By Elizabeth Nagelin-Anderson, MA, Isabel Platt, and Noy Birger, BS
WHAT IS OSTEOPOROSIS?
Osteoporosis is a silent disease that causes the bones to thin and weaken to a point where they break more easily, particularly the hip, spine and wrist. The human body is constantly destroying old bone cells and creating new ones; osteoporosis occurs when the rate of bone cell destruction is greater than bone cell production. Unfortunately, most don’t know that they have osteoporosis until they break a bone or have a bone density test.
WHY SHOULD YOU BE CONCERNED?
Osteoporosis can affect how you look, how you feel, and how long you live. People with osteoporosis often lose several inches in height, sometimes as much as 4-6 inches, because the vertebrae in the spine begin to collapse. They may also develop a hump in their back as they age. People with osteoporosis experience bone fractures more easily and live with the fear of a serious injury. A broken hip, for example, almost always requires hospitalization and major surgery, and even after it heals, many cannot walk unassisted. One in five nursing home residents that break a hip die within a year of the fracture from complications such as pneumonia, other infections, and general declining health after a hip fracture.1
WHAT CAUSES OSTEOPOROSIS?
Osteoporosis starts many years before a person suffers his or her first fracture. In a way, it is a disease of childhood that isn’t obvious until adulthood. Since 90% of bone mass is usually formed by the age of 18 in girls and age 20 in boys, the bone mass you develop as a child has a great impact on bone health later in life.2 Children should have a healthy diet rich in calcium, which they can get through fortified milk, other dairy products like cheese and yogurt, and green vegetables like broccoli and spinach. Vitamin D is essential to absorb the calcium, and children and adults can get Vitamin D through foods or from about 15 minutes of outdoor sun exposure each day.3 “Weight-bearing” exercise will strengthen the bones of children and adults, which includes walking, running, playing sports, dancing, yoga, and weight-lifting.4 An inactive childhood or a poor diet will make it almost impossible to have strong, healthy bones as an adult. To learn more about how kids can get an early start to keep their bones healthy, read Healthy Bones for Young Adults.
Although the body has almost reached maximum bone mass by age 18-20, it continues to build bone slowly until you reach your peak bone mass around age 30. After that, more bone mass is lost than formed. Women are more at risk for developing osteoporosis, because they lose bone mass during pregnancy, and in the five to seven years following menopause, falling estrogen levels can cause women to lose up to 20% of their bone mass. Bone loss continues into old age, although at a slower rate.
Hormone replacement therapy (HRT)—now called menopausal hormone therapy—is sometimes prescribed for the symptoms of menopause, including the prevention of osteoporosis. However, research by the National Institutes of Health (NIH) found that the risks of hormone therapy outweigh the benefits. Since diet and exercise have been shown to prevent and treat osteoporosis, NIH recommends that hormones be used to treat the symptoms of menopause only if the symptoms seriously disrupt daily functioning or the enjoyment of life. For more information, see Hormone Therapy and Menopause.
HOW CAN I PREVENT OSTEOPOROSIS?
There are several things you can do to prevent osteoporosis:
- Eat a balanced diet rich in calcium and vitamin D as a child and for the rest of your life
- Participate in weight-bearing exercise (i.e., walking, tennis, dancing, weight-training)
- Limit use of alcohol and don’t smoke
- Have a bone density test if you are over 65 or have risk factors (other than age, gender and postmenopausal status) for osteoporosis, and take medications when appropriate5
Calcium is important for everyone. If your mother told you to drink three glasses of milk each day, she was right. Children ages 4 to 8 need 1000 mg of calcium, and children between 9 and 18 require 1300 mg. Every adult needs about 1000 mg of calcium each day, and three 8-oz glasses of milk will provide 900 mg. According to NIH, women over the age of 50 and men over the age of 70 should get 1200 mg of calcium.6
In addition to milk products such as yogurt and cheese, other foods that are rich in calcium include broccoli, spinach, other dark green leafy vegetables, tofu, and almonds. Today, more and more foods such as orange juice, bread, and cereals are fortified with calcium and vitamin D, making it easier to consume the recommended level of calcium.
However, vegetables are not likely to provide all the calcium you need: a typical half cup serving of raw broccoli has about 25 mg of calcium, and a cup of raw spinach contains about 30 mg of calcium. Almonds have more calories than calcium: one ounce of almonds contains 70 mg of calcium and has about 160 calories; in order to get 1000 mg of calcium from almonds in one day, a woman would need to consume all of her recommended 1600 calories a day in almonds. For more information about the calcium content of various foods, you can use this osteoporosis website.
Dietary supplements can help if you don’t think you’re getting enough calcium and vitamin D from your diet and sun exposure. Results from the Women’s Health Initiative study show that women who took vitamin D and calcium supplements every day suffered fewer hip fractures than women who took placebos (sugar pills). However, these benefits only occurred if the women were very conscientious about taking these daily supplements: two pills every day, each containing 500 mg of calcium and 200 IU of vitamin D. These results, together with other research, support the idea that taking calcium and vitamin D supplements every day can reduce the risk of bone fracture. For more information about calcium and vitamin D supplements, read this article.
Adult women need a total of 1000 to 1200 mg of calcium each day, but our bodies can’t absorb that much all in one dose. The best strategy is to divide the total daily amount you need into two or three smaller doses and take them with meals (to improve their absorption) throughout the day. If a meal includes calcium-rich foods like cheese, yogurt, milk, or calcium-fortified orange juice, then it is better to skip your calcium supplement or take a multi-vitamin with that meal and take one more 600 mg supplement with other meals. Remember that calcium works together with vitamin D. According to the NIH, people should consider taking more than the recommended 400-600 IUs of Vitamin D each day and can safely increase their daily dose of vitamin D to as high as 2,000 IUs.6 Try to get 15 minutes of sunshine every day, but if your diet and sunshine exposure don’t provide enough vitamin D (and few people’s do!), then you will want to take a supplement.
Exercise is almost as important as your diet in developing and maintaining bone mass. Childhood exercise helps to develop bones, and exercise throughout adulthood helps to maintain bone density (Exercise for your Health). Throughout adulthood and especially after menopause, women also benefit from regular activity such as walking, dancing, weight-training, and low-impact aerobics, which can decrease the risk of fractures. Not only does exercise make you feel and look better, it will decrease your risk of fractures throughout your life.
Smoking is bad for your bones. Women who smoke increase their chances of developing osteoporosis. It has been shown that smokers may absorb less calcium from their diets, and low calcium intake is associated with low bone mass, rapid bone loss, and high rates of fracture. Also, women who smoke have lower levels of estrogen compared to nonsmokers, and frequently go through menopause earlier.
Antidepressant medications that are Selective Serotonin Reuptake Inhibitors (SSRIs), such as Paxil (Paroxetine), Celexa (Citalopram), Prozac (Fluoxetine), Luvox (Fluvoxamine), and Zoloft (Sertraline), have been reported to increase the risk of bone fractures in men and women by 50-70%. 7 8 Another study reported that patients taking SSRIs had an increased incidence of osteoporotic fractures. 9
Certain people are more likely to develop osteoporosis than others, and while there are many risk factors you can’t change, you do have control over others.
Factors you can’t change
- Being female
- Having a small frame
- Being Caucasian or Asian (although African Americans and Hispanics are also at risk)
- Advanced age
- A family history of osteoporosis
- History of fracture in an immediate relative
- Estrogen deficiency as a result of menopause, especially early or surgically induced
- Use of certain medications, such as corticosteroids and anticonvulsants
- Personal history of fracture after age 50
- Current low bone mass
- Abnormal absence of menstrual periods
Factors you can change
- Low lifetime calcium intake
- Being very thin or anorexic
- An inactive lifestyle
- Current cigarette smoking
- Excessive use of alcohol
The bone mineral density (BMD) test is a painless test that measures bone density in the spine, wrist, and/or hip (the most common sites of fractures due to osteoporosis), while other tests measure bone in the heel or hand. The results of this test can tell you how dense your bones are, whether or not you have osteoporosis, and the chances of a future fracture. This test can also be used to monitor bone loss, and the effects of any treatment you may be receiving.
The National Health Information Center (a service of the United States Department of Health and Human Services) recommends that women under 65 with risk factors and all women over the age of 65 have a BMD test.10
The treatment of osteoporosis is very similar to prevention: a balanced diet rich in calcium and vitamin D, exercise, limited alcohol consumption, no smoking, and in some cases, medication.
There are different categories of medications that are used to treat and delay bone loss. However, these medications have risks as well as benefits, and it is important to understand that researchers have not studied whether these medications are better at preventing bone loss and fracture than just having enough calcium and vitamin D in the body to support bone health.11 Taking plenty of calcium and vitamin D and doing weight-bearing exercise would be a better choice than prescription medications for many women.
ANTIRESORPTIVE MEDICATIONS (BISPHOSPHONATES): RISKS AND BENEFITS
Bisphosphonates are a group of medications that slow the progress of bone loss. The brand name drugs Fosamax, Actonel, Boniva, and Reclast are all bisphosphonates.
Since bone cells are constantly being produced and destroyed, slowing the bone loss allows bone formation to happen at the same pace as bone cell destruction. However, recent research suggests that bisphosphonates are most beneficial when used for no more than 4-5 years. Using them for longer may be harmful. Why is this? Although bisphosphonates are good at increasing the quantity of bone cells, these drugs may be causing the body to keep damaged bone cells that would normally be destroyed, as well as healthy ones. As the damaged bone cells and minerals build up over time, it can make bones weaker. So even if the patient is no longer losing bone mass, she may be at higher risk of a bone fracture if her bones are more brittle.12 13
A study published in 2008 found that postmenopausal women with osteoporosis who were taking a bisphosphonate for more than 4 years were at increased risk of an uncommon type of fracture (atypical subtrochanteric femur fracture) of the femur-the large leg bone just below the hip joint.14 15 Other studies have found similar results, raising concerns that that taking these drugs for extended periods of times may be harmful to bone health.8 16 17 As of October 2010, the FDA says that more research is needed to better understand the risks and benefits of these drugs.18
Bisphosphonates are generally taken as a daily or weekly pill and some patients have had damage to their gastrointestinal systems, particularly in the path from the mouth to the stomach.19 People taking bisphosphonates should be careful to follow the instructions about how to take them: with a large glass of water while standing or sitting, to remain vertical for at least 60 seconds after taking the pill, and to immediately swallow the pill rather than chewing or sucking it.13
While there are clearly risks to using bisphosphonates, research indicates the drugs may also lower a woman’s risk of getting breast cancer. A 2010 study published in the British Journal of Cancer found that women who took bisphosphonates were 30% less likely to develop breast cancer.20 These findings do not apply to women who are obese, because obese women taking bisphosphonates were just as likely to be diagnosed with breast cancer as obese women who were not taking these drugs.
The following information explains some of the risk and benefits of commonly used brands of bisphosphonate drugs. Since the risks and benefits of all bisphosphonates are similar, patients usually choose a brand based on how often the pill is taken (daily, weekly, or monthly) or whether their insurance covers it or not.
Fosamax (alendronate sodium)
Patients taking Fosamax were found to have a 4% increased risk of developing a condition in the jaw called osteonecrosis, in which the jaw bone does not heal after minor trauma such as tooth extraction.21 This condition leads to pain, swelling, and infection Osteonecrosis is a possible side effect of all bisphosphonates, not just Fosamax, however.22
A study conducted at the University of Washington found that women taking Fosamax have twice as high a risk of developing a chronic irregular heartbeat compared to those who took no osteoporosis medicines.23
What about the benefits? One study showed that there was no difference in risk of fracture between women who took Fosamax for five years and then stopped and women who took the medication longer and stayed on the medication.24 This finding suggests that for most women, there is no point (and as shown in another study, possibly some harm) to taking Fosamox or a similar bisphosphonate medicine for longer than five years.
This medication is nearly identical to Fosamax, just manufactured by a different company. Fosamax came onto the market earlier than Actonel, so there have been more studies focused on Fosamax. A study in 2001 showed that Actonel reduced hip fractures in elderly women who had been diagnosed with osteoporosis by about 40%.25
Boniva (ibandronate sodium)
Some patients taking this medicine have experienced a drop in calcium in their blood, so a patient considering this medication should talk to her doctor about also taking calcium and Vitamin D supplements.13
Anabolic drugs work by increasing the rate of bone formation.
Teriparatide is a human parathyroid hormone that encourages the body to produce new, healthy bone cells. It is not given to patients as frequently as bisphosphonate medicines because it must be injected daily in the lower abdomen or outer thigh, by the patient or a friend/family member. In a study of post menopausal women, the ones taking Forteo had improved bone density within 3 months of starting treatment and had fewer fractures, compared to the women who took oral bisphosphonates, who only saw improvements after 12 months.26 with alendronate in postmenopausal women with osteoporosis. The Journal of Clinical Endocrinology & Metabolism, 87(10): 4528-4535.]
This treatment is less convenient than the oral medicines, more expensive, and there is some concern that it might be linked to a bone cancer called osteosarcoma, which has been seen in rats given the drug. For these reasons, Forteo is only recommended for people with severe osteoporosis who are at high risk of fracture. Even people with severe osteoporosis should not take Forteo for more than 2 years.27
SELECTIVE ESTROGEN-RECEPTOR MODULATORS (SERMS)
Women don’t lose bone mass rapidly until their estrogen levels fall at menopause. SERMs are a broad group of substances that cause the body to respond more strongly to the hormone estrogen. They can also limit the body’s response to drops in estrogen.
Evista (raloxifene HCl)
Evista is taken in the form of a daily pill. It was approved for the treatment of osteoporosis in 1997.28 It works by preventing the body from destroying bone cells. A large study of 6,828 women who had osteoporosis or had already experienced at least one fracture, found that those who used Evista daily had a 30% reduced risk of fracture in their back bones but not their hips or other bones.29
In addition to the reduction in risk of bone fracture, Evista increases bone density in the neck, spine, hip, and throughout the body in general.25 30 SERMs may also reduce the risk of a particular type of breast cancer that targets estrogen receptors in breast tissue, known is “estrogen receptor-positive breast cancer.” One study found that postmenopausal women who took Evista for approximately 3 years reduced their risk of estrogen receptor-positive breast cancer by 90%. But Evista did not reduced risk of breast cancer for women with estrogen receptor-negative breast cancer.31 Another possible benefit is that women taking this medication have had a significant decrease in LDL (“bad”) cholesterol in the first three months of treatment. After the drop, cholesterol levels stayed steady.26
There are serious risks, however: Evista increases a woman’s chances of getting blood clots, especially in the lungs and in leg veins, so it should not be taken by women who are pregnant or who have a history of blood clots.25 In some studies, a slightly higher proportion of the women taking this medicine than those taking a placebo (sugar pill) said that they had hot flashes, but this finding was not consistent.
Each year about one third of people over age 65 falls, and some will face permanent disability from the broken bones suffered. Falls are the main concern for those with osteoporosis, because that is when breaks and fractures usually occur. To prevent broken bones, the best strategy is to avoid falling – even more than taking medication to prevent osteoporosis.
Several factors contribute to the greater likelihood of an older person falling. Many face physical factors such as poor eyesight, limited hearing, lack of strength and/or coordination, and poor balance. Others are affected by the medications they take, such as muscle relaxants, sedatives or blood pressure drugs, which can cause dizziness and/or lightheadedness. And finally, people are more likely to fall in a cluttered house, in dim lighting, or on loose carpeting or throw rugs.
Precautions you can take to avoid falls:
- Make sure all stairways, entrances and halls are well lit. Consider using nightlights, particularly in the bathroom.
- Install non-slip material and a grab bar in the tub/shower.
- Secure all loose cords and throw rugs.
- Make sure stairs are clear of clutter and treads or carpet is secure.
- Use non-skid rubber mats in front of the sink and stove and clean up spills immediately.
- Wear sturdy, rubber-soled shoes
- Ask your doctor if any of the medications you’re taking could contribute to a fall.
National Institutes of Health National Resource Center: Osteoporosis and Related Bone Diseases
National Health Information Center provides information about the process of bone density testing.
- Leibson CL, Toteson ANA, Gabriel SE, Ransom JE, Melton JL III. (2002) Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study. Journal of the American Geriatrics Society, 50(10): 1644-50. ▲
- Branch C and PL. Osteoporosis: Peak Bone Mass in Women. NIH. Available at: http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/bone_mass.asp. Accessed August 7, 2013. ▲
- Calcium. Informed Health Online. 2013. Available at: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0005075/. Accessed June 28, 2013. ▲
- Osteoporosis – overview. ADAM Medical Encyclopedia. 2012. Available at: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001400/. Accessed June 28, 2013. ▲
- New York State Department of Health. (November 2003) All About Bone Mineral Density Tests. <http://www.health.state.ny.us/diseases/conditions/osteoporosis/tests.htm> ▲
- Dietary Supplement Fact Sheet: Calcium. National Institutes of Health: Office of Dietary Supplements. Available at: http://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/#h2. Accessed August 7, 2013. ▲
- Sheu Y, Lanteigne A, Stürmer T, Pate V, Azrael D, Miller M. (2015) SSRI use and risk of fractures among perimenopausal women without mental disorders. Injury Prevention. ▲
- Wu Q, Bencaz AF, Hentz JG, Crowell MD. (2012). Selective serotonin reuptake inhibitor treatment and risk of fractures: a meta-analysis of cohort and case-control studies. Journal of Bone and Mineral Research, 27:1186-1195. ▲
- Diem SJ, Blackwell TL, Stone KL, Yaffe K, Haney EM, Bliziotes MM, Ensrud KE. (2007) Use of Antidepressants and Rates of Hip Bone Loss in Older Women: The Study of Osteoporotic Fractures. Archives of Internal Medicine, 167:1240-1245 ▲
- National Health Information Center. (January 28, 2010) Get a Bone Density Test. <http://www.healthfinder.gov/prevention/printtopic.aspx?topicid=12> ▲
- Ference JD, Wilson SA. (January 2006) Ibandronate (Boniva) for treatment and prevention of osteoporosis in postmenopausal women. American Family Physician, 73(2). ▲
- Kwek EBK, Goh SK, Koh JSB, Png MA, Howe TS. (2008) An emerging pattern of subtrochanteric stress fractures: A long-term complication of alendronate therapy?. Injury, 39(2): 224-231. ▲
- Mashiba T, Mori S, Burr DB, Komatsubara S, Cao Y, Manabe T, Norimatsu H. (2005) The effects of suppressed bone remodeling by bisphosphonates on microdamage accumulation and degree of mineralization in the cortical bone of dog rib. Journal of Bone and Mineral Metabolism, 23(S1): 36-42. ▲
- Rosenwasser MP. (March 10, 2010) 2010 Annual Meeting Podium Presentations: The Structural Effects of Long-Term Bisphosphonate Treatment Leading to Atypical Hip Fractures. American Academy of Orthopedic Surgeons. <http://www3.aaos.org/education/anmeet/anmt2010/podium/podium.cfm?Pevent=241> ▲
- Lenart BA, Lorich DG, Lane JM. (2008) Atypical fractures of the femoral diaphysis in postmenopausal women taking alendronate. New England Journal of Medicine, 358:1304-1306. ▲
- Lenart BA, Neviaser AS, Lyman S, Chang CC, Edobor-Osula F, Steele B, van der Meulen MC, Lorich DG, Lane JM. (2009) Association of low-energy femoral fractures with prolonged bisphosphonate use: a case control study. Osteoporosis International, 20(8): 1353-62. ▲
- Capeci CM, Tejwani NC. (2009) Bilateral low-energy simultaneous or sequential femoral fractures in patients on long-term alendronate therapy. Journal of Bone Joint Surgery. American volume, 91(11): 2556-61. ▲
- Commissioner O of the. Safety Alerts for Human Medical Products – Bisphosphonates (Osteoporosis Drugs): Label Change – Atypical Fractures Update. Available at: http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm229244.htm. Accessed August 7, 2013. ▲
- Waknine Y. (February 25, 2009) FDA Safety Changes: Boniva, Emend, Clozaril. Medscape Today. <http://www.medscape.com/viewarticle/588759> ▲
- Newcomb PA, Trentham-Dietz A, Hampton JM. (2010) Bisphosphonates for osteoporosis treatment are associated with reduced breast cancer risk. British Journal of Cancer. 102: 799-802. ▲
- DeNoon DJ. (January 2, 2009) Fosamax: Higher Risk of Jawbone Death? After Tooth Extraction, Fosamax Patients Have 4% Risk of Jaw Osteonecrosis. WebMD Health News. <http://www.webmd.com/osteoporosis/news/20090101/fosamax-higher-risk-of-jawbone-death> ▲
- Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL. (2004) Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases. Journal of Oral and Maxillofacial Surgery, 62(5): 527-534. ▲
- Sternberg S. (April 28, 2008) Fosamax tied to increased risk of heart condition. USA Today. <http://www.usatoday.com/news/health/2008-04-28-fosamax_N.htm> ▲
- DeNoon DJ. (December 26, 2006) Fosamax Break Won’t Up Fracture Risk Study Shows After 5 Years of Fosamax for Osteoporosis, Some Women Can Take a Break. WebMD Health News. <http://www.webmd.com/osteoporosis/news/20061226/fosamax-break-wont-up-fracture-risk> ▲
- McClung MR, Geusens P, Miller PD, Zippel H, Bensen WG, Roux C, et al. (2001) Effect of risedronate on the risk of hip fracture in elderly women. New England Journal of Medicine, 344(5): 333-340. ▲
- Body JJ, Gaich GA, Scheele WH, Kulkarni PM, Miller PD, Peretz A, et. al. (2002) A randomized double-blind trial to compare the efficacy of teriparatide [recombinant human parathyroid hormone (1-34) ▲
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- U.S. Food and Drug Administration. (September 14, 2007.) FDA Approves New Uses for Evista: Drug Reduces Risk of Invasive Breast Cancer in Postmenopausal Women. <http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2007/ucm108981.htm> ▲
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