Bone Up: How to Prevent Osteoporosis
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Bone Up: How to Prevent Osteoporosis

Too many women in their 30s and 40s blow off their osteoporosis risk, but if you want to stay strong and healthy for life, you've got to act now.

A Silent, Serious Disease

In her wildest fantasies Michele Rosenthal never dreamed that her sweet little wheaten terrier, Baylee, could put her bones at risk. Rosenthal was walking Baylee in her New York City neighborhood when he lunged at a squirrel. As she reached for a nearby railing to keep from falling, her hand slipped and she severely fractured two fingers. The orthopedist who treated her was concerned that she had such serious damage after a minor tumble and recommended that she take a bone-density test. The verdict was advanced osteoporosis.

"My doctor said that if I didn't start doing something soon my bones would spontaneously start to crumble," says Rosenthal. "I couldn't believe it. I was 36. I didn't think this could happen to someone my age."

Her case underscores what many experts have been trying to tell women for years: You can't wait until your AARP card arrives in the mail to start thinking about keeping your bones strong. "Osteoporosis is not just a disease of little old ladies and it's not a normal part of aging," says Lisa Callahan, MD, codirector of the Women's Sports Medicine Center at the Hospital for Special Surgery in New York City. "Though we used to define it as a disorder of postmenopausal women, we now know that it can develop at any age. But the problem is, younger women rarely think about it. So they don't do the simple things, such as exercising and boosting their calcium and vitamin D intake, that can make a tremendous difference in keeping their bones strong."

"Bone is living tissue," says Ethel S. Siris, MD, director of the Toni Stabile Osteoporosis Center at Columbia University Medical Center. "From the time you're born, your body is constantly removing old bone and creating new bone." During childhood and the teen years, your body grows more than it loses. But after 20 you can start to lose more bone than you make -- and the loss really accelerates after menopause. "If you lose too much bone or make too little of it, you can develop osteoporosis," says Dr. Siris. "That's why it's crucial to bank enough during childhood and adolescence -- and crucial to protect the reserves you do have."

An estimated 10 million Americans have osteoporosis (literally, "porous bones") and about 80 percent of them are women. Another 34 million have low bone density, or osteopenia, putting them at increased risk of osteoporosis and broken bones. "This is a silent, potentially crippling disease," says Dr. Siris. Most women have no idea their bones are weak until a fracture occurs. Despite advances in diagnosing and treating osteoporosis, there's still a major lack of awareness. Your risk of a fracture from osteoporosis is more than four times higher than your risk of getting breast cancer. But while 93 percent of women surveyed know osteoporosis is a serious disease, eight out of 10 don't believe they'll ever get it, according to the International Osteoporosis Foundation.

What's more, doctors report that they're increasingly seeing signs of the disease in women in their 20s, 30s, and 40s. "A few years ago I'd see a young woman with low bone mass once a month," says Kathryn Diemer, MD, director of the Bone Health Program at Washington University School of Medicine in St. Louis. "Now I see three or four every day."

Why the Increase?

Experts believe the spike among younger women is due to several factors, not just to better diagnostic tools. Many women are not getting the nutrients they need for healthy bone development during childhood and adolescence. "Tweens and teens are drinking soda instead of milk," says Dr. Diemer. "Either they think it's not cool to drink milk, they don't like the taste, or they think dairy products make them fat. Whatever the reason, they're not getting the calcium, vitamin D, and other nutrients they need during those prime bone-building years. And that puts them in a precarious situation later on."

Yo-yo dieting as well as eating disorders can also deplete bone strength, says anthropologist and nutritionist Susan E. Brown, PhD, author of Better Bones, Better Body: Beyond Estrogen and Calcium. So can depression or chronic stress. What's more, athletes and ballet dancers may stop menstruating for months at a clip, depriving their bodies of bone-boosting estrogen at critical times.

Certain health problems, and the medications needed to treat them, can also affect bone health. High doses of steroids or thyroid medications, some antidepressants, and proton pump inhibitors for gastric reflux can all be bad for bone health. "I was so bummed that after years of running and choking down calcium tablets I was diagnosed with osteoporosis when I was 51," says Debra Jarvis, a chaplain at the Seattle Cancer Care Alliance. "Why didn't anyone tell me that the antacids I was taking for reflux could wreak havoc on my bones?"

Some very fit women, like Becky Williamson, an exercise physiologist in San Jose, California, are shocked to discover they have weak bones. When Williamson was 38, her doctor suspected she had a stress fracture in her heel. The X-ray was inconclusive, but a bone-density test showed she had osteopenia. "I couldn't understand why this happened," she says. "I worked out all the time. I made sure I ate lots of calcium-rich foods. I was doing all the right things." A few Internet searches later, she realized she'd ignored many clues: For eight years she had taken Depo-Provera, a contraceptive that can cause you to lose stored calcium in bones, possibly causing osteoporosis. Williamson was also small-boned, another risk factor for the disease. "My gynecologist never told me that since Depo-Provera doesn't contain estrogen -- which helps to protect and maintain bones -- my bones were at risk," she says.

Testing, Testing

If you think you have risk factors, talk to your doctor about getting a Bone Mineral Density (BMD) test. It measures the mineral content in your spine and hip, the areas most likely to fracture when weak. The gold standard is DXA (dual-energy X-ray absorptiometry), which is painless, safe, and relatively inexpensive ($150 to $200, often covered by insurance). "DXA is a snapshot of where you are right now in terms of the mineral content of your bones and your chances of a fracture," says Dr. Diemer. You'll get two numbers: a T score, which compares your bone density with an average 30-year-old woman's; and a Z score, which compares you with women your own age. For postmenopausal women, a BMD of -1 or better is normal; -1 to -2.5 signals osteopenia; -2.5 or lower is osteoporosis. But if you still get your period, the Z score is a better bone strength judge. If it's low, you're losing more bone than average (though that doesn't necessarily mean you're at high risk for fractures). Make sure you're getting the nutrients and weight-bearing exercise you need and monitor progress closely.

While a BMD test alerts you to bone loss, it doesn't tell you why you're losing bone. For that you need other tests, as Gail Warshaw, of Demarest, New Jersey, discovered. When she was in her 40s, Warshaw, a runner, was diagnosed with a stress fracture in her right tibia. Later she also suffered stress fractures in her hip, rib, lower back, and shoulder blade. Her BMD was normal. But after her doctor ordered blood and urine tests, Warshaw learned that her low calcium and years of yo-yo dieting had sabotaged the quality of her bones. She also admits to being a coffee addict. "My level of vitamin D was really low and my doctor told me I was losing more bone than I was making," she says.

She committed to a vigorous strength-training program and nutritional makeover. Her most recent test indicated that her bone density was improving, so she's sticking with the program. "I've turned around the direction my bones were going and now I'm strengthening them," she says.

Michele Rosenthal has turned her loss around, too. Now living in Palm Beach Gardens, Florida, she follows a diet rich in calcium and vitamin D and a strength-training regimen designed by a trainer. Once very thin, she's now at a healthy weight. "I've completely reversed the osteoporosis," she says. "You feel so worried all the time when you have osteoporosis. Now I don't feel so fragile."

Bone-Building Medications

Except in special cases, you should take medications that specifically treat osteoporosis only if you've already gone through menopause. Still, it's important for all women to know what they are and how they work.

Antiresorptives (bisphosphonates such as Actonel, Fosamax, and Boniva, in pill form; or Reclast, a once-a-year injection) reduce bone breakdown. Selective Estrogen Receptor Modulators (SERMS, such as Evista) are helpful for women who may be at risk for breast cancer. The FDA recently approved Prolia, an antiresorptive that stops bone breakdown, given as twice-a-year injections.

Anabolics (such as Forteo) boost new bone formation but are recommended only for those with very high fracture risk.

Hormone therapy can also prevent bone loss but has been linked to an increased risk of breast cancer and heart attack.

Natural remedies such as black cohosh, dong quai, or Asian ginseng have not been evaluated extensively in terms of fracture prevention, says Dr. Diemer. "If you do take them, be sure to have your bone density tested regularly. If there's no improvement, switch to medications we know something about." The same holds true for bio-identical hormones, which are made from plants but are identical to hormones made by your body.

There is currently some debate about whether long-term use of bisphosphonates may lead to a risk of spontaneous thigh-bone fractures or osteonecrosis of the jawbone. "Both of these problems are very rare," says Dr. Siris. "We don't have enough research yet to prove that there is a direct link, but there may be. It doesn't take away from the fact that, for women who need them, bisphosphonates are extremely valuable."

What Kids Need

Help your children develop healthy habits during their peak bone-building years.

Make sure they get their calcium and vitamin D. Kids 1 to 3 years old need 500 mg of calcium, those 4 to 8 should get 800 to 1,000 mg, and those 9 to 18 need 1,500 mg. Three to four age-appropriate servings of dairy should do it, says the American Academy of Pediatrics. (One cup of milk has about 300 mg of calcium; 1 cup of plain low-fat yogurt, about 400 mg; 1.5 ounces of cheddar cheese, 300 mg.) If your child hates milk or is allergic to it, look for fortified cereals and orange juice or granola bars. You can also disguise milk in soups, puddings, sauces, and stews. Cut processed foods, as they tend to be lower in essential bone nutrients than fresh foods. Don't give your child more vitamin D than the RDA of 600 IU (for kids over 1); too much might be toxic.

Keep them moving. If kids aren't into school sports, they may need motivation to exercise. Studies have shown that brief, regular sessions of high-impact exercise, such as jumping jacks or jumping rope, boost bone mass.

Breaking Points

You're at risk for osteoporosis if...

  • You're female.
  • You're past menopause, either naturally or because you had a hysterectomy or chemotherapy.
  • You are thin, petite, Caucasian, or Asian.
  • Osteoporosis runs in your family.
  • You have, or had, an eating disorder.
  • There have been times when you didn't menstruate (and you weren't pregnant).
  • You smoke.
  • You rarely exercise.
  • You drink alcohol or caffeine excessively.

Smart Bone Steps to Take Now

Okay, so you can't change some risk factors, such as your sex, your genes, or whether you're in menopause. But you can make a difference to your bone health by getting lots of exercise, eating a healthy diet, not smoking, and not being too thin.

Get Your Calcium and Vitamin D

Calcium is essential, but many women don't get enough. And when the level of calcium in the blood drops, your body siphons some from the supply it stores in your bones.

"But calcium doesn't magically travel from your yogurt to your bones," says Dr. Brown. "To absorb it, you need vitamin D, and most of us don't get enough of that." Sun exposure triggers D production but, as you age, that mechanism falters. And while it's important to slather on the sunscreen to guard against skin cancer, that further decreases your vitamin D production.

According to recommendations from the National Osteoporosis Foundation, adults under age 50 need a total of 1,000 mg of calcium from either food or supplements, and 400 to 800 international units (IU) of vitamin D daily. Those 50-plus should get 1,200 mg of calcium and 800 to 1,000 IU of vitamin D. A simple blood test can determine if your D level is low. If so, look for vitamin D3, which is more easily absorbed than other types.

Get your calcium from low-fat or fat-free milk (one cup of skim milk has nearly 300 mg of calcium and is fortified with 100 IU of vitamin D3), soy products, ricotta cheese, low-fat yogurt, or hard cheeses. If you don't like milk or are lactose intolerant, look for calcium-fortified foods such as cereals and orange juice. Other good sources? Kale, broccoli, bok choy, almonds, beans, sardines, salmon, and some soups and stews.

"For 25 years I've been telling women it's best to get their calcium from food, but I can count on one hand those who get enough through diet alone," says Margaret Ecker, a nurse clinician recently retired from the Osteoporosis Prevention Center at the Hospital for Special Surgery. "That's why I suggest a supplement such as calcium carbonate or calcium citrate. The first must be taken with food and can trigger stomach upset and constipation. If you already take medications for reflux or an acidic stomach, opt for calcium citrate, which is generally well tolerated and can be taken without food."

Most calcium supplements and multivitamins have vitamin D. So do herring, salmon, sardines, mackerel, fortified orange juice, low-fat milk, and eggs. Some experts suggest spending a few minutes in the sun without sunscreen to boost vitamin D production, but with skin-cancer cases skyrocketing, food and supplements are safer, says Ecker.

Bones need other minerals, too. "Vitamin K, phosphorous, and magnesium are the glue that binds calcium to bone," says Dr. Brown. Find them in whole grains, soy, bananas, cantaloupes, and honeydew melons.

Ramp Up Weight-Bearing Exercise

"Bones, like muscles, must be used or they deteriorate," says Dr. Callahan. "Any activity that makes them work against an opposing force improves density. The more impact, the better." Swimming and bicycling, though terrific aerobic activities, don't make the cut. What does? Walking briskly, climbing stairs, running, hiking, dancing, tennis, and jumping rope. Aim for 20 to 30 minutes, four to six times a week.

Boost Your Strength and Balance

Use machines, free weights, or bands to increase bone density throughout your body. Try to do 30 minutes, two to three times a week. Pilates and some types of yoga can build bone, but their greatest benefit comes from strengthening core muscles that improve your balance and prevent falls. Do balance training for 20 to 30 minutes, three times a week.

Stop Smoking and Limit Alcohol and Coffee

Smoking increases your risk of osteoporosis, according to several studies. And the 2010 Dietary Guidelines for Americans say women should limit themselves to one alcoholic drink a day, meaning 5 ounces of wine, 12 ounces of beer, or a shot of hard liquor. One study found that women who drank more than four cups of coffee a day were three times more likely to suffer hip fractures than those who almost never drank it.