Very few women (and most men for that matter) worry about the state of their bones until one day a simple slip causes a broken hip and months of recuperation and physical therapy. Or when their dentist tells them that they are about to lose their teeth because the bony part of their jaw has receded. Or when their vertebrae start to crumble like old chalk, leaving them shorter, hump-backed, and in constant severe pain.
The winter months in the north are an especially worrisome time for people at risk for osteoporosis. Our skin produces less vitamin D (if any), we hurry along and risk falling on wet leaves or icy pavements, we exercise less because we stay indoors for longer times, and we suffer more from depression secondary to reduced sunlight. New research shows that being depressed increases the risk of osteoporosis and low bone mass – perhaps because of a link between chronic stress, depression and cortisol. Excessive cortisol, whether from chronic stress or prescription steroids, is an important risk factor for osteoporosis.
If anyone you know is at risk of osteoporosis or a hip fracture – help them size up their daily routine, their medications and test results and encourage them to talk to their doctor about getting a bone density scan. What greater gift could you give a loved one than the gift of prevention!!
A new study this week in JAMA reported on a computer program that may be able to predict your risk of hip fracture, the most deadly and feared complication of osteoporosis. Researchers at University of California Davis studied more than 100,000 postmenopausal women from the Women’s Health Initiative Study to see what factors increased the risk of having a hip fracture during the next five years. Here is what they found.
The following factors predicted risk the best:
1) Age: Older age is the greatest risk factor.
2) Race: Caucasian women are at greater risk, Asians have next highest risk.
3) Body Weight and Height: Thinner women and taller women have higher risk.
4) Lifestyle choices: Women who smoke and women who are not physically active.
5) Medical Condition: Women who have diabetes (especially if treated with blood sugar medications) have greater risk.
6) Medications: Women who take prescriptions steroids (e.g. prednisone, medrol).
7) Attitude: Although the first 6 factors are very important, a woman’s perception of how good her health was also a critical factor!!!
To determine your risk of hip fracture (postmenopausal women only were studied) over the next five years, click here for the Women’s Health Initiative (WHI) Hip Fracture Risk Calculator.
Prevention through a healthy lifestyle however is ALWAYS important – so I thought I would share with you some of my thoughts about preventing and diagnosing osteoporosis. I spend an entire chapter in my book, The Body Shape Solution to Weight Loss and Wellness discussing this important topic.
What you need to know
All postmenopausal women by age 65 and many elderly men should have a special bone density test called a dual-energy x-ray absorptiometry (DXA or DEXA). This simple, painless scan, which takes between 10 and 30 minutes, uses low-dose x-rays to measure bone density. The result is given in the form of two scores and can also help predict your risk of future fractures:
1) T score, which compares your bones to the bones of a young, healthy woman at peak bone mass. A score above -1 is considered “normal.” A score between -1 and -2.5 is considered at risk, and you may hear the word osteopenia, which basically means low bone density but not at osteoporosis severity. A score below -2.5 is considered the cut-off for defining osteoporosis. For every decrease by a score of -1, the risk of fractures doubles.
2) Z score, which compares your bones to someone of your same age. It is quite possible that your T score could indicate that you have osteoporosis, while your Z score is relatively normal. If most women your age have osteoporosis, and you have osteoporosis, then you will have similar bone density to most women your age. This is why you should be most concerned with your T score—how you compare with optimal bone density. The Z score is mostly helpful to doctors. For example, if a young woman has a Z score that is much lower than similar women her age; she may have a secondary cause of osteoporosis, such as an eating disorder. When I was the medical director at the Center for Women’s Health in Philadelphia I saw the lowest and most disturbing bone densities in young women with anorexia.
Remember, this is a baseline measurement, a snapshot of where you are now. Many women in late 40s panic if their T-score shows that they have osteopenia. I tell them that it doesn’t necessarily mean they are currently losing bone just that they didn’t build up a strong bone density in their youth. Further losses can be prevented. Just do everything right, have the DXA repeated in a year or two to see if you have lost any additional bone. If not, then you know that you’ve made a difference. If you have lost bone in that year, then the doctor will check for other factors that might contribute to bone loss, such as an overactive thyroid.
Ideally, we should all be practicing osteoporosis prevention throughout our lives. Children are taught good dental hygiene with the promise that it will keep their teeth from rotting and falling out when they are older. Long-term bone health is just as critical in the childhood through young adult years.
If you are a woman younger than age 30, now is the time to take advantage of your body’s ability to increase bone density. If you are over age 30, then your job is to protect the bone you have, and to try to make calcium replacement as efficient as possible. The best ways to accomplish these tasks are:
· Get plenty of calcium in your diet. Foods that are high in calcium include milk, yogurt, cheese, tofu, broccoli, bok choy, mustard greens, cauliflower, legumes, and almonds. Still, most people don’t get all the calcium they need from food alone, so I always recommend taking a calcium supplement just to be sure.
· Get vitamin D. Calcium and vitamin D work as partners in creating bone. Neither one can work without the other. Vitamin D is made naturally in the skin in response to sunlight. All you need is the equivalent of about 15 minutes of sunlight on the skin of your arms every day to make the vitamin D you need. Unfortunately, with extended work schedules, living in northern climates, aging and reduced skin production of vitamin D and the (wise) use of sunscreen (even an SPF of 8 will block vitamin D production, many people don’t get even that limited amount of sunlight every day. Although a multivitamin contains at least 400 I.U. of vitamin D, new research suggests we would be better off with up to 1,000 IU per day to protect our bones, brains, and maybe even reduce autoimmune disease and cancer risk. Vitamin D3 (called cholecalciferol) is the best way to take vitamin D.
· Eat a diet rich in all kinds of fruits and vegetables. There’s more to bone health than just calcium. Fruits and vegetables contain high amounts of other vitamins and minerals that contribute to bone strength, including iron, zinc, magnesium, potassium, and vitamin C.
· Avoid fried foods and store-bought baked goods. Bone loss seems to be greater among women who eat larger amounts of certain kinds of fats—especially the kinds of fats used to make fried foods (including French fries, potato chips, and corn chips) and packaged cookies, breads, cakes, and other snack treats.
· If you drink alcohol, do so in moderation. One glass of alcohol per day has been associated with less bone loss in the spine…but more than that increases bone loss. If you don’t drink alcohol, don’t start. It does not help that much. But if you enjoy a glass of wine with dinner, you won’t be hurting your bones to continue—as long as you don’t drink the whole bottle.
· Stop smoking—it decreases bone mass and increases hip fracture risk.
· Do weight-bearing or resistance exercise. Exercises that put stress on the bones of the body help preserve bone density. It’s almost as if the bones sense that they need to be stronger to hold up the extra weight, so they respond by becoming denser. The best general exercises for building bone are walking, dancing, aerobics, bicycling, and doing yard work… Even better is resistance training exercise. Studies have shown that resistance training helps reduce age-related bone loss, and can actually help increase bone density. Researchers found that postmenopausal women who did resistance training just two days per week for a year gained 1.0 percent bone mass in their thigh and back bones, while women who did no training lost 2.5 percent of their bone mass in those same locations.
You may have heard that caffeine reduces bone mass, and many postmenopausal women reluctantly gave up their coffee and tea for the sake of their bones. Some early studies did show a relationship, usually when measuring the amount of calcium excreted in the urine. Upon further research, it turned out that the body has a better balancing system than we thought, so that any calcium loss was made up by extra calcium retention later in the day. If you are generally healthy and get plenty of calcium in your diet, there is no evidence that drinking coffee or tea will hurt your bones.
The issue of carbonated beverages is also controversial. Studies of children found that those who drink large amounts of carbonated beverages (which are usually sodas) are more likely to get bone fractures. But researchers now think that it isn’t the carbonation that causes the bone loss. By choosing to drink soda instead of milk, the children simply weren’t getting enough calcium to keep their bones strong. There have been very few studies on adults, and those show little or no bad effects from carbonation. For example, a study published in a 2001 issue of the American Journal of Clinical Nutrition showed that carbonated beverages did not cause calcium to leach from the body, and an earlier study from researchers at Brigham and Women’s Hospital in Boston showed that over an intensive eight-week study, carbonated beverages did not have a bad effect on urine or blood levels of calcium.
However, I would like to go on record as recommending that women and men of all ages reduce the amount of soda they drink—sugared or artificially sweetened. Sugared sodas add unnecessary calories without adding any vitamins or minerals. Artificial sweeteners are controversial, and I come down on the side of avoidance. A recent research study found that as little as one can of diet or regular soda daily increased the risk of metabolic or apple-shape syndrome by 40% or more, “APPLE” SYNDROME LINKED TO ONE CAN OF DIET SODA”.
Much of the risk for osteoporosis is inherited, so if your mother or either of your grandmothers had osteoporosis, you also have an increased risk. Caucasian and Asian women have the highest risks of any of the racial or ethnic groups, and African American, Latino, and Hispanic women have a much lower—but still significant—risk. Small, thin women also have a very high risk, as do light-haired, blue-eyed women. Premature gray hair—being more than 50 percent gray by the time you are 40—has also been linked to a higher risk for osteoporosis.
At least some of the risk is due to things we do in young adulthood. Women build to their peak bone mass at age 30. That’s when your bones are the densest they will ever be. After that, you either start losing bone mass, or—if you do everything right—you maintain the same amount of bone mass. You can never again rebuild bone; you can only replace the calcium that the body uses. It’s sort of like stopping water from running out of a leaky bucket in the middle of a desert—you can save what’s left, but you can never refill the bucket. So after age 30, everything you do goes toward protecting the bone you have. The more abuse you put on your body when you were young, the more vigorous you’ll have to be when you are older to maintain enough bone to be healthy.
One big example of bone abuse is not getting enough calcium in the teenage and young adult years. Women who had anorexia nervosa or who dieted and exercised extensively for weight control may have depleted their bone mass to dangerous levels even before they got to age 30. This is so common that doctors have called a specific group of risk factors the “athletic triad”—disordered eating, excessive exercise, and amenorrhea (no ovulation and therefore no menstruation).
Estrogen is a critical component to the replacement of calcium in bones—it is part of the equation. After menopause, when estrogen levels plummet, bone density drops off dramatically for about 10 years before leveling off to a slower pace. Hormone therapy (HT) after menopause, which adds back the missing estrogen, delays this bone loss. In fact, the strong positive effect on bones is one of the main benefits of HT. Many, many studies have documented that women who use hormones after menopause have better bone density than women who don’t use hormones, and consequently a much lower risk of fracture. Although hormones are no longer recommended solely to protect your bones, women who are taking low dose hormones to relieve symptoms of menopause are getting an extra benefit!
Low body weight is also a risk factor for osteoporosis, so thin women will have the worst risks (especially if they are blond Caucasians or Asian). This is because body weight puts pressure on the bones, and this added force spurs more bone growth. Heavy women of all body shapes have stronger bones than thin women. This is the one time that being overweight is actually shown to be beneficial.
Although overall fat mass does improve bone density, so does overall lean mass. “Lean mass” means muscle. The waif-like young women who prize an emaciated, non-muscled look are heading for bone trouble in the not-too-distant future. The goal should be fit and well-muscled—think of women soccer players like Mia Hamm, think of tennis players Venus and Serena Williams. (I’d like to think of an actress to emulate, but I can’t. Even the ones who are fit are too underweight to be mentioned as role models.)
In fact, some studies show that total lean mass contributes more to total body bone density than total fat mass in both premenopausal and postmenopausal women—so muscle is better than fat at building bone throughout the body. Researchers from France studied women over age 60 for lean mass, fat mass, weight, and muscle strength. They found that lean mass was responsible for a large portion of the bone mass and the stronger the women’s thigh muscles (quadriceps), the stronger her thigh bones. This tells us that muscle is a critical component to building and keeping bone throughout the body—and that the force exerted by specific muscle groups can help protect bone in related areas. Or, to simplify further: Strong muscles mean strong bones.
The problem is that lean muscle mass naturally decreases as we get older, in part because of physiologic factors, and in part because we are generally less physically active.
Other risk factors to consider
Many women don’t know that some medications they may be taking might be weakening their bones. For example, a large number of women are currently taking Synthroid (levothyroxine) for hypothyroidism. But having too much thyroid hormone can weaken bones. If the dosage of Synthroid is not properly adjusted and regularly monitored, bone loss can occur. Also, the common seizure medication Dilantin (phenytoin) causes bone thinning by interfering with the synthesis and metabolism of vitamin D. Prescription steroids (I am not talking about the banned anabolic steroids) such as prednisone (even inhaled steroids increases the risk somewhat) taken for a long time, such as for control of asthma, can cause major loss of calcium and bone loss. If you are taking any of these medications, make sure you have your bone density monitored and that you take extra steps to improve your bone health.
The final course of action—if all the above methods fail—is to use a potent bone-building drug, such as Fosamax (alendronate) or Actonel (risedronate). These drugs have been demonstrated to slow or entirely stop bone loss and reduce the risk of fracture by half. They are most important for older women (and men) who have already suffered an osteoporotic fracture or who are at very high risk. Fosamax comes in a once-weekly pill with 28,000 units of potent vitamin D added which is a convenient way to get extra vitamin D if you are taking Fosamax already.
The winter months in the north are an especially worrisome time for people at risk for osteoporosis. Our skin produces less vitamin D (if any), we hurry along and risk falling on wet leaves or icy pavements, and we exercise less because we stay indoors for longer times. If anyone you know is at risk of a hip fracture – help them size up their daily routine, their medications and encourage them to talk to their doctors about getting a bone density scan. What greater gift could you give than the gift of prevention!!
ARE YOU UP-TO-DATE ON YOUR IMMUNIZATIONS???
The fall and early winter ushers in the flu season and a reminder for many of us to get our flu shots. (I am over 50 and a health care practitioner so dutifully received my flu shot already.) This is also a good time to see that you and your family are up-to-date on all.
As always, I welcome your questions and comments. Have a wonderful holiday season.