Your Healthy Bones Action Plan

Take Action Now

Katy Koontz was 38 and the mother of an active 4-year-old girl when her doctor delivered some upsetting news. The Knoxville, Tennessee, mom -- whose period inexplicably never came back after the birth of her daughter -- was in early menopause. Concerned about the rapid bone loss that occurs when a woman's period stops, her doctor referred Koontz for a bone-density test. "I thought it was weird that I was in menopause, but I didn't expect anything unusual because I had always been healthy," says Koontz, who regularly walked five miles per day. When she learned a few days later that she had severe osteoporosis -- bones so brittle that they could easily fracture -- she was horrified. "My doctor said she had last seen bones like mine in an 83-year-old," recalls Koontz, now 46. Overnight Koontz's life changed dramatically. A lifelong skier, she had to give up the sport for fear of having a bone-shattering fall. Ditto for ice-skating and sledding with her daughter, Sam. "I suddenly felt old and fragile," says Koontz.

What happened to Koontz is shocking because she's so young, but she's hardly unique. An estimated 1.5 million American women in their 40s or younger have osteoporosis, making them vulnerable to potentially devastating fractures of the hip, spine, and wrist. Because we tend to have bones that are smaller and less dense than men's and lose bone mass more quickly, 80 percent of the nation's 10 million osteoporosis sufferers are women. An additional 34 million American women have a serious but less-critical condition called osteopenia: bone mass that's significantly lower than normal, putting them at high risk for osteoporosis.

It's never too late to start improving your bones. And if you have daughters, it's also important to get them involved in keeping their bones strong. The steps you take now can pay off for a lifetime.

Why Your Bones Change -- and When

Though we think of bones as being static and unchanging, they aren't. They are composed of living tissue that is constantly in flux. Two types of cells that help with bone formation are osteoblasts, which make new bone tissue, and osteoclasts, which break down current bone tissue in a process known as remodeling. To build and maintain bone, your body needs a steady supply of calcium (along with Vitamin D to maximize calcium absorption) and estrogen. Bones also need weight-bearing exercise, such as walking, strength training, or jogging. But exercise alone won't keep bones healthy, as Koontz learned.

While we're young, this process ticks along smoothly, with the body building bone more rapidly than it loses it, till we reach our peak bone mass in our mid-20s. Then the scenario changes and we gradually lose bone faster than it can be replaced. When estrogen levels fluctuate during perimenopause (it typically starts between ages 45 and 47) then plummet after menopause (about 51), bone loss accelerates.

That's why we need to be vigilant about keeping the bone we have. Indeed, the only way to prevent osteoporosis is to make bones as strong as possible when we're young and keep them healthy as we get older, says Bess Dawson-Hughes, MD, director of the Bone Metabolism Laboratory at the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, in Medford, Massachusetts. Think of eating well and exercising as making deposits in your bone bank. Surveys show that nine out of 10 women don't get enough calcium to help maintain bone health. And only 40 percent of Americans regularly exercise.

If you've been remiss, you can still start helping yourself now. Case in point: Katy Koontz began taking a prescription bone-building medication as well as a calcium supplement to slow down her bone loss and strengthen the bone she had while continuing to walk five miles a day. Each year her bone density improved slightly. Nearly a decade later, though she still has osteopenia, her doctor is so pleased with her improved bone health that Koontz has returned to the slopes.

Your age and your estrogen level determine which strategies make the most sense for you at each stage of your life. Start by finding your age group (and that of your mother or postadolescent daughter) on the following pages. To protect your kids, see "Strong Bones Start Early."

Ages 19 to 24

What Happens: During these years you reach your lifetime peak bone mass. Childhood sets the stage -- you build about 60 percent of your skeleton then -- but the rest comes during adolescence and your 20s. That's when high levels of estrogen and two other hormones, growth hormone and insulin-like growth factor-1, increase bone density, helping you develop about 40 percent more bone than you had in your teens. You'll need it: "A peak bone density that's just 5 percent less than what it might have been can lead to a 40 percent increase in your risk of osteoporosis," says calcium researcher Dorothy Teegarden, PhD, professor of nutrition at Purdue University, in West Lafayette, Indiana.

Your Healthy Bone Regimen: Consume 1,000 milligrams (mg) of calcium per day -- slightly more than three 8-ounce glasses of skim milk -- and 200 International Units (IUs) of Vitamin D. (Milk is an excellent source of D, as well.) If you don't get enough from your regular diet, take a daily calcium/vitamin D supplement or a multivitamin containing these ingredients to make up the shortfall. To maximize bone growth you also need to do weight-bearing exercise that challenges your body's large muscle groups (shoulder muscles, back, and pelvic area). Good choices: strength training, running, walking, or step aerobics.

• Inventory your habits. Coffee, cola, and other caffeinated drinks inhibit calcium absorption slightly -- for every eight ounces of coffee you consume, your body fails to absorb 4 mg of calcium. That's a trivial amount when you're supposed to be consuming 1,000 mg of calcium a day. The main reason to monitor caffeine is that, if you sip a lot of black coffee or soda, you're less likely to drink milk. To spare your bones, limit caffeinated drinks to two to three 8-ounce servings a day, advises Nelson B. Watts, MD, director of the Bone Health and Osteoporosis Center at the University of Cincinnati College of Medicine. Sneak in an extra 40 mg of calcium a day by adding two tablespoons of milk to your coffee or tea, or indulging in cappuccino, latte, or milky chai (low-fat or fat-free milk will give you even more calcium per serving). If you smoke, your bones are yet another reason to quit -- the habit can weaken them. So can too much alcohol: Limit it to 6 ounces of wine, 12 ounces of beer, or 1 ounce of spirits per day.
• Watch the salt. Sodium makes your body excrete more calcium than usual when you sweat or urinate. We need only about one teaspoon of salt per day; most of us get far more, primarily from packaged foods. Eat more fresh foods; switch to lower-sodium versions of packaged products.
• See your doctor if your period stops. If you miss your period for three consecutive months or more -- and you're not pregnant or nursing -- get to a doctor. Amenorrhea can occur for many reasons, including an eating disorder or excessive physical activity. (Ballet dancers and athletes, for instance, may miss periods due to low body fat.) Whatever the cause of the problem, the consequences are the same: Estrogen levels drop, preventing bone-building cells from doing their job, a loss that can't be recouped later, says Michelle P. Warren, MD, director of the Center for Menopause, Hormonal Disorders and Women's Health at Columbia University Medical Center, in New York City.
• Be scrupulous about calcium if you take birth control pills. The pill maintains a steady level of estrogen, preventing the surges of estrogen that can aid bone formation. To protect bone, make sure you meet your calcium quota. Dr. Teegarden recently found that young women on the pill who consumed 1,000 mg of calcium per day didn't lose bone in their hip or spine over the course of a year. By contrast women on the pill who got 800 mg or less lost up to 2 percent of their bone mass in these areas.

Ages 25 to 39

What Happens: Your peak bone-building years have ended and you're beginning to lose bone more rapidly than it is replaced. Though you can't stop this natural process, getting enough calcium, vitamin D, and exercise can help slow it down.

Your Healthy Bone Regimen: Keep up the calcium and vitamin D. Your needs are the same as in young adulthood: 1,000 mg of calcium and 200 IUs of vitamin D per day, from diet or by adding a supplement.

• Make exercise a routine. If you have kids or a demanding job, you may find yourself slacking off on exercise. Don't. Try to walk at least 7,500 steps a day, about three miles. "Women in their 20s and early 30s who walk a mile or more each day reduce their risk of hip fracture by 30 percent as they grow older," says Miriam E. Nelson, PhD, director of the John Hancock Center for Physical Activity at Tufts University and coauthor of Strong Women, Strong Bones. If you can manage to squeeze in some strength training, even better. If you can't get to a gym, use your body weight to do push-ups, lunges, squats, calf raises, and triceps extensions. (Do 8 to 12 reps and two sets of each exercise.)
• Make sure you get your full quota of calcium and vitamin D when you're pregnant or nursing. Though your calcium needs increase if you get pregnant or nurse your baby, your body compensates by upping the amount of calcium it absorbs from food; as long as you get 1,000 mg of calcium a day, you'll be fine. You'll lose some bone when nursing, but regain it once you stop.
• Tell your doctor about any broken bones. "Whenever you fracture a bone as an adult, you should investigate the possibility of osteoporosis with your physician," says Kerry Siminoski, MD, professor of radiology, diagnostic imaging, and internal medicine at the University of Alberta, in Edmonton. This is particularly true for any low-trauma fracture -- one that's caused by a fall from standing or sitting height. Dr. Siminoski has found that women who broke a hip, back, wrist, or ankle bone after age 20 were up to 10 times more likely to be at risk for osteoporosis.

Ages 40 to 49

What Happens: During perimenopause, the transitional years leading to menopause when estrogen fluctuates and your periods become irregular, you can lose bone at a rate of half a percent to three percent per year.

Your Healthy Bone Regimen: It's too soon to up your calcium intake beyond 1,000 mg/day (plus 200 IUs of vitamin D), but be very sure you get this much or your bone loss could be even greater. If you don't get enough calcium and D from food, start taking a supplement. (If you enter menopause in this decade, read the next section.)

• Focus on strength training. It's still important to walk or run, but now the force you exert on bone really has to be greater than what it's used to in daily life, which is where strength training comes in. Ideally, join a gym: Resistance machines let you lift more weight than you can lift at home, advises Dr. Nelson. Studies show that 45 minutes of strength training twice a week are all it takes to maintain bone mass and slow bone loss. If you can't afford a gym, consult with a personal trainer who can design an effective at-home strengthening program.
• Consider taking an oral contraceptive. Although the pill can be bad for bone in younger women, some studies show it can increase bone density in women who are beginning to lose their body's natural supply of estrogen. If your period is irregular, the pill can regulate it -- and stop hot flashes, which can start now. If you smoke or have high blood pressure, the pill is off-limits.

Age 50 Plus

What Happens: After your period stops, you can lose 30 to 50 percent of your bone mass over the next 10 years, says Felicia Cosman, MD, clinical director of the National Osteoporosis Foundation, in Washington, D.C., and author of What Your Doctor May Not Tell You About Osteoporosis. Cut bone loss all you can in your crucial 50s and 60s.

Your Healthy Bone Regimen: Try to bump up your calcium intake to 1,200 mg per day and be sure to get enough vitamin D. Current guidelines call for 400 IUs of D from age 51 to 70, then 600 IUs thereafter (more may help, in some cases). More than 70 percent of women ages 51 to 70 and nearly 90 percent of older women don't get sufficient calcium or D. And get enough magnesium, too (women over 30 need 320 mg/day). Recent research suggests that every 100 mg of magnesium people age 70 and older consume translates into a one percent increase in bone density. For some, bone-building drugs can also help.

• Discuss osteoporosis with your doctor. How soon should you have your bones tested? If you have a family history or other risk factors (see "Are You at Risk for Brittle Bones?"), you may be a candidate for what insurers consider an "early" bone mineral density (BMD) test. DXA, the best type, is essentially a low-dose-radiation x-ray of your skeleton to assess the amount of calcium in your bones and gauge their health (see "Rate Your Bone Health"). Though BMD testing isn't used as a screening tool for all women until age 65, most insurers will cover a baseline screening at menopause or sooner if you're at risk for osteoporosis. It may make sense to insist on a DXA test soon after 50, even if you're not in the high-risk group, and pay for it yourself (it costs about $200). "I believe we really should be testing all women at menopause at the latest because you can have no risk factors yet still have very low bone mass or osteoporosis," says Dr. Cosman.
• Calcium supplements: Probably a "must" for most. The higher amount of calcium you need now may be difficult to get from food alone. Getting the amount right can make a difference -- especially if you pair it with exercise. A four-year study at the University of Arizona, in Tucson, found that postmenopausal women who did a weight-bearing and strength-training program three times a week for 60 to 75 minutes and took an 800-milligram calcium supplement on top of their usual dietary calcium intake improved their bone mineral density by one to two percent. (Another reason to emphasize strength training now: Strong muscles help balance, which reduces your risk of falls and chance of fractures.)
• Boost your B vitamins. Now, more than ever, you need folic acid and vitamins B12 and B6 to lower homocysteine, an amino acid in the blood. Though an elevated homocysteine level is best known as a sign of heart-attack risk, reducing this amino acid also protects your bones. People whose levels are greater than 10 to 12 micrograms per liter are at high risk for hip fracture, reports Katherine Tucker, PhD, an epidemiologist at Tufts University's USDA Human Nutrition Research Center on Aging, in Boston. Sources of homocysteine-lowering B vitamins include green vegetables, such as spinach, broccoli, and kale, and B-fortified cereal. If your levels are too high (there's a simple blood test), you may need to take a prescription-strength vitamin B complex supplement.
• Ask your doctor about bone-saving medications. On the basis of your bone density, medical history, and other risk factors, you may be a candidate. Even if you take one of these drugs, do weight-bearing exercise to improve your strength and balance and make sure you get enough calcium and vitamin D.

Strong Bones Start Early: How to Protect Your Kids

Start your kids off with the strongest possible bones by making sure they get enough calcium. It's not as easy as it sounds. Soda and other caffeinated drinks cut the calcium you absorb from food. In fact, kids drink nearly 15 ounces of soft drinks per day, with teens consuming anywhere from 20 to 30 ounces a day. This leaves less room for calcium-rich drinks, such as milk. According to the USDA, only 37 to 40 percent of kids ages 2 to 17 meet their daily calcium quota (500 mg for 2- to 3-year-olds; 800 mg for 4 to 8; and 1,300 mg for 9 through 18).

The best way to boost your child's calcium intake is to serve milk and other calcium-rich dairy foods or a dairy alternative, such as fortified soy or rice milk, at every meal, says Heather Fink, RD, assistant director for the Center for Educational Services at the National Institute for Fitness and Sport, in Indianapolis. (Calcium-fortified juice counts, too, but limit it to six ounces per day because of its calories.) If your child doesn't like milk, flavor it. Children who drink nonfat strawberry and vanilla milk up their total milk intake by 15 percent, according to one study. Yogurt, almonds, broccoli, tofu, and other calcium-rich foods are another option.

Calculate your child's calcium intake by tracking her food for a few days. Discuss it with her doctor or use the Centers for Disease Control and Prevention's calcium calculator.

Make up for insufficient calcium with a supplement or multivitamin. Girls ages 8 through 13 who took calcium supplements totaling 830 mg per day significantly increased their bone density, report researchers at Ohio State University Medical Center.

Rate Your Health

The gold standard for measuring bone density is the dual energy x-ray absorptiometry (DXA) test, which measures bone density in the spine, hip, or forearm. It's considered the best test because it uses the least amount of radiation (about 1/30th the amount in a chest X-ray) to scan and rate your bones. Cost: around $200.

When you take a DXA test, you'll get a T-score, a numerical grade for bone health, for the part of your body that's tested. Each number shows how your BMD (bone mineral density) compares with that of a 30-year-old with optimum bone density -- the norm. The difference between your BMD and the norm is called a standard deviation (SD). Normal bone density is within one SD (plus 1 or minus 1) of the 30-year-old. Scores below that are given in negative numbers. What you want is a BMD that's higher than -1. If you're -1 to -2.5 SD below the young-adult norm, you have low bone mass, or osteopenia. A score that's worse than -2.5 signals osteoporosis.

One of every two women over age 50 will suffer a fracture caused by osteoporosis. While anyone can develop the disease, you need to be especially vigilant if you have one or more of these risk factors:

• You have a family history of osteoporosis
• You're Caucasian or Asian
• You weigh less than 127 pounds
• You had irregular periods or your period stopped in your teens or 20s for three consecutive months or longer (not caused by pregnancy or nursing)
• You have ever taken a steroid medication for a condition such as asthma or lupus
• You have ever broken a bone as an adult, after low trauma, such as tripping on the curb

Which Supplement Is Best?

In an ideal world, it's best to get calcium from food. "Bone health isn't just a calcium issue," says Robert P. Heaney, MD, professor of medicine at Creighton University, in Omaha. "To rebuild themselves, bones also need protein, phosphorus, and a whole host of other nutrients that you would best get from food or milk." Yet many women drink water or diet soda instead of milk at meals and don't get enough calcium from other sources. If this sounds like you, it's smart to take a calcium supplement.

Supplements aren't regulated by the Food and Drug Administration in the same way drugs are, so you need to be scrupulous about choosing a reputable product. While easier said than done (all supplement makers say that they're reputable), experts generally advise choosing a nationally known brand rather than one from a small or obscure manufacturer.

Be sure that you buy a supplement with vitamin D3; bones need D to absorb calcium and D3 is its most potent and effective form. Supplements may contain three forms of calcium (calcium carbonate, calcium citrate, or calcium phosphate). Ask your doctor which is best for you, considering the following:

• Will you take it regularly? Many calcium supplements resemble horse pills -- so if you have trouble swallowing a pill, this may not be the form for you. You may be better off with a supplement that's chewable, such as a flavored tablet, soft gel, or chewable candy. Or swallow several smaller pills.
• How much does it cost? If cost matters, you may prefer calcium carbonate, the least-expensive form of calcium. Because it weighs less than other forms, manufacturers can pack more calcium into one pill, so you can end up taking fewer pills each day.
• Does it have side effects? Calcium carbonate can cause gas, nausea, and stomach pain in some women. If that's the case, try other forms of calcium.

Once you decide on a supplement, take it with meals to improve absorption by 10 to 15 percent. Also, spread your dosage equally over the course of the day. For example, if you down a 500 mg supplement every day, take 250 mg at breakfast and another 250 mg

If you need an iron supplement, don't take it at the same time as your calcium pills unless you wash both pills down with orange juice. Calcium (with the exception of calcium citrate) interferes with iron absorption. OJ increases iron absorption and overrides calcium's blocking effect.

Bone-Saving Drugs

Hormone therapy may be the most effective way to actually stop the rapid bone loss associated with menopause. But more and more, other medications that slow bone loss and even help build bone density (without the risks of HT) have become doctors' treatments of choice for osteopenia and osteoporosis. How long you stay on a medication depends on how well you tolerate it and how your bones fare. Some drugs also have suggested time limits. Here's a look at common bone savers.

Bisphosphonates. The three main types -- alendronate, risedronate, and ibandronate -- increase bone density in both the hip and spine. Prescribed for both osteopenia and osteoporosis, they're available in pill or liquid form and can be taken daily, weekly, or monthly, depending on the formulation. Some research on alendronate is starting to raise questions about whether these drugs, which increase bone density by inhibiting bone turnover, could make bones more brittle or increase the time it takes fractures to heal. In the high doses taken for bone cancer, bisphosphonates have been associated with breakdown of the jawbone in cancer patients. Discuss these issues with your physician.

Calcitonin. This naturally occurring hormone slows bone loss and reduces the risk of spinal fractures. It's available as a once-a-day nasal spray or as a shot administered either once a day, every other day, or three times a week.

Raloxifene. This estrogen-like substance is prescribed for osteoporosis in the spine but is not advised for women with cancer, congestive heart failure, liver disease, or a medical history of blood clots. Taken once a day in pill form, it increases bone density and decreases spine fractures. It may cause hot flashes, sudden sweating, or feelings of warmth, especially during the first six months.

Parathyroid hormone. This relatively new treatment for severe osteoporosis stimulates new bone formation and increases bone density. However, you need to give yourself daily injections and are advised to use it for two years at most.

Originally published in Ladies' Home Journal magazine, March 2006.