Osteopenia

What is osteopenia?

Osteopenia is a condition that begins when your bones start to lose mass, weakening the state of the bones. Bone mineral density (BMD) measures lower than average (for a young healthy woman), but is not quite as low as in someone with osteoporosis. Still, with osteopenia, the bones lose calcium and become porous and weak, making one more vulnerable to fractures. Osteopenia does not cause symptoms, but it can be a precursor to osteoporosis (Medical News Today, 2019). While it doesn’t always develop into osteoporosis, it’s important to address osteopenia immediately to prevent further decline in bone mass. 

Osteopenia is very common. In the US, there are more than 3 million people each year who are found to have osteopenia. Around half of all people in the United States over the age of 50 have osteopenia (Medical News Today, 2019). Because there are so many people with osteopenia, the majority of fractures occur in people with osteopenia, not osteoporosis. People who have adulthood fractures with a BMD in the osteopenia range can be considered to meet criteria for the clinical diagnosis of osteoporosis even if their T-score is not -2.5 or below.

If you have been diagnosed with osteopenia, it’s important to work closely with your doctor and other medical professionals to ensure that you receive proper treatment and guidance to strengthen your bones and prevent further decline. You may be able to treat osteopenia and prevent osteoporosis with lifestyle adjustments alone. However, treatment recommendations need to take account of your age, your actual BMD within the osteopenia category and other risk factors; in some cases, medication may also be indicated.

Causes

Osteopenia may be a function of your underlying genetics and bone size.  Some people already have osteopenia even at the time of peak bone mass (by the early 20s). Osteopenia can also occur when your bones lose more calcium than they accrue, leading to a weakening and a higher risk of fractures. Developing low bone mass or low bone density can be due to multiple risk factors, some of which are controllable, such as diet, exercise and lifestyle, and some of which are not, such as gender, family history, and ethnicity. Women, for example, are more likely to develop osteopenia than men, and certain medical conditions such as lupus, rheumatoid arthritis, and celiac disease can also increase one’s risk of developing osteopenia (Medical News Today, 2019). 

Why are women more susceptible to osteopenia than men?

• Bone size: Women have smaller bones than men, making them more vulnerable to later changes in bone mineral density and fractures.
• Body frame size: Smaller body frame size means smaller, more slender bones, which are already less dense and more prone to fracture.
• Menopause: During menopause, women experience a rapid decrease in the production of estrogen, a hormone that influences the function of bone cells such as osteocytes, osteoclasts and osteoblasts. This hormonal change contributes to decreased function of these cells and, in turn, a reduction in bone mineral density (Medical News Today, 2021).
  

Do certain medical conditions cause osteopenia?

Unfortunately, yes, certain medical conditions can predispose one to developing osteopenia. Medical conditions known to contribute to cause osteopenia include:

• Celiac disease
• Diabetes mellitus
• Lupus
• Multiple Sclerosis
• Overactive thyroid
• Rheumatoid arthritis
  

Can taking certain medications lead to osteopenia?

Some medications, such as antidepressants, anti-seizure medications, steroids, excess thyroid hormone, proton pump inhibitors, some diabetes medications and certain cancer drugs can also accelerate bone loss.

How does lifestyle affect one's chances of developing osteopenia?

• Vitamins: An individual is more susceptible to osteopenia if their diet lacks sufficient amounts of vitamin D and calcium (Karaguzel and Holick, 2010).
• Diet: A diet low in calcium and vitamin D can lead to a lack of calcium in the bones and reduced bone mineral density.
• Exercise levels: Those who live a more sedentary, inactive lifestyle are more likely to develop osteopenia. Certain exercises can help prevent bone loss associated with osteopenia.
• Alcohol and tobacco use:  Excessive alcohol consumption and smoking can interfere with calcium absorption, which causes the bones to weaken.
• Eating disorders: Eating disorders such as anorexia or bulimia are linked to a higher risk of developing osteoporosis and fractures due to reduced calcium intake, lower estrogen levels and smaller body frame size (International Osteoporosis Foundation, 2021).
• Infrequent menstruation (if not on contraception): Infrequent menstruation might be a sign of inadequate estrogen and a predictor of osteopenia or osteoporosis.
  

Symptoms

Osteopenia itself is not a disease and causes no symptoms. If you have osteopenia, it means your bone density is low compared to the average young woman. In this broad category, some women have a BMD which is close to normal and others have a BMD close to osteoporosis level. If you are in this latter group of women, any BMD decline with age could cause you to deteriorate into the osteoporosis range.

The risk of having fractures is higher in women who have BMD in the osteoporosis range but many people with osteopenia will also have fractures or broken bones. If you have a fracture, even if your BMD is in the osteopenia range, rather than the osteoporosis range, you are usually considered to have osteoporosis. In that case, the fracture is an even more important sign of osteoporosis than the BMD itself.

Diagnosis and testing

Bones are constantly being broken down and remodeled by the body, with significant bone loss typically happening painlessly and gradually over time. A screening test for osteopenia is usually done if you are a woman over 65 or if you are a postmenopausal woman of any age with risk factors for developing osteopenia.

A complete assessment for osteopenia will include a comprehensive medical history and physical examination to evaluate fracture history, falls risk and look for subtle evidence of vertebral fracture. Another essential piece of information is the bone mineral density (BMD) test, which is the best way to diagnose osteopenia. BMD tests are safe, fast, noninvasive and painless. They are associated with minimal radiation exposure, similar to flying from NY to Denver (International Osteoporosis Foundation, 2021).

While there are many types of bone mineral density tests, the most commonly used test is a DXA test which stands for dual x-ray absorptiometry test. The DXA test is capable of detecting very small percentages of bone loss. Results come in the form of a T-score.

Your T-score shows how much your bone mass differs from the bone mass of an average healthy adult in their twenties and is measured in standard deviations. This helps determine whether your bone mass is in a normal range (a T-score of -1 or higher), or if you have osteopenia (a T-score between -1 and -2.5), or if you have osteoporosis (a T-score of -2.5 or lower) (International Osteoporosis Foundation, 2021).

Treatment 

There is no “cure” for osteopenia but the disease can often be “put into remission” with the powerful medications we currently have available. Still, the easiest approach is to prevent osteopenia from developing or progressing by incorporating regular weight-bearing and resistance exercises into your lifestyle and eating a well-balanced, nutritious diet with the recommended daily allowances of calcium, protein and fruits and vegetables. However, if you are diagnosed with osteopenia and require medical treatment, there are many effective options to reduce progression and rebuild bone.

Your risk profile (how high-risk you are for fractures) will determine the best treatment option for you. Those who are at a high risk of fractures will likely be prescribed medication and supplements. Those at a lower risk may benefit from exercise and dietary changes alone.

There are two main types of drug treatments for osteopenia: antiresorptive agents, which help reduce bone breakdown, thus preserving bone mineral density; and anabolic agents, which stimulate bone formation, thereby increasing bone mineral density and repairing structural damage. Drug treatments have been shown to reduce the risk of hip fracture by up to 40%, vertebral fractures by up to 90%, and non-vertebral fractures by up to 50%. However these effective options can also be associated with some side effects. Decisions about osteopenia treatment require an assessment of risks and benefits and determining the balance for each individual patient  (International Osteoporosis Foundation, 2021).

It’s important to note that risk factors, nutrition, exercise, allergies and medical history, are important to consider when determining the best treatment for you. Be sure to have an in-depth conversation with your doctor before initiating a drug treatment plan for osteopenia.

Medications used to treat osteopenia

Antiresorptive Agents (reduce bone breakdown):

• Bisphosphonates (alendronate, risedronate, ibandronate, zoledronic acid)
• Conjugated Estrogen with Bazedoxifene
• Denosumab
• Hormone and Estrogen Therapy
• Raloxifene

Anabolic Agents (build bone tissue):

• Abaloparatide
• Romosozumab
• Teriparatide

Vitamins and supplements

• Calcium and vitamin D supplements can be prescribed alone or with some of the drugs listed above to ensure maximum effectiveness of the medication.
  

Exercises for osteopenia

• Weight-bearing exercises: Weight-bearing exercises such as walking, hiking and dancing are crucial for maintaining strong bones.
• Strength-training exercises: It is important to include regular strength training that incorporates resistance exercises for progressive loading of the muscles that will lead to physiologic changes in bone strength. Resistance can be added using elastic bands, free weights or weight machines.
• Core exercises: Core exercises are important for protecting the spine and extremities from injury. Your core is your foundation for all other exercises and it will help you with preventing falls and excessive twisting or bending of the spine, which could lead to fractures in people with osteopenia or osteoporosis.
• Balance, flexibility, and posture exercises: Exercises that improve balance, flexibility and posture are all critical for preventing falls, which could result in multiple fractures or catastrophic injuries for people with osteopenia.

Nutrition

Proper nutrition is key to giving your body the nutrients it needs to build and maintain strong and healthy bones. By incorporating the right vitamins and minerals into your diet (along with exercise), you may be able to keep osteopenia from progressing to osteoporosis. Here is what women over 50 years old should include in their diet, according to the Bone Health and Osteoporosis Foundation:

Calcium (1,200 mg/day)

• Dairy products (milk, yogurt and cheese)
• Dark leafy green vegetables
• Canned salmon or sardines with bones
• Enriched soy products, such as tofu
• Calcium fortified cereals and orange juice

Vitamin D (800-1,000 IU/day)

• Vitamin D fortified milk and cereal
• Cod liver oil, trout and salmon

Vitamins C, K and B12

• These vitamins can be found in leafy vegetables and fruits
• Aim for 1 cup of fruits and 1 cup of vegetables daily

Protein

• Protein consumption is important for building and maintain muscle which can contribute to increased bone mass.
• Aim for 1 cup of lean protein daily (beans, fish, milk or yogurt)

Foods to limit if you have osteopenia

While it is important to know which foods you should include in your diet for bone health, it is also important to consider which foods you should limit in your diet.

• Caffeine: According to the International Osteoporosis Foundation, caffeine increases urinary and fecal calcium loss. When combined with low calcium intake, this can impair the body’s ability to build strong bones.
• Alcohol: Frequent, heavy alcohol consumption is linked to low bone density, increased risk of bone fractures, and slower healing.
• Red meat: When too much animal protein is ingested, an excess of acid is produced in the body. The body buffers this reaction by halting the bones from absorbing calcium.
• Salt: When salt is eaten in excess, it encourages the excretion of calcium from your body. Too much sodium in the bloodstream will cause the body to excrete the sodium, and calcium is lost with it.
• Wheat bran: Wheat bran is one of the three parts that make up the grain. Although wheat bran has many health benefits, it is high in phytates, which decrease calcium absorption. Getting enough calcium in the diet will overcome the effect of phytates on calcium absorption.
• Legumes: Legumes are foods such as lentils, peas, and beans. These foods are high in calcium and magnesium, which are good for strong bones. However, they also contain phytates which, as mentioned earlier, decrease calcium absorption in the body. Getting enough calcium in the diet will overcome the effect of phytates on calcium absorption.
  

Working with medical professionals

After being diagnosed with osteopenia, it is important to have regular conversations with your doctor and other medical professionals to make sure you are making the right lifestyle, exercise and diet adjustments to prevent your osteopenia from developing into osteoporosis.

Meeting with a medical professional will help determine if you are a good candidate for any osteopenia medications or supplements, and which are the best for your body.

Prevention

Osteopenia cannot be reversed, which is why it is so important to focus on prevention to reduce the probability of developing osteopenia and cut the risk for developing osteoporosis. While some risk factors are not in our control such as family history and gender, and some are. By focusing on the controllable risk factors, you may be able to alter the probability of developing osteopenia. 

Prevention and treatment of osteopenia are often similar. Below you’ll find a list of adjustable dietary and lifestyle factors that will help you prevent osteopenia from developing or progressing:

Vitamins

• Vitamin D: Helps your body absorb dietary calcium (International Osteoporosis Foundation, 2022).
• Calcium: Key structural component of bone (International Osteoporosis Foundation, 2022). 
• Protein: Important for optimal bone mass and preserving muscle and bone mass throughout aging (International Osteoporosis Foundation, 2022).
• Potassium: Required to make osteocalcin, the second most abundant protein in bone after collagen (International Osteoporosis Foundation, 2022).
• Vitamin B: Deficiency in vitamin B12 may increase risk of developing sarcopenia, the age related decrease in muscle mass and a possible precursor to osteoporosis (Ates Bulut, 2017).
  

Nutrition

Proper nutrition is key to maintaining strong bones. It’s important to have adequate dietary intake of key nutrients such as calcium, protein and vitamin D to prevent the risk of developing osteopenia and experiencing fractures. While the recommended intake of each nutrient varies across the gender and age, they maintain an important role in musculoskeletal health throughout the lifespan (International Osteoporosis Foundation, 2022).

• Malnutrition: Malnutrition is more prevalent in older adults and can have negative health consequences including making one at higher risk for osteoporosis and fractures (International Osteoporosis Foundation, 2022).
• Alcohol: Excessive alcohol intake will negatively impact one’s risk of developing osteoporosis. Adults who consume 2 or more units of alcohol per day are at higher risk for fragility fractures.
• Caffeine: Caffeine increases urinary and fecal calcium loss. When combined with low calcium intake, this can impair the body’s ability to build strong bones.

Exercise

If you have been diagnosed with osteopenia, you want to do what is necessary to prevent it from progressing to osteoporosis.

• The combination of weight-bearing exercises such as walking, hiking, and dancing, paired with resistance exercises has been shown to be most effective in preventing osteoporosis (Porter, 2021). 
• Balance exercises can also help prevent catastrophic falls resulting in multiple fractures.

Lifestyle

Maintaining an active, healthy lifestyle with good nutrition, a healthy diet, regular weight-bearing and resistance exercises, and frequent visits with your doctor to monitor physical and emotional well being is the best way to prevent osteopenia and osteoporosis. Avoid smoking, excess alcohol and excess caffeine.

Frequently asked questions about osteopenia

How quickly does osteopenia progress?

The rate at which osteopenia progresses is depending on multiple factors, including whether or not exercise, nutrition and lifestyle have been adjusted after a diagnosis, age and menopause status, and how many risk factors a person has. The progression can be slowed down by your actions.

Is osteopenia related to osteoarthritis?

While both osteopenia and osteoarthritis affect the bones (“osteo”), osteoarthritis affects the cartilaginous end portions of the bone where they form joints, whereas osteopenia affects the density of the entire bone. Osteoarthritis affects certain joints more than others based on wear and tear over time while osteopenia affects the density of all the bones in the body making them more porous and weak.

Can osteopenia affect teeth?

Because teeth are made of bone, osteopenia can affect your teeth. You are more likely to fracture or break a tooth if you have osteopenia or osteoporosis, so be sure to let your dentist know if you have been diagnosed with either.

Does osteopenia make you feel tired?

While osteopenia does not directly cause fatigue, one can feel fatigue if they are putting in extra effort to accomplish certain tasks due either to pain, weakness or inactivity, which can be a precursor to developing osteopenia and osteoporosis. But there are many things that can cause one to feel tired, so feeling tired – alone – is not a good indicator of osteopenia. It’s important to see a medical professional who can do a thorough assessment in order to determine the cause of your fatigue and whether or not it may be related to a diagnosis of osteopenia. 

Around what age does osteopenia begin?

Osteopenia can occur in men and women at any age, but it is most commonly diagnosed in women after menopause due to a rapid decrease in the hormone estrogen. Estrogen supports bone grown, which is why a drop in estrogen levels during menopause can affect bone density. About 50% of all people in the United States over the age of 50 have osteopenia (Medical News Today, 2019), and about 50% of women in their 80s have osteoporosis, the more serious and advanced progression from osteopenia.