Osteoporosis is a disease that develops in the bone, lowering bone mineral density and bone mass. This reduces the strength of bones and increases the risk of fractures. Typically people do not have symptoms of osteoporosis and may not know they have the disease until they break a bone. Fractures from osteoporosis can occur in any bone in the body but are most common in the hip, spine, and wrist. Postmenopausal women and older men are most at risk for developing osteoporosis.
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Osteoporosis affects both men and women of all races and ethnic groups, though some populations are at higher risk than others. The population most at risk for osteoporosis is postmenopausal women due to the hormonal changes that occur during this time which affect bone density (1). African American and Hispanic women have an overall lower risk of developing osteoporosis than other races and ethnic groups. Among men, osteoporosis is more common in non-Hispanic whites.
Causes of Osteoporosis
Osteoporosis occurs when the rate of bone loss exceeds the rate of bone growth causing the bone tissue to become weakened. There are several different causes of osteoporosis and many people who develop the disease have several of the following characteristics:
- Sex: women are at a higher risk of developing osteoporosis compared to men due to their overall smaller bones and lower peak bone mass. Though men are still at risk, especially after the age of 70.
- Age: with advancing age, bone loss happens more quickly and new bone growth is slower. Over time this leads to weaker bones and a higher risk of developing osteoporosis.
- Body size: slender builds in both men and women lead to a greater risk of osteoporosis due to having overall less bone mass compared to larger-boned people.
- Race: white and Asian women are at the highest risk of developing osteoporosis. African American and Mexican American women have the lowest overall risk. Among men, whites are at a higher risk than African American and Mexican American men (2).
- Family history: those that have parents with osteoporosis are at a higher risk of developing osteoporosis themselves.
- Hormonal changes: low levels of certain hormones can affect your risk for osteoporosis (3).
- Low estrogen levels in women after menopause increase the risk of developing osteoporosis
- Low estrogen levels in women from the abnormal absence of menstruation due to either hormone disorders or extreme levels of exercise lead to a higher risk of osteoporosis
- Low levels of testosterone in men due to certain conditions can lead to the development of osteoporosis
- Diet: a diet low in calcium and vitamin D can increase the risk of developing osteoporosis. Excessive dieting and poor protein intake can also lead to osteoporosis.
- Medications: prolonged use of certain medications can increase the risk of osteoporosis including:
- Glucocorticoids which treat various conditions including asthma and autoimmune diseases
- Antiepileptic medications which treat seizures and neurological conditions
- Certain cancer medications which use hormones such as for breast or prostate cancer
- Proton pump inhibitors which lower stomach acid
- Selective serotonin reuptake inhibitors which treat depression and anxiety
- Thiazolidinediones which treat type II diabetes
- Co-morbidities such as endocrine and hormonal disease, gastrointestinal disease, rheumatoid arthritis, certain cancers, HIV/AIDS (4), and anorexia nervosa, among others, can increase the risk of osteoporosis
- Lifestyle: there are several lifestyle factors that can lead to reduced bone density and osteoporosis including:
- Low levels of physical activity or prolonged levels of inactivity can contribute to an increased rate of bone loss.
- Prolonged and heavy use of alcohol is a risk factor for the development of osteoporosis.
- Smoking is a risk factor for osteoporosis and fracture.
Summary: There are several different causes of osteoporosis including sex, age, family history, race, and lifestyle factors. Most people diagnosed with osteoporosis have a combination of several of these risk factors.
Signs and Symptoms
There are typically no symptoms of osteoporosis in the early stages of bone loss. Osteoporosis is called a “silent” disease because often the first symptom is a broken bone. Though once the bones have become significantly weakened by osteoporosis, signs and symptoms may develop including:
- Back pain caused by fracture or collapsed vertebrae
- Loss of height and stature
- A stooped posture
- A bone that breaks more easily than expected such as from bending or coughing
Doctors usually start screening for osteoporosis in all women over the age of 65 or women of any age who have risk factors that increase the chances of developing osteoporosis. The diagnosis of osteoporosis starts with a medical review and physical examination. The first thing your doctor will do is take your medical history with special attention to any history of fractures, lifestyle habits including diet, exercise, smoking, and alcohol use, family history, menstrual cycle history, medications, and any current or past medical conditions. During the physical examination, your doctor will be looking for any changes in height and weight, posture, balance, and muscle strength.
The most common test ordered for diagnosing osteoporosis is the dual-energy x-ray absorptiometry (DXA) which measures bone density in certain areas of the body that are prone to fracture from osteoporosis. The most commonly tested bones are the spine, hip, and forearm. This test uses low levels of x-rays as it moves a scanner over your body while you lay on a cushioned table. It is a quick and painless test.
The doctor will compare the results of your bone mineral density from the DXA scan to the average bone density of young, healthy people and to the average bone density of people of the same age, sex, and race. If your bone density is below a certain level you will be diagnosed with osteoporosis.
The DXA scan can also be used to evaluate changes in bone density in response to treatments to evaluate how well the treatments are working.
There are several different treatment options for those living with osteoporosis. They usually involve a combination of medication, exercise, fall prevention, lifestyle and dietary changes.
Treatment recommendations are often based on your risk of breaking a bone in the next 10 years taking into consideration your medical history and the results from your bone density test. If medication is recommended, there are several different classes of drugs that can be used.
Bisphosphonates are the most widely prescribed osteoporosis medications and work by slowing down bone loss, which can lower the risks of fractures. Side effects of bisphosphonates include nausea, abdominal pain, and heart-burn like symptoms. Some of these side effects can be avoided if given in the intravenous form, but this runs the risk of fever, headache, and muscle aches. Examples of bisphosphonates include Fosamax, Boniva, Atelvia, and Reclast.
This medication is made from a hormone from the thyroid gland and is approved for the treatment of osteoporosis in postmenopausal women who cannot take or tolerate medications for osteoporosis.
Denosumab is a monoclonal antibody and is administered via injection every 6 months. Compared with bisphosphonates, denosumab produces similar or better bone density results and reduces the risk of all types of fractures. There may be a high risk of spinal column fractures after stopping this drug, so it is recommended that if you start taking denosumab that you continue to take it indefinitely (5).
Estrogen can help maintain bone density, especially when started soon after menopause. The risks of estrogen therapy include breast cancer and blood clots, which increase the chance of stroke (6). A drug called Raloxifene mimics estrogen’s beneficial effects on bone density in postmenopausal women without some of the risks associated with estrogen.
In men, osteoporosis is linked with a gradual age-related decline in testosterone levels. Testosterone replacement therapy may help improve bone density, but osteoporosis-specific medications have been better studied and are thus recommended either alone or in addition to testosterone.
Severe osteoporosis is treated with bone-building medications. These are also recommended if common treatments for osteoporosis are not working well enough. These drugs stimulate new bone growth and are given by injection. If you stop taking any of these bone-building medications, you generally need to take another osteoporosis drug to maintain the new bone growth. Examples include Bonsity, Tymlos, and Evenity.
Exercise is one of the best ways to naturally improve bone density and is an important part of an osteoporosis treatment program. The best physical activities for bone health include strength training and impact exercises such as walking, stair climbing, and jumping if tolerated (7). Exercise that does not involve impact or body weight such as cycling and swimming does not help improve bone density. Bone is a living tissue and can get stronger with exercise, similar to working out for muscle strength. Though exercise should not put any excessive strain on bones that might lead to injury and fractures. Working with a physical therapist to teach specific exercises that are safe and appropriate for your level of strength and bone density is recommended.
Fall prevention is very important for those with osteoporosis since falling often leads to fractures in those with low bone density. These tips can help prevent falls:
- Wear well-fitted and supportive shoes with good traction
- Remove tripping hazards in your home such as rugs and cords
- Make sure pets are kept in enclosed areas when moving around the home
- Light up your living space, especially at night
- Install assistive devices such as handrails, nonslip treads, and a raised toilet seat with handrails
- Practice balance exercises in a safe space in the home or take up tai chi to improve balance
A healthy lifestyle is important for improving and maintaining bone density. The following lifestyle modifications can help optimize bone density:
- Drink alcohol in moderation: no more than one drink a day for women and no more than two drinks a day for men
- Avoid smoking and secondhand smoke
- See your doctor for regular checkups
Eating a healthy and balanced diet with foods containing calcium, vitamin D, and protein can help to prevent and treat osteoporosis. Calcium and vitamin D are important nutrients for preventing osteoporosis and improving bone density (8). When you don’t take in enough calcium, your body will take it from your bones resulting in weak and thin bones and osteoporosis. Good sources of calcium include low-fat dairy products, dark leafy vegetables, broccoli, sardines, and calcium-fortified foods such as soymilk, tofu, orange juice, cereals, and bread. Vitamin D is necessary for the absorption of calcium from the intestine. Good sources of vitamin D include fatty fish, fish oil, egg yolks, and liver.
The diet for osteoporosis should also include plenty of fruits and vegetables and an appropriate amount of calories for your age, height, and weight.
Summary: Treatment options for osteoporosis typically involve a combination of medication, exercise, diet, lifestyle modifications, and fall prevention. Treatment depends on the degree of bone loss present and individual characteristics such as strength and age.
Osteoporosis is a condition that lowers bone density and leads to an increased risk of fractures. It typically does not have any symptoms until a bone is broken. Osteoporosis is more common in women and the risk of developing osteoporosis increases as you age. Screening for osteoporosis starts in women at the age of 65 and involves a bone density scan. Treatments for osteoporosis involve a combination of medication, exercise, lifestyle modifications, fall prevention, and diet. If you have risk factors for osteoporosis or a history of broken bones, talk to your doctor today to get screened for osteoporosis and begin treatment to avoid further complications.