By Elizabeth Nagelin-Anderson, MA and Noy Birger, BS
Updated May 2010
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 production falls out of sync with bone cell destruction. One in two women, and one in eight men over the age of 50 will have an osteoporosis-related fracture in their lifetime. Most won’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 fracture 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. A broken hip could lead to permanent disability or even death; 20% of those who suffer this common injury die within a year of the fracture because patients may have complications such as pneumonia, other infections and general declining health after a hip fracture.
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 97% of bone mass is usually achieved by the age of 18, the bone mass you develop as a child, through exercise and a healthy diet rich in calcium and vitamin D, has a great impact on bone health later in life. An inactive childhood or a poor diet prevent you from reaching your peak bone mass.
Although the body has almost reached maximum bone mass by age 18, it continues to build bone slowly until you reach peak bone mass at about the age of 30, then the building slows down and, in women, is relatively unchanged until menopause. In the five to seven years following menopause, when estrogen levels fall and bone loss is the most rapid, women can lose up to 20% of their bone mass, making them more susceptible to osteoporosis. Bone loss continues into old age, although at a slower rate.
Hormone replacement therapy (HRT)-now more commonly called hormone therapy-is often prescribed for treating the symptoms of menopause, including the prevention of osteoporosis, but research by the National Institute of Health (NIH) found that the risks of hormones 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 appropriate
Calcium is important for everyone. If your mother told you to drink three glasses of milk each day, she was right. Children ages 4-8 need 800 mg, and ages 9-18 require 1300 mg. Every adult needs about 1000 mg of calcium each day and three 8-oz glasses of milk will provide 1050 mg. According to NIH, calcium intake should increase to 1200 mg a day for those ages 51-64 and to 1500 mg a day for those over 65.
In addition to milk products such as yogurt and cheese, other foods that are rich in calcium include broccoli, spinach and 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.
Vegetables are not likely to provide all the calcium you need: a typical half cup serving of raw broccoli has about 21 mg of calcium. 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, 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 see: www.nal.usda.gov/fnic/foodcomp/Data/SR15/wtrank/sr15w301.pdf
Dietary supplements can also help. Results from the Women’s Health Initiative, showed 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 regular use of calcium and vitamin D supplements can reduce the risk of bone fracture.
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 take a smaller dose of calcium with that meal (like a multi-vitamin that has only 200-300 mg of calcium or a TUMS), or to take none with that meal and save two 600 mg doses to take 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 a day and can safely increase their daily dose of vitamin D to as high as 2,000 IUs. (http://dietary-supplements.info.nih.gov/factsheets/vitamind.asp) 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 diet in developing and maintaining bone mass. Childhood exercise helps to develop bones, and exercise throughout adulthood helps to maintain and even slightly increase bone density. 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. So, exercising not only makes you feel and look better, it will decrease your risk of fractures now or later in life when fractures can be most dangerous to your quality of life.
Smoking is bad for your bones. Women who smoke increase their chances of developing osteoporosis. It has been found 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.
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 all women over the age of 65, and post-menopausal women under age 65 who have risk factors have a BMD test.
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 the progress of osteoporosis. 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. Taking plenty of calcium, vitamin D, and doing weight-bearing exercise does not have any risks and for many women would be a better choice than prescription medications.
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., 
A new study that has not yet been published 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. Other studies have found similar results, , ,  raising concerns that that taking these drugs for extended periods of times may be harmful to bone health. Further research is necessary to understand the true risks and benefits of bisphosphonates, and how long women should take them. As of April 2010, the FDA says that more research is needed to determine if these drugs cause the rare femur fracture. 
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. 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. 
While there are clearly risks to using bisphosphonates, new 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. 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. This condition leads to pain, swelling, and infection Osteonecrosis is a possible side effect of all bisphosphonates, not just Fosomax, however. 
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.
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. 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%.
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.
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.
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.
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. 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.
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. 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. 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.
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. 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.
Websites of interest
National Institutes of Health Osteoporosis and Related Bone Diseases – National Resource Center
National Health Information Center provides information about the process of bone density testing
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