What Is Osteoporosis & How Can You Prevent It?

May 20, 2024
Osteoporosis medical forms and medications

Bone is living tissue. It responds to the stress you put on it. Muscles pull on bone tissue when you run, jump, and climb. Bone responds by thickening to withstand the increased stress.

Bone is also a repository for calcium, a carefully controlled mineral that affects heart function. If bone is constantly broken down to increase blood calcium levels, it becomes thin and fragile. This condition is called osteoporosis.

Weak bones are more prone to fracture. People with osteoporosis are at increased risk for hip, spine, and wrist fractures. In fact, a bone fracture may be your first indication of osteoporosis.

Osteoporosis is the most common bone disease globally, affecting one out of every three women and one out of every five men. The incidence of osteoporosis rises with age. Osteoporosis affects approximately 200 million women worldwide, with 1 in 10 in their 60s, 1 in 5 in their 70s, 2 in 5 in their 80s, and 2 in 3 in their 90s affected. In men, bone density gradually decreases. Women experience a rapid decline in bone density after menopause.

What is osteoporosis?

The World Health Organization defined osteoporosis as “a disease characterized by low bone mass and micro-architectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk.”3

Osteoporosis increases with aging and is associated with a lack of estrogen, but it can occur in younger people, and it is under-recognized and under-treated in men. Osteoporosis is a silent disease that rarely has symptoms until the condition is well advanced and a fracture occurs after minimal or no trauma.

Thinned versus normal density bone

What causes osteoporosis?

Bone is an active tissue that is constantly being remodeled. Osteoclasts break down bone and increase blood calcium levels; osteoblasts build bone and decrease blood calcium levels. Osteoblast and osteoclast activity remodel bones in response to the stresses put upon them. A balance between osteoblast and osteoclast activity is maintained until around age 40 or so.

Aging, environmental, and genetic factors alter the balance between osteoclasts and osteoblasts, causing bone to be broken down more quickly than it is built.

What are the signs and symptoms of osteoporosis?                

Early in osteoporosis, symptoms are uncommon. However, as bones thin and become more porous, the risk of fracture rises, and symptoms may include:4

  • Decreased handgrip strength
  • Hip, spine, and wrist fractures
  • Loss of height
  • Stooped posture
  • Bone pain
  • Reduced physical activity

Who’s at increased risk for osteoporosis?

Risk factors for osteoporosis include: 

  • Increasing age
  • Family history of fractures
  • Female sex
  • Having a previous spine or hip fracture
  • Poor muscle strength
  • Weight loss after age 50 
  • White or Asian ethnicity

Lifestyle factors5-9

  • Excessive alcohol, caffeine, or vitamin A intake
  • Low body mass index
  • High BMI in men
  • High oxalate or salt intake
  • Immobilization
  • Inadequate physical activity
  • Low calcium or vitamin D intake
  • Poor muscle strength
  • Smoking

Medical Conditions10,11

  • Blood disorders: hemophilia, multiple myeloma, thalassemia, leukemia, sickle cell disease
  • Endocrine disorders: Diabetes mellitus, high thyroid hormones, increased parathyroid hormone, Cushing’s syndrome
  • Gastrointestinal disorders: celiac disease, inflammatory bowel disease, gastric bypass, pancreatic disease, gluten enteropathy
  • Genetic conditions: cystic fibrosis and metabolic disorders
  • Hypogonadal states: androgen insensitivity, elevated prolactin levels, anorexia nervosa, premature menopause
  • Medications: Aluminum-based antacids, heparin, anti-seizure medications, glucocorticoids, chemotherapeutic drugs, proton pump inhibitors, selective serotonin reuptake inhibitors, excess thyroid hormone
  • Rheumatoid and autoimmune disorders: rheumatoid arthritis and lupus
A DEXA scan for osteoporosis

How do you diagnose osteoporosis?

The most common bone density test is a central dual-energy X-ray absorptiometry (DEXA) scan. A DEXA scan can be used to assess bone density in the hip or lower spine (the preferred method, the central bone), as well as the wrist, heel, finger, or other peripheral bone.12

DEXA scans are painless and noninvasive. They look like an x-ray but give more detailed information about bone structure.

DEXA scans are recommended for the following populations:11,14

  • Women aged ≥65 years
  • Men aged ≥70 years
  • Postmenopausal women and men aged 50 to 69 with risk factors
  • Postmenopausal women and men aged 50 and older with a history of a fracture as an adult

A DEXA scan produces two scores: a T-score and a Z-score. The T-score compares the density of your bones to that of a young adult of the same gender. A -1 or higher score is acceptable. A Z-score compares your bone density to the average for people your age, gender, and sex.12,13

World Health Organization’s definition of osteoporosis based on bone mineral density:11

CategoryBone MIneral densityT-score
NormalBone mineral density within one standard deviation of the mean bone density for a young adult reference populationT-score ≥–1
Low bone massBone mineral density is 1–2.5 standard deviations below the mean for the young adult reference populationT-score between 1 and -2.5
OsteoporosisBone mineral density is ≥2.5 SD below the normal mean for the young adult reference populationT-score ≤-2.5
Severe osteoporosisBone mineral density is ≥2.5 SD below the normal mean for the young adult reference population with one or more fracturesT-score ≤ -2.5 with fractures

Vertebral imaging should be performed in the following populations:11,14 

  • Women aged 70 and older and men aged 80 and older if their bone mineral density T-score is ≤−1.0 at a central bone; women aged 65 and older if their T-score is less than or equal to −1.0 at the femoral neck
  • Women aged 65 to 69 and men aged 70 to 79, if the bone mineral density T-score is ≤−1.5 at a central bone
  • Postmenopausal women and men aged 50 or older with the following risk factors:11,14 
  • A fracture after the age of 50 after minimal trauma
  • A loss of ≥1.5 inches in height when compared to height at age 20
  • A loss of ≥ 0.8 inches in height when compared to a previously documented height
  • Recent or ongoing treatment with glucocorticoids
  • The diagnosis of hyperparathyroidism

The Fracture Risk Assessment Tool (FRAX®) was developed to calculate 10-year probabilities of hip fracture and major osteoporotic fracture (defined as clinical vertebral, hip, forearm, or proximal humerus fracture).14

An x-ray showing thinning bone

How do you treat osteoporosis?

Approved treatments for osteoporosis include:11,14 

  • Bisphosphonates: Bisphosphonates such as alendronate, risedronate, ibandronate, and zoledronic acid inhibit the activity of osteoclasts and, therefore, slow bone loss. Bisphosphonates are considered first-line therapies for osteoporosis. Oral bisphosphonates can cause stomach upset, indigestion, heartburn, and gastroesophageal reflux disease (GERD).15 Rare side effects of bisphosphonates include a breakdown of bone in the jaw after prolonged use, atrial fibrillation, and rare, low-trauma atypical femur fractures.
  • Calcitonin: Calcitonin hormone inhibits osteoclast activity and thus reduces bone resorption. While it is not a first-line treatment for osteoporosis, it is recommended for women who are at least five years postmenopausal and have tried all other options.
  • Estrogen agonist/antagonists (previously called selective estrogen receptor modulators): Raloxifene and other estrogen agonists/antagonists are medications that act like estrogen in some tissues, such as bone, but have anti-estrogen effects in others, such as breast tissue. They are approved for both the prevention and treatment of osteoporosis. Raloxifene has been linked to an increased risk of deep vein blood clots, hot flashes, and leg cramps.
  • Hormone replacement (estrogen): Estrogen is approved to prevent (not treat) osteoporosis and relieve vasomotor symptoms and vulvovaginal atrophy associated with menopause. Unopposed estrogens may increase the risk of uterine and breast cancer, as well as blood clots, in some women.
  • Parathyroid hormone: Teriparatide is a recombinant form of the natural hormone parathyroid hormone. It is an anabolic hormone that is approved to treat postmenopausal women and men at high risk of fractures but is typically used for a maximum of two years.
  • Receptor activator of nuclear factor kappa-B (RANK) ligand inhibitor: Denosumab is a human monoclonal antibody that inhibits osteoclast activity and thus slows bone breakdown. It is approved for postmenopausal women who are at high risk of fracture and have not tolerated other medications. Denosumab may cause calcium deficiency and increase the risk of skin infections and rashes.
A family running

How can you prevent osteoporosis?

To reduce your risk of osteoporosis, try the following:11,16,14

  • Meet the Recommended Daily Allowance (RDA) for calcium (1000 mg/day for men aged 50–70 years; 1200 mg/day for women ≥51 years and men ≥71 years) and vitamin D (800 to 1000 units of vitamin D for adults aged 50 and older; recommendations vary by organization).
  • Engage in regular weight-bearing exercise that stresses bones.
  • While not reducing your risk of osteoporosis, incorporating balance exercises into your daily routine can reduce your risk of falling.
  • Avoid excessive alcohol intake.
  • If you smoke, try a smoking cessation program.
  • Limit your caffeine intake, especially if your calcium levels are low.
  • Consume a diet rich in calcium, magnesium, selenium, vitamin K, vitamin D, and protein to reduce fracture risk and heal a fracture.

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Author: Leann Poston, M.D.
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