5 Steps to Strong Bones
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If your doctor has suggested that it’s time to start thinking about screening for osteoporosis—a disease that weakens bones and makes them more likely to break—there are a few things you should know about this common condition.
About 10 percent of Americans 50 and older have osteoporosis, and many more eventually develop a less severe form of low bone density called osteopenia, according to a 2014 review published in the Journal of Bone and Mineral Research. And an analysis published this past December in the journal Osteoporosis International found that hip fracture rates in older women are rising, after a decade of overall decline.
Here’s the latest thinking on osteoporosis—including the bottom line on who needs to get screened and when you should go on medication, plus the research on what you can do to keep your bones strong for decades to come.
Know When to Get Screened
The bone density test used to screen for osteoporosis is a low-dose X-ray known as a DEXA scan. It’s painless and quick; you lie on an exam table for 5 to 10 minutes while specific bones are scanned.
Women are about twice as likely as men to break a bone because of osteoporosis, according to the National Osteoporosis Foundation. So if you’re a woman 65 or older, you should have a baseline screening, according to the latest draft guidelines from the U.S. Preventive Services Task Force.
There’s less evidence for such screening in men, but preliminary research suggests that starting at “around age 80 is an optimum time,” says Robert Adler, M.D., chief of endocrinology and metabolism at McGuire Veterans Affairs Medical Center and a professor of epidemiology at Virginia Commonwealth University School of Medicine.
People with rheumatoid arthritis or who smoke, consume more than three alcoholic drinks a day, have had prolonged prednisone treatment, or previously experienced a fracture from only minimal impact should talk to the doctor about starting screening earlier—for women, around menopause, says Andrea Singer, M.D., director of the bone densitometry program at MedStar Georgetown University Hospital and a spokeswoman for the National Osteoporosis Foundation.
Healthy women 65 or older with a normal result on a bone density scan may not need another one for up to 10 years—as long as your risk factors don’t change. If you are told that you have osteopenia, you will need a follow-up scan somewhere between three and five years later; if you have osteoporosis, go for repeat testing every two years.
Test Your Steadiness
People 55 and older who are unsteady have more than twice the risk of an osteoporosis-related fracture compared with those with better balance, according to a Swedish study.
“Poor balance is one of the leading reasons for falls, which can cause a potentially devastating fracture even in people without osteoporosis,” explains Marvin M. Lipman, M.D., Consumer Reports’ chief medical adviser.
You can easily gauge your balance through two quick self-tests. Try both: “If you can’t do heel-to-toe walking (taking steps with one foot directly in front of the other) or stand on one leg for at least 30 seconds, you may have a balance problem,” Lipman says.
If you flunk one of these tests, speak with your primary care provider. Studies have shown that a prescription for physical therapy can help strengthen your muscles and improve your balance.
Eat a Well-Balanced Diet
Women who ate a diet thought to curb inflammation—rich in vegetables, fruits, fish, and whole grains—had better bone density and (in Caucasian women under 63) fewer hip fractures, according to a large study published last year.
Along with plenty of veggies and whole grains, you should also eat foods rich in calcium—a mineral key to building and preserving bone. An 8-ounce cup of skim milk or fortified orange juice has 300 mg of calcium; you should aim to get at least 1,000 mg a day.
“This is particularly important for older adults, since bone in this age group is broken down at a faster rate than it’s built,” says Abby Abelson, M.D., chair of the Cleveland Clinic’s department of rheumatic and immunologic diseases.
Other research has found that consuming plenty of magnesium and potassium—two nutrients found in fresh fruits and vegetables—is associated with better bone density in people older than 69.
Try Exercise Before Drugs
If you’re one of the 44 million Americans diagnosed with osteopenia, your doctor may suggest medication. But most of the time that’s unnecessary.
In fact, most new prescriptions written after a DEXA scan may be inappropriate—about two-thirds of them, according to a 2016 study in JAMA Internal Medicine.
“Women are getting screened in their 50s, diagnosed with osteopenia, and put on medication,” Lipman says. But those drugs can have side effects, such as stomach upset and heartburn. In rare cases, some can paradoxically cause thigh fractures or jawbone damage.
For most cases of mild bone loss, try weight-bearing exercises first, such as lifting weights or walking (at least 30 minutes a day).
Exercise can reduce the risk of fracture by helping to maintain bone density and can reduce risk of falls by improving balance and strengthening muscles. Getting at least 1,000 mg of calcium and 600 international units (IU) of vitamin D daily (800 IU if you’re 70 or older), avoiding smoking, and limiting alcohol can also help keep bones strong.
There are situations, however, where it may make sense to take medication if you have osteopenia, especially if your bone density is right on the cusp between osteopenia and osteoporosis.
“If your physician performs a fracture risk assessment [called FRAX] and you have a 10-year risk of osteoporotic fracture of at least 20 percent or a risk of hip fracture of at least 3 percent, then you should definitely consider drugs,” says Susan Hingle, M.D., chair of the Board of Regents for the American College of Physicians.
Understand Your Meds
Most of the time, if you and your doctor decide you need medication—either for osteoporosis or osteopenia—a group of drugs called bisphosphonates should be your first-line treatment, Adler says.
These drugs, which include alendronate (Fosamax and generic), ibandronate (Boniva and generic), and risedronate (Actonel and generic), bind to the surface of your bones, slowing down erosion so that the cells that build bone strength can be more effective.
If you have severe osteoporosis, however, most doctors now recommend first opting for a different class of drugs called anabolics, such as teriparatide (Forteo) or abaloparatide (Tymlos), Adler says. Research shows that they may be more effective in severe cases than the bisphosphonates, but there are downsides: Anabolics are very expensive, require daily injections, and shouldn’t be taken for more than two years (there’s limited safety data for prolonged use).
That’s why they’re only recommended for the most severe cases. After the two years are up, you’ll need to switch to another type of therapy, such as a bisphosphonate.
Even with bisphosphonates, most of the time you shouldn’t be treated for more than five years. The research, though limited, suggests that “there’s no benefit of being on these drugs for longer,” Adler says.
About two years after stopping, you should have another scan. If your bone density is stable, you don’t need to restart meds, but if it has decreased again, you can either go back on a bisphosphonate or try a different drug, such as the semi-annual injectable denosumab (Prolia).
Supplements or Calcium-Rich Foods?
Just a decade ago, doctors were advising everyone—especially postmenopausal women—to take calcium and vitamin D supplements as a way to ward off bone thinning and risk of fractures. But because research hasn’t borne out these benefits, the thinking has changed.
Adults older than 50 who take these supplements are no less likely to have a fracture than those who don’t, according to a review of more than 50,000 people published last December in the Journal of the American Medical Association.
“This paper just reaffirmed what we already suspected—that supplementation alone doesn’t really decrease the risk of fracture,” Lipman says.
Our experts still recommend getting adequate calcium. But the right way is through your diet (not supplements) so that your body can better absorb it, Lipman says.
Vitamin D is trickier because most of us don’t get enough from either food or sunlight, the two main sources. So it’s reasonable, Lipman says, to take a daily supplement of 400 to 800 IU vitamin D for people younger than 50, and 800 to 1,000 IU for people 50 and older.
Editor’s Note: This article also appeared in the April 2018 issue of Consumer Reports On Health.
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