Decoding Bone Health: Navigating Osteoporosis and Osteopenia for Women
My experience getting a bone density scan.
At my annual physical, the doctor announced I was due for a DEXA bone density scan according to the Medicare guidelines.
“We urge all female patients over sixty-five to get a baseline reading. That way, if it shows a problem, we can treat it. Over fifty percent of post-menopausal women will have osteoporosis in their lifetime,” Doc said.
The thought of having osteoporosis scared me.
Perhaps you’ve had friends or family members whose height steadily decreased or whose hip fracture was blamed on the condition.
And while I knew losing bone density could increase the chances of breaking a bone, I put off scheduling the test. Honestly, I was a little afraid. What if I had osteoporosis? Did that mean I’d have to give up hiking over fear I’d break a bone?
But other than my age and sex, I had few risk factors. I wasn’t thin, didn’t smoke, drank little alcohol, and paid careful attention to my nutrition. Plus, I checked my Vitamin D levels every year, and I’ve spent my adult life doing weight-bearing exercise, called work, in my case.
I did wonder whether spending nine years either pregnant or nursing may have depleted my body’s calcium and affected my bones.
Trauma caused my only broken bones. In fact, when I was forty and fell fifteen feet off a ladder, fortunately landing in the kitty litter box, I only had a stress fracture in my forearm. (No cat was present). When the radiologist looked at my x-ray, he’d said, “Well, that’s lucky! You have such dense bone structure I doubt you’ll ever have osteoporosis.”
But that was thirty years ago.
I agreed to do the bone density scan — and realized I needed to learn about bones and osteoporosis.
A Journey of Bone Density Through the Lifespan.
Our hair and skin become naturally thin as we age, so I wanted to know whether losing bone density is an inevitable progression or a disease to be treated.
It’s easy to see we inherit much of our bone size and strength. If you come from a family of tall people with large frames, you may wear a size ten shoe like me. Likewise, if the tallest person in your family is five foot six inches and small framed, you’ll favor that build.
Experts say genetic factors determine sixty to eighty percent of our height and structure. But that leaves a large percentage to be influenced by nutrition, exercise, and other environmental factors.
Our peak bone mass is formed during childhood, adolescence, and up through early adulthood, and exercise shapes that growth.
Most of those aged 50 or older remember whole days spent playing outdoors. Winter was my favorite time of year, ice skating, pulling sleds uphill, and racing with my friends, and we rarely spent summer indoors. None of us realized that play was producing strong bones.
But now, children in the United States receive a D- in physical activity, according to a report released by the Physical Activity Alliance.
The 2022 United States Report Card on Physical Activity for Children and Youth states:
Only twenty-one percent of US children and youth meet the guideline of 60 minutes of physical activity every day. In addition, physical activity levels drop as kids get older, with 42% of 6 to 11-year-olds meeting those guidelines but only 15% of 12 to 17-year-olds doing so.
Besides a lack of exercise, people of all ages are often deficient in Vitamin D, essential to developing strong bones. With the increased use of sunscreen and lots of time spent indoors, many of us should supplement this vitamin.
What about calcium? Despite widespread marketing by the dairy industry, less than 15% of adolescent girls are getting enough calcium. Seventy percent of the world’s population is lactose intolerant. Many others, like myself, choose a vegan diet, but we can meet our calcium needs directly from plants.
Fortunately, as we see in the chart below, plants provide calcium along with valuable protein and other nutrients essential to bone health at every age.
When do humans reach peak bone mass?
Most people reach their peak bone mass between 25 and 30; then, after age 40, we slowly lose bone mass. I was surprised to learn that even after bones are formed, they constantly change.
When another part of the body needs calcium, it is taken from the bones to meet the need. Looking back, I could have been more conscientious with my diet during my child-bearing years. I thought a lot about my kids' diets but not enough about mine.
Before thirty, humans build more bone than we lose. Those with a higher peak bone mass when young are better protected against osteoporosis and related fractures later in life.
This is especially critical for girls. The bone tissue accumulated from ages 11 to 13 just about matches what women will lose after menopause. I picture it as the chance to build a bank of strong bones when we’re young.
Sadly, this is the age when many girls worry about their weight and unnecessarily restrict their diets. As older women, we can look for opportunities to share the benefits of a healthy diet.
Osteoporosis has been called a pediatric disease with geriatric consequences. Bone-healthy nutrition and regular, vigorous exercise during childhood and adolescence are the critical ways to maximize a child’s genetic potential for strong bones — and a first step to osteoporosis prevention in later life. — IOF President, Prof. Cyrus Coope.
It’s clear that bone health is a lifelong commitment.
Bone density changes as we age.
Men develop a higher peak bone mass than women; that’s easy to see. However, it’s important to know that twenty percent of men do develop osteoporosis. If a man is losing height and developing a hunched posture, they may be experiencing bone loss, too.
Because women have smaller bones, they are more vulnerable to developing osteoporosis as the years draw down their bone reserves.
Since everybody’s bones become thinner as they age, when does this normal process become osteoporosis?
What exactly are osteoporosis and osteopenia?
The word osteo/porosis comes from two Greek words: osteo meaning bone, and porosis meaning porous.
Osteo/penia also includes osteo + penia, which means poverty.
Both words describe bone loss progression. The image shows how the bone becomes thinner and the pores grow.
A loss of height is usually the only outward sign a person may be losing bone mass. So, in most countries, doctors depend on a T-score determined from the DEXA scan. A T-score is a measurement comparing current bone density with normal bone mineral density (BMD).
- Normal BMD is a T-Score of -1 Standard Deviation (SD)
- Osteopenia is a T-score lower than -1 SD and greater than -2.5
- Osteoporosis is a T-score of -2.5 or lower
- Severe osteoporosis is a T-score of -2.5 or lower and at least one fragility fracture.
In general, the risk for bone fracture doubles with every SD below normal. Thus, a person with a BMD of 1 SD below normal (T-score of -1) has twice the risk for bone fracture as a person with a normal BMD.—from John Hopkins Medicine.
Twice the risk? That sounds alarming, but what is the chance that a 70-year-old person with average bone density will have a fracture?
Data from a long-term Swedish study of people, not divided by their bone density, showed a chance that 250 out of 100,000 seventy-year-old people fracture their femur in one year. That is one-quarter of 1%. By age eighty, it doubled to one-half of 1%.
So, we should be aware that statements such as ‘twice the risk’ can be hard to interpret regarding the likelihood of breaking a bone.
Does this mean we’re stuck with the bones we’ve got?
Not at all. But realize that bone density is only one part of your overall health. Rather than being paralyzed by less than optimal bone strength, let’s look at improving it.
All of us may have risk factors we can’t change.
Medications include long-term steroids, proton pump inhibitors, some diabetes medications, and more. Read a more complete list here.
But we can make choices to reduce bone loss and even encourage the production of more bone.
Things we can change include the items on the chart below.
Walking is a weight-bearing exercise, but dancing, jogging, and resistance weight training will also increase bone density. If your feet touch the ground, it’s weight-bearing. And exercise increases muscle strength and improves balance, greatly reducing the risk of falling.
Fractures aren’t a result of weak bones; they’re caused by falling.
However, falling is usually precipitated by poor balance and weak muscles. I’ve seen many older people nearly immobilized by a fear of falling, unwilling to walk on anything but level pavement, and afraid to lift anything heavy.
Exercise is recognized to be an effective and feasible treatment modality to prevent falls. Falls prevention exercise programs are generally multimodal, including balance and functional and resistance training, and can effect a 61% reduction in falls resulting in fracture.—Journal of Bone and Mineral Research.
Exercise is one of the best things we can do to optimize bone growth.
When is drug treatment for osteoporosis recommended?
That is a highly complex question with many things to consider. The goal of prescription drugs, in this case, is to reduce the risk of fracture by decreasing bone reabsorption or increasing bone formation.
But as we know, all drugs, including the most widely used, Fosamax, have limitations and must be used under the care of our doctors.
The American Association of Clinical Endocrinologists and American College of Endocrinology (AACE/ACE) recommends that pharmacological treatment should be initiated for:
- Patients with osteopenia or low bone mass and a history of fragility fracture at the hip or spine; or
- Patients with a T-score of −2.5 or less in the lumbar spine, femoral neck, total hip, or 33% radius despite the absence of a fracture; or
- Patients with a T-score between −1.0 and −2.5 if the FRAX 10-year probability for a major osteoporotic fracture is greater than 20% or for a hip fracture is greater than 3%.
Aha! I learned one more acronym, the Fracture Risk Assessment Tool (FRAX®). This tool was developed to help ordinary people and doctors understand a person’s risk of breaking a bone in a specified period.
All of us can use a basic online tool to help us understand our risk. After answering some basic questions, I was relieved to see that this simplified version of a FRAX test says there is less than a 1% chance that I’ll have a hip fracture in the next ten years.
I am beginning to understand the challenges doctors face. They must consider current research, pre-existing conditions, and additional recommendations to make the best choices for their patients.
My DEXA bone density test was easy.
Dual-energy X-ray absorptiometry, or DEXA, uses minimal radiation to produce pictures of the hips, femur, and forearm to measure bone loss. This machine has become the standard tool for diagnosing osteoporosis and osteopenia.
At my local imaging center, the same office that does mammograms, I simply lay fully clothed on a padded table while the technician took scans of my left forearm, hip, and lower spine. It was over in five minutes, and I was told the results would arrive within a week.
The report showed a T-score of -2 in my left forearm, the gray area termed osteopenia. I was grateful the experience had caused me to learn more about bone health and the risks of osteoporosis.
A few days later, my doctor’s nurse called to make an appointment to discuss the results and ask if I wanted to discuss medication.
After my days of studying, I felt confident to say, “Based on my research, medication is not recommended right now. But I’ll continue my healthy diet, take vitamin D, increase dietary calcium, and boost my weight-bearing exercise.”
Perhaps my experience will help you better understand bone density scanning, osteoporosis, and bone health. By understanding our risk factors, improving our nutrition, and exercising, we can improve our bone health at any age.
Knowledge helps us make informed decisions about our health in partnership with educated and experienced doctors.
Let’s encourage each other to maximize our health, including our bones.
Resources for more study: 1. Non-pharmacological management of osteoporosis: a consensus of the Belgian Bone Club
2. Can you improve bone health at any age?
5. Are Calcium Supplements Effective?
Cindy is passionate about people, plants, and health. To get her occasional newsletter, sign up here.