Osteopenia and Osteoporosis, Part 1

As is the case with many of our contemporary ailments, it was a combination of Baby Boomer longevity, the ready availability of devices to measure bone density, and Big Pharma creativity that taught both patients and physicians about osteopenia (low bone mineral density) and its more serious consequence, osteoporosis, in which bones become brittle and weak.

When I first started in practice and did a lot of geriatric medicine, thin white women were regularly breaking their hips or having compression fractures of their spines. Their bones had a washed-out look on x rays and, except for pinning broken hips and prescribing pain meds, there wasn’t much to offer. Heavier women and women of color generally have lower rates of osteoporosis because their estrogen stays at higher levels over the course of their lives.

Hip fractures were especially serious because orthopedists hadn’t yet realized the importance of getting the patient walking again right after surgery. As a result, pneumonia or a blood clot was a common and often fatal outcome. Compression fractures of the back, while less dangerous, were quite painful.

With bone density testing generally covered by insurance and relatively reasonably priced at about $250 if not, women today can check on the wellbeing of their bones. And everyone can take preventive steps to maintain strong bone.

What’s going on with my bones?
Your bones are at their very strongest when you’re about 30 years old. Starting in your mid-30s, estrogen levels slowly decline and, because healthy bone development relies on estrogen, ever so slowly your bones start losing their strength and density.

Osteoporosis describes a condition just like the word sounds: bones (osteo) are porous and less solid and more susceptible to fracture. Osteopenia is the midpoint between solid healthy bones and osteoporosis, “-penia” being a common medical suffix meaning deficiency. Men can get osteoporosis too, but for them it’s more related to their genes than to their hormones.

Doctors call the osteoporosis caused by estrogen decline Type 1. Because estrogen is so closely linked to bone health, younger women with scanty periods or infertility issues (two signs of low estrogen) might find their doctor suggesting regular measurement of estrogen levels. If your levels are chronically low, you could receive a prescription for hormone replacement simply as a bone protection measure.

Answering a frequently asked question: yes, birth control pills do offer some osteoporosis protection.

It’s worth noting that every woman who goes through menopause has less estrogen than she did before.

Type 2 osteoporosis is mainly caused by nutritional deficiencies, either a lack of calcium in the diet or a shortage of vitamin D (required to absorb calcium from the intestine), or both.

Interestingly, the two types of osteoporosis affect bones in different ways. Type 1 affects the inner, or trabecular, bone. Type 2 affects the outer, cortical, bone, and both types of osteoporosis can be present in the same person.

Some medications cause osteoporosis (steroids, taking too much thyroid), as does cigarette smoking, physical inactivity, and drinking more than two cups of coffee or two alcoholic beverages every day. Soft drinks have been shown to be especially harmful as they contain phosphoric acid, which pulls calcium from bones.

Also, if osteoporosis runs in your family or if your hair turned grey before age 45, you’re at greater risk.

The issue of bone density is complex. Read this piece for more.

Symptoms
Osteopenia and osteoporosis are so-called silent diseases, producing no symptoms until they’re in a relatively advanced stage. Unless yours is identified by chance during an x ray for an unrelated condition, the first sign might be something dramatic like a fractured wrist or hip, an awareness that you’re losing height, a sudden sharp and localized back pain (caused by a compression fracture), or a progressive curving of your upper back.

Diagnosis
A DEXA (dual energy x-ray absorptiometry) scan checks on bone strength by measuring a small part of your hip and spine. It’s considered the most useful and reliable test for evaluating bone density. Some doctors offer peripheral testing (wrist, heel, etc.), but these simply aren’t as accurate.

The US Preventive Services Task Force recommends that all women over 65 have a DEXA scan. The test is also recommended for younger women who have specific risk factors like low estrogen levels, early menopause, significant family history, poor nutrition, or noticeable height changes.

How soon you have a follow-up DEXA scan depends of the results of your first scan. If your scan is normal, or you have mild osteopenia, you can wait 15 years until your next one. If you’ve got significant osteopenia, it’s every five years and with untreated osteoporosis you’re scanned annually.

There is some controversy about whether or not it’s necessary to scan repeatedly in those who start taking medication for osteoporosis. The current position is that the scan will not pick up the subtle improvement in your bones caused by the meds and are simply not worth the time and expense.

Prevention
Although it may be quite some time before you need your first DEXA scan, preventing osteoporosis can begin now, in fact immediately after finishing this Health Tip.

Good nutrition is vital. Enjoy a calcium-rich diet that includes tofu and lots of dark green leafy vegetables such as mustard greens, kale, spinach, and collards. Also include fermented milk products like yogurt and kefir as well as cinnamon, bok choy, and canned salmon or sardines with their soft bones. Click here for an excellent review of the foods richest in calcium. Magnesium is also essential for bone health. Click here for magnesium-rich foods and a discussion of why this mineral is essential to keeping your bones strong. Eating some fermented vegetables every day also supports bone health. Since excessive protein can actually pull calcium from your bones, limit red meat to twice weekly. Sugar depletes vital calcium too and I recommend you avoid it.

If you smoke, stop. Cigarettes lower your ovarian estrogen and progesterone production and have been definitely shown to accelerate osteoporosis.  Need some help quitting?  Prescription drugs are one option, but our acupuncturists Mari Stecker, Cindy Kudelka, and Suzi Katlin treat patients who want to stop smoking.

Coffee, alcohol, and soda. Reduce coffee to one or two cups daily. Same for alcohol, with no more than two drinks a day. You simply don’t need carbonated beverages. Sweetened or not, the phosphorus they contain pulls calcium out of bones. And if they are sweetened, they’ll just make you fat(ter).

Weight-bearing exercises are extremely good for osteoporosis prevention. Often patients ask me to name a few. Actually, it’s harder to name an activity that doesn’t involve weight bearing. A flotation tank comes to mind. Maybe chess, or knitting. Here’s a list of 40 weight-bearing exercises.  Additionally, our Yoga Therapist Renee Zambo works with patients to incorporate a routine of gentle yoga poses that help maintain bone density while improving strength and flexibility.

For fun, you could get a small trampoline. I’ve seen one with all the bells and whistles, marketed to prevent osteoporosis, for hundreds of dollars. Or just get what looks like the same 50-inch trampoline without the medical recommendation for $80 at Sears.

Next week I’ll go into some detail about the pros and cons of treatment medications and the specific nutritional supplements that can help you with prevention.

Be well,
David Edelberg, MD