Osteoporosis

Osteoporosis

The Time to Think
about It Is Now

For Debbie, life isn't what it used to be.

She can't go biking and hiking with her husband anymore, and her ability to travel is severely limited. She can't even take a car ride for longer than an hour and a half, because when she does, she's so stiff and sore afterward she can barely walk.

When she goes grocery shopping, she can't lift any packages weighing more than five pounds. Somebody has to take the bags from her car to her house.

Debbie says her days are very routine. She does her exercises at the same time every day, has a list of certain foods she must eat and follows a strict medication regimen. She's too afraid to veer from her set schedule for fear that any changes might send her disease into a tailspin.

Debbie has severe osteoporosis. She's 40 years old.

A Disease for the Young, Too

If you expected Debbie to be 78 or 85, you're probably not alone. Osteoporosis, the steady, progressive loss of bone density, is typically associated with elderly women because the results of the disease don't become apparent until those later decades, when we can see the loss of height and the dowager's hump that can be a precursor of fractures.

But osteoporosis has its roots much earlier. It starts slowly and silently and progressively gets worse if not attended to. It can begin at menopause, when estrogen levels start to drop. Sometimes the foundation is laid in the thirties or forties when, for a number of reasons, a woman doesn't achieve peak bone mass. And it may come even earlier, as it did for Debbie. Doctors don't know why she has the disease, but they think she probably started developing it in her late twenties, about ten years before she was diagnosed at the age of 37.

Debbie's case is unusual in that few women have severe osteoporosis at her age. But it's a reminder that while you may not have the disease yet, as a woman you are at risk for it. And now--not later--is the time to do what you can to prevent it.

Osteoporosis is much harder to treat than it is to prevent, says Harold Rosen, M.D., instructor of medicine at Harvard Medical School. Once there's a loss in bone density, it's very hard, and sometimes impossible, to regain what's already lost, he says.

"We're trying to get the message out to younger women that there are things they can do to help prevent osteoporosis," explains Kendra Kaye, M.D., clinical assistant professor of medicine at the University of Pennsylvania School of Medicine and attending physician at Graduate Hospital, both in Philadelphia. "We don't want women to wait until they already have the disease to start paying attention to it," she says.

The Risk for Women

While men can get osteoporosis, women are at much greater risk. An estimated 25 million Americans have the disease, and four-fifths of them are women. Hip fractures are a particular problem. The rate of hip fractures is two or three times higher in women than in men, and osteoporosis is the underlying cause of many of these injuries.

Bones tend to get stronger and build up through the teen years and into the twenties and thirties, says Dr. Kaye. In other words, the osteoblasts, or bone-building cells, outpace the osteoclasts, or bone-destroying cells, and bone continues to get stronger. When you're between 25 and 40, the bone reaches its maximum strength, she says. Afterward, the process that leads to bone buildup slows down. That is, the osteoclasts take the lead, and bone loss is greater than bone buildup. "At that point, you start to lose bone strength as the bones become thinner and thinner," Dr. Kaye says.

So bones can lose density just through aging. But there are two reasons women are at greater risk for osteoporosis, says Dr. Kaye. The first is that for whatever reason, women tend to achieve lower bone mass than men do. So whatever decline takes place after 40 affects their bones faster. The second is that women's bone loss accelerates at menopause. Estrogen helps stimulate bone growth; in addition, "estrogen improves the intestinal absorption of calcium," says Lorraine A. Fitzpatrick, M.D., associate professor of medicine at the Mayo Clinic and Mayo Foundation in Rochester, Minnesota. So when estrogen levels decline, there's not enough to protect bone, and that's when density drops.

Postmenopausal women lose about 2 to 3 percent of their bone density per year, and the loss continues at that rate for the first five to ten years after menopause. While that may not seem like much, if bone loss continues at that rate for a number of years, the total bone loss can be substantial. If a woman loses 3 percent per year over ten years, that's a 30 percent decrease in bone strength.

This substantial drop in bone density at menopause and during the first ten years after is the reason doctors often recommend that women take hormone replacement therapy (HRT), a formulation of hormones that replenishes a woman's declining level of estrogen. Research indicates that the use of HRT can decrease the risk of osteoporosis-related hip fractures by 50 percent. If you already have osteoporosis, HRT may increase bone density by as much as 5 percent.

How long women need to take HRT for it to be effective is a matter of debate. The Framingham Osteoporosis Study, which analyzed the bone density of 670 white women from the Framingham Study--which began in 1948 and followed women through their lives to evaluate risks for heart disease--indicates that HRT was most effective in women who took it for at least seven years. The study also found that women who took HRT for seven to ten years and then stopped were protected against declining bone strength only until the age of 75.

How the Risks Go On

Just the fact that you're a woman places you at risk for osteoporosis, but a slew of other risk factors are involved, ranging from things you can control, like your diet, to things you can't, like your family history.

If you're Caucasian or Asian, you're more likely to be affected by osteoporosis than if you're African American, says Dr. Kaye. And if someone in your family, say your mother or grandmother, has had the disease, that places you at increased risk as well, she says.

Although researchers aren't clear how the disease gets passed through the generations, there's some indication that a "vitamin D" gene may have something to do with it. Research from Australia indicates that there are different types of vitamin D receptors and that some are associated with good bone density, while others are associated with bad bone density, says Dr. Fitzpatrick. Women who inherit a certain type of vitamin D receptor may be more at risk for osteoporosis. The ultimate hope is to develop a screening test that could tell which women are at greater risk and that such a test could motivate high-risk women to take preventive measures early on, says Dr. Fitzpatrick.

Women whose diets are low in calcium are also at greater risk, says Dr. Kaye. Calcium is one of the central building blocks for bone, so if you're not getting enough, new bone can't form to replenish old. The National Institutes of Health recommend that premenopausal women get at least 1,000 milligrams of calcium a day, though many doctors recommend increasing that to 1,200 milligrams. Menopausal and postmenopausal women need more--about 1,500 milligrams.

Leading a sedentary lifestyle also places you at risk. Exercise such as walking or running, which places weight-bearing stress on bones, stimulates the bone tissue and triggers bone growth.

Women who smoke have also been found to be at increased risk. The reason is unclear, but experts suspect that smoking enhances the metabolism of estrogen, making less available to feed bone growth.

Overweight women appear to have somewhat less risk of bone fractures than women with low body weight. Possibly this is because extra weight stimulates additional bone formation. In addition, heavy women have more fat stores, which convert androgen hormones to estrogen, so they may have more estrogen available to spur bone growth.

But women who have been on and off diets, a phenomenon called yo-yo dieting, and women who have or have had an eating disorder, may be at increased risk because their bodies have been deprived of proper nutrition. And women who have amenorrhea (lack of menstrual periods), either because of an eating disorder or through exercise, may also be at increased risk. Since the absence of periods indicates a decline in estrogen, these women may be lacking the levels of estrogen necessary to stimulate bone growth.

Certain diseases and medications can be responsible for osteoporosis, experts say. Women with certain thyroid diseases, cancer, liver disease and rheumatoid arthritis are at greater risk for osteoporosis, says Dr. Fitzpatrick. And medications, particularly steroid hormones and anti-seizure medications, can contribute to the development of osteoporosis.

No Time like the Present

The stronger your bones are when you hit menopause, the better. If you're between 30 and 50 and haven't hit menopause yet, there's a lot you can do now to build up and maintain your bone strength.

Get your calcium. The typical American diet includes only about 300 milligrams of calcium, so most women need to add a lot more. Each serving of dairy food--an eight-ounce glass of low-fat milk, a cup of low-fat yogurt, a hunk of cheese--is worth about 300 milligrams. So aim to eat three additional servings of dairy foods a day.

Don't fear the fat. Don't shy away from dairy products because of their fat content. Practically every dairy product out there is available in a low-fat version, says Laurie Gibson Lindberg, director of patient education and information at the National Osteoporosis Foundation in Washington, D.C. Milk, yogurt, cheese and cottage cheese all come in low-fat and nonfat forms, she says.

Supplement your diet. Another quick, easy, fat-free way to add calcium to your diet is to take calcium supplements. "The most economical is calcium carbonate," says Dr. Rosen. Take supplements with a meal to aid absorbtion of the calcium from the stomach.

Read the label on your bottle of calcium supplements carefully. "Look at the fine print," says Dr. Kaye. Look to see how many grams of your tablet are considered "elemental" or "bioavailable"--that's the form of calcium that your body will absorb. If you're taking a 750-milligram supplement, probably only 300 milligrams will be elemental. So check to see that you are really getting the amount you think you are.

Look again at the label. Check the label to see if the tablets will dissolve in time to be absorbed by the body. (If they don't dissolve within 30 minutes, they will be excreted, and the calcium won't be absorbed.) Some pills don't dissolve in the stomach in a half-hour, says Dr. Kaye. Look for something like "this calcium supplement has passed the rigorous 30-minute dissolution test," she says. This will confirm that the pill has been tested for dissolvability.

Check the pills yourself. Test whether your calcium supplements will dissolve in your stomach in time through a simple home test. Put some vinegar in a glass, then put a supplement in it and let it sit for half an hour, says Dr. Kaye. Vinegar has roughly the same pH as the acid in your stomach, so if you come back after a half-hour and the supplement is dissolved, you can rest assured that your supplements will be absorbed by your body. If the pills you purchased don't dissolve, don't take them; try another brand. You might consider chewable calcium carbonate tablets (Tums) so dissolvability isn't a problem.

Set a time to take it. Plan to take your calcium at a specific time each day to make taking it a habit, says Lindberg.

Get a move on. Weight-bearing and impact-loading exercise have been shown to stimulate bone growth, so do your best to get enough. Generally, three sessions a week of about 20 to 30 minutes each are sufficient, says Dr. Kaye. But "if you can do more, that's wonderful," she adds. Things like walking, running, aerobics, or climbing stairs are best, whereas non-weight-bearing exercise like swimming is of little help. "Walking is one exercise that almost anyone can do that's good," says Dr. Kaye. Pick an exercise you like, adds Dr. Rosen.

Stay strong. "Work on strengthening your lower extremities," says Dr. Rosen. Fractures tend to happen when people fall, and people often fall because they're weak, he says. So strengthening your leg, hip, thigh and back muscles through weight training will help you build and maintain your strength and may help prevent a fall.

Give up the cigs. Quit smoking or cut back as much as you can. Smoking increases your risk for osteoporosis. Researchers suspect it's because smoking accelerates the metabolism of estrogen, making less available to stimulate bone growth.

Cut out caffeine. Reduce your caffeine intake as much as you can. While the results are contradictory, some studies indicate there may be a link between high caffeine intake and osteoporosis. The thinking is that caffeine may draw calcium from the bone and also cause it to be excreted rather than absorbed, since caffeine increases urination. If you're drinking about two cups a day, you probably don't have to worry, says Dr. Kaye. It's women who are drinking five cups or more a day who should try to cut back. Try weaning yourself off caffeine by mixing your caffeinated coffee with decaf a little at a time, she says.

Get your D. Vitamin D plays a key role in helping your body absorb calcium, so do your best to get enough. The current Daily Value is 400 international units. A cheap and easy way to get an adequate amount of vitamin D is to take a multivitamin, says Dr. Rosen. Because it is toxic in high doses, doctors do not advise taking vitamin D supplements with more than 800 international units.

Getting your vitamin D from milk is another possibility, but the amount of D in milk is not closely regulated, says Dr. Rosen. Many foods, including cereals, are fortified with vitamin D.

Schedule a family visit. If it's an option, take your mother and daughters with you to the doctor for a joint visit, says Dr. Fitzpatrick. That way the doctor can get a full family history and recommend some preventive measures for all the women in the family.

What to Do at Menopause

If you're in menopause, you're at higher risk for osteoporosis because your estrogen levels are declining. Here are some things to consider.

Consider HRT. Weigh the pros and cons of hormone replacement therapy with your doctor. By replacing diminishing levels of estrogen, HRT helps prevent the dramatic bone loss that occurs during menopause.

If your main objective for taking HRT is to prevent osteoporosis, you probably should continue taking it for at least seven years, research indicates. The therapy will prevent bone loss while you are taking it, but once you stop, bone density starts to decline again, experts say.

See your doctor. Even if you have decided that you don't want to take HRT, it's a good idea to be evaluated by a doctor to see if you have any other medical conditions that might increase your risk for osteoporosis, says Dr. Fitzpatrick. Contact the National Osteoporosis Foundation at 1150 17th Street NW, Suite 500, Washington, DC 20036 for a list of doctors who have a special interest in osteoporosis.

Get screened. If you're not going to take HRT, you should probably undergo a screening test to assess your bone mineral density. Different tests are available.

Keep exercising. Stay as active as you can through menopause; any weight-bearing activity or weight-lifting exercise you can do will stimulate your bone and help you maintain the bone mass you already have. It's best to consult a doctor and have a physical before embarking on any exercise program.

Boost that calcium. Increase the amount of calcium you take in to about 1,500 milligrams a day, experts say. Women in menopause require more calcium because as they get older, the absorption of calcium from the intestines drops, says Dr. Fitzpatrick.