Osteoporosis A Guide To Prevention and Treatment Harvard Health

A HARVARD MEDICAL SCHOOL
SPECIAL HEALTH REPORT
Osteoporosis
A guide to prevention and treatment
PRICE: $29
This Harvard Health Publication was prepared exclusively for Fred Hirshberg - Purchased at https://www.health.harvard.edu
OSTEOPOROSIS
SPECIAL HEALTH REPORT
Contents
The basics of bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Medical Editor
David M. Slovik, MD Two types of bone tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Endocrinologist, Massachusetts General Hospital Bone remodeling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Chief, Division of Endocrinology, The life cycle of bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Newton-Wellesley Hospital
Associate Professor of Medicine, What causes osteoporosis?. . . . . . . . . . . . . . . . . . . . . . . . . . 6
Harvard Medical School Primary osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Executive Editor Secondary osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Anne Underwood
Writers Know your risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Stephanie Watson, Daniel Pendick Risk factors you can’t control . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Copy Editor Risk factors you can control . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Robin Netherton
The consequences of osteoporosis. . . . . . . . . . . . . . . . . . . 13
Creative Director
Judi Crouse Hip fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Spinal fractures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Production/Design Manager
Lori Wendin Wrist fractures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Illustrators Other consequences. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Jesse Tarantino, Matt Holt
Detecting osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Published by Harvard Medical School
Gregory D. Curfman, MD, Editor in Chief DEXA scans for bone density. . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Urmila R. Parlikar, Senior Content Editor Vertebral fracture assessment . . . . . . . . . . . . . . . . . . . . . . . . . 17
Lab tests for bone turnover. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
In association with
Belvoir Media Group, LLC, 535 Connecticut Avenue, Nor- Developing a plan of action. . . . . . . . . . . . . . . . . . . . . . . . . 19
walk, CT 06854-1713. Robert Englander, Chairman and If you have osteopenia (T-score between –1 and –2.5) . . . . . . . . 19
CEO; Timothy H. Cole, Executive Vice President, Editorial
Director; Philip L. Penny, Chief Operating Officer; Greg If you have osteoporosis (T-score –2.5 and below) . . . . . . . . . . . 19
King, Executive Vice President, Marketing Director; Ron Goldberg,
Chief Financial Officer; Tom Canfield, Vice President, Circulation. Protecting your bones: Nutrition. . . . . . . . . . . . . . . . . . . . . 21
Copyright © 2016 by Harvard University. Permission is Calcium and vitamin D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
required to reproduce, in any manner, in whole, or in part, Vitamin K. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
the material contained herein. Submit reprint requests to:
Potential dietary dangers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Harvard Health Publications Permissions
10 Shattuck St., 2nd Floor, Boston, MA 02115 Protecting your bones: Exercise . . . . . . . . . . . . . . . . . . . . . 29
www.health.harvard.edu/permissions
Fax: 617-432-1506
How weight-bearing exercise benefits bones. . . . . . . . . . . . . . . . 29
Classic strength training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Website
For the latest information and most up-to-date publication Preventing falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
list, visit us online at www.health.harvard.edu.
SPECIAL SECTION
Customer Service
For all subscription questions or problems (rates, Strength training and balance exercises for bone health. . . 34
subscribing, address changes, billing problems), email
to HarvardProd@StrategicFulfillment.com, call 877- Protecting your bones: Medication. . . . . . . . . . . . . . . . . . . 39
649-9457 (toll-free), or write to Harvard Health Bisphosphonates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Publications, P.O. Box 9308, Big Sandy, TX 75755-9308.
SERMs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Ordering Special Health Reports
Monoclonal antibodies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Harvard Medical School publishes Special Health Reports
on a wide range of topics. To order copies of this or other Hormones. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
reports, please see the instructions at the back of this
report, or go to our website: www.health.harvard.edu. Coping with fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
For Licensing, Bulk Rates, or Corporate Sales: Living with a hip fracture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Call 203-828-0349, or Support groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
email HHP_licensing@hms.harvard.edu,
or visit www.harvardhealthcontent.com Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
ISBN 978-1-61401-124-8
Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
The goal of materials provided by Harvard Health Publications
is to interpret medical information for the general reader.
Cover Image: © Wavebreakmedia Ltd | Thinkstock
This report is not intended as a substitute for personal medical
advice, which should be obtained directly from a physician.
Dear Reader,
“Hard as bone”—that’s an expression we’ve all heard. But what does it really mean? Healthy
bones are indeed hard. Your skeletal system does yeoman’s work in supporting your body and
facilitating your movements. But when you have osteoporosis (literally “porous bone”), you can
no longer count on your skeleton to be sturdy enough to withstand even routine stress. A twist,
a bend, an unexpected jolt—all can snap a dangerously weak bone. Sadly, many people have
no inkling that they have been losing bone mass for years until a painful fracture of the wrist,
spine, or hip brings the problem into sharp focus.
More than 10 million Americans currently live with osteoporosis, and another 43 million show
early signs of bone loss. And those numbers are expected to grow as baby boomers age. Ac-
cording to the National Osteoporosis Foundation, an estimated 64 million Americans over age
50 are expected to have low bone density or osteoporosis by 2020. That number will jump to
more than 71 million by 2030, resulting in more bone fractures.
For the individual, the consequences of an osteoporosis-related fracture can be devastating.
Many older adults never regain the good health and quality of life they enjoyed before suffer-
ing a broken bone. Physical complications ranging from ongoing pain and stooped posture to
breathing and digestive problems are common. Hip fractures can significantly impair a person’s
mobility, making it impossible to drive, cook, or even walk across a room without assistance.
But you don’t have to wait until the damage is done to fight this disease. You can start making
lifestyle changes at any age that will promote good bone health and prevent or delay severe
bone loss. Ways of doing that are detailed in this report. And if you already have the disease,
there have never been more options for treating it. Doctors have sophisticated tools to detect
bone thinning in the earliest stages and identify those who should begin treatment and when.
For those in greatest danger of an osteoporosis-related fracture, a number of highly effective
medications to curb bone loss are already available, and more are on the way.
By learning about osteoporosis, you’re taking a step toward better bone health. This report can
help you become aware of your risk and serve as a guide for making the lifestyle changes that
have been proved to reap long-term bone benefits. Regardless of your age, it’s never too late—
or too early—to begin boning up on bone health.
Sincerely,
David M. Slovik, M.D.

Medical Editor
Harvard Health Publications | Harvard Medical School | 10 Shattuck Street, Second Floor | Boston, MA 02115
The basics of bone
Y our bones are surprisingly strong. Ounce for

ounce, they bear as much weight as reinforced
concrete. But unlike concrete, bone isn’t inert. It is
As you age, that process of flux inevitably
includes losing some of your youthful bone density, as
withdrawals outpace deposits. However, osteoporosis
a living tissue that can grow stronger in response to is not inevitable. You can lose a certain amount of
stresses and heal itself if injured. bone and still be in the normal range for bone density.
Bones serve many roles in the body. They support At a certain point, however, if you keep losing bone,
your weight. They join forces with muscles, ligaments, you will be at an intermediate stage of bone loss called
and tendons to allow complex, highly articulated osteopenia, or simply low bone density. If you do not
movements. Less obviously, they also serve as a manage to halt or slow the loss at this point, you may
repository of minerals that are used by the body. Like eventually cross the line into osteoporosis, in which
a savings bank, they allow both withdrawals and porous bones become weak and susceptible to breaks
deposits of their mineral assets—a process that requires or fractures.
breaking down and rebuilding part of the bone matrix This report will examine both of these problems
in order to release or absorb the minerals. Thus, even and explain the various measures you can take to help
though bones seem solid and unchanging, they are in your bones, no matter which stage you are at. But first,
a constant state of flux, like other tissues in the body. to understand how and why osteoporosis occurs and
what can be done to prevent and treat this potentially
devastating ailment, it helps to know some basics
Figure 1: Compact and trabecular bone about the living tissue that makes up the more than
200 individual bones of the body.
Two types of bone tissue

The bones in your body contain two essential types of
Trabecular bone tissue.
• Compact bone. As the name implies, compact
bone tissue is densely packed. It is composed of
units called osteons, which consist of tight plates
wound into tubular forms that resemble rolled-up
magazines (see Figure 1, at left). A tiny blood ves-
sel, or capillary, runs through the center of each
Compact bone osteon, supplying nutrients and oxygen. Osteons
are arranged in stacks to form a bone’s hard outer
casing. In fact, compact bone is sometimes referred
to as cortical bone, derived from the Latin word
Most bones in your body are composed of two types of tissue:
compact bone and trabecular bone. Often, the compact bone—
“cortex,” meaning “bark” or “shell.”
tightly packed tubes of bone tissue whose cross-sections resemble • Trabecular bone. The second major type of mate-
the rings of a tree trunk—forms the outer casing, while the tra- rial in your skeleton is called trabecular bone,
becular bone, which is more porous, is found at the center. meaning “like a little beam.” Trabecular bone is
2 Osteoporosis w w w.h ealt h .ha r va r d.e du
composed of millions of tiny beams and plates Calcium carries a lot of weight in the body, both
that form a lattice-like matrix (see Figure 1, page literally and figuratively. It’s the major component of
2). It is less dense and spongier in consistency than the cement-like mineral, hydroxyapatite, that lends
compact bone and, for this reason, is sometimes bones their strength. But it also plays a crucial role in
known as spongy bone or cancellous bone (mean- other parts of the body. Buoyed along in the blood,
ing “lattice-like”). calcium bustles in and out of cells, transmitting sig-
Most bones contain a combination of compact nals to nerves and muscles. In this capacity, it is vital
and trabecular tissue, with compact bone forming the for maintaining heart rate and blood pressure, as well
dense outer casing and trabecular bone filling the inte- as regulating internal organs.
rior. Over all, the ratio of compact to trabecular bone Calcium is so important that when blood levels of
in adults is about four to one, although the proportion this mineral drop below a certain threshold, the body
varies greatly from bone to bone. Long, regular bones, raids the bones to compensate. However, the amount
like those of the arms, legs, and ribs, consist primarily of calcium required to maintain all these other func-
of compact bone. Irregularly shaped bones—such as tions is slight—only about 1% of your body’s total
the ends of the leg or arm bones, the spinal vertebrae, calcium stores. The rest—weighing about 2.25 to 4.5
and the pelvis—consist mostly of trabecular bone. pounds—is sequestered in your bones.
Why is this relevant? It helps explain, for example,
why the spine is particularly vulnerable to osteoporo- Tapping and replenishing calcium stores
sis. Not only is trabecular bone—the main constitu- The process by which calcium is removed from bone
ent tissue in vertebrae—less dense than compact bone is known as resorption, and it is performed by special
by its very nature. It is also metabolically more active, cells called osteoclasts. Their sawtooth membranes
so when bones begin to lose density, trabecular bone enable them to attach to the surface of bone. Once
grows weaker faster and therefore starts earlier in the attached, they use acids and enzymes to break down
progression toward osteoporosis. It is for this reason the bone’s matrix of collagen and minerals, releasing
that trabecular bone in the spine is lost first, and why these materials into the bloodstream for reuse in other
it’s important to see your doctor for a bone density test parts of the body (see Figure 2, page 4). This recycling
of the spine no later than age 65 in women and age 70 effort leaves tiny trenches in the bone.
in men, or sooner if you have risk factors. A bone-building process known as formation—
carried out by cells called osteoblasts—counterbal-
ances resorption. Osteoblasts move into the trenches
Bone remodeling left by the osteoclasts and release strands of collagen
Although compact and trabecular bone differ in struc- into the void. Eventually, they become trapped in the
ture, they are composed of the same basic material: a web they have woven. Held by these moorings, they
meshwork of protein fibers, called collagen. The col- evolve into structural bone cells, or osteocytes. Cal-
lagen matrix is inlaid with calcium and phosphate cium, phosphate, and other minerals carried in the
minerals, which are mixed with water to form a hard, bloodstream also accumulate in the web woven by
cement-like substance called hydroxyapatite. Smaller osteoblasts. The minerals coalesce into crystalline
amounts of sodium, magnesium, and potassium are hydroxyapatite, and the formation process is complete:
also present in the matrix. the bone that was removed has been fully replaced.
Calcium, however, is the main ingredient of bone. To maintain bone density, the body needs to keep
The dynamic process by which bones take in or release a constant balance between bone production and
this vital mineral is known as remodeling, or bone breakdown. Enter the osteocytes—mature osteoblasts
metabolism. Osteoporosis is the eventual result when that have become trapped within the bone matrix they
bone remodeling gets out of balance, causing more helped construct. Osteocytes send out signals that
calcium to leave the bones than is added. oversee bone remodeling. They direct osteoclasts to
ww w. h ealt h . h ar v ar d . e du Osteoporosis 3
Another key player in bone health is parathyroid
Figure 2: The cycle of bone construction hormone, which is secreted by small glands behind
and demolition the thyroid. The glands release parathyroid hormone
when the level of calcium in the blood falls below
A Osteoclast B
the amount needed by the body’s cells. In response,
Trenches left by osteoclasts
the digestive system absorbs more calcium from
food and the kidneys excrete less calcium in urine,
both of which help to raise blood levels of calcium.
Parathyroid hormone also stimulates the osteoclasts
to break down bone, releasing calcium into the
C D bloodstream. When the blood levels are adequate, the
Osteoblast production of parathyroid hormone falls.
Osteocyte
The life cycle of bone

Bone remodeling is a lifelong process. At first, build-
Bone is constantly being constructed and demolished.
ing outpaces demolition (resorption). Later in life the
ratio is reversed. In the middle—earlier than most
During resorption (A), cells known as osteoclasts break down
bone, releasing calcium into the bloodstream. people realize—you reach peak bone mass, the maxi-
The trenches that are left behind (B) are then filled in by construc-
mum bone density you will achieve.
tion cells known as osteoblasts.
The osteoblasts release collagen into these troughs and eventually The early years
evolve into structural bone cells, or osteocytes (C). During the first 20 years of life, the body builds new
Once these osteocytes mix together with calcium, phosphate, and bone more quickly than it removes old bone. By the
other minerals to form a cement-like substance known as hydroxy- late teens, most bone formation has already occurred.
apatite, the process of replacing the lost bone is complete (D). In fact, by age 20, most women have built 98% of
their skeletal mass. Over the next decade, building
slows, but still outpaces resorption. By age 30, most
break down bone and osteoblasts to form new bone, men and women reach their peak bone mass (see Fig-
thereby maintaining a kind of balance or equilibrium ure 3, page 5). In an ideal world, you will have built
within the bones. strong bones early in life. But even if you haven’t, you
should not be discouraged. It’s never too late to adopt
Other key players bone-preserving habits.
The remodeling process releases stored calcium for The density of bones at their peak varies from per-
critical functions elsewhere in the body, and it also son to person. Heredity, lifestyle, and medical condi-
keeps your skeleton fresh and healthy by replacing tions all influence how much bone you’ll have in the
old bone with new. This important task in the body’s bank when heavy withdrawals begin. It’s important to
housekeeping scheme requires more than just osteo- begin building this “rainy day fund” early, when you
clasts, osteoblasts, and osteocytes. It also takes a siz- have the most opportunity to influence your bone
able squad of hormones and other substances to carry mass.
out bone formation. For example, vitamin D (which Following are some of the factors that influence
is actually a hormone) plays a pivotal role, limiting peak bone mass.
withdrawals of calcium from bone by enhancing cal- Sex, race, and genes. In general, bone density is
cium absorption from food in the intestines into the 30% higher in men than in women and 10% higher
bloodstream. in blacks than in whites. Even so, there is wide varia-
Medications. Use of certain
Figure 3: Bone density through the ages drugs may be accompanied by
bone loss (see “Medical conditions
Attainment of bone mass Consolidation Age-related bone loss and medications that can lead to
bone loss,” page 7). Too much syn-
thetic thyroid hormone taken for
an underactive thyroid gland can
BONE MASS
Menopause weaken bones. Other drugs that

Men
diminish bone strength include
glucocorticoids, which are taken to
Women Fracture threshold control asthma and immune disor-
ders (see “6 ways glucocorticoids
0 10 20 30 40 50 60 hinder bone formation,” page 8),
AGE (YEARS) as well as medications used to treat
breast and prostate cancers. Also,
Bone formation outpaces resorption up to age 30, when both men and women reach their
peak bone mass. Then the process reverses, leading to a plateau and finally a loss of bone because several drugs that speed
mass that occurs gradually in men but much faster in menopausal women. bone loss are commonly given
Source: Compston JE. Clinical Endocrinology, 1990. after organ transplants, people
who have had these operations are
tion within these groups. The difference may trace to at considerable risk of developing osteoporosis.
several genes that influence bone mass, bone turnover,
and bone loss. Middle age and beyond
Diet. Nutrition early in life strongly influences Among women, bone mass usually remains steady
bone health in adulthood. Research indicates that until the onset of menopause, when bone is lost rap-
women whose diets contain the greatest amounts idly. But for many women, bone degeneration begins
of calcium and vitamin D during childhood and in the years just preceding menopause (perimeno-
adolescence have denser and stronger bones during pause), as estrogen levels start to dip. While the pace of
adulthood. Consuming enough calories is also vital: bone loss slows after the first few years of menopause,
when girls and women have too little body fat to sup- women continue to lose bone in the following years.
port menstruation because of anorexia or bulimia, In fact, during the five to seven years after menopause,
their bones suffer and they are in greater jeopardy of women can lose up to 20% of their bone mineral den-
developing osteoporosis. sity (the measure of how densely the bones are packed
Exercise. Regular weight-bearing exercise con- with calcium and other minerals).
tributes to peak bone density. This includes any activi- Because androgen levels in men fall off more
ties that involve overcoming gravity’s pull, including gradually, bone loss usually begins later for them—
weight lifting and other forms of resistance train- typically in their late 50s—and progresses more slowly.
ing, running, walking, aerobics, soccer, basketball, The main contributors to their bone loss are medical
gymnastics, tennis, and golf. Exercise puts stress on conditions and the general effects of aging. Men also
bone, and bones respond by bulking up. However, for start off with greater bone mass than women.
women, exercising to an extreme can result in declin- By ages 65 to 70, men and women lose bone
ing estrogen levels, amenorrhea (abnormal absence at the same rate, although more women than men
of menstrual periods), and eventually bone loss. This are diagnosed with osteoporosis at all ages. And
unhealthy situation is particularly common among the process can be hastened by a variety of medical
young dancers, elite athletes, long-distance runners, conditions and medications that are covered in the
and gymnasts. next chapter.
What causes osteoporosis?
W hile a certain amount of bone loss is normal, not

everyone develops osteoporosis. Many things
can cause osteoporosis. Some are factors you can
change. Others are beyond your control.
Bone loss begins when the cells that form bone
(osteoblasts) cannot keep pace with the cells that
break down bone (osteoclasts). If you were to view a
© Jacob Ammentorp Lund | Thinkstock

microscopic video of the process, you would see the
osteoclasts going about business as usual, while the
osteoblasts’ efforts fall short. Although the trenches
dug by the osteoclasts don’t get any deeper, neither are
they refilled completely. As trenches accumulate, the
bone becomes thinner, more porous, and weaker than Although a certain amount of bone loss is inevitable, osteoporosis is
it once was, leading to a condition called osteopenia not. Osteoporosis can be the result of menopause, aging, or certain
that precedes osteoporosis. drugs or medical conditions—or a combination of these.
There are no symptoms associated with such
bone loss. But if it continues long enough, leading to of chemical regulators, such as interleukin-1,
osteoporosis, bones will eventually become too weak interleukin-6, prostaglandin E2, and tumor necrosis
to bear the load they were designed to carry. The result factor, which appear to speed up bone resorption by
is usually a fracture of the wrist, hip, or spine. spurring on osteoclasts as estrogen levels decline. Such
Doctors sometimes classify osteoporosis as research could someday lead to better drugs to prevent
primary or secondary, depending on the cause. postmenopausal bone loss.
Aging
Primary osteoporosis Gradual bone loss with aging may also lead to osteo-
The term primary osteoporosis is used to describe the porosis. In this case, the bone loss develops more
most common form of the disease, which is the con- slowly than postmenopausal osteoporosis and is usu-
sequence of a normal physiological process, such as ally not apparent until age 75 or later. As with all age-
menopause or aging. related changes, it probably reflects several factors.
Slowdown in bone formation. As described ear-
Menopause lier, bone in older people is broken down more quickly
Postmenopausal osteoporosis occurs when declin- than it is formed.
ing estrogen levels in women lead to rapid bone loss. Reduced levels of calcium in the bloodstream.
Typically, the process accelerates in the first few years With age, the intestines gradually absorb less calcium
of menopause and then begins to level off. The effects from food, and the kidneys seem to be less efficient
are most prominent in trabecular bone, which isn’t as at conserving calcium. Thus, less calcium reaches the
dense as compact bone. bloodstream, and more calcium leaves the body in
Several factors may contribute to this process. feces and urine, making it increasingly likely that the
A number of researchers are examining the roles body will need to tap the calcium stored in bones.
To make matters worse, most people consume less lem, many older adults consume fewer dairy products,
calcium in their diets as they age, further straining which are fortified with vitamin D, so they take in less
their calcium reserves. Some older adults may avoid through their diets. Vitamin D plays a central role in
dairy products if they have lactose intolerance (a the body’s absorption of calcium and in the process of
reduced ability to digest milk sugar), which can pro- turning calcium into bone. If you don’t have enough
duce gas and abdominal discomfort. Others may shun vitamin D to signal your intestines to absorb calcium,
calcium-containing foods and supplements because of your body will break down bone to get the calcium
their constipating effects. it needs—no matter how much calcium you’re getting
Reduced vitamin D production. The body’s pro- from food or supplements.
duction of vitamin D frequently drops with age as
well. Your skin cells use sunlight to produce the chem-
ical raw material that the body needs to make vitamin Secondary osteoporosis
D. The liver and kidneys then convert this precursor The term secondary osteoporosis is used to describe
into active vitamin D. However, people often spend osteoporosis resulting from a medical condition or the
less time in the sunlight as they grow older, so there use of certain medications. If you have one of these
is less of the raw material available—and in addition, conditions or if you’re taking any of these drugs, talk
the body becomes less efficient at converting this pre- to your doctor about what you can do to keep your
cursor to active vitamin D. Compounding the prob- bones healthy.
Medical conditions and medications that can lead to bone loss

MEDICAL CONDITIONS
• Acromegaly • Ehlers-Danlos syndrome • Hyperthyroidism • Pancreatic disease
• Alcoholism • Emphysema • Hypogonadism • Panhypopituitarism
• Amyloidosis • End-stage renal disease • Hypophosphatasia • Porphyria
• Androgen insensitivity • Epilepsy • Idiopathic scoliosis • Post-transplant bone
• Ankylosing spondylitis • Gastric bypass • Inflammatory bowel disease
• Anorexia • Gastrointestinal surgery disease • Premature ovarian failure
• Klinefelter’s syndrome
• Athletic amenorrhea • Gaucher’s disease • Primary biliary cirrhosis
• Leukemia and lymphoma
• Bulimia • Glycogen storage diseases • Renal tubular acidosis
• Liver disease
• Calcium deficiency • Heart failure • Rheumatoid arthritis
• Lupus
• Celiac disease • Hemochromatosis • Sarcoidosis
• Malabsorptive disorders
• Chronic metabolic acidosis • Hemophilia • Sickle cell disease
• Marfan’s syndrome
• Cushing’s syndrome • Homocystinuria • Multiple myeloma • Systemic mastocytosis
• Cystic fibrosis • Hypercalciuria • Multiple sclerosis • Thalassemia
• Depression • Hyperparathyroidism • Muscular dystrophy • Thyrotoxicosis
• Diabetes (types 1 and 2) • Hyperprolactinemia • Osteogenesis imperfecta • Turner’s syndrome
MEDICATIONS
• Anti-androgens • Cyclosporine (Neoral, • Heparin therapy (long-term) • Selective serotonin
• Anticonvulsants Sandimmune, others) • Lithium (Eskalith, Lithobid, reuptake inhibitors (SSRIs)
• Aromatase inhibitors (Arim- • Depot medroxyprogester- others) • Tacrolimus (Hecoria,
idex, Aromasin, Femara) one (Depo-Provera) • Loop diuretics Prograf, others)
• Barbiturates • Glucocorticoids • Methotrexate (Rheumatrex, • Thiazolidinediones (TZDs)
• Canagliflozin (Invokana) • Gonadotropin-releasing Trexall, others) • Thyroid hormone
hormone agonists • Proton-pump inhibitors (PPIs) (in excessive doses)
Medical conditions that cause bone loss strength and possibly raise the risk of suffering a
Certain medical problems can affect bone health— harmful fracture. In an otherwise healthy person, such
some severely. For example, congenital disorders that medications might have a small effect that doesn’t
affect bone mass over a lifetime—such as Marfan’s unduly raise fracture risk. But if you have already
syndrome, Ehlers-Danlos syndrome, or osteogenesis begun to lose bone or you’ve been diagnosed with
imperfecta—increase the risk for osteoporosis. Some osteoporosis, the effects of these drugs may be enough
chronic conditions, including anorexia, certain can- of a concern to warrant discussing them with your
cers, liver disease, and disorders that affect mineral doctor. You and your doctor can decide whether you
absorption, may also have an impact (see “Medical should stay on these drugs or switch off them based
conditions and medications that can lead to bone loss,” on your bone health and overall health.
page 7). Researchers have found a definitive link between
So does primary hyperparathyroidism, a condition the following drugs and bone loss:
in which people have abnormally high levels of Glucocorticoids. The most common cause of
parathyroid hormone. This hormone helps regulate the drug-related osteoporosis is the use of glucocorti-
amount of calcium in the blood. Excessive levels spur coids, also known as corticosteroids (see “6 ways
the removal of calcium from bones and increase the glucocorticoids hinder bone formation,” below left).
amount of calcium in the blood. In turn, the kidneys These drugs, which include prednisone, are often
often try to compensate for the extraordinarily high prescribed to treat conditions such as asthma, rheu-
blood levels of calcium by excreting large amounts of matoid arthritis, and chronic obstructive pulmonary
it in the urine. Every year, approximately 100,000 new disease. Glucocorticoids are also used to prevent
cases are detected, the majority of them in women. rejection after organ transplantation. Although
Often, this condition has no symptoms and is found inhaled corticosteroids, which are an integral part of
only when a routine blood test shows high calcium asthma treatment, are less likely to cause bone loss
levels. However, as primary hyperparathyroidism than oral corticosteroids, they can still weaken bones,
advances, it can cause kidney stones, muscle weakness, especially at high doses.
fatigue, and eventually osteoporosis. Aromatase inhibitors (for women). Many women
with breast cancer have benefited from a class of drugs
Medications that cause bone loss called aromatase inhibitors, which block estrogen
A variety of medications, both prescription drugs production. These drugs include anastrozole (Arimi-
and those available over the counter, can affect bone dex), exemestane (Aromasin), and letrozole (Femara).
These drugs reduce the chance of cancer coming
back in women whose cancers are “estrogen positive,”
6 ways glucocorticoids hinder meaning they tend to grow in response to estrogen.
bone formation Aromatase inhibitors are more effective than tamoxi-
These medications—including prednisone, methylpred- fen (Nolvadex, Apo-Tamox, Tamofen, Tamone), a
nisolone, and hydrocortisone—do the following: leading cancer drug, in preventing cancer recurrence
• interfere with the • possibly trigger the body after treatment. But because estrogen slows bone loss,
body’s ability to absorb to produce too much lowering levels of this hormone with an aromatase
calcium from food parathyroid hormone,
inhibitor can harm bone health. As a result, women
• increase the amount of which removes calcium
from bone stores taking these drugs are at greater risk of spinal and
calcium lost in the urine
• fuel bone-destroying • reduce the production of other fractures.
osteoclasts estrogen in women and Androgen-suppressing drugs (for men). Certain
testosterone in men. men with prostate cancer undergo androgen depri-
• hamper bone-building
osteoblasts vation therapy with a variety of different medica-
tions that lower levels of male hormones to suppress
the cancer. But at the same time, androgen depriva- ate, which does require acid for maximal absorption).
tion therapy can put them at greater risk of bone loss Calcium citrate is often recommended for people tak-
and fractures. In one study, about 20% of men given ing PPIs long-term.
this therapy who survived for at least five years expe- Antidepressants. Researchers have also uncovered
rienced a bone fracture, compared with 13% of men a possible association between reduced bone strength
who did not receive this treatment. and a class of antidepressants called selective serotonin
Anyone being treated for prostate cancer with reuptake inhibitors (SSRIs). These drugs may contribute
hormonal therapies should discuss the ramifications to bone loss by enhancing the effects of osteoclasts in
to bone health and how to prevent bone loss. This triggering bone turnover. However, the link is far from
may involve having regular bone density screenings certain. Although people who use SSRIs seem to have
and ramping up appropriate preventive measures, a modestly higher risk of fractures, it’s not possible yet
such as calcium and vitamin D supplementation, to show a definite cause-and-effect connection. In the
weight-bearing exercise, and possibly medication to meantime, if you are taking these medications long-
prevent bone loss. term at your doctor’s recommendation, you may want
to discuss whether there is more you could do to protect
Medications that might cause bone loss yourself against fractures, such as being screened for
The following drugs may cause bone loss, although low bone density or increasing your calcium, vitamin
the effect has not been proved yet. D, and exercise.
Organ transplant drugs. Some medications, such Diuretics. Diuretics, or “water pills,” make the
as cyclosporine, that are used to prevent organ rejec- body excrete water and salt. They are often used
tion after transplants may also further bone loss. Peo- to treat high blood pressure. One type, called loop
ple using any of these medications should be vigilant diuretics, causes the kidneys to release more calcium.
about protecting their bones. They should pay special Commonly prescribed loop diuretics that have this
attention to diet and exercise and consider other steps effect include ethacrynic acid (Edecrin) and furose-
to prevent bone loss and fractures. mide (Lasix). Several studies have shown that people
Proton-pump inhibitors (PPIs). This popular who take loop diuretics have slightly lower bone den-
class of medications, used to reduce stomach acid, sity in fracture danger zones like the hip, and a greater
may erode bone strength and increase the risk of overall fracture risk.
fractures. (Omeprazole, marketed as Prilosec, is one Diabetes drugs. In the fall of 2015, the FDA added
of the best-known PPIs.) By reducing stomach acid, a new warning to the label of canagliflozin (Invokana),
PPIs may also impair the absorption of calcium from which is used to lower blood sugar in people with type
food, potentially leading to weaker bones and a greater 2 diabetes. Canagliflozin belongs to a class of drugs
risk of bone fractures. Research to date suggests that called sodium-glucose cotransporter-2 (SGLT2) inhib-
the effect, if it is real, is modest, though not all studies itors, which also includes dapagliflozin (Farxiga) and
agree. However, in a person already at risk of low bone empaglifozin (Jardiance). Doctors have noticed bone
density or fractures, long-term use of PPIs could pose fractures, as well as decreases in the bone density of
a legitimate concern. the hip and lower spine, in people taking canagliflozin.
If you’re at risk for fractures and you use a PPI for Another class of diabetes drugs called thiazolidin-
heartburn or to prevent ulcer flare-ups, ask your doc- ediones (TZDs), which includes pioglitazone (Actos)
tor how to counterbalance the effect of the PPI. If you and rosiglitazone (Avandia), has also been linked to
take calcium supplements, you may want to switch to increased bone loss and fracture risk. Before you start
a product with calcium citrate, which does not require taking one of these drugs, it may be worth discussing
stomach acid for absorption (unlike calcium carbon- the bone risks with your doctor.
Know your risk factors
C ertain factors make you more vulnerable to devel-

oping the bone weakening that can lead to frac-
tures. Some of these risk factors—like age and family
Race. Caucasian and Asian women face the high-
est osteoporosis risk, because their bones tend to be
thinner and smaller than those of African American
history—aren’t within your control. Others are modi- and Hispanic women. Asian women also tend to have
fiable with some relatively simple lifestyle changes. a lower dietary intake of calcium, because many of
If you haven’t yet been diagnosed with osteo- them are lactose intolerant. Yet surprisingly, despite
porosis, use these risk factors as a guide to launching having thinner bones, Asian women are less likely to
a discussion about bone density testing with your fracture a hip than white women. This lower risk may
doctor. If you have already been diagnosed, addressing be due to anatomical differences in the hip bone.
the lifestyle factors you can change can help preserve
the bone strength you still have.
Risk factors you can control
A poor diet, lack of exercise, smoking, and alcohol
Risk factors you can’t control use can all hasten the onset of osteopenia or osteo-
Though you can’t change these factors, being aware porosis as you age. If you’ve already been diagnosed
that you have them can enable you to discuss bone with bone loss, addressing these risks can help protect
preservation steps with your doctor. and preserve the integrity of your bones for as long as
Gender. For a variety of reasons, women are at possible.
higher risk than men, though men can develop it, Inadequate calcium and vitamin D levels. Inad-
too (see “Osteoporosis risk in women,” page 11, and equate intake of calcium from your diet—as well as
“Osteoporosis risk in men,” page 12). conditions that may interfere with calcium absorp-
Aging. Advancing years inevitably bring a higher tion by the intestines—leads to lower calcium lev-
risk for osteoporosis—particularly for women. els in the blood. The body compensates by releasing
According to the Centers for Disease Control and Pre- calcium from the bones, which weakens them. Your
vention (CDC), 16% of women and 4% of men ages 50
and over have osteoporosis as measured at the neck of
the femur (near where the upper leg bone connects to Figure 4: A look at osteoporotic bone
the hip) or the lumbar spine (the vertebrae of the lower
back). People in this age group also show signs of low
bone strength in the spine or femoral neck, making
them more likely to eventually develop osteoporosis.
Family history of the disease. The genetic traits
you inherit also strongly influence your risk. Between
70% and 80% of bone structure is genetically deter-
mined. Both men and women whose first-degree fam-
ily members (parents, siblings) have had fractures The photograph at left shows a microscopic view of bone from
are at greater risk. In fact, a woman whose mother or a woman who does not suffer from osteoporosis. Her bone is
father had a fracture is at twice the risk of a break— denser than the bone shown at right, which is from a woman
regardless of her measured bone density. with osteoporosis. (The arrow points to a microscopic fracture.)
body needs vitamin D to properly absorb calcium, so
adequate amounts of this vitamin are also necessary. Figure 5: Fracture risk
Sedentary lifestyle. When you are at rest, bone
formation slows; when you are physically active,
bones bulk up and become stronger. The research to
date suggests that leading a physically active life can
decrease the risk of having a fracture in the spine or
hip by 30% to 50%.
Smoking. Smokers tend to lose bone faster than
nonsmokers. Smoking may both interfere with the
absorption of calcium and lower the amount of bone-
protective estrogen the body produces. A number of ▲ FOR WOMEN ▲ FOR MEN
studies, some of them quite large, have found that men 50% risk: One out of two 25% risk: One out of four
and women who smoked were at greater risk of break- women over age 50 will have men over age 50 will have an
an osteoporosis-related osteoporosis-related fracture
ing a hip or other bone. In fact, a report from the U.S.
fracture in her lifetime. in his lifetime.
Surgeon General on osteoporosis noted that smokers
are 55% more likely than nonsmokers to break a hip.
Excess alcohol consumption. The amount of on average, bone mass fell by approximately 5% every
alcohol you drink can affect your bone health. Alco- five years in women after age 65.
hol may interfere with the body’s ability to convert The study looked at characteristics that are
inactive vitamin D into its active form. It also appears significantly more common among women who have
to hamper bone formation and increase losses of cal- osteoporosis. Together with other research, it provides
cium and magnesium from the body. Excessive drink- a good idea of the factors that can predispose certain
ing may be accompanied by poor nutrition and an women to osteoporosis. These include the risk factors
increased tendency to fall. People who consume more below, as well as the list of general risk factors above.
than two drinks per day may be at moderately higher Talk to your doctor about your risk and what, if
risk of low bone density and fractures, compared with anything, you should do about it, including having a
nondrinkers. bone density evaluation.
Medications. In addition, people who take certain Small-boned, thin women tend to have lower
drugs that contribute to bone loss may be at greater bone density and a higher risk of fractures. It may
risk for osteoporosis. If you have a condition or you’re be because their bones are smaller, but the science
taking a medication known to affect bone density, talk doesn’t give us a definite answer on this point. In the
to your doctor about what steps you may need to take Study of Osteoporotic Fractures, women 65 and older
to keep your bones healthy. with the smallest body size had twice the rate of hip
fracture (10 in 1,000) compared with the rate among
the largest women in the study (five in 1,000).
Osteoporosis risk in women Because estrogen slows bone resorption, women
Women are more likely than men to develop osteopo- who are past menopause and those who have had their
rosis because they have smaller skeletons, their bone ovaries removed are at higher risk. So are younger
loss begins earlier and occurs more rapidly, and they women who have too little body fat (sometimes
have a lower peak bone density to begin with. About because of excessive exercise, anorexia, or bulimia)
80% of the 10 million Americans with osteoporosis and consequently too little estrogen to menstruate
are women. The Study of Osteoporotic Fractures— regularly.
a landmark National Institutes of Health study of The National Osteoporosis Foundation recom-
almost 10,000 women ages 65 and older—found that, mends routine dual energy x-ray absorptiometry
(DEXA or DXA) testing for women starting at age 65 under age 75 develop osteoporosis, it’s often because
to measure bone density. (For a more complete list of of an underlying health condition. In these cases,
screening guidelines, see “Who should be screened?” treatments address the condition or conditions that
on page 16.) are responsible.
But “less vulnerable” does not mean “invulnerable,”
and the reason comes right back to declining sex
Osteoporosis risk in men hormones. Experts believe that age-related declines
It is a persistent misperception that osteoporosis is a in testosterone levels may cause bone loss. Men also
“women’s disease.” Although bone loss strikes women produce estrogen (though in smaller quantities than
younger and harder, men, too, are at significant risk of women), and declining estrogen with aging may be
low bone density and the harmful fractures that can as significant for bone loss as low testosterone. In the
follow. According to the National Osteoporosis Foun- Osteoporotic Fractures in Men Study, which involved
dation, two million American men have osteoporosis over 2,400 men 65 and older, men who had low levels
and about 12 million more are at risk. Each year, about of both testosterone and estrogen were more likely to
80,000 men break a hip—and when they do, they are have osteoporosis than men with normal levels of these
two to three times more likely to die of complications hormones. Researchers have also found that men with
from their injuries than women are. low hormone levels are more likely to fracture a hip.
Nonetheless, men constitute only 20% of The National Osteoporosis Foundation recom-
Americans with osteoporosis. Two factors make men mends routine DEXA testing for men starting at
less vulnerable than women to bone loss: they have age 70 to measure bone density. Men ages 50 to
greater bone density at maturity, and they experience 69 should also be tested if they have risk factors
a more gradual decline in hormone levels. When men for osteoporosis, such as a history of a previous
fracture, low body weight, and smoking. In 2012, the
Endocrine Society issued a clinical practice guideline
Online tool estimates your risk that also recommended the same level of osteoporosis
screening for men. However, the U.S. Preventive
I f you have five minutes and access to the Internet, you
can estimate your risk of developing osteoporosis at
www.diseaseriskindex.harvard.edu. This tool, developed
Services Task Force, an independent panel of experts,
concluded that “the current evidence is insufficient to
by the Harvard Center for Cancer Prevention, also helps
assess the balance of benefits and harms of screening
you gauge your risk of heart disease, stroke, cancer, and
diabetes. There’s a separate quiz for each disease, and for osteoporosis in men.”
you can choose which one you would like to complete. There is one thing that all experts agree on,
For each quiz, you answer some questions about your however: men should protect their bones by following
lifestyle and health history. The questions are focused on the same lifestyle recommendations suggested for
proven risk factors for each disease. Once you’ve complet- women. That means engaging in regular weight-
ed the questionnaire, your personal risk is calculated and
bearing exercise, getting adequate amounts of calcium
compared with the average risk for a person of your age
and sex, so you can see if you are more or less likely than and vitamin D from food and (if needed) supplements,
average to develop these diseases. Even better, you’ll get and avoiding habits known to deplete bone mass,
information on what you are already doing to lower your such as smoking and drinking excessive amounts of
risk and find out what more you can do. alcohol. These habits will help maintain a solid reserve
of bone mass to ward off fractures later in life.
The consequences of osteoporosis
O steoporosis was once known as a silent disease

because it gives no warning signs as it gnaws away
at bones. Eventually, it would make itself known when
that fractures in the spine, hip, and femur have the
greatest impact on quality of life.
a break occurred without due cause, perhaps triggered

by something as innocent as a sneeze. Hip fractures
Although any bone can be affected, most breaks About one in seven osteoporosis-related fractures
related to osteoporosis occur in one of three sites: occurs at the hip. Typically, these are the most seri-
the hip, the spine, or the wrist (see Figure 6, below). ous types of osteoporotic fracture. Hip fractures usu-
Fractures at these sites, particularly in women who ally involve the neck or the intertrochanteric region
are past menopause, are most common because of the thighbone (see Figure 7, page 14). Breaks can
these regions contain relatively high proportions of also occur in bones of the pelvis. The impact of a hip
trabecular bone and are therefore especially vulnerable fracture on someone’s life and activity level usually
to the effects of bone loss. depends on the state of the bone and on the person’s
Osteoporotic fractures exact a high toll, leaving physical condition.
some people in pain while stripping others of their At best, the breaks are temporarily immobilizing,
ability to perform everyday activities or to move requiring confinement to bed or a wheelchair. Surgery
around independently. Three in five people who break is usually needed but may not be feasible because of
a hip because of osteoporosis will never fully regain other disorders, such as heart or lung disease, which
their previous level of functioning. Many people increase the risk for complications following an
become so fearful of breaking another bone that operation. As a result, the damaged bone often heals
they limit their activities, which causes them to feel badly, resulting in permanent disability.
helpless, isolated, and depressed. Research has shown The injury often has devastating effects on
mobility and independence. Six out of 10 people
who break a hip never fully regain their former level
Figure 6: Fractures by site of independence. Some are permanently less able to
800,000 perform ordinary daily activities, such as dressing
700,000 themselves or rising from a chair. Even walking across
a room may be difficult. These changes in mobility
600,000
and daily functioning can make it necessary to seek
500,000 home health care or to move to a facility that can
400,000 provide care. Half of the people who suffer a hip or
300,000 spine fracture will need assistance walking, and one in
four will need long-term nursing home care.
200,000
While people seldom die directly from a hip
100,000 fracture, this injury and its accompanying medical
0 problems can trigger a downward spiral in health.
Spine Hip Wrist Pelvis Other
Complications, such as pneumonia or blood clots,
Osteoporosis-related fractures reported in United States annually that result from the fracture itself or surgery to treat it
Source: National Osteoporosis Foundation, 2008. are sometimes fatal. One in five people who have a hip
cause like a fall. Even without the added trauma, these
Figure 7: Common hip fractures injuries can be quite debilitating.
Simple acts of daily life, such as bending over,
Most hip fractures occur at twisting, coughing, or lifting, can be enough to
the neck of the femur, or collapse a vertebra weakened by osteoporosis. In such
A thighbone—also known as cases, the bones of the spine, which consist primarily
the femoral neck (A), or of trabecular bone, aren’t broken in the usual sense
at the intertrochanteric
of the term. Rather than being snapped like twigs—
region (B).
B as in the case of a broken arm or leg—the vertebrae
Each year there are nearly
are compressed, in the same way that a paper cup
300,000 hip fractures from
would be flattened when stepped on. Figure 8 (see
osteoporosis in the United
States. Fracturing a hip can page 15) compares compressed and normal vertebrae
have serious consequences, and shows the effects of compression fractures on the
such as impairing the abil- spine. Vertebral fractures can cause a loss of height
ity to walk or to perform and, more seriously, a rounding of the back known as
simple everyday chores. dorsal kyphosis, or dowager’s hump.
Compression fractures may be accompanied by
pain that is sharp, dull, intense, or radiating around
the side. Pain may also come from spasms in the
muscles at the sides of the spine. It may come and go
for several months, often recurring after the person sits
fracture dies in the first year after the injury. The risk in the same position for a long time. Discomfort from
of death is 10% to 20% in the first six months after a fractures can usually be relieved with pain medications
fracture in the hip or spine. Fractures are particularly such as aspirin or ibuprofen (Advil, Motrin).
deadly among nursing home residents and people
with cognitive impairment or other health issues.
The risk of death also disproportionately affects those Can hip protectors prevent breaks?
ages 80 and older, who are 10 to 15 times more likely
to fracture a hip than people 60 to 65. Those who do
survive may have trouble living on their own.
A quick online search will turn up plenty of hip pads
that are touted as a way to help prevent a hip frac-
ture if you fall. The pads, which consist of a stiff plastic
But there is some encouraging news about hip shield underlaid with foam padding, are meant to be
strapped onto the hip.
fractures, too. According to a recent study, the number
of hip fractures among people in the Medicare system For those living in nursing homes, who are at high
risk of a fracture, some studies suggest hip protectors
is declining. This trend is probably in part due to the
may reduce injuries. But systematic reviews of the best
increased use of medications to prevent bone loss. research available have failed to prove that providing hip
Although the death risk for people who’ve suffered a protectors to older adults living independently reduces
fracture may also be going down, the dangers of hip the incidence of hip fractures.
fracture remain a powerful incentive to do all you can The main challenge is getting people to wear the hip
to preserve your bone health. protectors consistently and properly. The pads can be
uncomfortable and awkward, and many people just don’t
like wearing them. Also, people may fall in circumstances
in which they would not be wearing the pads, for ex-
Spinal fractures ample in the bath or shower. But if worn consistently by
Fractures in the spine are much more common than people at risk of hip fracture, these pads could theoreti-
hip fractures (see Figure 6, page 13). Unlike hip frac- cally be of benefit.
tures, spinal fractures often occur without a traumatic
In many instances, vertebral fractures cause becomes progressively more distorted. The upper body
little or no pain. The principal clue that they have is thrust down and forward. The abdominal muscles
occurred is a gradual shrinkage or stooped posture. sag, and the space between the ribs and pelvis closes.
The amount of height lost and the degree of deformity The chest wall becomes cramped, and the abdominal
will depend on the number, location, and severity of organs are compressed and pushed forward. Breathing
the compression fractures. However, narrowing of the may become difficult and digestion may be impaired,
cushion-like disks between vertebrae—which often leading to bloating and heartburn.
occurs as part of aging—may also cause deformity and Severe spinal deformity affects mobility almost as
a loss of height. significantly as a hip fracture. Since walking erect is
Most people who have vertebral fractures have difficult, a cane or walker becomes essential. Riding
one or two, most commonly in the thoracic, or mid- in a car for more than a few minutes can be very
back, region. While one or two mid-back compression uncomfortable. Two procedures—vertebroplasty and
fractures may produce only a slight loss of height, many kyphoplasty (see page 50)—can stabilize compressed
can profoundly affect your appearance, mobility, and vertebrae, relieve pain, and improve daily functioning.
health. As the number of fractures increases, the spine
Figure 8: A look at normal and compressed Wrist fractures

vertebrae Osteoporosis accounts for nearly 400,000 wrist frac-
tures a year. These breaks are usually the result of an
attempt to break a fall. The force of the impact usually
snaps the end of the radius, the long bone that runs
from the elbow to the thumb, often producing a char-
acteristic break known as a Colles’ fracture. Normally,
after a wrist fracture occurs, the arm is immobilized
in a cast, splint, or sling and allowed to heal, although
surgery is sometimes needed. Wrist fractures usually
Vertebrae mend completely. However, they can occasionally
with fractures
result in deformity and a loss of some function that
interferes with the ability to perform everyday activi-
ties with ease.
Other consequences
Normal Although trabecular bone loses strength more rapidly,
vertebrae compact bone eventually becomes vulnerable as well.
As osteoporosis advances, bones with a high propor-
tion of compact tissue—such as the pelvis, tibia (shin),
humerus (upper arm), and femur (thigh)—are frac-
tured with increasing frequency. Ribs may be broken
from the force of a cough.
Normal vertebrae are upright, but if several vertebrae collapse, Although the jawbone may not snap, it is not
it can cause a curvature of the spinal column known as dorsal exempt from bone loss. As the jaw becomes increasingly
kyphosis or dowager’s hump. This condition can make it difficult porous, it provides less support for the teeth anchored
to walk without a cane or walker and can interfere with proper into it. The result can be dental problems such as loose
breathing and digestion.
teeth and ill-fitting dental plates.
Detecting osteoporosis
I n the past, osteoporosis was frequently diagnosed

only after a bone fracture. For many people, that
diagnosis came too late to be of much use. Today,
Who should be screened?
Screenings for osteoporosis are not routinely given to
osteoporosis can be detected earlier with a bone min- everyone; instead, they are done on a case-by-case basis.
eral density test. Such a test can also provide informa- Experts are still debating who should receive bone density
screening, and it remains unclear whether the benefits
tion regarding your risk of suffering a fracture and can of tests such as dual energy x-ray absorptiometry (DEXA)
help you and your doctor monitor your progress if justify the cost of testing everyone. Talk to your doctor
you’re taking bone-building medications. about whether testing is right for you.
Consider being screened if you are
• a woman age 65 or older or a man age 70 or older
DEXA scans for bone density • a postmenopausal woman under age 65 or a man age
Several technologies can assess bone density, but the 50 to 70 with one or more risk factors for osteoporosis
most common is known as dual energy x-ray absorpti- • a woman or man with a medical condition or taking a
ometry (DEXA). For this procedure, a machine sends medication that places you at high risk for osteoporotic
fractures
x-rays through bones in order to calculate bone den-
• a woman who is in menopausal transition who has
sity. The process is quick, taking only five minutes. And
specific risk factors that increase fracture risk (such as
it’s simple: you lie on a table while a scanner passes over low body weight or a prior fracture)
your body (see Figure 9, below). While this technology • a woman or man over age 50 who has fractured a bone
can measure bone density at any spot in the body, it is • a woman or man who has taken glucocorticoids for at
usually used to measure it at the lumbar spine (in the least two months.
lower back), total hip (a specific site in the hip near the However, it’s important to note that coverage varies
among insurance plans. Some plans may refuse to pay
for a DEXA scan. Others might specify how often you can
Figure 9: Scanning for osteoporosis have this test repeated. For example, Medicare will cover
the cost of one bone density test every two years, or more
often if your doctor deems it medically necessary. So that
you don’t wind up footing the bill yourself, it pays to
check with your plan first.
hip joint), and femoral neck (the top of the thighbone,

or femur; see Figure 7, page 14). DEXA accomplishes
© Image Point Fr | Shutterstock.com
this with only one-tenth of the radiation exposure of a

standard chest x-ray and is considered the gold stan-
dard for osteoporosis screening—though ultrasound,
which uses sound waves to measure bone mineral den-
sity at the heel, shin, or finger, is also used at health
Dual energy x-ray absorptiometry (DEXA) is the most common fairs and in some medical offices.
method of detecting osteoporosis today. Most physicians consider The DEXA scan or ultrasound will give you a
it the most accurate diagnostic procedure. number called a T-score, which represents how close
you are to average peak bone density. The World tebral fracture assessment (VFA) uses the same type
Health Organization has established the following of x-ray as DEXA, but instead of measuring bone den-
classification system for bone density: sity, it shows the shape of the vertebrae. The goal is to
• If your T-score is –1 or greater: your bone density see if any of the vertebrae are deformed—a possible
is considered normal. sign of fracture. More vertebrae are scanned in VFA
• If your T-score is between –1 and –2.5: you have than in a traditional DEXA test for bone density. If
low bone density, known as osteopenia, but not the VFA shows that you have one or more fractures,
osteoporosis. you likely have severe osteoporosis and will need more
• If your T-score is –2.5 or less: you have osteoporo- aggressive treatment. VFA is recommended for
sis, even if you haven’t yet broken a bone. • women ages 70 and older and men ages 80 and
older with a T-score of –1 or less at the lumbar
spine, total hip, or femoral neck
Vertebral fracture assessment • women ages 65 to 69 and men ages 70 to 79 with
Because vertebral fractures are so common in older a T-score of –1.5 or less at the lumbar spine, total
adults, and they often occur with no symptoms to warn hip, or femoral neck
of their presence, the National Osteoporosis Founda- • women and men ages 50 and older with risks such
tion recommends vertebral imaging at the same time as a fracture during adulthood, total height loss of
as the DEXA test for certain groups of people. A ver- 1.5 inches or more, recent height loss of 0.8 inches
How likely are you to break a bone? Your FRAX score and more
W hile bone mineral density tests can identify people who

are at greater risk for fractures, they aren’t the only
predictors. A tool developed by the World Health Organiza-
• a previous hip or spinal fracture
• a T-score of –2.5 or less at the hip or spine
• a T-score between –1 and –2.5 at the hip or spine together
tion calculates an individual’s real-life risk of suffering an
with a 10-year FRAX-estimated risk of at least 20% for a
osteoporosis-related fracture in the coming years. FRAX (frac-
ture risk assessment tool) incorporates bone mineral density major fracture or 3% for a hip fracture.
scores with other weighted risk factors to arrive at a percent ▼ Watch for these red flags
probability that a person will break a hip or suffer another If you don’t know your bone density measurement or FRAX
type of osteoporotic fracture such as a break in the verte- score, familiarize yourself with the factors that increase your
bra, forearm, or shoulder within 10 years. Risk factors used chance of falling and breaking a bone. If any of the following
are age, sex, height, weight, previous fragility fracture as an red flags apply to you, discuss them with your doctor:
adult, parental history of hip fracture, current smoking, alco-
• low levels of physical activity
hol use (three or more drinks per day), glucocorticoid use for
more than three months, rheumatoid arthritis, and secondary • overall weakness and frailty
osteoporosis. The FRAX score is measured in people whose • low muscle mass or impaired strength
bone mineral density is in the osteopenic range (T-score • advancing age
between –1 and –2.5).
• excessive alcohol use
FRAX was developed to help physicians better identify high-
• a history of falls
risk individuals whose bone density is in the range of osteo-
penia. If you’ve had a bone density test or if you think you • balance problems
might have an increased risk of osteoporosis, you may want • poor eyesight
to ask your physician about calculating your FRAX score. The
• taking medications (such as sedatives and blood pres-
tool is geared for doctors’ use, but you can find it online at
sure drugs) that can cause dizziness, lightheadedness, or
www.shef.ac.uk/FRAX. Based in part on the FRAX tool, the
impaired balance
National Osteoporosis Foundation recommends that doctors
consider drug therapy for men and women ages 50 and over • hazards such as electrical cords or throw rugs cluttering
who meet one or more of the following criteria: the walking paths around your house.
or more, and recent or long-term glucocorticoid urine test revealing that bone turnover slowed after
treatment. you started taking an osteoporosis drug could be a
sign that the treatment is working. Conversely, if tests
show that the rate of bone turnover has remained the
Lab tests for bone turnover same or increased, it may suggest that the treatment
Your doctor may use blood and urine tests to check for is ineffective (or that you are not taking your
secondary causes of osteoporosis. In addition, these medication). Your doctor should find out what’s going
tests can provide information about bone turnover, on and determine the best course of action, which may
the rate at which old bone is being remodeled. The include adjusting your dose or offering suggestions to
tests measure substances called biochemical markers ensure that you take your medicine as prescribed.
that are released during bone formation and resorp- The bottom line on lab tests for bone turnover is
tion. High levels of biomarkers associated with bone this: Doctors don’t routinely use these tests to diagnose
resorption can indicate high bone turnover, a red flag osteoporosis or predict fracture risk—DEXA is the
for declining bone health. best tool for that job. But they may be helpful under
A doctor might also order one of these tests to certain circumstances when bone turnover needs to
assess your response to treatment. For example, a be assessed.
Developing a plan of action
I f you’ve been diagnosed with osteopenia or osteo-

porosis, your doctor will help you develop a plan
to slow bone destruction and even gain back some of
the bone you’ve lost. That plan will likely include four
main strategies: diet, exercise, medication, and fall
prevention. You’ll find more detail on these strategies
in later chapters.
If you have osteopenia

(T-score between –1 and –2.5)
© Stockbyte | Thinkstock
According to your T-score, your bone density is

lower than normal, but your fracture risk isn’t as
high as that of someone with osteoporosis. You may
not need medicines at this point, and you won’t Even if you are at risk for osteoporosis, there are steps you can take
necessarily progress to osteoporosis. A few lifestyle to help protect your bones. Start by getting plenty of weight-bearing
interventions should slow down the rate of bone exercise and sufficient calcium and vitamin D.
loss, although they won’t help you regain what you’ve
already lost. Don’t drink too much alcohol. Excess alcohol
To protect bones, your doctor will likely suggest consumption can decrease bone mass, and heavy alco-
the following: hol use can also make you more apt to fall.
Exercise. The stress on bones from weight-bear- Take additional measures to help avoid a fall.
ing exercise causes your body to keep reinforcing Remove clutter that might cause you to trip, and be
bone. Staying active slows bone loss, strengthens the careful about using sedative medications and sleep
muscles that support your skeleton, and improves aids that can make you uneasy on your feet.
your coordination and balance so you’re less likely to Possibly take medicine. Your doctor may recom-
fall. A combination of strength training (weight train- mend an osteoporosis drug for treating osteopenia if
ing) and weight-bearing exercises (walking, tennis, all three of the following apply to you:
stair climbing) is ideal for preserving bones. • You’re age 50 or older.
Get enough calcium and vitamin D. These nutri- • Your T-score is between –1 and –2.5 at the hip or
ents are important for both fall and fracture preven- spine.
tion. Ask your doctor whether you can get enough • You have a 10-year FRAX-estimated risk of at least
calcium and vitamin D from your diet alone or if you 20% for a major fracture or 3% for a hip fracture.
need to take a supplement.
Quit smoking. This habit, which is also bad for
your heart, lungs, skin, and other organs, can increase If you have osteoporosis
your fracture risk. Ask your doctor about nicotine (T-score –2.5 and below)
replacement products, medicines, and other strategies Once you’ve been diagnosed with osteoporosis, your
to help you kick the habit. doctor will likely start you on a medicine such as a
bisphosphonate, SERM, monoclonal antibody, or hor- Check your calcium and vitamin D levels. Meet-
mone (see “Protecting your bones: Medication,” page ing the recommended intake for these nutrients is
39). Osteoporosis drugs can help you maintain bone a good start. But in addition, it’s wise to have blood
density and in some cases improve it. Your doctor will tests for both. Calcium tests are often part of standard
continually reassess your bone density to determine bloodwork, but you may have to ask for a vitamin D
how well the medicine is working and how long you test. The level should be at least 30 ng/ml.
should stay on it. Re-evaluate your exercise regimen. Exercise not
Just because you start on medication, however, only builds bone but also increases strength, flexibil-
doesn’t mean you should abandon lifestyle inter- ity, and balance. Now is a good time to incorporate
ventions. Although diet and exercise won’t reverse weights into your routine, if you haven’t already been
bone loss once you’ve been diagnosed with using them (see the Special Section, “Strength training
osteoporosis, they can slow it. Continue with all of and balance exercises for bone health,” page 34).
the lifestyle interventions listed above—get enough Discuss preventive medications with your doc-
calcium and vitamin D, do regular weight-bearing and tor. Many medications can help prevent osteoporosis
strengthening exercises, avoid smoking and excess (see “Protecting your bones: Medication,” page 39).
alcohol consumption, and reduce your fall risks. Your doctor can help you determine which one may
be best suited for you.
If your bone density is normal If you are 65 or older

While the basics of protecting your bones—such as At this point, bone loss has tapered off for women. But
getting enough calcium and engaging in weight-bear- for men, bone loss is speeding up. Regardless of your
ing exercises—remain the same throughout your life, sex, you are still losing bone as you age. All of the pre-
there are different factors to consider as you get older. vious suggestions for bone maintenance still apply. In
addition, consider these options.
If you are a woman at menopause Increase your calcium intake and get plenty
If you are a woman in the early years of menopause, of vitamin D. The recommended intake of calcium is
you are probably in the stage of your greatest bone 1,200 milligrams (mg) for everyone in this age range.
loss. All of the recommendations above apply, and you Make sure that you accompany it with 800 to 1,000
should do the following as well. international units (IU) of vitamin D.
Assess your risk. If you have reason to believe Keep up your exercise routine. In addition to
you’re at elevated risk for osteoporosis (see “Know strength training, work on balance exercises or tai chi
your risk factors,” page 10), talk to your clinician about to lessen the likelihood of falling.
having a bone density evaluation. If you have condi- Consider medication. Some drugs are used for
tions or take medications that reduce bone mass (see osteoporosis prevention and treatment, while others
“Medical conditions and medications that can lead to are for treatment only (see Table 6, page 44). You may
bone loss,” page 7), ask your doctor what you can do want to talk to your doctor about whether you should
to counteract these effects. take a preventive medication and, if so, which one.
Protecting your bones: Nutrition
A nutritious diet is just as important in later life as it

was when your mother urged you to “drink your
milk” to strengthen your bones. Along with exercise,
Table 1: Recommended daily calcium and
vitamin D intake in adults
nutrition is a cornerstone of bone health—and general The Institute of Medicine gives recommended intakes for both
calcium and vitamin D. However, its recommendations for vitamin
health, too. D are lower than those of the National Osteoporosis Foundation,
Even if you’ve been lax about eating a healthy diet which are listed in Table 4 (page 26).
in the past, it’s never too late to start making positive SEX/AGE CALCIUM VITAMIN D
changes. Although foods that are rich in the bone-
Women
building nutrients calcium, vitamin D, and vitamin K
won’t reverse osteopenia or osteoporosis, they can help 19 to 50 1,000 mg 600 IU
preserve the bone you have and keep you healthier 51 to 70 1,200 mg 600 IU
over all. The ideal way to get these and other essential 71 and older 1,200 mg 800 IU
nutrients is through food, but if you’re a little short,
Men
supplements may help you get the recommended
amounts—particularly for vitamin D, which can be 19 to 50 1,000 mg 600 IU
hard to get enough of in your diet. 51 to 70 1,000 mg 600 IU
71 and older 1,200 mg 800 IU
Calcium and vitamin D Source: Institute of Medicine.
Calcium and vitamin D have long been recognized

as essential to bone health, as well as other important still being worked out, experts disagree on how much
functions in the body. Calcium provides the building of these nutrients we need at different stages of life.
material for strong bones. Vitamin D helps your intes- For this reason, the U.S. and Canadian governments
tines absorb calcium into the bloodstream, which deliv- asked the Institute of Medicine (IOM), a group of
ers it to your bones, muscles, and other body tissues. distinguished physicians and researchers, to review
Experts agree that people need calcium and the evidence available and come to a consensus on
vitamin D to maintain bone health. Yet whether we basic daily requirements for these two vital nutrients.
should increase our intake expressly for the purpose The 14-member IOM panel examined more than
of preventing fractures is a little more controversial. 1,000 studies and listened to testimony from various
Two 2015 studies in the journal BMJ found that experts. The panel weighed the evidence for a range
adding calcium to the diet, whether through food of health benefits—not just for bone health, but also
or supplements, increases bone density by only a for reproductive health, immune and mental function,
minimal amount, which is unlikely to translate into and reduced risk of cancer, heart disease, and diabetes.
a noticeably reduced fracture risk. This is why, for One key outcome of the review were new
people with existing osteoporosis, nutrition is only Recommended Dietary Allowances (RDAs) for
one part of a strategy that also includes medication to calcium and vitamin D, specifying the amounts that
strengthen bones and prevent fractures. meet the basic health needs of 97% of all people at
In part because the benefits of calcium and a given age. The RDAs for calcium and vitamin D
vitamin D on bones and other aspects of health are appear in Table 1 (see above).
Calcium supplements: Harmful to the heart?
F or several years, evidence has sug-

gested that people who consume the
highest levels of calcium from supple-
to calcium supplements may be a coin-
cidence. But there is at least a hypothet-
ical connection. Over time, calcium does
ments may be more likely to have heart tend to accumulate in arteries that are
disease and heart attacks, or to die damaged by high blood pressure and
from heart problems. In contrast, none the buildup of fatty plaque deposits. As
of the studies has found that calcium in a result, the arteries become stiffer and
food—milk, cheese, leafy greens, and a narrower. If a plaque bursts open, it can
range of vitamin- and mineral-fortified trigger a heart attack, stroke, or sudden
grocery products—is associated with cardiac arrest.
© Donna Beeler | Shutterstock.com

greater risk. For someone who is already losing bone
These studies do not provide conclusive or at risk of bone fractures, however,
proof that calcium supplementation the benefits of calcium may outweigh
causes cardiac problems, however. any hypothetical risk of heart disease.
People develop cardiovascular disease Talk with your doctor about what’s right
for various reasons, and the connection for you.
Controversy over the IOM recommendations you would need to take quite a large amount of it
These recommendations were not met with univer- to get into the danger zone. According to the IOM
sal approval, however. Some experts think that the report, the safe upper limit for vitamin D is 4,000 IU.
IOM’s recommendations underestimate the amount So what should you do? Here is a reasonable
of vitamin D that people ages 51 and older should take approach: Get as much calcium and vitamin D as you
to prevent bone loss and lower the chance of harm- can from food (up to the recommended amounts),
ful fractures. The National Osteoporosis Foundation, and make up any shortfall with a daily supplement.
for example, concurs with the IOM on calcium, but You can also get vitamin D from sun exposure, at
boosts the recommendation for vitamin D to 800– least during the summer (see “Sources of vitamin
1,000 IU daily for men and women in this age group. D,” page 26). If you are in your 50s or older, aim for
Some vitamin D researchers recommend even higher 1,200 mg of calcium and 800 to 1,000 IU of vitamin
levels. But the U.S. Preventive Services Task Force D per day. And ask your doctor for advice if you are
reviewed the existing studies and found no evidence confused about mixed messages from the media.
that more than 400 IU of vitamin D a day was helpful
for preventing fractures. The task force does not deny Calcium in your diet
that higher levels could be beneficial—it only states Most experts would agree that getting calcium from
that the current evidence is insufficient to prove it. a balanced, nutritious diet is preferable to taking sup-
Why be so picky? Why not just take more than plements. Foods typically don’t have the side effects of
enough vitamin D, as a sort of insurance policy? One calcium supplements, like constipation and a small but
reason not to overconsume any vitamin or mineral worrisome increase in cardiovascular risk. Moreover,
supplement is that it requires time, effort, and money. calcium-rich fruits, vegetables, nuts, and legumes con-
Ideally, you want to take what you need and no more. tain many other healthy nutrients that can help pro-
More important, taking too much of certain nutrients tect you against heart disease.
can be harmful (see “Calcium supplements: Harmful Luckily, if you want to increase your dietary
to the heart?” above). The IOM report set the safe calcium intake, you have plenty of foods from which to
upper limit for calcium intake at 2,000 mg daily. choose. Table 2 (see page 23) shows how much calcium
Excessive vitamin D could also be harmful, although is found in a number of common grocery items. You
may be surprised at how much calcium you can add to as a source of calcium. Dairy provides the most
your diet by making a few simple substitutions, such concentrated sources. Moreover, milk is often fortified
as choosing ricotta instead of cottage cheese, or opting with vitamin D. And the many reduced-fat milks,
for fortified orange juice over regular. yogurts, and cheeses available today make it possible
Many osteoporosis experts favor dairy products to cut fat and calories without skimping on calcium.
Table 2: Calcium-containing foods

FOOD CALCIUM (mg) FOOD CALCIUM (mg)
Cheeses (1 oz., unless otherwise noted) Vegetables (1 cup, boiled, unless otherwise noted)
ricotta, part skim (½ cup) 334 spinach 245
Swiss 224 kale 94
provolone 214 broccoli 62
mozzarella, part skim 207 parsnips 58
cheddar 204 Brussels sprouts 56
mozzarella, regular 143 artichoke (1 medium) 54
feta 140 summer squash 49
cottage cheese, 1% fat (½ cup) 69 cabbage 47
Frozen desserts (½ cup) Fruits and fruit juices (1 cup, fresh, unless otherwise noted)
ice cream, light, vanilla 106 rhubarb, frozen, cooked 348
ice cream, regular, vanilla 84 orange juice, calcium-fortified 300
Milk (1 cup) blackberries 42
skim 306 orange juice, regular 27
1% fat 290 strawberries 27
2% fat 285 kiwi (1 medium) 26
whole 276 apricots, dried (10 halves) 19
Yogurt (8 oz.) raisins, dried (¼ cup) 18
flavored, low-fat 345 Fish (3 oz.)
plain, whole-milk 275 sardines, Atlantic, canned in oil, including bones 325
Nuts and seeds (1 oz., unless otherwise noted) salmon, pink, canned, including bones 181
almonds, unblanched 70 ocean perch, Atlantic 116
sesame paste, tahini (1 tablespoon) 64 bass, freshwater 68
hazelnuts 32 trout, rainbow 73
sunflower seeds 20 halibut, Atlantic or Pacific 51
peanuts, oil-roasted 17 anchovies, canned in oil, drained (5) 46
Legume products (½ cup) Shellfish (3 oz.)
tofu, firm, made with calcium sulfate (¼ block) 163 crab, blue 88
soybeans, green, boiled 130 lobster, boiled 52
navy beans 63 crab, Alaska king 50
baked beans, canned, with franks 62 shrimp 50
Adapted, with permission, from the U.S. Department of Agriculture, Composition of Foods; Ohio State University Hospital, Nutrient Database Catalog.
In fact, these products often contain slightly more
calcium than their high-fat counterparts do. There is, Spread it out
however, one potential concern about dairy that has Your body has a hard time absorbing large amounts of
calcium all at once. So it’s best to get your calcium in doses
not yet been resolved. Some research suggests that men
of 500 mg or less, a few times throughout the day. To get
who consume a large amount of dairy products may the most out of calcium-rich foods and supplements, don’t
be at greater risk for prostate cancer. Because the men take your supplement with a glass of milk. Instead, take your
in these studies also ate fewer fruits and vegetables, it’s supplement a few hours after drinking your milk or calcium-
difficult to tease out which factor—more milk or less fortified orange juice; that gives your body a chance to draw
as much calcium from these sources as possible.
produce—contributed to the risk. More research is
needed to determine whether the bone benefits of dairy
are worth the possible associated risks in certain men.
Many people avoid dairy for other reasons—most To determine how many milligrams of calcium per
prominently, lactose intolerance. If you’re lactose serving a product contains, multiply the percentage
intolerant and have trouble digesting dairy products, figure in the Nutrition Facts box by 10. For example,
try taking the enzyme lactase—either as a pill or in if a product’s food label says that one serving provides
liquid form—to help you enjoy these foods without 20% of your daily calcium requirement, that means it
worrying about unpleasant side effects. You can even contains 200 mg of calcium. (This works for calcium
find some dairy products that already have lactase because the Daily Value is 1,000 mg, but it will not
added. Or switch to soy or almond milk, which also work for other nutrients listed on the label.) Also
have calcium added. know what constitutes a serving. It may be not be the
Dairy products are not the only sources of calcium same amount you normally eat.
in the diet. The plant kingdom is also calcium-rich,
with spinach, dried beans, and nuts among the best Calcium supplements
sources. Their calcium content can’t always be accepted While experts recommend getting your nutrients from
at face value, however. For example, the oxalic acid in foods instead of supplements, you may find that it just
spinach and rhubarb binds the calcium in these plants isn’t practical or possible for you to get all the calcium
so that the calcium isn’t readily absorbed. Insoluble you need from your diet. In that case, a supplement
fiber, such as that in wheat bran, also reduces calcium can shore up your calcium intake and your bones. In
absorption. (Soluble fiber, such as the pectin in fruit, fact, one analysis of several studies of postmenopausal
does not.) Unfortunately, there is no easy equation for women found that the women who took calcium and
determining how much of the calcium content of a vitamin D supplements for at least two years were 23%
fruit or vegetable is actually absorbed. less likely to suffer a spinal fracture.
Fortified foods are another option. Just a cup A dizzying array of calcium supplements are
of fortified orange juice supplies about 300 mg of available, including pills, chewable tablets, flavored
calcium, and three-quarters of a cup of some fortified chews, and liquids (see Table 3, page 25). When making
cereals, such as Whole Grain Total, offers 1,000 mg. a decision, it’s wise to consider cost, convenience, and
Food labels, while helpful, often require how well your body tolerates the supplement.
translating. The label information helps you deter- The calcium in supplements is found in
mine how much calcium is in the preparation, not combination with another substance, typically
how much you need. Packaged foods list calcium carbonate or citrate—though, less commonly, you
content as a percentage of the FDA’s Daily Value, find products that combine calcium with phosphate,
which is 1,000 mg for adults. However, if you are a lactate, or gluconate.
woman age 51 or older, the IOM recommends 1,200 Calcium carbonate. This tends to be the best
mg of calcium a day—not 1,000—so the percentages value, because it contains the highest amount of ele-
on the label will not be accurate for you. mental calcium—the actual amount of calcium in
Table 3: Common calcium supplements
SERVING SIZE
AMOUNT OF (number of pills you must
TYPE OF CALCIUM ELEMENTAL take to get the amount of COST
BRAND COMPOUND (ACTUAL) CALCIUM calcium listed at left) PER SERVING*
Caltrate 600+D Calcium Supplement Calcium carbonate 600 mg 1 tablet 12–13 cents
Caltrate 600+D3 Plus Minerals Chewables Calcium carbonate 600 mg 1 chewable tablet 12–13 cents
Citracal Calcium + D3 Petites Calcium citrate 400 mg 2 caplets 14 cents
Citracal Plus Magnesium Calcium citrate 500 mg 2 tablets 11 cents
GNC Calcimate Plus 800 with Magnesium Calcium citrate 800 mg 4 tablets 24–33 cents
and Vitamin D3 malate
GNC Calcium 1,000 with Magnesium and Calcium carbonate 1,000 mg 3 tablets 16–21 cents
Vitamin D3
GNC Calcium Citrate 1,000 Calcium citrate 1,000 mg 4 tablets 21–28 cents
Os-Cal Calcium with Vitamin D3 Calcium carbonate 500 mg 1 tablet 8–10 cents
Os-Cal Ultra 600 Plus Caplets Calcium carbonate 600 mg 1 caplet 12–13 cents
Tums (regular strength) Calcium carbonate 400 mg 2–4 chewable tablets 8–10 cents
Tums E-X Extra Strength Antacid/Calcium Calcium carbonate 600 mg 2 chewable tablets 11 cents
Supplement
Tums Ultra Calcium carbonate 800 mg 2 chewable tablets 12–15 cents
Viactiv Calcium Chews Plus Vitamin D and Calcium carbonate 500 mg 1 flavored chew 14 cents
K Supplement for Women
*Based on a random sampling. Prices may vary.
each supplement. The compound calcium carbonate In weighing your options, check the labels of
contains 40% calcium by weight, while calcium citrate products to see what the serving size is and what the
is 21% calcium. Because calcium carbonate requires “% Daily Value” for calcium is. Then multiply the
stomach acid for absorption, it’s best to take this prod- percentage by 10 to find out how much elemental
uct with food. Most people tolerate calcium carbonate calcium the product contains. For example, if the label
well. However, some people complain of mild consti- says a serving of the product contains 40% of the Daily
pation or feeling bloated. Some well-known calcium Value, it has 400 mg of elemental calcium.
carbonate products include Caltrate, Viactiv Calcium Reading the labels with an eye toward cost and
Chews, Os-Cal, and Tums. convenience may help you sift through your options.
Calcium citrate. These products are absorbed Would you find it inconvenient to take several tablets
more easily than calcium carbonate. They can be taken a day? How many tablets or chews does the package
on an empty stomach and are more readily absorbed contain, and what is your cost per serving? While
by people who are taking an acid-reducing heartburn products that yield a high amount of calcium may seem
medication. But because calcium citrate is only 21% to be the best bet at first blush, they may not serve you
calcium, you may need to take more tablets to get your best. Because your body has difficulty absorbing more
daily requirement. Calcium citrate products include than 500 mg of calcium at a time, more of the mineral
Citracal and GNC Calcimate Plus 800. may go to waste (see “Spread it out,” page 24). So while
calcium four hours before and after taking levothy-
roxine, because calcium can interfere with this drug’s
absorption. Ask your doctor or pharmacist whether
a supplement will interact with any other prescrip-
tion medications you’re taking.
• Don’t exceed the daily dose recommended by the
manufacturer, since doing so increases the risk for
side effects.
• Vitamin D helps your body absorb calcium, but it’s
© Haydoce | Thinkstock
not necessary to take them at the same time. How-
ever, if you aren’t getting enough vitamin D from
sunlight, your diet, or your multivitamin, you may
want to choose a calcium supplement that contains
Experts generally recommend getting your nutrients from food
rather than supplements. There are many foods that contain
the vitamin.
calcium and a few, such as eggs, that contain vitamin D.
Sources of vitamin D
you may think that you’ve met your daily requirements Vitamin D is called “the sunshine vitamin,” and for
by taking that 1,000-mg calcium pill, you may actually good reason. Your skin cells use sunlight to produce
be only halfway to your target. a precursor chemical that the liver and kidneys then
Here are a few other things to keep in mind when convert into active vitamin D. Some people make all
choosing and taking a calcium supplement: the vitamin D they need by going outside for a few
• Generally, calcium pills are better choices than multi- minutes a day with bare arms and legs. (Don’t wear
vitamins, which tend to have small amounts of ele- sunscreen during this short time, except on your face
mental calcium. to avoid the photoaging effects of the sun.) Keep your
• The National Osteoporosis Foundation recommends exposure time short—just 10 minutes or so a day—
avoiding calcium products made from unrefined to guard against skin cancer. And if you’re out longer
oyster shell, bone meal, or dolomite that don’t say than that, do cover up or apply sunscreen.
“purified” or have the United States Pharmacopeia However, it’s unlikely that sunlight alone will
(USP) symbol on them, since these products have generate adequate amounts of vitamin D for most
tended to contain higher levels of lead, a toxic metal. Americans during much of the year. For example,
• Also avoid coral calcium, a supplement made from if you live above 40 degrees latitude (the latitude of
Japanese coral. Coral calcium supplements have also Denver, Indianapolis, and Philadelphia), the winter
been found to contain lead, along with mercury and sunlight isn’t strong enough to enable you to produce
cadmium—a metal that has been linked to cancer as
well as kidney and lung diseases. And although man-
ufacturers have asserted that the body absorbs more
Table 4: Recommended daily vitamin D
calcium from coral calcium than from other supple- intake in adults
ments, no evidence exists to back up this claim. The National Osteoporosis Foundation recommends a higher daily
intake of Vitamin D than the Institute of Medicine does. (For the
• Because calcium, iron, and zinc supplements inter- IOM recommendations, see Table 1, page 21.)
fere with each other, take them several hours apart.
SEX/AGE VITAMIN D
• Similarly, delay consuming calcium (either from
food or supplements) for two to four hours after Men and women under 50 400–800 IU
taking tetracycline antibiotics, since calcium can Men and women 50 and older 800–1,000 IU
decrease the drugs’ effectiveness. People with hypo-
Source: National Osteoporosis Foundation.
thyroidism (underactive thyroid) should avoid
significant amounts of vitamin D. Sunscreen, glass, and
clothing also interfere with this process, diminishing Table 5: Foods containing vitamin D
your ability to produce the vitamin. People with dark FOOD SERVING VITAMIN D (IU)
skin produce less vitamin D than those with fair skin.
Sockeye salmon, cooked 3 ounces 447
And no matter who you are, as you age, your skin can’t
produce vitamin D as readily, and your intestines have Tuna fish, 3 ounces 154
canned in water, drained
more difficulty absorbing this vitamin from food or
supplements. Orange juice, 1 cup 137 (amounts vary
fortified with vitamin D by product)
For this reason, many vitamin D experts would
recommend that you not only follow the National Whole milk, fortified 1 cup 124
Osteoporosis Foundation’s recommendations for Ready-to-eat breakfast 1 cup 100
vitamin D intake (see Table 4, page 26), but also have cereal (without milk)
your blood tested for vitamin D to gauge how much Yogurt, fortified 6 ounces 80 (check the label,
is actually getting into your system. The National because many brands
are not fortified)
Institutes of Health defines a normal blood level of
vitamin D as 30 to 74 nanograms per milliliter. Sardines, canned in oil 2 sardines 46
Beef liver, cooked 3 ounces 42

Vitamin D in your diet Egg 1 large 41
You can try to make up for the shortfall with your
Source: National Institutes of Health, Office of Dietary Supplements.
diet, but only a few foods—such as eggs, saltwater fish,
and liver—naturally contain vitamin D (see Table 5,
at right). Mushrooms have vitamin D if they’ve been who took ultra-high-dose vitamin D supplements
exposed to sunlight, but don’t assume they contain it (50,000 IU daily for 15 days, followed by 50,000 IU
unless the packaging says so. every 15 days for a year) had no difference in bone
In the United States, milk is fortified with this density of the spine, total hip, femoral neck, or total
vitamin; an 8-ounce glass should have about 100 IU body compared with women who took low-dose
or more. In addition, the FDA has approved the use of supplements or a dummy pill. Although their calcium
a particular type of yeast that can quadruple vitamin absorption increased, the increase was slight. It’s not
D levels in bread. A slice of bread should have roughly wise to double up on your multivitamins either, since
100 IU or more, if it’s labeled “rich in” or “an excellent that will deliver unhealthy amounts of other nutrients,
source of ” vitamin D. such as vitamin A, which can actually lower bone
density (see “Potential dietary dangers,” page 28).
Vitamin D supplements
Given the difficulties of obtaining adequate vitamin D
from the sun and food, most people find they need Vitamin K
to supplement. Vitamin D3, or cholecalciferol, is the You know that calcium and vitamin D are good for
form most easily absorbed and used by the body, so your bones, but did you know that the vitamin K
choose a product with D3 if possible. in leafy greens may also help keep them strong?
Most multivitamins contain 400, 1,000, or 2,000 Vitamin K helps your body produce osteocalcin, a
IU of vitamin D, but 1,000 IU is the most popular protein that is instrumental in bone formation. It also
dosage. Check the amount of vitamin D carefully. If blocks substances that break down bone and helps
it’s low, you may need to add an additional source, regulate calcium excretion from the body in urine.
such as a vitamin D capsule or a teaspoon of cod-liver Furthermore, research has shown that people deficient
oil. Just don’t overdo it. A 2015 study sponsored by in vitamin K tend to have lower bone strength and are
the National Institutes of Health found that women more prone to fractures.
For example, in a systematic review of 13 studies stances they take in. After all, it’s easier to preserve
in Annals of Internal Medicine, most of the studies bone than to rebuild it once it’s lost.
showed that taking vitamin K increased bone density. Caffeine. Some preliminary research suggests that
Seven trials found reduced fracture risk, all involving drinking four or more cups of coffee a day can put you
Japanese people taking the form of vitamin K called at greater risk of breaking a bone. It seems that tak-
menaquinone (vitamin K2). Menaquinone is a popular ing in high levels of caffeine increases calcium excre-
osteoporosis treatment in Japan. tion by the kidneys. More study is needed, but in the
That’s not the only evidence. In the Nurses’ Health meantime you may want to forgo that fourth cup.
Study, women who got at least 100 micrograms (mcg) Salt. In addition to raising blood pressure, too
of vitamin K a day were 30% less likely to break much sodium in your diet can increase the amount of
a hip than women who got less. Similarly, in the calcium your body excretes in urine. Following nutri-
Framingham Heart Study, people who got the most tional guidelines by consuming no more than 2,300
vitamin K were less likely to break a hip than those mg daily can help prevent this effect. So can eating
who got the least. foods high in potassium, such as bananas, avocados,
and leafy green vegetables.
Vitamin K in your diet Protein. Some experts believe that high levels of
Current recommendations call for 120 mcg of vita- protein, particularly protein from animal sources, may
min K per day for men and 90 mcg for women. Most raise the acidity of the body, causing calcium to leach
diets easily supply this amount. For example, a cup from your bones in order to neutralize the acidity.
of fresh raw spinach will deliver more than enough This issue is still being investigated, and there is no
to meet the daily requirement, and so will a generous consensus on how much protein may be harmful to
portion of cooked broccoli or Brussels sprouts. Other bones—if there is such a threshold at all.
good sources of vitamin K include collard greens and Alcohol. Heavy drinking seems to sap calcium
other green leafy vegetables. If you don’t like those from bones and interfere with production of vitamin
vegetables, try scallions, asparagus, or cabbage. Cer- D (see “Excess alcohol consumption,” page 11).
tain herbs, such as basil, sage, and thyme, also have Soda. Soft drinks—both full-sugar and diet
significant amounts of vitamin K. ones—affect the body’s calcium stores because the
Some people have to be careful with vitamin K, phosphate in soda interferes with the absorption of
however. If you take anticoagulants like warfarin calcium from foods. If the soda is caffeinated, that
(Coumadin), it’s particularly important to keep your compounds the trouble, as the caffeine increases the
vitamin K intake consistent from day to day, since amount of calcium removed.
this vitamin influences blood clotting. If you take an Vitamin A. Several studies have found a link
anticoagulant, ask your doctor if it’s safe for you to between high vitamin A intake and fractures. Cur-
take vitamin K. rently, the recommended daily amount of vitamin A
is 700 mcg (about 2,300 IU) for women and 900 mcg
(about 3,000 IU) for men. You can get vitamin A as
Potential dietary dangers preformed vitamin A or as its precursor, the nutrient
Researchers have identified some components of a beta carotene (which the body converts into vitamin
typical American diet that may compromise bone A). Beta carotene has not been linked to fractures
health. In some cases, the science is not absolutely and is therefore a safer way to fulfill your vitamin
clear on how much of these foods are harmful. How- A requirements. If you take a multivitamin, check
ever, the evidence is strong enough that anyone who is to make sure that a significant part of its vitamin A
at risk of low bone density—postmenopausal women, comes from beta carotene. Also, avoid taking high-
for example—might consider how much of these sub- potency vitamin A supplements.
Protecting your bones: Exercise
E xercise plays a dual role in fighting the effects of

osteoporosis. First, it can help preserve the bone
strength you still have. Second, it improves coordi-
your doctor about the types of activity that are right
for you. (Note that while swimming and bicycling are
excellent ways to keep fit, they aren’t weight-bearing,
nation and balance, which can prevent the falls that so they won’t improve your bone mass or density.)
could lead to fractures. A study by Harvard research- There are a couple of rules of thumb to be aware
ers found that women who walked more than four of if you’re aiming for maximum effect on bone and
hours per week had a significantly lower risk of hip you are able to work out vigorously. Generally, higher-
fractures than women who walked less than an hour impact activities have a more pronounced effect on
per week. While exercise, like diet, can’t rebuild bone bone than lower-impact exercises; sports such as
to the extent that medicine can, it might contribute to tennis, volleyball, or running build bone faster than
small increases in bone density. walking or low-impact aerobics. Velocity is also a
However, bone health is not the only reason to factor; jogging or fast-paced aerobics will do more to
work out. Regular exercise also lessens your chances strengthen bone than more leisurely movement. And
of getting heart disease, lowers blood pressure, helps keep in mind that only those bones that bear the load
prevent diabetes, reduces the risk for colon and breast of the exercise will benefit. For example, walking or
cancer, improves mood, and adds years to your life. If running protects only the bones in your lower body,
these health benefits came in a pill, people would be including the hip.
clamoring for a prescription. By contrast, a well-rounded strength training
program that works out all the major muscle groups
can benefit practically all of your bones. And strength
How weight-bearing exercise training is the only type of exercise that targets
benefits bones the very sites most likely to sustain fractures from
Weight-bearing exercise can significantly increase osteoporosis—bones of the hip, spine, and arms. (See
bone density during childhood and adolescence. The the Special Section, “Strength training and balance
effects aren’t as dramatic in adulthood. But weight- exercises for bone health,” page 34, for workout ideas,
bearing exercise is helpful then, too, because move- particularly if you’re new to strength training.)
ment that compels you to work against gravity stresses To keep your bones healthy, aim to get at least 30
your bones enough that your body responds by rein- minutes of general weight-bearing exercise a day—
forcing the bones that are under duress. reserving classic strength training with weights for
What exactly is weight-bearing exercise? It’s not just two to three days a week, with at least 48 hours
just classic strength training (also known as weight between sessions. It’s important to exercise regularly;
training or resistance training), where you work out infrequent activity won’t strengthen your bones.
with weights in the gym. Weight-bearing exercise In addition to helping maintain bone density,
includes any exercise where your body is bearing exercise helps protect against fractures in other ways.
your weight. That could include vigorous sports, Strength training increases muscle mass, which in
such as tennis or running, which are options if you’re turn enhances muscle control, strength, balance, and
trying to prevent osteoporosis. If you already have coordination. Good balance and coordination can
the condition, start with a gentler form of weight- mean the difference between falling—and suffering
bearing exercise, such as walking or tai chi. Talk with a fracture—and staying on your feet. Strong evidence
Beyond bones: Putting together a total fitness routine for overall health
Exercise delivers powerful, wide-ranging health benefits, but
to reap its full rewards you must perform several different
types of activities on a regular basis. Here are the various ele-
ments of a well-rounded program.
Aerobic. Each week, accumulate at least 150 minutes of
moderate activity or 75 minutes of vigorous activity, or an
equivalent mix of the two. Sustain activities for at least 10
minutes at a time.
Strength. Do strength exercises for all major muscle groups
(legs, hips, back, chest, abdominals, shoulders, arms) at least
twice weekly. Repeat each exercise eight to 12 times per
set, aiming for two to three sets. Rest muscles for at least 48
© Wavebreakmedia Ltd
hours between strength training sessions.
Balance. For older adults at risk for falls and others con-
cerned about osteoporosis, include activities that enhance
balance, such as tai chi or yoga, at least twice a week. A sedentary lifestyle is one of the major risk factors for heart
Flexibility. Do stretching or other flexibility exercises, prefer- disease. Regular physical activity—such as walking, gardening,
ably on days when you do aerobic or strength activities, or or golfing—can reduce your risks.
at least twice a week. Hold stretches for 10 to 30 seconds,
repeating each stretch three to four times.
shows that regular physical activity can reduce falls by Groups of eight to 12 reps make up one set. Though
nearly a third in older adults at higher risk of falling. performing one set is effective, two to three sets may
be better. Give yourself a minute or more to rest
between sets.
Classic strength training No matter what routine you use, the following tips
Although there are many types of weight-bearing for safe and effective strength training will help you
exercise, classic strength training can deliver the most get the most from your workouts.
benefits to the maximum number of bones. A strength Warm up and cool down for five to 10 minutes.
training program typically employs equipment such as Warming up brings nutrient-rich, oxygenated blood
weight machines, free weights, and resistance bands or to your muscles while raising your heart rate and
tubing. Not only does strength training protect against breathing. Cooling down slows breathing and heart
bone loss, but it also builds muscle and improves your rate to help prevent a sudden drop in blood pressure
body’s ratio of lean muscle mass to fat. As a result, it that can cause dizziness. End with stretches.
deserves an important place in your exercise routine. Focus on form, not weight. Align your body
The Physical Activity Guidelines for Americans, correctly and move smoothly through each exercise.
issued by the U.S. Department of Health and Human Poor form can prompt injuries and delay gains. Many
Services, recommend strengthening exercises for experts suggest starting with no weight, or very light
all major muscle groups (legs, hips, back, chest, weight, when learning a strength training routine.
abdominals, shoulders, and arms) two or three times Concentrate on slow, smooth lifts and equally con-
per week. Generally each exercise is done multiple trolled descents while isolating a muscle group—that
times—for example, you might do eight biceps curls is, contracting and releasing the specific muscles that
in a row. These are known as repetitions, or “reps.” you want to strengthen.
Maintain a steady tempo. Tempo—for example,
counting to three while lowering a dumbbell, then Vibrating platforms: Do they help those
counting to three while raising it again—helps you who are unable to exercise?
stay in control. Too much speed and momentum can
undercut strength gains and undermine form. A therapy called whole body vibration is being promoted
as a way to prevent bone loss in those who are too frail
or too incapacitated to exercise. The idea is that by stand-
Breathe. Blood pressure rises if you hold your
ing on a vibrating platform, a person experiences barely
breath while performing strength exercises. Exhale as perceptible vibrations that travel up through the soles of
you lift, push, or pull a weight; inhale as you release. the feet. These vibrations cause muscle cells to react as
Keep challenging your muscles. Begin with a they would to common activities such as standing, keeping
weight that you can comfortably lift for eight to 12 balance, and walking. They twitch in sequence, making tiny
contractions that exert small stresses on bones, resulting in
repetitions. The right weight differs depending on the
increased bone density and muscle mass.
exercise. Choose a weight that tires the targeted mus-
But the platforms can be expensive, and the evidence is
cle or muscles by the last two reps while still allowing mixed that this therapy actually strengthens bones and
you to maintain good form. If you can’t do the last two prevents osteoporosis. In one study, postmenopausal
reps, choose a lighter weight. When the complete set women were asked to stand on a vibrating platform for
feels too easy, challenge your muscles again by adding 20 minutes a day on either the high or low speed; these
women were compared with a group who did not use the
weight (roughly 1 to 2 pounds for arms, 2 to 5 pounds
device. After a year, there was no difference in bone loss
for legs) or adding another set of reps to your workout between the two treated groups and the untreated group.
(up to three sets). If you add weight, remember that
A 2015 review of studies on vibrating platforms for post-
you should be able to do all the reps with good form menopausal osteoporosis concluded that more research
and the targeted muscles should feel tired by the last is needed to determine the mechanisms behind this
two reps. Most sporting goods stores sell dumbbells therapy’s potential effects on bone. And while the authors
with adjustable weights, as well as wrist and ankle say vibrating platforms might provide some benefits when
used as an add-on therapy, they are no substitute for
bands that fasten with Velcro and have pockets for standard treatments like bone-building medications and a
weights. Look for sets that allow you to add weights in bone-healthy diet.
half- to 1-pound increments.
Practice regularly. Working all the major muscles
of your body two or three times a week is ideal. You strength training. As little as four to six months of reg-
can choose to do one full-body strength workout two ular weight training can help you maintain—or even
or three times a week, or you may opt to break your improve—bone density. But people who stick with it
strength workout into upper- and lower-body compo- for a year or more achieve the greatest gains. If you
nents. In that case, be sure that you perform each of stop working out, any increases in bone and muscle
these components two or three times a week. strength will disappear within five years.
Give your muscles time off. Strenuous exercise
like strength training causes tiny tears in muscle tis-
sue. Muscles grow stronger as the tears knit up. Always Safety first
allow at least 48 hours between sessions for muscles A well-designed fitness program can improve your
to recover. So, if you do a full-body strength workout strength and mobility, but a poorly executed plan
on Monday, wait until at least Wednesday to repeat it. could actually lead to a fracture. With weak bones,
If you’re doing a split strength session, however, you it’s imperative that you exercise safely. Here are some
might do upper-body exercises on Monday, lower- general guidelines to help anyone with osteopenia or
body exercises on Tuesday, upper-body exercises on osteoporosis make a smooth transition to a new work-
Wednesday, lower-body exercises on Thursday, etc. out routine:
Keep it up. As with other forms of exercise, • Run the exercises by your doctor first to make
consistency is the key to getting good results from sure they’re safe for you to try. Getting your doc-
tor’s okay is especially important if you’ve fractured • Avoid risky movements. Don’t lift heavy weights.
a bone in the past or if you have an additional con- And stay away from any exercise that could end in
dition, such as diabetes or heart disease. a fall—for example, an unbalanced yoga pose or
• Book a few sessions with a physical therapist. standing on a chair.
Go through each exercise, step by step, having the • Avoid spinal bends and twists. Be careful not to
therapist check your form. Keep going back to the make any quick reaching or twisting motions, espe-
therapist until you’re completely comfortable doing cially if you’ve broken a bone. You may need to
the exercises on your own. modify certain exercises to make them safe or avoid
• Pace yourself. No effective exercise program was them altogether. For example, to protect your ver-
created in a day. Start slowly, giving yourself time tebrae, forgo exercises and machines that put added
to adjust to the pace and movements. Gradually stress on the spine, such as leg press machines, leg
increase both the length and intensity of your work- raises performed lying down, and squats done with
outs as you feel ready. weight bars resting on the shoulders. Golf swings
Tai chi improves balance, muscle strength, and flexibility
E vidence is growing that tai chi, a mind-body practice that originated in China as a
martial art, has value in treating or preventing many health problems. Tai chi helps
improve balance, and there is preliminary evidence that it may help maintain bone
facilities. Here is more detail on tai chi’s
benefits:
Muscle strength. Even without the as-
strength, too.
sistance of weights or resistance bands,
In this low-impact exer- Although the research on tai chi can help build muscle strength
cise program, you move tai chi for bone strength in the lower and upper extremities as
without pausing through has yielded mixed results, well as the core muscles of the back and
a series of slow motions. one study in Taiwan abdomen.
Throughout these gentle found that longtime
Flexibility. Tai chi significantly boosts
movements, the muscles practitioners of tai chi
had greater bone density upper- and lower-body flexibility.
are relaxed rather than
tensed, the joints are at the hip and spine com- Balance. Not only does tai chi help keep
not fully extended or pared with people who you from losing your balance in the first
bent, and connective didn’t do tai chi. Another place. If you do stumble, the muscle
tissues are not stretched. study found that bone strength and flexibility you gain from tai
Because you are standing density actually increased chi can help you recover before a stumble
© humonia | Thinkstock
and you shift your body in the hip and spine in turns into a fall.
weight from leg to leg, people who practiced
tai chi for 10 months. Proprioception. Proprioception is the
you get the benefit of ability to sense the position of one’s body
weight-bearing exercise, By contrast, those who
didn’t practice tai chi in space, and it declines with age. Tai chi
which may account for helps train this sense, which is a func-
the potential bone-strengthening ef- saw declines in bone density over the
same period. A third study found benefits tion of sensory neurons in the inner ear
fect—though the impact is much lower and stretch receptors in the muscles and
equivalent to 12 months of resistance
and thus the effect on bone is less than ligaments.
training.
with more vigorous exercise. On the other
hand, tai chi is slow and gentle enough In addition to its effects on bones, tai chi Aerobic conditioning. Depending on
to be easily adapted for anyone, from the improves muscle strength, flexibility, and the speed and size of the movements, tai
fittest individuals to people confined to balance—all of which help you stay fit chi can provide some aerobic benefits.
wheelchairs or recovering from surgery. and avoid falls and fractures. It can also But to meet government fitness guide-
Especially important is that it is safe for slightly improve aerobic conditioning, lines and get full cardiovascular and
people who are elderly, frail, and out of if it is done at a fairly rapid pace and is other health benefits, you’re better off
condition—individuals at particularly challenging enough. What’s more, tai chi relying on standard aerobic activities,
high risk for falls and broken bones. doesn’t require any special equipment or such as brisk walking.
and sit-ups also place stress on the spine and may
result in vertebral fractures. Can yoga help prevent osteoporosis?
• Don’t overdo it. Expect to be sore during your Could regularly performing a series of poses help preserve
early exercise sessions, but if you’re in pain, ease bone strength? A 2016 study in the journal Topics in
Geriatric Rehabilitation suggests that a daily yoga practice
back. You might be moving too quickly or pushing
might do just that. The study included 741 people, who
yourself too hard. were an average of 68 years old when they started. Most
had lower-than-normal bone density. After participating in
a daily 12-minute yoga routine over a period of 10 years,
Preventing falls the participants underwent DEXA scans, which revealed
gains in bone density in their spines, hips, and femurs.
In essence, the treatment and prevention of osteopo-
rosis is aimed at a single goal: to forestall the fractures While promising, the study applies to people with osteo-
penia, not osteoporosis. Many of the yoga poses used in
that can threaten independence, steal mobility, trig- this study involved spinal twists, side bends, and back
ger depression, and result in pain, disability, or even extensions that help with prevention, because they place
death. You can do that either by building bone or by stress on the muscles around the spine. However, people
preventing the falls that often lead to fractures—or who already have osteoporosis should avoid exercises that
involve flexing the spine because they can further damage
better yet, by doing both. Falling is one of the biggest
vertebrae that are already weakened by osteoporosis.
causes of fractures, particularly among older people.
Yoga does have undeniable health benefits, including im-
More than 95% of hip fractures result from a spill. proved balance and coordination that could prevent falls.
Therefore, researchers, doctors, and osteoporosis-pre- If you are interested in trying yoga, check with your doctor
vention organizations focus quite a bit on this subject. or a physical therapist first, to make sure it’s appropriate
All people are more susceptible to falls as they for you and to be sure you know what poses are safe for
your level of bone strength.
age, but women are even more likely than men to fall.
You can help reduce the threat of falls by practicing
exercises that improve your balance. (For specific
examples, see “Balance exercises,” page 38.) If you are house that can help minimize your risk of falling:
already doing some strength training, you may find 1. Clear your floors of clutter and any items that could
that many of your current exercises are helpful for trip you up, including loose wires, cords, and throw
improving balance as well, because they strengthen rugs.
muscles that you use to maintain balance. 2. Make sure that stairways, entrances, and walkways
In addition to balance exercises, power exercises are well lit, and install night lights in your bedroom
(strength exercises that emphasize speed) can help and bathroom.
reduce falls by improving your reaction time if you 3. Clean up spills immediately.
start to trip or lose your balance. There are four power 4. Wear rubber-soled shoes for better traction. Avoid
exercises in the workout of the Special Section. They’re walking around in socks.
listed as variations under the standing calf raise (see 5. Limit your intake of alcohol.
page 35), stair climbing (page 35), triceps dip (page 6. Keep items that you use often in easy-to-reach
36), and chair stand (page 36). cabinets. Also, consider using reaching and grasping
tools to get at difficult-to-reach items.
10 more ways to prevent falls 7. Add grab bars to your tub, and use nonskid mats on
Exercise is not the only thing you should do to pre- bathroom floors.
vent falls. Falls can result from a host of factors, some 8. Be careful when pets are nearby. Tripping over a pet,
health-related and some environmental, such as fail- most often a dog or cat, is a common cause of falls.
ing vision or hearing, dizziness (sometimes caused by 9. Talk to your doctor about whether any medications
medications), bad lighting, wet floors, and obstacles in you are taking can cause dizziness or impair balance.
pathways. Here are some simple changes around the 10. Have your eyes checked regularly.
SPECIAL SECTION
Strength training and balance

exercises for bone health
“
W
hat type of exercise program should I follow?” This is one of the most common ques-
tions doctors hear from patients who have concerns about thinning bones. They are
aware that exercise can play a role in slowing bone loss, but they don’t know what type
of exercise is best.
The short answer is weight-bearing exercise. But what does that mean? As discussed in the
previous chapter, it’s not just lifting weights, but rather any exercise in which your body is bearing
your weight. (See “Protecting your bones: Exercise,” page 29, for more detail.)
However, a well-rounded strength training to 12 exercises that, combined, exercise all the major
program that works all the major muscle groups muscle groups. This workout does that. Four of these
is most effective. This creates stresses on bones exercises include “power moves”—variations designed
throughout the body, stimulating extra deposits of to enhance speed as well as strength. In addition, at
calcium and nudging bone-forming cells into action. the end, we’ve included a few exercises that directly
The bones that benefit are those that attach to the target balance.
muscles that are being worked. For example, the Our workout is designed for older adults and
standing calf raise (page 35) benefits your shin bones. people who are new to strength training. Still, it’s
The bridge (page 35) is good for the hips and spine. wise to talk to your doctor before trying these
Finally, strength training—particularly if it includes exercises, particularly if you’ve been diagnosed with
work on power and balance—enhances stability, osteoporosis.
which can help protect you from falling. For the best results, do this workout two or
Like most strength training routines, the workout three times a week, allowing at least 48 hours for
presented here calls for doing each exercise eight to 12 your muscles to recover between workouts. For the
times, or repetitions (“reps”). Those repetitions make greatest overall health benefits, also try to get 30
up one set. Typically, in a complete workout, you minutes of moderate aerobic exercise on most days
will do two to four sets each of approximately eight of the week.
Note: This workout is adapted from another Harvard Special Health Report, Strength and Power Training: A Guide for
Older Adults, by Elizabeth Pegg Frates, M.D. (Harvard Medical School, 2015).
34 Osteoporosis www.health.har vard.edu
Strength training and balance exercises for bone health | SPECIAL SECTION
Strength training exercises

A ll you’ll need to begin this workout
is a sturdy chair with armrests,
a small pillow, athletic shoes with
After that, add enough weight so the
maximum number of repetitions you
can do is eight to 12. If an exercise
lifting or pushing, since holding your
breath will increase your blood pres-
sure. As you release, breathe in. Rest for
nonskid soles, an exercise mat, and starts to feel easy, it’s time to increase 30 to 60 seconds between sets.
appropriate weights. Begin by choosing the weight you are using (within safe For further tips on performing these
weights that are as light as 2 pounds limits set by your doctor). types of exercises, see “Classic strength
for your first few training sessions, so As you perform each of these exercises, training,” page 30, and “Safety first,”
you can concentrate on good form. remember to breathe out when you are page 31.
1 Standing calf raise

Exercises the calf muscles
Stand with your feet flat on 2 Stair climbing
the floor. Hold on to the back
Exercises the muscles
of your chair for balance. Raise
of the buttocks and fronts
yourself up on the balls of your
of the thighs
feet, as high as possible. Hold
briefly, then lower yourself. Aim Holding on to the handrail
for eight to 12 repetitions. for balance if necessary,
Rest and repeat the set. walk up and down a flight of
▶ Make it harder: Once your at least 10 stairs at a pace
balance and strength improve, that feels comfortable. Pause
tuck one foot behind the other at the top only if you need
calf before rising on the ball of to do so. Rest when you
your foot; repeat on the other reach the bottom. Repeat
leg. Or stand on both feet, but four times.
do not hold on to a chair. ▶ Power move: If your
▶ Power move: Change the balance is good, go up the
move slightly for the final set stairs as briskly as you can
by rising up on the ball of your and down at your normal
foot quickly. Hold briefly. Lower pace for the last set.
yourself at a normal pace.
3 Bridge
Exercises the muscles of the back, backs of the thighs,
and buttocks
Lie on your back on a mat with your knees bent and your feet
flat on the floor. Put your hands next to your hips with palms
flat on the floor. Keep your back straight as you lift your
buttocks as high as you can off the mat, using your hands for
balance only. Pause. Lower your buttocks without touching
the mat, then lift again. Do eight to 12 repetitions. Rest and
repeat the set.
www.health.har vard.edu Osteoporosis 35

SPECIAL SECTION | Strength training and balance exercises for bone health
4 Triceps dip
Exercises the muscles
of the backs of the
upper arms, chest, and
shoulders
Put a chair with armrests
up against a wall. Sit in the
chair and put your feet to-
gether flat on the floor. Lean
forward a bit while keeping
your shoulders and back
straight. Bend your elbows
and place your hands on the
armrests of the chair, so they
are in line with your torso.
Pressing downward on your
hands, try to lift yourself up a few inches by straightening out
5 Hip extension
your arms. Raise your upper body and thighs, but keep your Exercises the muscles of the buttocks and
feet in contact with the floor. Pause. Slowly release until you’re backs of the thighs
sitting back down again. Aim for eight to 12 repetitions.
Stand 12 inches behind a sturdy chair. Holding on to the
Rest and repeat the set.
back of the chair for balance, bend your trunk forward 45
▶ Variation: If you don’t have a chair with armrests, sit on the degrees. Slowly raise your right leg straight out behind
stairs. Put your palms down on the stair above the one you are you. Lift it as high as possible without bending your knee.
seated on. Press downward on the heels of your hands, lifting Pause. Slowly lower the leg. Aim for eight to 12 repeti-
your body a few inches as you straighten your arms. Pause. tions. Repeat with your left leg. This is one complete set.
Slowly release your body until you are sitting back down again. Rest and repeat the set.
Aim for eight to 12 repetitions. Rest and repeat the set. For greater effect, try adding ankle weights, available
▶ Power move: During your last set, lift your body quickly. from sporting goods stores. Brands with ¼- or ½-pound
Slowly release until you are seated again. weight bar inserts are best. Look for cuffs that can hold
up to at least 5 pounds per leg.
6 Chair stand
Exercises the muscles of the abdomen, hips, fronts of the thighs,
and buttocks
Place a small pillow at the back of your and shoulders straight, raise your upper
chair and position the chair so that body forward until you are sitting up-
the back of it is resting against a wall. right. Stand up slowly, using your hands
Sit at the front of the chair with your as little as possible. Slowly sit back
knees bent and your feet flat on the down. Aim for eight to 12 repetitions.
floor and slightly apart. Lean back on Rest and repeat the set.
the pillow in a half-reclining position ▶ Power move: Change the move slightly
with your arms crossed and your hands for the last set by rising from the chair
on your shoulders. Keeping your back quickly. Sit down again at a normal pace.
Strength training and balance exercises for bone health | SPECIAL SECTION
7 Overhead 8 Side leg raise

press Exercises the muscles of the hips and sides
Exercises the muscles of the thighs
of the shoulders, up- Wearing a weight on
per back, sides of the your right ankle, stand
rib cage, and backs of behind a sturdy chair
the upper arms with your feet together.
Stand with your feet Hold on to the back of
slightly apart. Hold a the chair for balance.
dumbbell in each hand Slowly raise your right
at shoulder height (your leg straight to the side
elbows should be bent until your foot is eight
and the weights should inches off the floor.
be about six inches from Keep your knee straight.
your body). Hold the Pause. Slowly lower your
weights so your palms foot to the floor. Do eight
are facing forward. to 12 repetitions. Repeat
Slowly lift the weights with the left leg. This is
straight up until your one complete set. Rest
arms are fully extended. and repeat the set.
Pause. Slowly lower the dumbbells to shoulder level. Do
eight to 12 repetitions. Rest and repeat the set.
9 Double biceps curl 10 Forward fly

Exercises the front upper arm muscles Exercises the muscles of the shoulders and upper back
Stand or sit holding Sit in a chair holding weights about 12 inches in front of
dumbbells down at your your chest. Your elbows should be up and slightly bent and
sides with your palms your palms should be facing each other (as if your arms are
facing inward. Slowly wrapped around a large beach ball). Lean forward at a slight
bend both elbows, lifting angle in the chair, bending from your hips and keeping your
the weights toward your back straight. Now,
upper chest. Keep your pull the weights
elbows close to your sides. apart while trying to
As you lift, rotate your bring your shoulder
palms so they face your blades as close
shoulders. Pause. Slowly together as possible.
lower your arms to the Let the movement
starting position. Do eight pull your elbows
to 12 repetitions. Rest and back as far as pos-
repeat the set. sible. Pause. Return
to the starting posi-
tion. Do eight to
12 repetitions.
Rest and repeat
the set.
www.health.har vard.edu Osteoporosis 37

SPECIAL SECTION | Strength training and balance exercises for bone health
Balance exercises
An osteoporosis workout should ideally including the standing calf raise (page balance. But the following four
have two goals—shoring up bones, 35), hip extension (page 36), chair exercises are more specifically
and improving balance to prevent stand (page 36), and side leg raise targeted at making you steadier on
falls. Many of the previous exercises, (page 37), are also useful for improving your feet.
1 Thigh raise 2 Tree pose (not shown)

Stand with your hands on your This popular yoga pose is good for develop-
hips. Raise one foot, keeping a ing balance. Stand straight up, feet hip-width
toe on the floor. Keeping your apart and weight evenly distributed on both
back straight, raise your knee feet. Put your arms at your sides. Then slowly
until your thigh is parallel to shift your weight to your right leg while bend-
the floor (your foot will be lifted ing the left knee. Lift your left foot and place
off the floor). Pause. Lower the it on the inside of your right leg, either above
leg to the starting position. Do or below the knee. To help you balance, place
eight to 12 repetitions. Repeat the sole of your left foot firmly against your
with the opposite leg. This is one right leg and press your right leg against your
complete set. Rest and repeat left foot. Brace your abdominal muscles as
the set. Note: Ankle weights are you bend your elbows and bring your hands
optional, but if you use them for up in front of your chest in a prayer position.
this exercise, they will provide Hold. Return to the starting position, and then
added resistance and increased repeat while standing on your left leg.
muscle strengthening. ▶ Make it easier: If this pose is too hard,
▶ Make it harder: Stand next place your foot at the calf or ankle. The only
to a chair and hold on to the back of it for balance, if necessary. place you shouldn’t put it is against the knee.
Raise the knee that’s farthest away from the chair up toward
your chest. Pause. Lower the leg. Do eight to 12 repetitions. Rest
and repeat the set. Repeat with your other leg.
3 Reverse lunge (not shown) 4 Heel-to-toe walk (not shown)

Stand up straight, with your feet together and weight evenly Position your heel directly in front of the toes
distributed on both feet. Put your arms at your sides. Keeping of the opposite foot each time you take a step.
your left foot where it is, step back on the ball of your right foot Heel and toes should actually touch as you
and bend both knees, sinking into a lunge, with your right knee walk forward for eight to 12 steps. If neces-
pointing to the floor. If this is too difficult, don’t put your right sary, steady yourself by putting one hand on a
foot so far back, and don’t bend your knees as much. Return to counter as you walk. Then work toward doing
the starting position. Repeat on the other side, performing 10 the exercise without support. Repeat two to
repetitions on each side. four times.
Protecting your bones: Medication
N utrition and weight-bearing exercise can do some

of the heavy lifting when it comes to maintaining
bone strength, but medication also plays a key role,
phonates typically prescribed for osteoporosis are
alendronate (Fosamax), risedronate (Actonel), and
ibandronate (Boniva). Once they were available only
especially for women who have reached menopause. in daily doses, but thanks to new formulations, more
Because medicines can have risks, they aren’t patients are opting for weekly or monthly versions
recommended for everyone. According to National because of the convenience. One of the medications in
Osteoporosis Foundation guidelines, your doctor is this class, zoledronic acid (Reclast), can even be taken
most likely to put you on a bone-strengthening drug just once a year via an intravenous infusion. With an
if you infusion, the medicine is delivered into a vein through
• have fractured a hip or vertebra a needle or a tube called a catheter. The infusion takes
• have a T-score of –2.5 or less at the lumbar spine, about 15 minutes.
hip, or femoral neck Like most of the medications approved for treating
• are 50 or older with a T-score between –1 and –2.5, osteoporosis, bisphosphonates reduce bone resorption,
and a 10-year hip fracture risk of 3% or more or a slowing bone loss and producing modest increases
10-year major osteoporosis-related fracture risk of in bone density. They accomplish this by binding to
20% or more based on your FRAX score (see “How hydroxyapatite and interfering with bone-depleting
likely are you to break a bone? Your FRAX score osteoclasts. Osteoblasts then have an opportunity to
and more,” page 17). fill in more of the trenches left by osteoclasts. As a
This chapter lists the major types of medications result, bisphosphonates reduce hip, wrist, and spinal
used for osteoporosis. Which one is right for you? That fractures. They have become an attractive alternative
depends on your individual health status, fracture to hormone therapy, which was once widely used for
risk, and treatment preferences. stemming bone loss but has fallen out of favor because
No matter which medicine your doctor prescribes, of safety concerns (see “Hormones,” page 46).
your goal isn’t to stay on it indefinitely. The doctor will If taken correctly, oral bisphosphonates do not
likely do repeat tests of bone density a year or two cause side effects in most people. But if they are not
after starting you on the drug, and then every two taken correctly, they may be hard to digest and can
years after that. You might also have blood or urine cause nausea, heartburn, or irritation of the stomach
tests for biochemical markers that determine how well or esophagus (see “How to take Fosamax, Actonel,
the drug is working. These bone assessments will help and Boniva properly,” page 41). Many people find
your doctor determine whether and how much the these instructions cumbersome. The inconvenience,
drug is helping, and if it’s time to stop taking it or shift coupled with the fact that osteoporosis doesn’t have
to another medication. any symptoms, causes some people to question
whether they need medication at all and to give up
treatment. Others continue with therapy but fail to
Bisphosphonates take their medication properly. Experts hope that
Since the mid-1990s, when the FDA approved the first the development of more convenient formulations of
bisphosphonate drug, this class of drugs has become bisphosphonates will translate into better compliance,
the first choice of doctors for treating or preventing meaning that more people will take their medications
osteoporosis (see Table 6, page 44). The oral bisphos- as directed.
While bisphosphonates are usually well toler- bone mass in the spine and hip as effectively as
ated, some people taking these medications develop hormone therapy, but without the same risks. It travels
severe or even incapacitating bone, joint, or muscle preferentially to spots where bone turnover is high,
pain. According to a warning from the FDA, this pain such as the hips and spine.
can occur days, months, or even years after starting Studies suggest that alendronate is safe and
a bisphosphonate; for this reason, physicians some- effective for at least 10 years. And it yields results
times attribute the pain to other medical conditions, quickly. A follow-up of the Fracture Intervention
resulting in prolonged discomfort and delayed treat- Trial, an important study conducted in the 1990s,
ment. While some people on bisphosphonates report found that alendronate was able to reduce the risk for
that the pain disappears completely as soon as they spinal fractures within a year.
stop taking the medications, others have found that Furthermore, the benefits seem to linger
the pain ebbs slowly or only partially. even after people stop using the medication. In
Other reports have surfaced that bisphosphonates another follow-up to the Fracture Intervention
may be linked to unusual bone fractures, damage Trial, researchers compared women who had taken
to the jawbone, or disturbances in heart rhythm. alendronate for five years with women treated for 10
However, some of these effects remain unproven, years. In those who took the drug for five years and
and problems like these are very rare (see “How safe then stopped, bone mineral density showed a small
are bisphosphonates? A doctor weighs in,” page 42). decline but remained at or above where it was at the
As with any prescription, report new or unusual start of treatment. Moreover, fracture risk for the most
symptoms to your doctor immediately. Let your part did not rise, except for a small increased risk of
physician decide whether or not the symptom is a a vertebral fracture, and was generally comparable to
concern instead of dismissing it yourself. that in women who continued to take alendronate for
the full 10 years.
Alendronate (Fosamax) The researchers concluded that many women may
Alendronate is FDA-approved for the prevention and be able to stop using the medication after five years
treatment of osteoporosis in postmenopausal women, without putting themselves in greater jeopardy of
the treatment of glucocorticoid-induced osteoporosis, breaking a bone. However, they noted that women
and the treatment of osteoporosis in men. It is avail- at high risk of spinal fractures may benefit from
able as a pill that’s taken daily or as either a liquid or continuing the treatment beyond that five-year time
pill that’s taken once a week. Another version com- frame.
bines alendronate and vitamin D. A generic version of
alendronate is also available. Risedronate (Actonel)
Since 1995, when alendronate received its initial Like its cousin alendronate, risedronate is approved
FDA approval, studies have consistently shown that it to prevent and treat osteoporosis in postmenopausal
can slow or even halt bone loss, increase bone density, women, and it may be used to prevent or treat glu-
and reduce the risk for spinal and hip fractures. In a cocorticoid-related osteoporosis in men and women
systematic review of clinical trials involving a total of and to treat osteoporosis in men. It is available as a
more than 12,000 women, treatment with alendronate daily pill, a weekly pill, or a tablet taken once a month.
reduced the overall risk for vertebral fractures by 45% Also like alendronate, risedronate has been shown to
and hip fractures by 40%, compared with not taking impede bone loss, increase bone mineral density, and
any medication. However, it’s important to note that reduce the risk for fractures.
the medication had this effect only in women who had A handful of studies, including one randomized
already had a fracture before the study. clinical trial, have directly compared alendronate
Alendronate is also effective for prevention. and risedronate. In the clinical trial, once-weekly
Studies have found that the medication increases alendronate raised bone mineral density in
How to take Fosamax, Actonel, and Boniva properly
S ince alendronate (Fosamax), risedronate

(Actonel), and ibandronate (Boniva) can be
difficult to digest, people taking these medica-
The consequences of not taking alendronate
properly became evident a few months after it
was on the market. The manufacturer, Merck,
tions must follow instructions carefully to avoid notified physicians that women were expe-
unpleasant side effects such as heartburn, riencing more esophagitis, ulcers, and other
nausea, or difficulty swallowing. gastrointestinal side effects than reported
© Eyecandy Images | Thinkstock
First thing in the morning, take the medica- during clinical trials. The company attributed
tion on an empty stomach with a large glass these side effects to patients failing to drink
of water (at least 8 ounces) and then remain enough water with the pills or lying down in
upright for at least 30 minutes (60 minutes for bed after taking the medication. Although it
once-a-month Boniva). During this time, avoid can be a hassle to take bisphosphonates as
eating, drinking, or taking another medication. directed, the extra care can pay off by helping
It’s important to take the medication with water, rather than you sidestep unpleasant side effects.
coffee or orange juice, both of which can interfere with your While bisphosphonates are quite effective in preventing
body’s ability to absorb and use the drug. fractures, the oral forms may not be the best choice for those
Most people tolerate these medications well when they take who have recurrent heartburn, acid reflux, esophagitis, stom-
them as instructed. In fact, side effects are uncommon among ach ulcers, or difficulty swallowing. People who have Barrett’s
people taking bisphosphonates in clinical studies. Perhaps esophagus should not take oral bisphosphonates. If you have
these study participants are more likely to take their medica- any of these conditions, ask your doctor about taking inject-
tions exactly as directed. able or intravenous osteoporosis medications instead.
postmenopausal women more than did risedronate to short-lived flu-like symptoms in a small percentage
after a year of treatment, although both drugs reduced of people receiving the intravenous version.
fracture risk the same amount. Like alendronate,
risedronate works relatively quickly and helps to reduce Zoledronic acid (Reclast)
bone loss and fractures in men as well as women. Zoledronic acid (Reclast) is a bisphosphonate given as
a 15-minute infusion once a year for the treatment of
Ibandronate (Boniva) osteoporosis, or every other year for preventing bone
Ibandronate is approved for the prevention and treat- loss. When zoledronic acid earned FDA approval in
ment of postmenopausal osteoporosis. It is available in 2007, many women wondered whether they should
a daily or monthly tablet or as an injection every three switch over to it. Not only was this new drug more
months. Like the other bisphosphonates, ibandronate convenient for patients, but it also showed an impres-
increases bone mineral density and reduces the risk of sive ability to reduce fractures and boost bone density.
fractures of the spine in women with postmenopausal In a study published in The New England Journal of
osteoporosis. The side effects of ibandronate are simi- Medicine, women with osteoporosis received either an
lar to those of alendronate and risedronate, including annual infusion of zoledronic acid or a placebo. Over
heartburn, ulcers, irritation of the esophagus, and dif- three years, the drug reduced the risk of vertebral
ficulty swallowing. fractures by 70% and hip fractures by 41%. Women on
The quarterly intravenous injection of the drug also enjoyed higher bone mineral densities at
ibandronate is currently FDA-approved only for the the hip and spine.
treatment of postmenopausal osteoporosis. Because While these results are promising, some women
the medication bypasses the gastrointestinal tract, taking zoledronic acid may experience significant side
injected ibandronate doesn’t cause the heartburn effects, including fever, muscle and joint aches, and
and esophageal problems seen with the oral headache for several days after the infusion. The drug
bisphosphonates. However, the drug has been linked may also temporarily affect kidney function.
Strontium ranelate Currently, strontium ranelate isn’t available in
Strontium ranelate (Protelos) is a compound that the United States. And while it is sold in Europe, the
incorporates the element strontium, which is found European Medicines Agency has advised limiting
in trace amounts throughout the skeleton. Protelos is its use to people who haven’t been helped by other
believed to prevent fractures by both reducing bone medicines. Because of its potential for increasing
breakdown and increasing bone formation. Stud- the risk of serious heart problems, the drug is not
ies find it may be particularly effective in managing recommended for women with heart disease, a history
osteoporosis risk in women ages 75 and older. of blood clots, or high blood pressure.
How safe are bisphosphonates? A doctor weighs in

Media reports have fueled concerns about a connection between bisphosphonates and some troubling side ef-
fects, leading many women to ask their doctors whether they should continue taking these medications. To help
sort facts from unfounded fears, Dr. David Slovik, medical editor of this report and an endocrinologist at Massa-
chusetts General Hospital, answers some of the most common questions he hears from his patients.
Will Fosamax make my bones weaker? alendronate (Fosamax), risedronate (Actonel), and ibandronate
Dr. Slovik: There have been reports that (Boniva) for osteoporosis.
some women taking alendronate (Fosamax) It’s important to remember, though, that compared with
experienced unusual bone fractures or delays in the healing of the millions of women taking bisphosphonates, the number of
fractures. This led researchers to question whether the drug may osteonecrosis cases is tiny. According to one estimate, the risk
have weakened their bones. In these cases, it may be that the is between one in 10,000 and one in 100,000 per year. In bot-
bisphosphonate decreases bone turnover to such a degree that tom-line terms, that means for every 10,000 people who take a
the body is much slower in repairing microdamage that occurs bisphosphonate for a year, one may develop bone loss in the jaw.
naturally to bone. Still, I think it’s a good idea to have a dental exam and com-
Fractures may be related to dose and duration of treatment. The plete any necessary extractions or implants before you start tak-
longer you take the medicine and the higher the dose, the more ing a bisphosphonate. If you are already taking one, tell your
likely you are to experience an unusual fracture. Still, any possible dentist so she or he can consider it in planning your treatment.
connection between alendronate, or other bisphosphonates, and Also, be aware of the symptoms of osteonecrosis, which include
unusual bone fractures is unproven, and more study is needed. pain, swelling, or infection of the gums or jaw; gums that aren’t
However, that finding has to be balanced by the fact that even if healing; loose teeth; and numbness in the jaw.
alendronate is responsible, these events are extremely rare.
Someday we may be able to determine who is more likely to Is it true some osteoporosis drugs can cause atrial fibrillation?
suffer side effects from a particular drug. But in the meantime, Dr. Slovik: Atrial fibrillation is a common heart rhythm distur-
it’s important to keep in mind that more than two decades of bance that affects more than two million people. Considering the
research on alendronate and similar drugs has overwhelmingly millions of people who take bisphosphonates, it would be surpris-
concluded that bisphosphonates are highly effective at improving ing if there weren’t some overlap with this very common heart
bone density and reducing fractures. problem. Still, atrial fibrillation as an adverse event was noted
in the initial zoledronic acid Pivotal Fracture Trial in 2007, but it
Can bisphosphonates damage my jawbone? has not been seen in other trials of zoledronic acid (Reclast) or
Dr. Slovik: There has been concern about a connection between other bisphosphonates. These initial results prompted the FDA to
bisphosphonates and the death of bone tissue (osteonecrosis) in go back to data involving nearly 40,000 clinical trial participants
the jaw. While no clear cause-and-effect relationship has been who took one of these drugs or a placebo. Ultimately, officials
established, and scientists are unsure why some patients develop didn’t find a link between bisphosphonates and atrial fibrillation.
osteonecrosis of the jaw, there are good reasons to suspect Meanwhile, regardless of whether or not you take a bisphos-
bisphosphonates play a role. Just as with atypical fractures, the phonate, contact your doctor immediately if you experience any
dose and duration of use play a role in osteonecrosis risk. of the following symptoms: a racing heart, fluttering sensation in
Most of these cases of osteonecrosis—about 94%—have your chest, chest pain, or unexpected shortness of breath.
involved cancer patients receiving intravenous drugs such as
pamidronate (Aredia) and a type of zoledronic acid (Zometa) Do bisphosphonates put me at higher risk for breaking my
in doses much higher than are used for the treatment of osteo- thighbone?
porosis. But this side effect also has been reported, with much Dr. Slovik: The controversy over whether bisphosphonate use
lower frequency, in patients taking oral bisphosphonates such as is linked to thighbone (femoral) fractures dates back to around
SERMs In the body, SERMs attach to special proteins,
Bisphosphonates are not the only game in town. Bone called receptors, on the surfaces of cells, in the way
loss can also be treated with a class of drugs known a key would fit into a lock. When a natural estrogen
as selective estrogen receptor modulators (SERMs). molecule binds to such a receptor, it stimulates a
These are often called “designer estrogens”—or estro- response in the cell—and not always a good one. For
gen agonists/antagonists—because they mimic some of example, estrogen can stimulate the growth of certain
estrogen’s positive effects without also causing some of kinds of malignant tumors, including some breast,
the negative consequences (see “Hormones,” page 46). uterine, and ovarian cancers.
2007 or 2008 when reports started to emerge of an association After taking into consideration the combined results of these
between these unusual breaks without major trauma in women and other studies, a task force of the American Society for Bone
who had been taking alendronate for about five years. Since then, and Mineral Research in 2016 recommended that doctors re-evalu-
there have been other reports of so-called low-energy thighbone ate their patients after five years on oral bisphosphonates, or three
fractures in patients who had been on long-term bisphosphonate years on intravenous bisphosphonates. For some women—includ-
therapy. (Low-energy fractures occur from a fall from standing ing those who have a high fracture risk score, a low hip T-score, or
height or less.) Sometimes patients complain of achiness or pain a past fracture—it may be worth staying on the drug for longer (up
in their thighs or hips before the fracture occurs. to 10 years for oral bisphosphonates, and six years for intravenous
Some researchers speculate that continued suppression of bisphosphonates). Women who aren’t at such high risk may be
bone remodeling by alendronate and other bisphosphonates able to take a two- or three-year holiday after three to five years of
may have encouraged microdamage to the bone. In the short treatment, without suffering significant bone degeneration.
term, slowing bone resorption increases bone density because Whatever you do, don’t simply stop taking the drug without
new bone formation continues. But over time it may impair new first talking to your doctor. Although we know that bisphospho-
bone formation and reduce the bone’s ability to repair micro- nates stay in bone for years, we have little solid evidence to guide
scopic cracks from normal wear and tear. Ultimately bone may us in this area, so it’s not clear whether a drug holiday will lower
become more brittle and less resilient to wear and tear. But at the risk for long-term effects. If you do decide to stop the medica-
this point, the incidence of atypical femoral (thighbone) frac- tion, be sure to have your bone density tested after a year or two.
tures is very low, particularly in comparison with fractures of the If it has declined significantly, you can always resume therapy,
hip, spine, and other areas, and a causal relationship has not although when to do so is unclear and awaits further study.
been established. Can I safely take bisphosphonates after fracture surgery?
Should I consider taking a “drug holiday” from bisphos- Dr. Slovik: Bisphosphonates are known for their ability to
phonates? strengthen bones and reduce the risk of fractures. Yet there has
Dr. Slovik: This is a very popular question among patients. been some debate over whether it’s wise to take them shortly
Limited research on the subject has made recommendations chal- after you have surgery to repair a fractured bone. In years past,
lenging. Yet based on the available evidence, experts have offered experts raised concerns that these drugs might interfere with
some guidance on whether a drug holiday is a wise choice for bone remodeling and delay recovery. A 2015 review and meta-
postmenopausal women with osteoporosis. analysis of studies counters these concerns. The authors found
The first study to suggest that some women can eventually that taking bisphosphonates had no adverse effect on fracture
stop or take a drug holiday was the Fracture Intervention Trial healing. And, they said the ability of these drugs to reduce bone
Long-term Extension (FLEX) study, in which women who had resorption should lower the rate of fractures following surgery.
taken alendronate for at least five years were randomly assigned What’s your overall take on bisphosphonates?
to continue the drug or switch to a placebo for five more years. Dr. Slovik: In the years since bisphosphonate drugs first came on
Those who discontinued the drug showed a gradual decline in the market for the treatment of osteoporosis, millions of women
bone density, but at 10 years their bone density was still above and men have benefited from them. According to recent research,
baseline. They had a slight increase in the risk for clinical spine there’s been a decrease in hip fractures. That is likely due in large
fractures, but the rate of hip fracture, a far more serious injury, part to the use of bisphosphonates, along with our ability to
was the same in the two groups. diagnose and treat osteoporosis earlier. It’s clear to me that these
The HORIZON extension, which investigated the long-term medications play an important role in building bone strength and
safety and effectiveness of zoledronic acid in postmenopausal preventing fractures. And in my experience they are usually quite
women with osteoporosis, found that women who stuck with six safe. Major side effects are rare if they are taken properly, for the
yearly injections had fewer vertebral fractures than those who shortest time necessary to achieve the beneficial effect and with
switched to a placebo after three years. collaboration between the patient and physician.
But SERMs don’t fit the cell receptors quite as cancer. Raloxifene is also approved to reduce the risk
perfectly as natural estrogen molecules. That turns out of invasive breast cancer in women who have post-
to be good. It means that SERMs have different effects menopausal osteoporosis or who are at high risk of
in different parts of the body, depending on the type breast cancer.
of tissue—presumably because the estrogen receptors In clinical trials, raloxifene slowed bone loss
on these tissues are somewhat different. As a result, and reduced spinal fractures by 30% to 50%. And
SERMs have positive effects on building bone, but in a major clinical trial, the Multiple Outcomes of
without promoting cancer. Raloxifene Evaluation (MORE), raloxifene worked
as well as tamoxifen (Nolvadex) in reducing the risk
Raloxifene (Evista) of breast cancer in high-risk women, and apparently
Raloxifene is the only SERM currently approved for with fewer side effects.
preventing and treating osteoporosis, but others are The MORE study also suggested that raloxifene
in development. Like estrogen, raloxifene slows bone might protect some women from heart problems.
loss; unlike estrogen, it does not increase the risk for To explore this further, researchers launched the
uterine cancer, and it actually protects against breast Raloxifene Use for the Heart (RUTH) study. The
Table 6: Medications approved for osteoporosis

GENERIC NAME TYPE OF PRODUCT/
(BRAND NAME) FREQUENCY OF USE APPROVED USES BENEFITS SIDE EFFECTS/COMMENTS
Bisphosphonates
alendronate Daily tablet or Prevention and treatment of Increases bone density Difficult to digest. May cause
(Fosamax, Fosamax weekly liquid or osteoporosis in postmenopausal at the spine and hip. nausea, heartburn, or irritation of
Plus D) tablet. women. Treatment of Reduces the risk for the esophagus if not taken properly.
osteoporosis in men. Treatment spine and hip fractures. Generally well tolerated.
of glucocorticoid-induced
osteoporosis in men and women.
ibandronate Daily or monthly Prevention and treatment of Increases bone density. The oral versions can be difficult to
(Boniva) tablet, or quarterly osteoporosis in postmenopausal Reduces the risk for digest; may cause ulcers, nausea,
intravenous women (oral version). spine fractures. heartburn, or irritation of the
injection. Treatment of osteoporosis esophagus if not taken properly. The
in postmenopausal women intravenous preparation may cause
(intravenous version). fever and flu-like symptoms.
risedronate Daily, weekly, or Prevention and treatment of Increases bone density Difficult to digest. May cause
(Actonel, Atelvia) monthly tablet. osteoporosis in postmenopausal at the spine and hip. nausea, heartburn, or irritation of
women. Treatment of Reduces the risk for the esophagus if not taken properly.
osteoporosis in men. Treatment spine and nonvertebral Generally well tolerated.
of glucocorticoid-induced fractures.
zoledronic acid 15-minute infusion, Prevention and treatment of Increases bone density. May cause fever, flu-like symptoms,
(Reclast) given annually osteoporosis in postmenopausal Reduces the risk for muscle and joint aches, and
for treatment or women. Treatment of spine and hip fractures. headache for several days after the
every two years for osteoporosis in men. Treatment infusion. Kidney function may be
prevention. of glucocorticoid-induced transiently affected.
Monoclonal antibody
denosumab Subcutaneous Treatment of osteoporosis in Increases bone density. An increase in infections, especially
(Prolia) injection every six postmenopausal women and Reduces the risk for of the skin, has been reported.
months. men. spine and hip fractures.
continued on page 45
trial, involving some 10,000 women, did not find any Monoclonal antibodies
change—either an increase or decrease—in the risk Human antibodies, manufactured with genetically
of heart attacks or other heart problems with the use engineered cells, can strongly block the activity of
of raloxifene. But it found reason for caution. While osteoclasts. So far there is only one approved drug in
raloxifene did not increase the overall risk of stroke, this class.
women using the drug who did have a stroke were
more likely to die from it. Also, the risk of blood clots Denosumab (Prolia)
in the legs was higher. On the plus side, the women The FDA approved denosumab (Prolia) in 2010 for the
were much less likely to develop invasive breast cancer, treatment of osteoporosis in postmenopausal women
and were less likely to suffer a vertebral fracture. who are at high risk of fracture and later approved it
One lesson to take home from this research is that for treating osteoporosis in men. It is not approved for
raloxifene, like estrogen, has wide-ranging effects on prevention. It is taken every six months as a subcuta-
the body—some desirable, some not. If your doctor neous (under the skin) injection, like a flu shot.
recommends this drug to you, make sure you fully Denosumab is a human monoclonal antibody
understand the risks and benefits. that acts to reduce the formation and action of
Table 6 continued
GENERIC NAME TYPE OF PRODUCT/
(BRAND NAME) FREQUENCY OF USE APPROVED USES BENEFITS SIDE EFFECTS/COMMENTS
Selective estrogen receptor modulator (SERM)

raloxifene Daily tablet. Prevention and treatment of Increases bone density, Side effects are uncommon, but
(Evista) osteoporosis in postmenopausal although not as much can include hot flashes, leg cramps,
women. as the bisphosphonates. and blood clots.
Reduces the risk for
spine fractures. Reduces
risk for invasive breast
cancer. Lowers LDL (bad)
cholesterol.
Hormones
calcitonin Injection, given Treatment of postmenopausal Increases bone density, Long-term safety is under evaluation.
(Calcimar, Fortical, daily or every other osteoporosis. but not as dramatically In the short term, the injected form
Miacalcin) day. Daily nasal as any of the other can cause flushing of the face and
spray. approved medications. hands, nausea, increased urination,
Reduces the risk for and rash. The nasal spray can cause a
spine fractures. runny nose.
estrogen Tablets and Prevention of osteoporosis in Increases bone density. Estrogen alone increases the risk for
(Activella, Climara, patches. women. Reduces the risk for stroke and uterine cancer. Prempro,
Estrace, Estraderm, fractures. Helps alleviate an estrogen-plus-progestin formula,
Estratab, FemHRT, the symptoms of increases the risk for heart attack,
Ogen, Premarin, menopause, including stroke, blood clots, and breast
Premphase, Prempro, hot flashes, vaginal cancer; other estrogen-plus-progestin
Vivelle-Dot, others) dryness, and insomnia. formulas have not been studied as
Improves cholesterol extensively, so it is unclear if they
levels. carry the same risks.
teriparatide Daily injection. Treatment of osteoporosis in May double the rate of Must be taken as an injection.
(Forteo)—synthetic men and postmenopausal bone formation. Reduces Because effects appear to wane and
parathyroid hormone, women. Treatment of the risk for spine and long-term safety data are lacking,
or PTH glucocorticoid-induced nonvertebral fractures. should not be prescribed for more
osteoporosis in men and women. than two years.
osteoclasts, the cells that break down bone. In clinical taking a combination of estrogen and progestin were
trials, denosumab reduced bone resorption, increased found to be at higher risk of breast cancer, heart dis-
bone density, and reduced fractures in both men and ease, stroke, and blood clots in the veins and lungs.
women. It represents a new option for people who Critics of this study say the risks were exaggerated.
have trouble taking oral bisphosphonates or other They point out that only one hormone preparation was
standard drugs. used in each arm of the trial and that other formulas
may not carry the same risks or benefits. Others
note that the women who suffered the most health
Hormones problems in the study began taking the hormones in
Naturally occurring hormones can have important their 60s and 70s, long after the start of menopause.
effects on bone. So can synthetic ones. Nevertheless, the North American Menopause
Society and other authorities recommend taking
Estrogen products (Premarin, Estrace, others) the smallest effective dose of hormones for the
Many women use hormones in the years leading up to shortest period of time—and only if you have no
and following menopause to ease hot flashes, insom- contraindications (reasons not to take it), such as a
nia, and vaginal dryness. At one time hormone ther- history of breast cancer. Since by definition, taking
apy was also widely prescribed to reduce menopausal hormones to preserve bone involves long-term use
bone loss. Its use for this purpose has fallen sharply, of the therapy, most doctors no longer prescribe
however, since the Women’s Health Initiative—the hormone therapy just for preventing osteoporosis—
only large, long-term randomized controlled trial of especially since other drugs can effectively prevent
hormone therapy—was halted in 2002, after women and treat the problem.
New osteoporosis drugs in the pipeline
A s osteoblasts (bone-building cells) and osteoclasts (bone-

removing cells) go about their work keeping your bones
healthy, they use a variety of biochemical signals to “talk” to
mineral density in the lumbar spine and total hip compared
with placebo among postmenopausal women. Odanacatib
and several other cathepsin K inhibitors have been studied in
each other. Tweaking the activity of these messengers with clinical trials. However, none has come to market yet, in part
medicine is one way to intervene if the process gets out of because safety issues are still being evaluated.
balance, and you start losing more bone than you gain. An- Human parathyroid hormone–related protein (hPTHrP).
other way is to block the bone-dissolving enzymes that help Drugs like bisphosphonates, which decrease bone resorption,
break down old bone. significantly reduce fracture risk, but they can’t stimulate
Sclerostin. This protein is under development as a target for new bone formation. Anabolic (bone-building) agents such
bone-loss drugs. Bone cells produce sclerostin as a message as the parathyroid hormone teriparatide (Forteo) offer the
to tell the osteoblasts to slow down. By blocking this chemi- advantage of stimulating osteoblasts to trigger new bone
cal conversation, drugs could trick the body into continuing formation. A new analog of human parathyroid hormone-
to make new bone. A monoclonal antibody designed to bind related protein (hPTHrP) is being studied for the treatment of
to and block sclerostin is currently being tested. postmenopausal osteoporosis. In one recent study, abalo-
paratide, an hPTHrP drug under investigation, increased bone
Cathepsin K inhibitors. Cathepsin K is an enzyme pro-
density in the lumbar spine, total hip, and femoral neck even
duced by osteoclasts that helps break down the structure of
better than Forteo.
bone, releasing the minerals stored within. Drugs that block
cathepsin K’s bone-dissolving activity could help reduce New drug delivery methods
bone loss. A new medication, odanacatib, is in advanced For women who rely on the bone-protective abilities of drugs
clinical trials. A 2015 study of this drug was stopped early, like the bisphosphonates but dread the needle or multiple
after researchers found evidence of “robust efficacy and a pill instructions, researchers are developing other ways to
favorable benefit/risk profile.” The treatment significantly simplify drug delivery, such as a patch that would deliver
reduced vertebral and hip fractures and increased bone osteoporosis drugs through the skin.
That said, if you do choose hormone therapy to And it can increase bone mass dramatically. One
combat menopausal symptoms, you can expect a boost study found that teriparatide was more effective than
to bone health, since hormone therapy both increases alendronate in increasing bone mineral density and
bone strength and reduces the risk of fracture in the decreasing fractures in postmenopausal women with
spine and hip—at least during the time you’re using it. osteoporosis. Teriparatide appears to reduce vertebral
Unfortunately, as soon as you stop taking hormones, fractures by 65% to 70% and to reduce nonvertebral
the bone benefit begins to fade, with bone mineral fractures by about 50%.
density dropping back to baseline within a year or two. Because teriparatide builds bone while bisphos-
phonates reduce bone resorption, doctors have
Teriparatide (Forteo) wondered if giving both drugs—at the same time or
The FDA has approved teriparatide (Forteo), a syn- sequentially—would have a greater effect than either
thetic version of parathyroid hormone, for the treat- alone. Clinical trials on the subject are ongoing.
ment—but not prevention—of osteoporosis in both Teriparatide is recommended for people who
men and postmenopausal women and for the treat- have osteoporosis and are at high risk for a fracture.
ment of glucocorticoid-induced osteoporosis. This includes people who have already suffered a
Parathyroid hormone is produced naturally in nontraumatic fracture of the spine, hip, or another
the body and works in several ways to increase the major bone, as well as people with multiple risk factors
amount of calcium in circulation. It promotes calcium for fractures (such as a family history of osteoporosis,
absorption in the intestines and slows its excretion poor calcium intake, and a T-score of less than –2.5).
by the kidneys. While too much of the hormone The drug is available only as a once-a-day injection,
accelerates bone loss, low doses given intermittently and it is recommended that treatment be limited to no
can increase bone mass and strengthen bone (see more than two years. Some experts recommend using
Figure 10, below). teriparatide alone for two years and then switching
Unlike medications that slow the rate of bone loss, to a bisphosphonate or other antiresorptive agent to
teriparatide actually helps build new bone by increasing protect or augment any gains in bone density.
the activity and number of bone-building osteoblasts. Side effects can include nausea, dizziness, and leg
cramps. Studies in rats have found an increased risk of
bone cancer, but at much higher doses than are used
Figure 10: Parathyroid hormone and bone in people. Teriparatide has been around for more than
A B a decade, and to date, no studies have shown that it
increases bone cancer risk in humans.
Calcitonin (Miacalcin, Fortical, others)

Calcitonin (Miacalcin, Fortical, others) is approved
only for the treatment, not the prevention, of osteopo-
rosis. This hormone is produced by the thyroid gland,
but its physiologic role in humans is not established.
Salmon is the most common source of calcitonin used
in medications. When administered—as either an
These scanning electron microscopy pictures show bone biopsies injection or a nasal spray—it inhibits bone resorption
taken from a 64-year-old woman, before (A) and after (B) para- by osteoclasts.
thyroid hormone treatment. Improvements can be seen in interior
Although calcitonin has been tested in a large
structure (microarchitecture) and outer (cortical) thickness.
number of clinical trials and has been used to treat
Reproduced from Dempster DW, et al. Journal of Bone and Mineral Research (Oct.
2001), Vol. 16, No. 10, pp. 1846–53, with permission of the American Society for
women with bone loss for many years, it doesn’t build
Bone and Mineral Research. bone as robustly as other medications. Women who
take it usually see a slowing of bone loss or just a slight taking the drug. The data were not specific enough
increase in bone mass. It reduces the risk for spinal to single out particular types of cancer. But in 2012,
fractures but hasn’t been shown to lessen the risk for the European Medicines Agency recommended that
other kinds of fractures. There also is some evidence calcitonin not be used to treat osteoporosis because
that calcitonin has painkilling properties. of the overall increase in risk. Canada’s health agency
People who take calcitonin by injection generally took calcitonin nasal spray off the market in 2013.
experience more side effects than do those who use After reviewing the drug’s safety, however, the FDA
the nasal spray version. Side effects include flushing found insufficient evidence to justify pulling calcitonin
in the face and hands, dizziness, nausea, rash, and from the U.S. market. Instead, it recommends that
increased urination. The spray formulation can cause calcitonin be used only in cases where people can’t
nasal symptoms, including a runny nose or nasal tolerate or don’t want to take other osteoporosis drugs.
crusts and irritation. If you’re considering this treatment, weigh its
In addition to these minor side effects, a few potential side effects carefully when making your
studies found slightly higher cancer risks in people decision.
Coping with fractures
B reaking a bone is often painful and frighten-

ing. Recovery can take months, and a break can
threaten your ability to perform simple everyday tasks
Living with vertebral fractures
Spinal fractures, which often take two to four months
to heal, can be very painful. The most common way to
such as carrying groceries, making your own meals, or treat pain is with over-the-counter medications such
cleaning. But there is a lot you can do to recover from as aspirin, acetaminophen (Tylenol), ibuprofen (Advil,
a fracture and prevent future breaks. The first step may Motrin), or naproxen (Aleve, Naprosyn). Sometimes
be as simple as reaching out for help. Physical thera- doctors prescribe stronger medications for pain, such
pists, occupational therapists, and support groups can as short-term narcotics. But be careful, as these medi-
assist you. In addition, this section offers more infor- cations may cause drowsiness, confusion, and a drop
mation on how to mend your bones. in blood pressure—all of which increase your chances
Meanwhile, getting enough calcium and vitamin of falling.
D, performing weight-bearing exercises regularly, Another staple of treatment is bed rest, although
taking steps to prevent falls, and using an osteoporosis it should be short-term because prolonged inactivity
medication can help guard your bones against future can lead to further bone loss. Your doctor may also
fractures. recommend that you use ice or heat packs to ease
Easing the strain with a cane

For something so low-tech and simple in design, a cane Standard canes. These
performs complex functions. You hold the cane in the hand are low-tech, lightweight,
opposite the side that needs support, about four inches to and generally inexpen-
the side of your stronger leg. This redistributes weight to sive. They usually come
improve stability, helps reduce demand on muscles that may with a curved or T-shaped
be weak, and takes the load off weight-bearing structures handle and a rubber-
such as the hip, knee, and spine. capped tip at the bottom.
Many people find that
A cane can help you maintain mobility and ward off further
a T-shaped handle is
disability if you have one or more fractures, as well as assist more comfortable than
in recovery after surgery. So don’t let self-consciousness stop a curved one. A standard
you from using a cane if your doctor recommends that you Standard Offset Quad
model is good for people cane cane cane
try one. who need help with bal-
A physical therapist or other clinician can help you select a ance but don’t need the cane to bear a lot of weight.
cane, check that it’s the proper height, and show you how to Offset canes. The upper shaft of an offset cane bends
use it. He or she may also suggest certain muscle-strength- outward, and the handle grip is usually flat—often a good
ening exercises before you start walking with your cane. choice for people whose hands are weak or who need a cane
Canes are available at medical supply stores and pharma- that bears more weight than the standard type.
cies, through specialty catalogs, and on the Internet. They Quad canes. Multiple legs offer considerable support and
generally come in standard, offset, and multiple-legged allow the cane to stand on its own when not in use. One
versions. Government or private insurance usually covers the drawback to using such a cane is that for maximum support,
cost of a basic cane if you have a written prescription from you must plant all the legs solidly on the ground. Doing so
your doctor. takes time and can slow the pace of walking.
pain. Massage, acupuncture, biofeedback, and the use kyphoplasty (see below)—that may reduce your pain,
of a lumbar corset or back brace may also help for though both have potential side effects.
certain fractures. However you ultimately treat the pain, you
If these interventions do not help (or help enough), will also likely find it useful to make some lifestyle
there are two surgical procedures—vertebroplasty and adjustments. You may want to enlist your physical
Vertebroplasty and kyphoplasty
T wo procedures are available to stabilize compressed vertebrae, alleviate the

pain associated with this type of fracture, and improve daily functioning:
vertebroplasty and kyphoplasty. These interventions are geared toward patients
occur. In addition, there is an increased
fracture risk in the vertebrae adjacent
to the one treated. The FDA has also
who haven’t responded to traditional measures such as bed rest and pain medica- warned that soft tissue damage, nerve
tions. In addition, kyphoplasty may restore some of the height lost when a cracked root pain and compression, pulmonary
vertebra gets compressed, or at least prevent it from getting worse. embolism (blood clot in the lung), and
respiratory and cardiac failure have
Vertebroplasty is an outpatient and improve function compared with
been reported among some patients un-
procedure that takes less than an hour. lifestyle changes and pain medications.
dergoing vertebroplasty or kyphoplasty.
After the patient is given mild sedation, However, a lack of good comparative
the physician inserts a needle into the studies makes it hard to definitively Given the uncertainties, it’s important
affected vertebra, using an x-ray as a determine which therapy is preferable. to find a physician who is experienced
guide. Then bone cement is injected with the procedure and is willing to
Although uncommon, the potential
into the compressed vertebra, filling the engage in a frank conversation about
complications of vertebroplasty and
holes and crevices. The cement hardens the risks. You may want to ask your doc-
kyphoplasty include bleeding, infection,
in about 15 to 20 minutes, stabilizing tor what type of cement will be used,
and nerve damage. Occasionally bone
the vertebra, creating a support that whether it is currently FDA-approved
cement leaks from the treated area.
helps prevent any further collapse, and for the procedure, and what experience
If the cement enters the bloodstream
(ideally) alleviating pain. your doctor has had with the product
or spinal canal, serious problems can
and the procedure in general.
Kyphoplasty (see Figure 11, at right)
is a refinement of vertebroplasty. Like
vertebroplasty, this procedure is aimed Figure 11: Repairing a compressed vertebra
at stabilizing compressed vertebrae and
relieving pain. Also like vertebroplasty,
kyphoplasty takes less than an hour,
although it may require an overnight
hospital stay. In this procedure, the
physician administers a mild sedative
and then inserts a small tube-like instru-
ment into the affected vertebra, using a
special viewing device called a fluoro-
scope as a guide. Once the instrument
is correctly placed, a balloon is inflated,
creating a cavity in the bone. The bal-
loon is then deflated, and the physician
injects surgical cement into the void. A B
The creation of this hollow minimizes
the risk of the cement leaking and
pushes the vertebral endplates apart, Kyphoplasty treats the pain associated with vertebral compressions.
restoring some height. This technique restores some of the height of the treated vertebra.
Do these approaches work? Reviews First, a tube is inserted into the vertebra (A). Then a balloon at the end is inflated
of studies suggest that both vertebro- and deflated, leaving a hollow in the bone (B). Finally, surgical cement is injected
plasty and kyphoplasty reduce pain into the cavity, shoring up the vertebral endplates.
therapist’s help in selecting a cane or walker, if you Living with a hip fracture
need one. He or she can assess your needs and help After a hip fracture, proper rehabilitation can make
you choose the one that best suits your purpose (see the difference between returning to active life and
“Easing the strain with a cane,” page 49). requiring long-term care. If the hip fracture doesn’t
Exercise regularly, too. Talk with your orthopedist heal properly, you may become limited in your ability
or the physician overseeing your care about what to walk and function in an independent manner. Both
exercises are safe for you at each stage of recovery. physical and occupational therapy can be very helpful.
Ultimately, your routine should include weight- Physical therapists can teach you exercises to
bearing exercise, which can build bone, and balance strengthen your hips, improve your coordination
and flexibility exercises, which can make future falls and balance, and increase your flexibility. A home
less likely. visit with a physical therapist may help you transition
You may find that you also need to make a few from a hospital or rehab facility to a suitable at-home
practical changes around your house that will make exercise program that can get you up and moving
it easier for you to maintain your self-sufficiency. An again and help condition your body to reduce the
occupational therapist can give you expert advice. risk of falling. The therapist can also teach you safety
For example, if you can’t reach the top shelves of measures that will lessen the likelihood of injuring
cabinets any longer, he or she can suggest a number yourself and improve your day-to-day functioning.
of solutions, from tools to help you grasp objects to You should also schedule a home visit with an
ways of reorganizing your kitchen. An assistive device occupational therapist to eliminate potential hazards
called a “dressing stick” can help people with limited in your home—such as electrical cords and loose rugs
mobility to put on and remove clothing without in pathways, poor lighting, or a lack of handrails or
bending too much. grab bars. Also, talk to your doctor about other factors
Finding clothing that fits correctly may also that can lead to falls, such as alcohol consumption or
become a concern as your body changes. If you have the use of certain medications.
had several vertebral fractures, you may notice that
your ribcage has moved closer to your hip bones. As
a result, many women find that their garments don’t Support groups
fit at the waist, while a large size is too baggy in other Osteoporosis doesn’t affect only your bones. It can
places. Some women solve this problem by buying leave you feeling depressed, isolated, anxious, or
maternity clothes. The elastic panels in slacks and afraid. You may worry about breaking a bone or losing
skirts are roomy in the front without giving too much your independence. Or perhaps you’re overwhelmed
in the back, and the loose-fitting tops are well suited by pain or upset by changes in your appearance.
for accommodating spinal changes. Maybe you are discouraged because you are no longer
Low-heeled, comfortable shoes that offer adequate able to perform certain activities.
support are also essential. There are many styles of A support group may help you cope with these
“walking shoes” that fill the bill. If you have difficulty feelings and move ahead with your recovery. Talk
finding shoes that fit properly, you may want to have to your doctor about finding a program, or check
orthotic devices—supportive insoles that affect the with your insurer, local hospital, or the National
distribution of weight—fitted by a podiatrist. Osteoporosis Foundation (see “Resources,” page 52).
Resources
Organizations a quarterly newsletter, The Osteoporosis Report, which reviews
the latest scientific information. You can order materials online, by
American Academy of Orthopaedic Surgeons mail, or by telephone.
9400 W. Higgins Road
Rosemont, IL 60018 Osteoporosis and Related Bone Diseases National
847-823-7186 Resource Center
www.aaos.org National Institutes of Health
This medical association for orthopedic surgeons offers 2 AMS Circle
information on osteoporosis for laypeople. The website features Bethesda, MD 20892
fact sheets on such topics as keeping your bones healthy, 800-624-2663 (toll-free)
recognizing the warning signs of osteoporosis, and preventing hip TTY: 202-466-4315
fractures. www.osteo.org
This information center is dedicated to increasing awareness
National Center for Injury Prevention and Control of osteoporosis, Paget’s disease of the bone, osteogenesis
Centers for Disease Control and Prevention imperfecta, and hyperparathyroidism. The center was created
1600 Clifton Road to provide health professionals and the general public with
Atlanta, GA 30329 information about these conditions and their treatment, as
800-232-4636 (toll-free) well as links to other resources. You’ll find fact sheets, general
TTY: 888-232-6348 (toll-free) information, and news about osteoporosis on the website, where
www.cdc.gov/injury you can also sign up to receive the center’s electronic newsletter.
This arm of the Centers for Disease Control and Prevention
focuses on reducing accidents and their resulting injuries and
deaths. The division supports fall-prevention programs, and its Special Health Reports
website includes fall-prevention fact sheets and tips and an
Better Balance: Easy exercises to improve stability and
online fall-prevention tool kit for seniors.
prevent falls
National Institute on Aging Suzanne Salamon, M.D., and Brad Manor, Ph.D., Medical Editors
Building 31, Room 5C27 Josie Gardiner and Joy Prouty, Master Trainers
31 Center Drive, MSC 2292 (Harvard Medical School, 2014)
Bethesda, MD 20892 If you have osteoporosis, it’s important to avoid falls. This
800-222-2225 (toll-free) Harvard Special Health Report helps you learn how to do that by
TTY: 800-222-4225 (toll-free) improving your balance and mobility, with safe, effective balance
www.nia.nih.gov exercises that also increase flexibility, sharpen reflexes, increase
This branch of the National Institutes of Health offers reliable, muscle strength and speed, and firm your core. Order online at
free information on osteoporosis for physicians and consumers. www.health.harvard.edu or by calling 877-649-9457 (toll-free).
Publications are available on the website, or you can order them
by mail or telephone. Strength and Power Training: A guide for older adults
Elizabeth Pegg Frates, M.D., with Michele Stanten, Fitness
National Osteoporosis Foundation Consultant
251 18th St. S., Suite 630 (Harvard Medical School, 2015)
Arlington, VA 22202 Strength training can help prevent bone loss. It can also protect
800-231-4222 (toll-free) vitality, make everyday tasks more manageable, and help you
www.nof.org maintain a healthy weight. This Harvard Special Health Report
This nonprofit organization supports research on osteoporosis includes two complete workouts, plus stretches and suggestions
and develops educational programs and materials. Much of its for varying your routine. Order online at www.health.harvard.edu
material is also available in Spanish. Membership benefits include or by calling 877-649-9457 (toll-free).
Glossary
bisphosphonates: A class of compounds that slow bone resorp- osteoblasts: Bone-forming cells.
tion. These medications are used to prevent and treat osteoporosis.
osteoclasts: Bone-removing cells.
bone mass: The total amount of bone tissue in the body.
osteocytes: Osteoblasts that have completed their bone-forming
bone density (bone mineral density): The amount of mineral- function and have become trapped in new bone tissue, evolving
ized bone tissue in a given area, usually calculated in grams per into structural bone cells.
square centimeter.
osteons: The basic units of compact bone, each consisting of
calcium: A mineral that is the primary component of hydroxyapa- tightly packed concentric rings of tissue with a blood vessel run-
tite in bone. It is also vital to many physical processes, including ning through the central channel.
heart rate, blood pressure, muscle contractions, the transmission of
parathyroid hormone (PTH): A hormone that regulates calcium
nerve signals, and the regulation of internal organs.
levels. It prevents the level of blood calcium from going too low by
compact bone: Very dense bone tissue that forms the outer shell stimulating the breakdown of bone. In addition to triggering bone
of bones and constitutes a large part of the long bones of the loss, it can stimulate bone formation. Given appropriately, it can
arms, legs, and ribs. Also called cortical bone. increase bone mass, and a synthetic form is used as a treatment
for osteoporosis.
compression fracture: The collapse of a bone, most often a
vertebra. peak bone mass: The greatest amount of bone tissue that a
person has during his or her life; typically reached by age 30.
dorsal kyphosis: An abnormal front-to-back curvature of the
mid-to-upper spine that can result from compression fractures of primary osteoporosis: Bone loss that doesn’t result from an
vertebrae. Sometimes called dowager’s hump. identifiable pathological process.
dual energy x-ray absorptiometry (DEXA or DXA): A test in remodeling: The body’s mechanism for systematically removing
which x-rays are used to measure bone density and produce an old bone tissue and replacing it with new bone to preserve the
image of the bone; the preferred screening test for osteoporosis. strength of the skeleton.
femoral neck: The fracture-prone top portion of the femur, or resorption: The removal of bone tissue—both protein and miner-
thighbone, just below the hip joint. als—by osteoclasts.
glucocorticoids: A class of hormones produced by the adrenal secondary osteoporosis: Bone loss associated with an identifi-
gland and simulated by medications such as prednisone. These able medical condition or treatment with certain drugs.
medications can contribute to osteoporosis.
total hip: A term used in bone scanning to refer to a specific area
hormone therapy: Augmentation of a woman’s depleted in the hip, near the hip joint.
hormones with estrogen alone or a combination of estrogen and
trabecular bone: Bone tissue arranged in a meshwork of thin
progestin or progesterone; sometimes used to reduce osteoporosis plates or beams that is commonly found at the center of long
risk in postmenopausal women. bones and that constitutes a large part of the hip and vertebrae.
hydroxyapatite: The mature, hard, somewhat crystalline mineral Also called cancellous bone or spongy bone.
compounds in bone tissue. vertebral fracture assessment: A scan of the spine to look
hyperparathyroidism: A condition in which the body produces for deformities in the vertebrae. These deformities may indicate
excessive amounts of parathyroid hormone, disrupting the regu- fractures.
lation of calcium. As a result, calcium is taken from the bones, vitamin D: A hormone that plays a key role in ensuring the
blood levels of calcium rise, and increased amounts of calcium absorption of calcium from the intestines.
may be excreted in urine.
Receive HEALTHbeat, Harvard Health Other publications from Harvard Medical School
Publications’ free email newsletter Special Health Reports Harvard Medical School publishes in-depth reports on
a wide range of health topics, including:
Go to: www.health.harvard.edu to subscribe to HEALTHbeat.
Addiction Exercise Your Joints Positive Psychology
This free weekly email newsletter brings you health tips, advice,
Allergies Eye Disease Prostate Disease
and information on a wide range of topics.
Advance Care Planning Foot Care Reducing Sugar & Salt
You can also join in discussion with experts from Harvard Health Aging Successfully Grief & Loss Rheumatoid Arthritis
Publications and folks like you on a variety of health topics, Alzheimer’s Disease Hands Sensitive Gut
medical news, and views by reading the Harvard Health Blog Anxiety & Stress Disorders Headache Sexuality
(www.health.harvard.edu/blog). Back Pain Hearing Loss Six-Week Eating Plan
Balance Heart Disease Skin Care
Caregivers Heart Disease & Diet Sleep
Order this report and other publications Change Made Easy High Blood Pressure Strength Training
from Harvard Medical School Cholesterol Incontinence Stress Management
COPD Knees & Hips Stretching
online | www.health.harvard.edu
Core Workout Living Longer Stroke
phone | 877-649-9457 (toll-free) Gentle Core Workout Memory Thyroid Disease
mail |
Belvoir Media Group Depression Men’s Health Vitamins & Minerals
Attn: Harvard Health Publications Diabetes Neck Pain Walking for Health
P.O. Box 5656 Diabetes & Diet Nutrition Weight Loss
Norwalk, CT 06856-5656 Energy/Fatigue Osteoarthritis Women’s Health
Erectile Dysfunction Osteoporosis Workout Workbook
Licensing, bulk rates, or corporate sales Exercise Pain Relief Yoga
phone | 203-828-0349
Periodicals Monthly newsletters and annual publications, including:
email | HHP_licensing@hms.harvard.edu
Harvard Health Letter Harvard Heart Letter Prostate Disease Annual
online | www.harvardhealthcontent.com Harvard Women’s Health Watch Harvard Men’s Health Watch
ISBN 978-1-61401-124-8 OS0716

SW75000

Osteoporosis A Guide To Prevention and Treatment Harvard Health

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Osteoporosis A Guide To Prevention and Treatment Harvard Health

Hochgeladen von

Copyright:

Verfügbare Formate

A HARVARD MEDICAL SCHOOL

SPECIAL HEALTH REPORT

David M. Slovik, M.D.

Y our bones are surprisingly strong. Ounce for

Two types of bone tissue

2 Osteoporosis  w w w.h ealt h .ha r va r d.e du

The life cycle of bone

4 Osteoporosis  w w w.h ealt h .ha r va r d.e du

Menopause weaken bones. Other drugs that

W hile a certain amount of bone loss is normal, not

© Jacob Ammentorp Lund | Thinkstock

6 Osteoporosis  w w w.h ealt h .ha r va r d.e du

Medical conditions and medications that can lead to bone loss

8 Osteoporosis  w w w.h ealt h .ha r va r d.e du

C ertain factors make you more vulnerable to devel-

10 Osteoporosis  w w w.h ealt h .ha r va r d.e du

12 Osteoporosis  w w w.h ealt h .ha r va r d.e du

O steoporosis was once known as a silent disease

a break occurred without due cause, perhaps triggered

14 Osteoporosis  w w w.h ealt h .ha r va r d.e du

Figure 8: A look at normal and compressed Wrist fractures

I n the past, osteoporosis was frequently diagnosed

hip joint), and femoral neck (the top of the thighbone,

this with only one-tenth of the radiation exposure of a

16 Osteoporosis  w w w.h ealt h .ha r va r d.e du

W hile bone mineral density tests can identify people who

18 Osteoporosis  w w w.h ealt h .ha r va r d.e du

I f you’ve been diagnosed with osteopenia or osteo-

If you have osteopenia

According to your T-score, your bone density is

If your bone density is normal If you are 65 or older

20 Osteoporosis  w w w.h ealt h .ha r va r d.e du

A nutritious diet is just as important in later life as it

71 and older 1,200 mg 800 IU

Calcium and vitamin D Source: Institute of Medicine.

Calcium and vitamin D have long been recognized

F or several years, evidence has sug-

© Donna Beeler | Shutterstock.com

22 Osteoporosis  w w w.h ealt h .ha r va r d.e du

Table 2: Calcium-containing foods

24 Osteoporosis  w w w.h ealt h .ha r va r d.e du

Citracal Calcium + D3 Petites Calcium citrate 400 mg 2 caplets 14 cents

Citracal Plus Magnesium Calcium citrate 500 mg 2 tablets 11 cents

Tums Ultra Calcium carbonate 800 mg 2 chewable tablets 12–15 cents

26 Osteoporosis  w w w.h ealt h .ha r va r d.e du

Beef liver, cooked 3 ounces 42

28 Osteoporosis  w w w.h ealt h .ha r va r d.e du

E xercise plays a dual role in fighting the effects of

30 Osteoporosis  w w w.h ealt h .ha r va r d.e du

Tai chi improves balance, muscle strength, and flexibility

32 Osteoporosis  w w w.h ealt h .ha r va r d.e du

Strength training and balance

34 Osteoporosis www.health.har vard.edu

Strength training exercises

1 Standing calf raise

www.health.har vard.edu Osteoporosis 35

36 Osteoporosis www.health.har vard.edu

7 Overhead 8 Side leg raise

9 Double biceps curl 10 Forward fly

www.health.har vard.edu Osteoporosis 37

1 Thigh raise 2 Tree pose (not shown)

3 Reverse lunge (not shown) 4 Heel-to-toe walk (not shown)

38 Osteoporosis www.health.har vard.edu

2 Osteoporosis w w w.h ealt h .ha r va r d.e du

4 Osteoporosis w w w.h ealt h .ha r va r d.e du

6 Osteoporosis w w w.h ealt h .ha r va r d.e du

8 Osteoporosis w w w.h ealt h .ha r va r d.e du

10 Osteoporosis w w w.h ealt h .ha r va r d.e du

12 Osteoporosis w w w.h ealt h .ha r va r d.e du

14 Osteoporosis w w w.h ealt h .ha r va r d.e du

Figure 8: A look at normal and compressed Wrist fractures

16 Osteoporosis w w w.h ealt h .ha r va r d.e du

18 Osteoporosis w w w.h ealt h .ha r va r d.e du

20 Osteoporosis w w w.h ealt h .ha r va r d.e du

22 Osteoporosis w w w.h ealt h .ha r va r d.e du

24 Osteoporosis w w w.h ealt h .ha r va r d.e du

26 Osteoporosis w w w.h ealt h .ha r va r d.e du

28 Osteoporosis w w w.h ealt h .ha r va r d.e du

30 Osteoporosis w w w.h ealt h .ha r va r d.e du

32 Osteoporosis w w w.h ealt h .ha r va r d.e du

34 Osteoporosis www.health.har vard.edu

www.health.har vard.edu Osteoporosis 35

36 Osteoporosis www.health.har vard.edu

www.health.har vard.edu Osteoporosis 37

38 Osteoporosis www.health.har vard.edu

40 Osteoporosis w w w.h ealt h .ha r va r d.e du

42 Osteoporosis w w w.h ealt h .ha r va r d.e du

46 Osteoporosis w w w.h ealt h .ha r va r d.e du

48 Osteoporosis w w w.h ealt h .ha r va r d.e du

50 Osteoporosis w w w.h ealt h .ha r va r d.e du

52 Osteoporosis w w w.h ealt h .ha r va r d.e du