Osteoporosis

Diagnosing osteoporosis involves several steps, starting with a

• Physical exam and a careful medical history.
• General testing, such as blood test and x-rays.
• Bone mineral density testing.

Physical Exam and Medical History

When recording information about your medical history, your doctor will ask questions to find out whether you have risk factors for osteoporosis and fractures. The doctor may ask about:

• Any previous fractures.
• Your lifestyle (including diet, exercise habits, and whether you smoke).
• Current or past health problems and medications that could contribute to low bone mass and increased fracture risk.
• Your family history of osteoporosis and other diseases.
• For women, your menstrual history.

The doctor will also do a physical exam that should include checking for loss of height and changes in posture and may include checking your balance and gait (the way you walk).

General Testing

If you have back pain or have experienced a loss in height or a change in posture, the doctor may request an x ray of your spine to look for spinal fractures or malformations due to osteoporosis. However, x rays cannot necessarily detect osteoporosis. The results of laboratory tests of blood and urine samples can help your doctor identify conditions that may be contributing to bone loss, such as hormonal problems or vitamin D deficiency. If the results of your physical exam, medical history, x rays, or laboratory tests indicate that you may have osteoporosis or that you have significant risk factors for the disease, your doctor may recommend a bone density test.

Bone Mineral Density (BMD) Testing

Mineral is what gives hardness to bones, and the density of mineral in the bones is an important determinant of bone strength. BMD testing can be used to

• Definitively diagnose osteoporosis.
• Detect low bone mass before osteoporosis develops.
• Help predict your risk of future fractures.
• Monitor the effectiveness of ongoing therapy.

In general, the lower your bone density, the higher your risk for fracture. The results of a bone density test will help guide your doctor’s decisions about starting therapy to prevent or treat osteoporosis.

The most widely recognized test for measuring bone mineral density is a quick, painless, noninvasive technology known as dual-energy x-ray absorptiometry (DXA). This technique, which uses low levels of x rays, involves passing a scanner over your body while you are lying on a cushioned table. DXA can be used to determine BMD of the entire skeleton and at various sites that are prone to fracture, such as the hip, spine, or wrist. Bone density measurement by DXA at the hip and spine is generally considered the most reliable way to diagnose osteoporosis and predict fracture risk.

Your doctor will compare your BMD test results to the average bone density of young, healthy people and to the average bone density of other people of your age, sex, and race. If you are diagnosed with osteoporosis or very low bone density, or if your bone density is below a certain level and you have other risk factors for fractures, the doctor will talk with you about options for treatment or prevention of osteoporosis.

The primary goal in treating people with osteoporosis is preventing fractures. A comprehensive treatment program includes:

• Proper nutrition.
• Lifestyle changes.
• Exercise.
• Prevention of falls that may result in fractures.
• Medications.
• Alternative therapies.

If you take medication to prevent or treat osteoporosis, it is still essential that you obtain the recommended amounts of calcium and vitamin D. Exercising and maintaining other aspects of a healthy lifestyle are also important.

For people with osteoporosis resulting from another condition, the best approach is to identify and treat the underlying cause. If you are taking a medication that causes bone loss, your doctor may be able to reduce the dose of that medication or switch you to another medication that is effective but not harmful to your bones. If you have a disease that requires long-term glucocorticoid therapy, such as rheumatoid arthritis or lupus, you can also take certain medications approved for the prevention or treatment of osteoporosis associated with aging or menopause.

Nutrition

A healthy, balanced diet that includes:

• Plenty of fruits and vegetables.
• Enough calories.
• Adequate calcium, vitamin D, and vitamin K is essential for minimizing bone loss and maintaining overall health. Calcium and vitamin D are especially important for bone health.

Calcium

Calcium is the most important nutrient for preventing osteoporosis and for reaching peak bone mass. For healthy postmenopausal women who are not consuming enough calcium (1,200 mg per day) in their diet, calcium and vitamin D supplements help to preserve bone mass and prevent hip fracture. Calcium is also needed for the proper function of

• The heart.
• Muscles.
• Nerves
• Blood clotting.

We take in calcium from our diet and lose it from the body mainly through urine, feces, and sweat. The body depends on dietary calcium to build healthy new bone and avoid excessive loss of calcium from bone to meet other needs. The Institute of Medicine of the National Academy of Sciences recommends specific amounts of dietary calcium and vitamin D for various stages of life. Men and women up to age 50 need 1,000 milligrams of calcium per day, and the recommendation increases to 1,200 milligrams for women after age 50 and for men after age 70.

Many people in the United States consume much less than the recommended amount of calcium in their diets. Good sources of calcium include

• Low-fat dairy products.
• Dark green leafy vegetables, such as bok choy, collards, and turnip greens.
• Broccoli.
• Sardines and salmon with bones.
• Soy beans, tofu, and other soy products.
• Calcium-fortified foods such as orange juice, cereals, and breads.

If you have trouble getting enough calcium in your diet, you may need to take a calcium supplement such as calcium carbonate, calcium phosphate, or calcium citrate. If you are between the ages of 19 and 50, your daily calcium intake should not exceed 2,500 milligrams because too much calcium can cause problems such as kidney stones. (After age 50, intakes should not exceed 2,000 milligrams per day.) Calcium coming from food sources provides better protection from kidney stones. Anyone who has had a kidney stone should increase their dietary calcium and decrease the amount from supplements as well as increase fluid intake.

Vitamin D

Vitamin D is required for proper absorption of calcium from the intestine. It is made in the skin after exposure to sunlight. Only a few foods naturally contain significant amounts of vitamin D, including fatty fish and fish oils. Foods fortified with vitamin D, such as milk and cereals, are a major dietary source of vitamin D. Although many people obtain enough vitamin D naturally, studies show that vitamin D production decreases in older adults, in people who are housebound, and during the winter—especially in northern latitudes.

If you are at risk for vitamin D deficiency, you can take multivitamins or calcium supplements that contain vitamin D to meet the recommended daily intake of 600 International Units (IU) for men and women up to the age of 70 and 800 IU for people over 70. Doses of more than 2,000 IU per day are not advised unless under the supervision of a doctor. Larger doses can be given initially to people who are deficient as a way to replenish stores of vitamin D.

Lifestyle

In addition to a healthy diet, a healthy lifestyle is important for optimizing bone health. You should:

• Avoid smoking and second-hand smoke.
• Drink alcohol in moderation (no more than one drink per day is a good general guideline).
• Talk to your doctor about medications you are taking. Some prescription medications can cause bone loss or increase your risk of falling and breaking a bone.

Exercise

Exercise is an important part of an osteoporosis treatment program. The evidence suggests that the most beneficial physical activities for bone health include strength training or resistance training. Physical activity can:

• Build and maintain bone throughout adulthood.
• Help maintain or even modestly increase bone density in adulthood.
• Reduce your risk of falling by increasing muscle mass and strength and improving coordination and balance.
• Help older people improve function and delay loss of independence.

Although exercise is beneficial for people with osteoporosis, it should not put any sudden or excessive strain on your bones. If you have osteoporosis, you should avoid high-impact exercise. To help ensure against fractures, a physical therapist or rehabilitation medicine specialist can:

• Recommend specific exercises to strengthen and support your back.
• Teach you safe ways of moving and carrying out daily activities.
• Recommend an exercise program that is tailored to your circumstances.

Other trained exercise specialists, such as exercise physiologists, may also be able to help you develop a safe and effective exercise program.

Fall Prevention

Fall prevention is a critical concern for men and women with osteoporosis. Falls increase your likelihood of fracturing a bone in the hip, wrist, spine, or other part of the skeleton. Fractures can affect your quality of life and lead to loss of independence and even premature death. A host of factors can contribute to your risk of falling.

Falls can be caused by:

• Impaired vision or balance.
• Loss of muscle mass.
• Chronic or short-term illnesses that impair your mental or physical functioning.
• Use of four or more prescription medications.
• Side effects of certain medications, such as
  • Sedatives or tranquilizer.
  • Sleeping pills.
  • Antidepressants.
  • Anticonvulsants.
  • Muscle relaxants.
  • Heart medicines.
  • Blood pressure pills.
  • Diuretics.
• Drinking alcoholic beverages.

If you have osteoporosis, it is important to be aware of any physical changes you may be experiencing that affect your balance or gait and to discuss these changes with your doctor or other health care provider. It is also important to have regular checkups and tell your doctor if you have had problems with falling.

The force or impact of a fall (how hard you land) plays a major role in determining whether you will break a bone. Catching yourself so that you land on your hands or grabbing onto an object as you fall can prevent a hip fracture. You may break your wrist or arm instead, but the consequences are not as serious as if you break your hip. Studies have shown that wearing a specially designed garment that contains hip padding may reduce hip fractures resulting from falls in frail, elderly people living in nursing homes or residential care facilities, but use of the garments by residents is often low.

Falls can also be caused by factors in your environment that create unsafe conditions. Some tips to help eliminate the environmental factors that lead to falls include:

Outdoors and away from home:

• Use a cane or walker for added stability.
• Wear shoes that give good support and have thin nonslip soles. Avoid wearing slippers and athletic shoes with deep treads.
• Walk on grass when sidewalks are slippery; in winter, sprinkle salt or kitty litter on slippery sidewalks.
• Be careful on highly polished floors that are slick and dangerous, especially when wet, and walk on plastic or carpet runners when possible.
• Stop at curbs and check their height before stepping up or down.

Indoors:

• Keep rooms free of clutter, especially on floors.
• Keep floor surfaces smooth but not slippery.
• Wear shoes that give good support and have thin nonslip soles. Avoid wearing slippers and athletic shoes with deep treads.
• Be sure carpets and area rugs have skid-proof backing or are tacked to the floor. Use double-stick tape to keep rugs from slipping.
• Be sure stairwells are well lit and that stairs have handrails.
• Install grab bars on bathroom walls near tub, shower, and toilet.
• Use a rubber bath mat or slip-proof seat in the shower or tub.
• Improve the lighting in your home. Use a nightlight or flashlight if you get up at night.
• Use step ladders that are stable and have a handrail.
• Install ceiling fixtures or lamps that can be turned on by a switch near the room's entrance.
• If you live alone (or spend large amounts of time alone), consider purchasing a cordless phone; you won't have to rush to answer the phone when it rings and you can call for help if you do fall.
• Consider having a personal emergency-response system; you can use it to call for help if you fall.

Medications

Your doctor may prescribe medications that have been shown to slow or stop bone loss or build new bone, increase bone density, and reduce fracture risk. The U.S. Food and Drug Administration (FDA) has approved several medications for prevention or treatment of osteoporosis, based on their ability to reduce fractures:¹

• Bisphosphonates: Several bisphosphonates are approved for the prevention or treatment of osteoporosis. These medications reduce the activity of cells that cause bone loss.
• Parathyroid hormone: A form of human parathyroid hormone (PTH) is approved for postmenopausal women and men with osteoporosis who are at high risk for having a fracture. Use of the drug for more than 2 years is not recommended.
• RANK ligand (RANKL) inhibitor: A RANK ligand (RANKL) inhibitor is approved for postmenopausal women with osteoporosis who are at high risk for fracture.
• Estrogen agonists/antagonists: An estrogen agonist/ antagonist (also called a selective estrogen receptor modulator or SERM) is approved for the prevention and treatment of osteoporosis in postmenopausal women. SERMs are not estrogens, but they have estrogen-like effects on some tissues and estrogen-blocking effects on other tissues.
• Calcitonin: Calcitonin is approved for the treatment of osteoporosis in women who are at least 5 years beyond menopause. Calcitonin is a hormone involved in calcium regulation and bone metabolism.
• Estrogen and hormone therapy: Estrogen and combined estrogen and progestin (hormone therapy) are approved for the prevention of postmenopausal osteoporosis as well as the treatment of moderate to severe hot flashes and vaginal dryness that may accompany menopause. Estrogen without an added progestin is recommended only for women who have had a hysterectomy (surgery to remove the uterus), because estrogen increases the risk of developing cancer of the uterine lining and progestin reduces that risk.

Results of the NIH-sponsored Women’s Health Initiative, a large, long-term study of disease prevention strategies in postmenopausal women, suggest that, in most women, the harmful effects of long-term use of hormone therapy are likely to outweigh the disease prevention benefits.

The Food and Drug Administration has recommended that women use hormone therapy at the lowest dose and for the shortest time, and carefully consider and discuss with their doctor other approved osteoporosis treatments.

Alternative Therapies

Isoflavones are naturally occurring compounds found in soybeans. Because they are structurally similar to estrogen, researchers have thought that they may hold promise as an alternative to estrogen therapy to protect postmenopausal women from osteoporosis. Several studies have explored the effects of soy isoflavones on bone health, but results have been mixed, ranging from a modest impact to no effect. Most of these studies had various limitations, including their short duration and small sample size, making it difficult to fully evaluate the impact of these compounds on bone health. Moreover, reports from NIH-supported clinical trials have failed to demonstrate a bone-sparing effect of soy isoflavones.

Footnote

¹All medicines can have side effects. Some medicines and side effects are mentioned in this publication. Some side effects may be more severe than others. You should review the package insert that comes with your medicine and ask your health care provider or pharmacist if you have any questions about the possible side effects.

Medical specialists who treat osteoporosis include:

• family physicians
• internists
• endocrinologists
• geriatricians
• gynecologists
• orthopaedic surgeons
• rheumatologists
• physiatrists (doctors specializing in physical medicine and rehabilitation).

Physical and occupational therapists and nurses may also participate in the care of people with osteoporosis.

Preventing osteoporosis is a lifelong endeavor. To reach optimal peak bone mass and minimize loss of bone as you get older, there are several factors you should consider. Addressing all of these factors is the best way to optimize bone health throughout life.

Screening for Osteoporosis

Prevention also includes screening for osteoporosis. The U.S. Preventive Services Task Force, an independent panel of experts in primary care and prevention, recommends screening for osteoporosis for:

• All women age 65 and older be screened for osteoporosis.
• Women under the age of 65 who are at high risk for fractures.

You should also ask your doctor about osteoporosis if you:

• Are over 50 and have broken a bone.
• Have lost height or your posture has become stooped or hunched.
• Experience sudden back pain.
• Have a chronic disease or eating disorder known to increase the risk of osteoporosis.
• Are taking one or more medications known to cause bone loss.
• Have multiple risk factors for osteoporosis and osteoporosis-related fractures.

Consider talking to your doctor about being evaluated for osteoporosis if:

• You are a man or woman over age 50 or a postmenopausal woman and you break a bone.
• You are a woman age 65 or older.
• You are a woman younger than 65 and at high risk for fractures.
• You have lost height, developed a stooped or hunched posture, or experienced sudden back pain with no apparent cause.
• You have been taking glucocorticoid medications such as prednisone, cortisone, or dexamethasone for 2 months or longer or are taking other medications known to cause bone loss.
• You have a chronic illness or are taking a medication that is known to cause bone loss.
• You have anorexia nervosa or a history of this eating disorder.
• You are a premenopausal woman, not pregnant, and your menstrual periods have stopped, are irregular, or never started when you reached puberty.

Overall Nutrition

A healthy, balanced diet that includes lots of fruits and vegetables and enough calories is also important for lifelong bone health. If you take in adequate amounts of calcium and vitamin D throughout your life, you are more likely to have optimal skeletal mass early in life and are less likely to lose bone later in life.

Calcium

Taking the recommended amount of calcium over a lifetime is thought to play an important role in the development of osteoporosis. Many published studies show that low calcium intakes are associated with

• Low bone mass.
• Rapid bone loss.
• High fracture rates.

National surveys suggest that the average calcium intake of individuals is far below the levels recommended for optimal bone health.

The body's demand for calcium is greater in:

• Childhood and adolescence, when the skeleton is growing rapidly.
• Women during pregnancy and breastfeeding.
• Postmenopausal women and older men. Increased calcium requirements in older people may be related to vitamin D deficiencies that reduce intestinal absorption of calcium.

Also, as you age, your body becomes less efficient at absorbing calcium and other nutrients. Older adults are also more likely to have chronic medical problems and to use medications that may impair calcium absorption.
Adolescence is the most critical period for building bone mass that helps protect against osteoporosis later in life. Yet studies show that among children age 9 to 19 in the United States, few meet the recommended levels. Therefore, it is especially important for parents, other caregivers, and pediatricians to talk to children and young teens about developing bone-healthy habits, including eating calcium-rich foods and getting enough exercise.

Vitamin D

Vitamin D plays an important role in calcium absorption and bone health. It is made in the skin after exposure to sunlight and can also be obtained through the diet. Although many people are able to obtain enough vitamin D naturally, vitamin D production decreases if you:

• Are older.
• Are housebound.
• Do not get enough sun.
• Have a chronic neurological or gastrointestinal diseases.

If you are at for vitamin D deficiency your doctor may recommend vitamin D supplements.

Calcium and vitamin D supplements may help slow bone loss and prevent hip fracture.

Exercise

Like muscle, bone is living tissue that responds to exercise by becoming stronger. There is good evidence that physical activity early in life contributes to higher peak bone mass. The best exercise for building and maintaining bone mass is weight-bearing exercise: exercise that you do on your feet and that forces you to work against gravity. Weight-bearing exercises include:

• Jogging.
• Aerobics.
• Hiking.
• Walking.
• Stair climbing.
• Gardening.
• Weight training.
• Tennis.
• Dancing.

High-impact exercises may provide the most benefit. Bicycling and swimming are not weight-bearing exercises, but they have other health benefits. Exercise machines that provide some degree of weight-bearing exercise include:

• Treadmills.
• Stair-climbing machines.
• Ski machines.
• Exercise bicycles.

Strength training to build and maintain muscle mass and exercises that help with coordination and balance are also important. Later in life, the benefits of exercise for building and maintaining bone mass are not nearly as great, but staying active and doing weight-bearing exercise is still important.

A properly designed exercise program that builds muscles and improves balance and coordination provides other benefits for older people, including helping to prevent falls and maintaining overall health and independence. Experts recommend 30 minutes or more of moderate physical activity on most (preferably all) days of the week, including a mix of weight-bearing exercises, strength training (two or three times a week), and balance training.

Smoking

Smoking is bad for your bones and for your heart and lungs. Women who smoke have lower levels of estrogen compared to nonsmokers and frequently go through menopause earlier.

Alcohol

People who drink heavily are more prone to bone loss and fractures because of poor nutrition and harmful effects on calcium balance and hormonal factors. Drinking too much also increases the risk of falling, which is likely to increase fracture risk.

Medications

The long-term use of glucocorticoids can lead to a loss of bone density and fractures. Other forms of drug therapy that can cause bone loss include:

• Long-term treatment with certain antiseizure drugs and barbiturates
• Some drugs used to treat endometriosis
• Excessive use of aluminum-containing antacids
• Certain cancer treatments; and excessive thyroid hormone.

It is important to discuss the use of these drugs with your doctor, and not to stop or alter your medication dose on your own.