Bones go through a constant state of loss and regrowth. The greatest time of bone growth is the year prior to your first period and the following 3 years. As a person ages, more bone loss than bone growth occurs. This can lead to osteoporosis. Then bone becomes thin, fragile and can fracture or break easily.
normal bone development
Bone is made up of calcium and protein. There are two types of bone—compact bone and spongy bone. Each bone in the body contains some of each type. Compact bone looks solid and hard and is found on the outer part of bones. Spongy bone is filled with holes, just like a sponge, and is found on the inside of bones. The first signs of osteoporosis are seen in bones that have a lot of spongy bone, such as the spine and hip.
Once made, bone is always changing. Old bone is removed in a process called resorption, and new bone is formed in a process called formation. From childhood until age 30 years, bone is formed faster than it is broken down. The bones become larger and denser. After age 30, the process begins to reverse: bone is broken down faster than it is made. This process continues for the rest of your life. A small amount of bone loss after age 35 years is normal in all women and men. Most of the time, it does not cause any problems. However, too much bone loss can result in osteoporosis.
a pediatric condition
what is osteoporosis?
With osteoporosis, bones become thin and brittle because more bone is lost than formed. Although the bones are still the same size, the outside walls of compact bone become thinner, and the holes in spongy bone become larger. These changes weaken the bone.
Osteoporosis poses a special threat to women. Estrogen—a female hormone—protects against bone loss. As a woman nears menopause, her body produces less estrogen. However, bone loss begins to happen long before menopause. Often, by the time symptoms of menopause occur, a great deal of bone loss has already occurred.
At least 10 million Americans—mostly women —are affected by osteoporosis, developing in 80% of women vs 20% of men. Each year, more than 1.5 million fractures related to osteoporosis occur in the US. One in two women older than 50 will have a fracture related to osteoporosis in their lifetime. Approximately 15% of the US population is at risk for disability or even death as a result of osteoporotic fractures.
what are signs & symptoms of osteoporosis?
loss of height
slight curving of upper back (dowager's hump)
what are risk factors?
Personal history of fracture
Family history of osteoporosis
History of falls
Diet low in calcium (lifelong)
Low body weight
Early menopause (<45 y/o)
Surgical removal of ovaries before menopause
Prolonged amenorrhea before menopause (more than 1 year)
Lack of exercise
Certain medications — proton pump inhibitors, anticonvulsants, immunosuppressant drugs (i.e. steroids), excessive thyroid hormone, blood thinners, lithium, certain anti-cancer medications
how to detect osteoporosis
You should have a physical exam once a year during which your height is measured.
Bone density test
All women aged 65 years and older or younger women who have had a bone fracture should be tested every 2 years. Testing also may be suggested for postmenopausal women younger than 65 years who have one or more risk factors for osteoporosis. A Bone Density Test can help determine whether you have osteoporosis and your risk of future fracture.
iIt is a good idea to get a baseline in your 50’s particularly if you are in menopause. However, your insurance may NOT COVER this test until you are 65. Please call them and ask if you have an “out-of-pocket” expense for CPT code 77085 before you have the test.
Bone Density Test
Dual-Energy X-ray Absorptiometry (DEXA) aka Bone Density Test
DEXA is used most often to measure the bone density of your spine and hip. It is currently the most accurate test available. During the test, you lie down for 3–10 minutes while an arm-like device (an imager) scans your body. With this test you are exposed to a very small amount of radiation, less than the amount in a normal chest X-ray.
After the test, you will be given a T-score. This is a standard deviation (SD)—a number that is calculated when your DEXA test results are compared to the average bone density of a healthy 30-year-old (when we reach our peak bone mass). A negative score means you have thinner bones than an average 30-year-old. A Z-score compares your value to a woman in your age group.
If your T-score is –1.0 or greater: your bone density is considered normal, no increase risk of fracture.
If your T-score is between –1.0 and –2.5, you have low bone density, known as osteopenia.
A score of -2.5 or lower defines osteoporosis.
For every one SD below peak bone mass, the risk of vertebral fracture is 2 times that of normal bone mass, and for the hip, the risk is 2.5 times.
Now...what can you do?
Regardless of your age and current bone status there are habits you can optimize NOW. For better or worse, you cannot change your genetics or the aging process but you can make changes now to maintain and perhaps improve the bone that you have.
eliminate bad habits
eliminate foods that deplete your micronutrients such as sugary beverages and other processed or sugary foods, particularly those containing high-fructose corn syrup, refined carbohydrates or refined vegetable oils, as well as artificial sweeteners. Eat foods in their whole form (usually those without labels or packaging).
maximize your nutrients through food sources. There are many micronutrients that contribute to bone health.
Calcium slows the rate of bone loss. If the amount of calcium in your bloodstream is too low, it will be taken from your bones to supply the rest of your body. Food sources of calcium are best. This includes dark leafy greens, dairy or dairy equivalents depending on your tolerability, as well as almonds.
Recommended daily intake of calcium is 1,000 mg for young women and 1,200–1,500 mg per day for women aged 51 years and older. If you cannot consume enough calcium in your diet then a supplement is recommended.
Data from the Women’s Health Initiative discovered that women who took 1,000 mg of calcium in the form of supplements had a 33% increased risk of heart attack! This association was not found with 500 mg doses of supplement. So try to get most of your calcium from your diet.
helps your body absorb calcium and also prevents weakness, which may lead to a fall and fracture. Recent data about vitamin D reveals its growing importance in bone health. The main source is from the sun but due to sunblock there is decreased production of D in our skin (but decreased skin cancer!).
Food sources are unpopular (oily fish and organ meats). 80% of people are deficient thus a supplement is highly recommended. You can have your blood levels checked with a 25-OH vitamin D test. You might need more than the RDA of 400-800 IU. Most of us need at least 1,000-2,000 IU of Vitamin D3 each day to reach optimal levels.
vitamin K2 plays a central role in the metabolism of calcium — the main mineral found in your bones and teeth. Vitamin K2 activates the calcium-binding actions of two proteins — matrix GLA protein and osteocalcin, which help to build and maintain bones
plays a role in calcium metabolism and may help to protect against osteoporosis. It is also known to have a stool softening effect. Magnesium glycinate is better absorbed and has less softening effect.
Recommended amounts are 400 mg per day. Food sources include dark leafy greens, nuts, seeds, avocados, and even dark chocolate
may positively affect the human skeleton as demonstrated in a recent study from researches at the University of Gothenburg, Sweden. Among older women who received probiotics (specifically a supplement containing Lactobacillus reuteri), bone loss was halved compared to women who only received a placebo.
Thus, adding a daily serving of plain whole milk yogurt or kefir provides probiotics as well as being a good dietary source of calcium!
Exercise increases bone mass before menopause and slows bone loss after menopause.
To help prevent bone loss, the exercise should be weight-bearing, so that your skeleton bears the burden of your body weight. Movement such as walking, running, also jumping, hopping and even dancing.
Resistance training which builds muscle is good for overall fitness.
Use 2-3 lb weights or resistance bands.
Exercise that improves balance will prevent falling such as Tai Chi or simply balancing on one foot at a time for 10 seconds, 10 times for each foot!
eliminate unhealthy habits
Smoking decreases estrogen which helps the bones absorb calcium as well as decreasing blood supply to the bones and other body tissues. Not to mention other negative health effects.
Excessive alcohol consumption often leads to poor nutrition, hormone deficiencies (elevated cortisol, your stress hormone, that decreases bone formation and decreased estrogen which helps with calcium uptake in the bones) as well as leads to poor balance leading to an increase risk of falling and subsequent fracture. Try to limit alcohol to not more than one standard beverage (12 oz beer, 5 oz glass of wine, 1 oz spirit) on any given day for overall health.
There are many treatment options available to help reduce the risk of fracture. Some are taken daily, while others are used weekly or monthly. There is also an option of getting a yearly injection. No matter what method you choose, the earlier treatment is started, the better it works.
Bisphosphonates (Fosamax, Boniva, Actonel, Reclast) are medications used to prevent and treat osteoporosis. In cases of prevention, they are used to slow bone breakdown. To treat osteoporosis, they are used to help increase bone density and reduce the risk of fractures. Long-term use is controversial!
Oral biphosphonates that are taken weekly. These medications when administered orally must be taken on an empty stomach. Although rare, side effects may include nausea, stomach pain, and digestive problems.
Take the tablet first thing in the morning before you have had anything to eat or drink. Swallow the tablet with plain water only. Do no chew or crush the tablet. After taking any oral biphosphonate wait one hour before: eating or drinking, lying down, taking other medications.
Boniva may be taken once a month as an oral medication or every 3 months as an injection. Injectable forms will have less GI effects.
Reclast is an infusion that is adminstered once a year. Since it is not taken orallyi t has less GI side effects. Hoever, side effects may include flu-like symptoms, headache, nausea, vomiting, diarrhea, joint, bone, or muscle pain.
selective estrogen receptor modulator
Selective estrogen receptor modulators (SERMs) help prevent or treat some of the bone problems that can occur during menopause. SERMs may be a good choice for women who need protection from osteoporosis, but cannot or do not want to take hormone therapy.
Evista (raloxifene) affects the cycle of bone formation and breakdown in the body, and reduces loss of bone tissue. It will also offer a preventative effect in breast cancer but may cause hot flashes or vaginal dryness.
Fosteum is a medical food that may be prescribed to treat osteoporosis. Fosteum contains genistein (a natural plant estrogen from soybeans), vitamin D, and zinc. This plant estrogen may help enhance bone health and reduce fracture risk. In addition to bone health, it is FDA approved to treat hot flashes.
Femarelle is derived from non-genetically engineered soy. It activates the estrogen to relieve menopausal symptoms and help prevent osteoporosis, but it won’t activate the estrogen where it’s not wanted, like in the breasts or the uterus. It is also beneficial in treating hot flashes and vaginal dryness
Starting estrogen at any time after menopause can help prevent bone loss.
Hormone replacement therapy (HRT) is NOT indicated for the treatment of osteoporosis, but it may be a good choice for women who also have symptoms of menopause. However, it only protects bones for as long as you use it. When you stop taking hormone therapy, bone loss resumes. You and your doctor should decide whether this treatment is right for you.
Prolia is a monoclonal antibody. It is generally reserved for women who cannot tolerate the bisphosphonates or the other osteoporosis medications did not work well.
It is administered as an injection given every 6 months.
Evenity is a new monoclonal antibody that blocks the effects of a protein called scleronin. Scleronin stops bone production and causes bone to break down. Evenity works by increasing bone formation.
Calcitonin is another class of drugs used for bone health. It works by slowing bone loss to help maintain strong bones and reduce the risk of fracture.
Forteo is indicated for postmenopausal women with osteoporosis at high risk of fracture. It is administered in a self-injectable pen for daily use.
Fortical is a calcitonin nasal spray.