If your doctor has suggested a screening for osteoporosis – or even if your doctor hasn't – there are some basic facts about this common disease of brittle bones that every mature adult needs to know.

About 10 percent of North Americans over the age of 50 have the brittle bone disease osteoporosisTens of millions more have a condition of reduced bone strength called osteopenia, according to a review published in the Journal of Bone and Mineral Research.

Osteoporosis can cause chronic pain and permanent disability. It can arise on its own, as primary osteoporosis, or it can be a consequence of other conditions or the medications used to treat them, as secondary osteoporosis. But the important thing to know about osteoporosis is that it is often preventable, if you get a few years' head start on the disease.

Do you need to get screened for osteoporosis?

Osteoporosis is a stealth disease, so recognizing the early warning signs of brittle bones by yourself is a tough task. Decades of damage to bone may accumulate until some tiny impact, something as trivial as sneezing or picking up the cat, triggers a fragility fracture that leads to chronic pain and disability. The broken bones caused by osteoporosis can put you in nursing care. A substantial percentage of men die after osteoporosis-related hip fractures

For these reasons, the current thinking of the US Preventive Services Task Force is:

  • If you are a woman over the age of 65, you should get a baseline screening for osteoporosis even if there is no osteoporosis in your family and even if you are experiencing no symptoms.
  • If you are a man over the age of 70, you should get a screening, too.
  • Anyone who experiences a "fragility fracture," a broken bone from a minimal impact, should get screened for osteoporosis.
  • Anyone who is found to have compression fractures of the spine, the kind of tiny bone breaks that accumulate and cause vertebrae to collapse with resulting loss of height and/or lower back pain, likewise needs screening.

What kind of doctor should you see about osteoporosis?

Endocrinologists usually take care of people who have osteoporosis. The endocrinologist has a long-term interest in preventing fractures and helping you maintain and improve bone mineral density. There are some primary care providers who specialize in osteoporosis, but typically you will want to see someone in the endocrinology department.

Orthopedic surgeons are great for treating osteoporosis-related fractures, but they don't usually treat the underlying disease. ER doctors are even less invested in long-term care. If you have to get emergency treatment or emergency surgery for a fracture, you will probably get good care, as far it goes. But you may have to insist on a referral to an endocrinologist who sees osteoporosis patients to get the care you need to prevent more fractures from occurring in the future.

How do doctors test for osteoporosis?

The primary tool of osteoporosis screening is the DXA (sometimes abbreviated DEXA) dual energy x-ray absorptiometry scan. The term is a mouthful, but it's simply a method of measuring the mineral content of your bone. You lie on a table, under which is an x-ray source. A scanner moves over your body taking measurements of how much of the radiation gets through your bones. "Black" areas in the scan correspond to the mineral content of your bones. The test is painless, and the amount of radiation it uses is less than is required for x-rays (and thousands of times less than the amount of radiation in a CT scan). DXA scanning has become so common that it is less expensive than x-rays for detection of bone fractures.

The machine computes a T score that compares your bone mineral content to a standard. The figures are standardized for easy comparison to the bone mineral density of a healthy young person or a healthy person of your age, race, and sex. Positive scores indicate "better than average" bone mineral density. Negative scores indicate "less than average" bone mineral density. A score down to -1.0 is "normal enough." If your T score is less than -1.0 but greater than -2.5, you have osteopenia, which you consider a kind of "pre-osteoporosis." A T score of -2.5 or less indicates full-blown osteoporosis that requires immediate treatment.

Sometimes symptoms indicate a particular problem with osteoporosis of the spine. Maybe you have unexplained lower back pain. Maybe you have gotten shorter since your young adult years as your spine "settled." The doctor may order another test called the VFA, or vertebral fracture assessment. It's done with the same machine that is used for the DXA scan. It is also quick and painless, and not terribly expensive. In fact, doing the vertebral fracture assessment with conventional x-rays exposes you to twice as much radiation and the radiologist fees will run four times as much. 

If I my tests show that I have low bone mineral density, what will my doctor do?

The honest answer to this question is, "It depends."

If you have the condition of low bone mineral density called osteopenia, more and more doctors will advise you to exercise rather than giving you a prescription for a bone-building drug. The kind of exercise that maintains bone with lowest risk of exercise-related injury is resistance exercise, making your muscles work against the force of gravity. That can be as simple as walking. Flowing exercises like tai chi and yoga increase flexibility and balance, so you are less likely to take a tumble that breaks a bone. 

You will probably need to avoid some of the kinds of exercise that built bone when you were younger. Impact against the body stimulates bone building. That could have been the impact of pounding your feet on the ground when you jumped rope. Or it could have been the impact of a contact sport (provided, of course, the impact wasn't so great that it broke a bone). Or it could have been the impact of snatching a weight that you could barely lift.

Those kinds of impacts can prove to be too great for fragile bones. So you can pursue another aspect of exercise that stimulates the production of new bone, variety. Changes in exercise signal the bones that they need to remodel and rebuild. Do gentle exercise, but do lots of kinds of gentle exercise to stimulate your bones to deposit more minerals. Just be sure to get follow-up examinations to make sure that your exercise plan is working for you.

If you have full-blown osteoporosis, or if you have any kind of compression fractures of the spine, the doctor is going to recommend pharmaceutical treatment. Usually, bisphosphonates are the first line of treatment for osteoporosis.

Bisphosphonate medications are a class that includes:

  • Alendronate (Fosamax)
  • Clodronate (Bonefos, Loron)
  • Etidronate (Didronel)
  • Ibandronate (Boniva - US, Bonviva - Asia)Neridronate (Nerixia)
  • Olpadronate
  • Pamidronate (APD, Aredia)
  • Risedronate (Actonel)
  • Tiludronate (Skelid)
  • Zoledronate (Zometa, Aclasta)

They harden bone by slowing down the process that bones use to clear out old bone to make way for new bone. That makes their benefits strictly a short-term proposition. Healthy bones don't so much accumulate minerals as they "remodel" with them. Bisphosphonates interrupt the "remodeling" phase of bone growth. Crystals of bone don't get a chance to organize themselves into compact, strong, new bones. It's OK to interrupt the normal process of bone breakdown for up to about ten years, but then the doctor has to move on to a different kind of medication.

One approach to encouraging bone growth is hormone replacement therapy for osteoporosis, sometimes abbreviated HRT. In both women and men, the objective of hormone replacement therapy is to increase the availability of estrogen to bone. Women are given estrogen replacement therapy (usually with the addition of progestin in amounts that mimic the menstrual cycle to protect against cancer of the uterus). Men are given testosterone for osteoporosis, which their bodies turn into small amounts of estrogen used by bone. But HRT is also a short-term solution.

Doctors will treat osteoporosis with selective estrogen receptor modulators, also known as SERMs, to change the way bone responds to the small amount of estrogen still in circulation. SERMs are only available for the treatment of osteoporosis in women.The most often prescribed SERM is raloxifene (Evista). 

Sometimes doctors offer synthetic parathyroid hormone, a medication called teriparatide, marketed under the brand name Forteo. This intervention is also only for relatively short-term use, up to 18 months in a lifetime. There are shockingly expensive monoclonal antibodies that bind to and deactivate the hormones that break down bone. Doctors will offer one treatment after another after another, and the truth is, all of them offer some benefits, while none of the is perfect. But if you have osteoporosis, there are also things you need to do for yourself.

If I have osteoporosis, what do I need to do?

People who already have osteoporosis absolutely must get certain nutritional interventions for bone health:

  • Calcium supplements for osteoporosisYour body can't build bones without calcium. Some natural health gurus say that people who have osteoporosis don't need calcium. That's simply not true. They need more nutrients than just calcium, but calcium is an absolute must for building bones that have the density they need to avoid breaks. If you already have osteoporosis, you need to be taking 1,000 to 1,500 mg of calcium every day. It's more important to take calcium every day than it is to take the best absorbed calcium. What good does it do to buy a highly absorbable form of calcium like calcium citrate or calcium orotate and not take it? You should take calcium in divided doses, no more than 500 mg in any four-hour period. That is all the calcium that your digestive tract can absorb.
  • Fruits and vegetables, which are great sources of magnesium and potassium. If you have osteoporosis, you need to follow the five-a-day rule. Eat five servings of fruits and vegetables (that's five servings total, not five servings of each) every day. Up to nine servings may be beneficial. Fruits and vegetables, especially leafy greens, provide the alkaline "ash" that your kidneys need to maintain a non-acidic pH of the bloodstream. If you don't get this alkali, your kidneys will use calcium from bone. It is more important to get daily servings of plant foods than it is to take magnesium or potassium supplements. If you just can't get your veggies, then take 200 to 600 mg of magnesium every day. Potassium supplements aren't really practical. It is better to eat fruit to get the potassium your bones need to draw in the glucose and amino acids they use to make the collagen scaffold laid down by bone building cells called osteoblasts. There are substantial differences in bone health between people who eat their veggies and people who don't by age 70.
  • Vitamin D. The sunshine vitamin is essential for bone health in two major ways. Your digestive tract needs vitamin D to absorb calcium from food. And your bones need vitamin D to absorb vitamin D from your bloodstream. Countless conditions lead to vitamin D deficiency, but the main cause of deficient D may surprise you: It's overweight. Fat cells soak up vitamin D and keep it out of circulation. If you have a few excess pounds, then you probably need to be taking supplemental vitamin D. Anyone who has already been diagnosed with osteoporosis needs at least 1,000 IU of vitamin D, preferably in the form of D3, every day.
  • Vitamin K2 supplemets for osteoporosis (menaquinone, sometimes labeled as M-4 or M-7, M-7 being the preferred form). This underappreciated vitamin helps your body deposit calcium where it is needed (in the bones, for example) and keeps out of places where it is not (for example, the cholesterol deposits in your arteries). It is easy to get all the K2 your body needs by eating small servings of a Japanese fermented soy food called natto. It is more challenging to get your K2 from bright orange egg yolks, Irish butter, and French cheese. But it is easy to take a 45 mg K2 supplement once a day.

There are two other changes in lifestyle that can make a huge difference in osteoporosis. One is to stop smoking if you have osteoporosis, and to avoid second-hand smoke. The other is to drink only moderately (one to three drinks a week for women, four to six drinks a week for men) or less — too much alcohol depletes bone density. Both changes in lifestyle can be very challenging but very rewarding in preventing future fractures.

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