Osteoporosis — Are You At Risk?

Circa 2006

Your hip bone connected to your back bone, your back bone connected to your shoulder bone… dem bones gonna dance around… or so the gospel spiritual goes, based on the biblical story of Ezekiel, who walked into a valley of dead, dry bones and brought them back to life.

These days, for millions of women with the disease osteoporosis—literally meaning porous bones—superior medical treatments can also bring their bones back to life.

An estimated 10 million Americans aged 50 and older currently have osteoporosis, an illness in which their bones are thin, weak and more likely to break. Another 34 million have a preliminary condition called osteopenia (low bone mass), which puts them at increased risk for developing osteoporosis. Eight out of 10 people affected by osteoporosis are women, although the disease also occurs in men.

A chronic condition, osteoporosis presents a serious public health problem. Each year the disease is responsible for more than 1.5 million fractures of the hip, spine, wrist and other sites. One in two women over age 50 will incur an osteoporosis-related fracture in her lifetime, which can result in significant pain, loss of height and functional limitations. In fact, a woman’s risk of a hip fracture—a seriously immobilizing break linked with potentially severe secondary medical problems—is equivalent to her combined risk of developing breast, uterine and ovarian cancer.

Fractures resulting from osteoporosis can cause women to lose their ability to stand up, walk or perform basic activities like dressing themselves. Several studies indicate that the death rate in the year after hip fracture averages 25 percent. Another 25 percent of hip fracture patients require care in a nursing home or other institution for at least a year, and more than 50 percent report ongoing mobility problems.

Even without fracture, osteoporosis can affect self-esteem. Many women who develop osteoporosis-related kyphosis (curvature of the spine), height loss or other physical changes do not feel desirable. Emotional reactions like fear, anxiety and depression are not infrequent.

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Bone is living, growing tissue that is constantly being broken down and replaced by new bone. In young people, bone is created faster than it is broken down, so bones increase in density and strength until somewhere around age 30. The process then gradually reverses and bone begins breaking down faster than it is replaced.

Several factors increase the risk for osteoporosis. In women, the rate of bone loss is most rapid in the first few years following menopause because the ovaries stop producing estrogen, a hormone that helps protect against bone loss. Men tend to develop osteoporosis somewhat later, but by their 60s have caught up to women in the rate of bone loss.

In addition, not getting enough calcium and vitamin D—even during the childhood and teen years—can contribute to osteoporosis, because if bones do not reach the highest possible peak bone mass during developmental years, osteoporosis is more likely to develop later. Other risk factors include a history of bone fracture as an adult, low body weight, a family history of osteoporosis, and long-term use of certain medications (e.g., steroids, anticonvulsants, aluminumcontaining antacids and certain cancer treatments). Additionally, smoking and excessive alcohol use can accelerate bone loss, as can eating disorders, abnormal hormone levels, diabetes and chronic diseases of the kidneys, lungs, stomach or intestines.


Osteoporosis and low bone mass are preventable and treatable; therefore, it’s important for both men and women to understand all they can about caring for their bones. Consider the following suggestions for maintaining bone health:

1) Get adequate calcium and vitamin D. An adequate intake of calcium throughout life is important for maintaining bone strength. If you are age 50 or older, studies suggest you should have between 1,200 mg (for men) and 1,500 mg (for women) of calcium each day, along with 400-600 IU of vitamin D. Most people do not get this amount of calcium from diet alone, so supplements are frequently necessary. Your body can best handle about 500 mg of calcium at any one time, whether from food or supplements. Therefore, consume your calcium-rich foods and/or supplements in smaller doses throughout the day, preferably with a meal.

2) Take your osteoporosis medication as directed. Medicine can be a key factor in protecting bone health. Prescription medication is available that can build and maintain bone density and reduce the risk of fracture. But no medicine can work if you don’t take it. So fill your prescription, take it properly and continue taking it—as directed.

3) Exercise to build strength, flexibility and balance. Lack of exercise, especially as people get older, can contribute to lower bone mass or density. Two types of exercise are important for preventing and managing osteoporosis: a) weight-bearing exercise, like walking, stair climbing and dancing, and b) resistance exercise, like the use of free weights or weight machines. These exercises can help maintain bone health and prevent further bone loss. Exercise can also reduce the risk of falling by improving balance, flexibility and strength. One caution: it is important for people with osteoporosis to avoid certain types of exercise that can injure already weakened bones, so talk to your doctor about a safe, effective exercise program that best meets your needs.

4) Visit your doctor regularly. Work with your doctor to monitor your osteoporosis and bone mineral density (BMD), as well as your overall health. It’s important to evaluate the steps being taken to maintain the health of your bones and decide proactively what treatment is right for you.

5) Stop smoking. Smoking interferes with the way your body uses calcium to help bones. In fact, smoking just one pack of cigarettes a day through adult life reduces bone mass by an average of 5 to 10 percent. So if you don’t smoke, don’t start, and if you do smoke, quit!

6) Limit alcohol and caffeine. The evidence for alcohol and caffeine is less compelling than for smoking and exercise, but moderation is wise. For women, limit your alcohol intake to one drink or less a day—this equals 12 ounces of regular beer, five ounces of wine or one-and-a-half ounces of hard liquor. Also, recent research suggests that drinking as few as four cola drinks a week may be associated with lower bone mass, so consider replacing some of your coffee and cola with non-caffeinated beverages.

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Medications for osteoporosis act by either slowing the body’s breakdown of bone (anti-resorptive medications) or by promoting bone formation (anabolic medications).

Currently, the most effective FDA-approved treatments for osteoporosis are the anti-resorptive medications. This category includes the bisphosphonates (Boniva, Actonel, Fosamax and others), calcitonin (Calcimar, Miacalcin), estrogen replacement therapy and selective estrogen receptor modulators (SERMs such as Evista). These medications don’t cause the body to build bone any faster, but by inhibiting bone removal they tip the balance in favor of rebuilding, leading to stronger and thicker bones.

Of these anti-resorptive medications, the most commonly prescribed are the bisphosphonates, which have been proven to decrease wrist fractures and spine fractures, and are the only agents definitively proven to reduce hip fractures in postmenopausal women with osteoporosis. Alendronate (Fosamax) was the first bisphosphonate marketed for osteoporosis and is now available in a once-a-week formulation. Newer bisphosphonates approved for osteoporosis are risedronate (Actonel), taken either daily or once a week, and ibandronate (Boniva), available as a daily pill, a monthly pill or an injection given by physicians every three months.

Patients should take oral bisphosphonate medications while standing or sitting upright and should remain upright for 30 to 60 minutes after taking them to minimize side effects such as difficulty or pain in swallowing and irritation of the esophagus and stomach. These gastrointestinal problems appear to be somewhat reduced with the newer bisphosphonates, and taking the once-a-week or once-a-month formulations also minimizes the exposure of the GI tract. Food, calcium, iron and other mineral supplements, and antacids containing calcium, aluminum can reduce the absorption of bisphosphonates, lowering their effectiveness. Therefore, the medications should be taken in the morning before breakfast with plain water only, with no food or drink for at least 30 minutes afterward.

All the bisphosphonates work similarly, but each has its own advantages and disadvantages. Fosamax is the only one FDA-approved for treatment of osteoporosis in men (although many doctors still prescribe the others for men) and has the greatest accumulated evidence for effectiveness when taken as prescribed. The newer agents may have fewer side effects, however, which may make patients more likely to continue taking them. Similarly, studies have generally shown that the less frequently people have to take a medication, the more likely they are to get in all the required doses, so Boniva’s once-a-month oral formulation and every-threemonths injection present a significant advantage for many patients.

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Another type of anti-resorptive is calcitonin, a hormone the body produces naturally to inhibit bone breakdown. Synthetic calcitonin derived from a variety of animal sources—most commonly salmon—is available as an injection or nasal spray. Common side effects include flushing, skin rash and nausea. Calcitonin is not as effective in building back bone or preventing fractures as the other anti-resorptives, but it is used to supplement other therapies or for patients who cannot tolerate other agents.

A third option is hormonal treatment either with estrogen or with a class of drugs called SERMs, which work like estrogen in some tissues, but act as anti-estrogens in other tissues. The SERMs allow patients to reap the benefits of estrogen (such as maintaining bone mass) while avoiding many of the potential side effects of estrogen (such as increased risk for uterine cancer).

The first SERM on the market was tamoxifen, which blocks the effects of estrogen on breast tissue and is therefore used to prevent recurrence of breast cancer. Raloxifene (Evista), the second FDA-approved SERM, can be used to prevent breast cancer but is also approved for the prevention and treatment of osteoporosis in postmenopausal women. Because of some of Evista’s anti-estrogen effects, one of the main side effects is hot flashes. But Evista retains estrogen’s positive effects on maintaining bone mass, lowering LDL cholesterol (the bad cholesterol) and increasing HDL cholesterol (the good cholesterol). Unfortunately, it also retains estrogen’s propensity to promote blood clots, slightly increasing the risks for stroke, deep venous thrombosis (DVT) in the legs, and a life-threatening clot in the lungs called pulmonary embolus (PE). To reduce the chances of these serious side effects, patients taking Evista should avoid prolonged periods of immobility (for instance, sitting in one position during car or airplane rides), which make blood clots more likely.

There is currently one anabolic medication—parathyroid hormone (Forteo)—that acts on the bone formation part of the cycle. Forteo must be given by injection and is used to stimulate new bone formation. However, because its long-term safety is still unknown, it is FDAapproved for only 24 months of use.

In summary, used alone or in combination, many effective medications are available. Along with positive lifestyle changes, they can help prevent and treat osteoporosis and keep your bones up and dancing.

National Institutes of Health

Osteoporosis and Related Bone Diseases—National Resource Center www.niams.nih.gov/bone

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