can be started at almost any age.

•Cut down on bad habits. Don't smoke tobacco, cut down caffeine intake and drink alcohol only in moderation. All these substances have been linked to osteoporosis.

Just remember that your bones aren't as strong as they used to be, even if your muscles are. Falls are especially dangerous for people with osteoporosis. Here are some ways to prevent injury:

•Don't lift heavy objects.

•Don't overdo the exercise; start an exercise program like walking slowly and gradually build up speed and distance.

•Wear good shoes: no heels or slippery soles.

•Don't let your pride get in the way of using a cane or walker if it helps you.

•Have handrails installed on stairways.

•Try to avoid icy, wet and slippery surfaces; use nonslip mats and have grab bars installed in the bathroom.

•Take care of your vision so you can better avoid falls; get a new prescription for your glasses if necessary.

•Use bright lamps and night-lights.

•Don't use throw rugs; keep your floors uncluttered to help avoid falls.

•Put more phone extensions around the house so you don't have to walk as far to get the phone.

The National Osteoporosis Foundation has a Web page (http://www.nof.org). A book by Nancy E. Lane, MD at University of California at San Francisco, explains the disease in laypeople's terms: The Osteoporosis Book: A Guide for Patients and Their Families, 2001, Oxford University Press.

-- Paige Bierma is a health and medical writer who has contributed to Hippocrates, Safety + Health magazine, and Vibe. Chris Woolston, MS, is a health and medical writer with a master's degree in biology. He is a contributing editor at Consumer Health Interactive, and was the staff writer at Hippocrates, a magazine for physicians. He has also covered science issues for Time Inc. Health, WebMD, and the Chronicle of Higher Education.

References

First published September 13, 1999
Last updated August 12, 2008
Copyright © 1999 Consumer Health Interactive

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