Osteoporosis

What is osteoporosis?

Osteoporosis is a disease characterized by a weakening of the bones that makes them more prone to fractures (bone breaks). According to the International Osteoporosis Foundation (IOF), osteoporosis occurs when the body produces an insufficient amount of bone, loses too much bone, or a combination of both resulting in a weakened state (International Osteoporosis Foundation, 2021).

On a microscopic level, healthy bones usually have a honeycomb appearance. But for individuals with osteoporosis, the holes or spaces in the honeycomb pattern become bigger leaving less structural bone tissue. This makes the bones brittle and weak. Weakened bones have a higher risk of fractures, which makes people with osteoporosis particularly vulnerable to falls. Fractures are problematic because they can lead to limitations in functional independence and a general decline in overall health, both mental and physical (Bone Health & Osteoporosis Foundation, 2021).

The transition from strong bones to weakened bones does not happen overnight. The speed at which we build bone changes throughout the lifespan. Children and teenagers form bone faster than they lose it, with bone mass peaking between the ages of 18 and 25. As we age, we begin to lose more bone than we make, with women especially prone to rapid bone loss as they approach menopause due to rapid decreases in the hormone estrogen. 

Osteoporosis is very common. It affects 54 million Americans, with 1 in 2 women over 50 experiencing fractures due to osteoporosis. Osteoporosis is diagnosed by a medical doctor through a complete physical exam and a bone mineral density scan. Women over 65 are routinely recommended for osteoporosis screening, as are younger women who are at an increased risk of developing osteoporosis (National Institute of Health, 2021). 

Despite the natural changes that can occur in our bones over time, it’s never too late to improve your bone health. 

Causes and risk factors

Osteoporosis is the result of the body losing more bone than it creates. While there is no single cause of osteoporosis, certain factors make one more at risk for developing the disease. Risk factors fall into two categories: controllable and uncontrollable risk factors.

Uncontrollable risk factors

• Gender: Women are more likely to develop osteoporosis due to bone size and rapid hormonal changes during menopause. However, men can also develop osteoporosis. Women with early onset menopause (before age 45) or a history of ovariectomy (removal of the ovaries) are also more likely to develop osteoporosis (Bone Health & Osteoporosis Foundation, 2021). 
• Race: Osteoporosis is more common in non-Hispanic white women and Asian women than Hispanic or African American women (National Institute of Health, 2021).
• Age: The older you are, the more likely you are to have osteoporosis, with 75% of fractures due to osteoporosis occurring in people 65 years and older (International Osteoporosis Foundation, 2021). 
• Family history: You are more likely to develop osteoporosis if a parent had osteoporosis, especially if they ever experienced a broken hip (International Osteoporosis Foundation, 2021). 
• Body frame size: Slender, thin boned women and men are more likely to experience a fracture than larger boned individuals (National Institute of Health, 2021).
• Chronic diseases: Many chronic diseases can increase the likelihood of osteoporosis including autoimmune diseases such as rheumatoid arthritis and ulcerative colitis, gastrointestinal disorders, such as celiac disease, endocrine disorders, such as diabetes and hyperthyroidism and neurologic diseases such as multiple sclerosis.
• Medications: Medications used to treat certain diseases can also adversely affect bone density and strength, such as glucocorticoids, anti-seizure medications and even some antidepressants.
  

Controllable risk factors

• Abnormal hormone levels: Managing hormone levels can decrease your risk of developing osteoporosis. Women with low estrogen levels and men with low testosterone levels are more prone to developing osteoporosis. Overactive adrenal, thyroid and parathyroid glands can also lead to an excess in thyroid hormone, which contributes to bone loss (Mayo Clinic, 2021).
• Dietary factors: A diet low in calcium and Vitamin D can lead to a lack of calcium in the bones and reduced bone mineral density. Read more about the best vitamins for bone health and the ideal diet to strengthen your bones in the Well Guide. 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).
• Alcohol consumption: Drinking more than 2 units of alcohol a day increases your risk of bone breaks (International Osteoporosis Foundation, 2021).
• Medications: Be mindful of the fact that many medications come with an increased risk of fractures or side effects linked to osteoporosis. While some medications are lifesaving and required to treat underlying diseases, there may be an opportunity to reduce the dose or discontinue use of others. Long-term use of corticosteroids, proton pump inhibitors and chemotherapy are among the medications that can make you at higher risk for fractures. A complete list of medications with this association can be found on the International Osteoporosis Foundation website. 
• Sedentary lifestyle: Adults who are inactive are much more likely to experience a hip fracture. Lack of exercise leads to weaker muscles, which leads to weaker bones. Participating in regular resistance training and weight bearing exercise can help you build muscle and improve bone strength.

While osteopenia, the precursor to osteoporosis, does not have symptoms, it is a sign of a decline in bone mass that can lead to osteoporosis (De Pietro, 2019). 

Symptoms

Often considered a “silent disease,” most people don’t know they have osteoporosis until they experience a fracture. 

The most common symptoms of osteoporosis include:

• Frequent fractures or broken bones: Fractures (bone breaks) due to osteoporosis are most common in the hip, spine and wrist bones, but adulthood fractures of any bone (with the exception of fingers, toes, face and skull) are likely related to underlying osteoporosis (National Institute of Health, 2021). A bone that breaks more easily than expected is also a sign of osteoporosis.
• Back pain: This could be a sign of a compression fracture in the spine, one of the most common types of fractures in people with osteoporosis.
• Hunched posture, or a rounded upper back: Weakness in the muscles of the upper back and shoulders can lead to this forward, rounded positioning. Reduced bone mineral density in the vertebrae can lead to reduced vertebral height and hunched, rounded posture. The vertebral bones often compress more towards the front of the bone than the back of the bone, which tends to produce this hunched posture, also known as kyphosis.‍
• Loss of height by 4cm (approximately 1 inch) or more: Loss of bone density leading to vertebral fractures often produces a visible loss of height.
  

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 osteoporosis 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 osteoporosis.

While a complete physical exam should be performed including blood tests, medical history, and falls risk, posture, BMI and movement assessments, osteoporosis is usually diagnosed using a bone mineral density (BMD) test. BMD tests are safe, fast and painless. They are radiological tests that are more comprehensive at assessing bone density than a traditional X-ray and 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. DXA (often referred to as “DEXA”) stands for dual-energy X-ray absorptiometry. This type of X-ray 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), a precursor to osteoporosis, or if you do in fact have osteoporosis (a T-score of -2.5 or lower) (International Osteoporosis Foundation, 2021).

Treatment

There is no “cure” for osteoporosis but the disease can often be “put into remission” with the powerful medications we currently have available. Still, the easiest approach is to prevent osteoporosis 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 osteoporosis 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 osteoporosis: 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 osteoporosis 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 osteoporosis.

Medications used to treat osteoporosis

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. 
  

Exercise

Maintaining an active lifestyle with frequent exercise is one of the most important and effective treatments for osteoporosis, but certain types of exercise are better than others.  

• Weight-bearing exercise: Weight-bearing exercises such as walking, hiking and dancing have been shown to improve bone health. 
• Strength training exercises: Strength training is one of the most important forms of exercise for people with osteoporosis. It is especially important to incorporate resistance training, which adds an increased load and challenge to the body by incorporating resistance bands, dumbbells or other props that encourage the body not just to maintain muscle mass, but to increase muscle mass. This, in turn, leads to stronger bones. 
• Core exercises: It’s always important to incorporate breath and core work into your workout routine. Having a strong core is important for balance, posture and effective recruitment of other muscles during resistance exercises. 
• Balance, flexibility, and posture exercises: Balance exercises can help prevent falls, which lead to fractures in people with osteoporosis. Flexibility exercises can help promote healthy movement and better muscle recruitment. Posture exercises can target the muscles that maintain good spinal alignment and prevent an overly flexed spine, which can often lead to compression fractures in people with osteoporosis.
  

Nutrition

The following is a list of vitamins that are essential for healthy bones, along with their dietary sources. These vitamins work together to help increase calcium absorption in the bones.

Calcium

• 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 juices

Vitamin D

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

Vitamins C, K and B12 and protein are also important for healthy bones and can be found in many leafy vegetables and fruits.

Foods to limit if you have osteoporosis

There are certain foods you should limit in your diet if you have osteoporosis:

• 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: Chronic, 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 goes along for the ride and is also lost. 

Foods to pair with calcium

• 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. For this reason, it's important to make sure you add a good source of calcium when consuming wheat bran.
• 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, so be sure to pair consumption of legumes with a good source of calcium to enjoy its benefits.
  

Mental health

• While the evidence establishing the negative mental health consequences of osteoporosis is limited, one study found that osteoporotic fractures can lead to poorer quality of life and a negative impact on physical, social, financial, and psychological well-being. This study also found that osteoporosis can lead to anxiety due to fear of falling and sustaining debilitating fractures (Kelly et al,  2019).
• While more research is needed on the mental health aspects of osteoporosis, this study found that management of osteoporosis can have indirect positive effects on psychological wellbeing in those living with osteoporosis (Kelly et al,  2019).
• Regular visits with a mental health professional can help people with osteoporosis both identify and treat any mental health issues that come up, such as anxiety or depression. It’s important not to ignore how this disease, like many chronic diseases, can affect psychological well being.
  

Working with medical professionals

After being diagnosed with osteoporosis, it is important to have regular conversations with your doctor and other medical professionals when appropriate to ensure that you’re on the right treatment plan. Monitoring bone density, bloodwork, pain level, bodyweight and posture is important for determining how effective a treatment plan is and the best way to manage your osteoporosis in the future. Creating a checklist to talk about with your healthcare provider can also be an important step in your care.

Prevention

While it is not always possible to prevent osteoporosis, there are ways to reduce the probability of developing osteopenia and osteoporosis, reduce falls risk and strengthen your bones, even after diagnosis. The key is to keep your body strong and steady to help prevent falls and further decline in both function and bone mineral density. If you consider the risk factors that are controllable (listed above), you’ll be able to identify ways to get ahead of a diagnosis and/or manage your osteoporosis with proper lifestyle adjustments.

According to research, the best way to prevent and manage osteoporosis is to make sure you are getting plenty of the vitamins that help build bone, maintain a healthy diet to keep your body strong and within a healthy BMI, and do the best exercises to help your body build muscle and strengthen bones while also preventing falls.

Below is a list of the most important influential lifestyle factors for preventing and managing osteoporosis:

Vitamins

• Vitamin D: Helps your body absorb dietary calcium (International Osteoporosis Foundation, 2021).
• Calcium: Key structural component of bone (International Osteoporosis Foundation, 2021). 
• Protein: Important for optimal bone mass and preserving muscle and bone mass throughout aging (International Osteoporosis Foundation, 2021).
• Potassium: Required to make osteocalcin, the second most abundant protein in bone after collagen (International Osteoporosis Foundation, 2021).
• 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).
• Vitamin C: According to a 2018 study, having more Vitamin C in the diet was associated with a lower risk of hip fracture, higher bone mineral density and a 33% lower risk of being diagnosed with osteoporosis (Malmir, 2018). 
• Vitamin K: Required to make osteocalcin, the second most abundant protein in bone after collagen (International Osteoporosis Foundation, 2021).

Nutrition

• Good nutrition and strong bones go hand-in-hand. It’s important to have adequate dietary intake of key nutrients such as calcium, protein and Vitamin D to prevent the risk of developing osteoporosis and fractures. While the recommended intake of each nutrient varies across the gender and age, they have an important role in musculoskeletal health throughout the lifespan (International Osteoporosis Foundation, 2021).
• Malnutrition: Malnutrition, which is more prevalent in older adults, can have negative health consequences including making one at higher risk for osteoporosis and fractures (International Osteoporosis Foundation, 2021).
• 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 (International Osteoporosis Foundation, 2021).
• 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 (International Osteoporosis Foundation, 2021).

Exercise

• 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.
• Maintaining an active, healthy lifestyle with good nutrition, a healthy diet, regular weight bearing and resistance exercises, and frequent doctor’s visits to monitor physical and emotional well being is the best way to prevent osteoporosis.
  

Frequently asked questions about osteoporosis

What will happen if osteoporosis is left untreated?

If left untreated, osteoporosis will continue to progress, making one more vulnerable to fractures, more frail and likely less independent over time. It is extremely important to be properly diagnosed and treated for osteoporosis for the best outcome possible.

Can you die because of osteoporosis?

While osteoporosis will not cause death directly, it can lead to weakness and a decline in overall health, function and independence. Certain complications of osteoporosis, most importantly hip fractures, are associated with earlier death. 

How quickly does osteoporosis progress?

Osteoporosis can progress at a different rate for different people. The decline of bone mineral density is based on a combination of factors, including one’s lifestyle choices, genetics and diet. However, it usually progresses at a faster rate as one ages. It can progress more rapidly in people who have more risk factors. 

Where does osteoporosis usually start?

Osteoporosis can occur in any bone in the body, but fractures due to osteoporosis are most prevalent in the bones of the spine, hip and wrists.