4 Proven Steps to Prevent Osteoporosis Fractures

By: Scott Boden, MD

Osteoporosis and spine fractures
While it receives a lot of attention in the media, still few people understand how prevalent osteoporosis and related fractures—which bring painful disability—truly are, especially within the high risk population with a failure for weight loss. In the U.S., about 8 million women and 2 million men have osteoporosis, and another 34 million Americans have low bone mass. In total, these 44 million people represent 55 percent of the people aged 50 and older in the United States. After age 50, one in every two women and one in every four men will sustain some type of osteoporosis-related fracture¹.

Osteoporosis is a condition marked by low bone mass (a thinning of the bone), which can lead to a weakening of the bone architecture and increased susceptibility to fracture (usually of the hip, wrist and/or spine). In the spine, fractures can lead to chronic pain, decreased physical function, spinal deformity (e.g. dowager’s hump), social isolation, and, in rare cases, complications that can cause death. Spinal fractures from osteoporosis are quite common, with an estimated 700,000 compression fractures occurring each year².

Unlike many other common causes of back pain, osteoporosis and associated spinal fractures (also called “vertebral compression fractures” or “vertebral fractures”) are largely preventable. This article focuses on the most important action steps for people at risk for osteoporosis, those with a diagnosis of osteopenia (low bone density, the precursor to osteoporosis), or those already diagnosed with osteoporosis:

1. Understanding risk factors for osteoporosis
2. Getting a bone density test to assess bone mass
3. Developing an individualized plan to fight osteoporosis
4. Making lifestyle and health changes (including taking prescribed medications and actively monitoring bone health) designed to slow bone loss and build bone density

Osteoporosis risk factors
The first step in preventing osteoporosis and associated spine fractures is to determine whether you are at risk or high risk for developing the bone condition.

Risk factors for osteoporosis³ include:

• Advanced age. Those over 65 years of age are at particular risk.
• Gender. Women are at much greater risk, losing bone more rapidly than men due to menopause. However, men are also at risk and constitute 20% of the patient population with osteoporosis.
• Family and personal history. This includes family history of osteoporosis, history of fracture on the mother’s side of the family, and a personal history of any kind of bone fracture as an adult (after age 50).
• Race. Caucasian and Asian women are at increased risk.
• Body type. At greater risk are small-boned women who weigh less than 127 pounds.
• Menstrual history and menopause. Normal menopause alone increases a woman’s risk of osteoporosis. Early menopause or cessation of menstruation before menopause increases the risk even more.
• (Males) Hypogonadism (small gonads, e.g., testosterone deficiency)
• Lifestyle. Lifestyle behaviors that increase osteoporosis risk include: calcium and/or vitamin D deficiency; little or no exercise, especially weight-bearing exercise; alcohol abuse; cigarette smoking.
• Chronic diseases and medications. Certain types of medications can damage bone and lead to what is termed “secondary osteoporosis”. This type of osteoporosis is estimated to occur in almost 50% of pre-menopausal women with osteoporosis and from 30% to 60% of men with osteoporosis. Also, secondary osteoporosis can cause further bone loss in postmenopausal women and older men with primary osteoporosis⁴. Included in this category are certain medications to treat endocrine disorders such as hyperthyroidism, marrow disorders, collagen disorders, gastrointestinal problems and seizure disorders. Use of glucocorticoids (steroids) to treat diseases such as asthma, rheumatoid arthritis and inflammatory bowel disease, especially the oral form of these medications (at higher doses and over longer periods of time e.g., more than 2 months), can be particularly damaging to bone. Given the serious nature of the diseases these medications treat, it is not advisable to alter or stop taking these drugs unless under a physician’s advice.

People considered at especially high risk for developing osteoporosis include:

• All women over age 65.
• Women less than age 65 who are postmenopausal and have one or more of the above described risk factors for osteoporosis.
• Postmenopausal women who experience any type of bone fracture.
• Men who have a testosterone deficiency.

For those with any of the above risk factors for osteoporosis, it is advisable to get a bone density test to assess bone mass and the presence of osteoporosis. Knowledge of one’s bone density is vital to developing an appropriate action plan to prevent worsening of the condition and hopefully prevent a painful osteoporosis-related fracture.

Bone density testing

The second step in preventing osteoporosis and associated spine fractures is to get an assessment of bone mass. A bone density test (also termed “bone mineral density test” or “BMD test”) is the gold standard diagnostic procedure used to detect osteoporosis. The test measures bone mass, usually in the hip and lumbar spine, quickly and painlessly.

According to the National Osteoporosis Foundation and the U.S. Preventive Service Task Force, a bone density test is recommended in the following situations:

• All women over age 65
• Postmenopausal women under age 65 who have multiple risk factors
• At menopause, if undecided about hormone replacement therapy
• Abnormal spine x-rays
• Long-term oral steroid use
• Hyperparathyroidism (over-active parathyroid gland)

DEXA scan⁵
The established standard for measuring bone density is the dual energy x-ray absorption scan (termed a DEXA scan or DXA scan). The test is performed by passing low energy x-rays through a bone, most often of the lower spine and hips. The DEXA scan results will indicate whether a person has normal bone density, low bone mass, or osteoporosis. This particular bone density test is the only one that can be used to diagnose osteoporosis and track bone density changes over time.

While bone mass density testing involves a low level of radiation exposure, most medical professionals agree this risk is low (e.g., just a fraction of the exposure in a chest x-ray) compared with the benefits of identifying osteoporosis before a fracture occurs.

Patients are advised to decide with their physician whether or not to have a DEXA bone density test. Given the criticality of early diagnosis and prevention of osteoporosis to avoid a fracture, patients who believe they are at risk for osteoporosis are encouraged to proactively bring up the topic of bone density testing to discuss with their treating physician.

Medicare usually covers the cost of a DEXA scan to screen for bone density for the following groups of individuals:

• Women over 65 years of age
• Women less than 65 who have significant risk factors for osteoporosis
• Men who have significant risk factors for osteoporosis.

Medicare may cover follow-up tests every 2 years for certain individuals. Private insurance companies vary in their coverage of DEXA scans, and many will cover screening DEXA scans provided that the patient has several osteoporosis risk factors. As of 2006, the cost of a DEXA scan typically ranges from about $125-$350.

A combination of results of the DEXA bone density test, a thorough history and physical exam, and any other necessary examinations and diagnostic tests, will provide the facts to accurately diagnose both:

1. The presence of osteopenia (loss of bone density, a precursor to osteoporosis) or osteoporosis, and;
2. Whether osteoporosis is a primary problem or secondary to another problem (e.g., long-term use of oral steroids). This distinction is important because the treatments are often different.

Regardless of the stage of osteoporosis, the next step in outsmarting the disease is to develop a personalized treatment plan to slow bone loss and/or rebuild bone density to help avoid an osteoporosis-related fracture of the spine or other bones.

Individualized osteoporosis treatment plan

The patient at risk for osteoporosis and the treating physician (or team of medical professionals, as necessary) together should develop the treatment plan for slowing the patient’s bone loss.

It is important to note that while there are many “ideal” behaviors that sound great in theory, the hard part is often in the implementation.  For many patients, behavioral changes such as stopping smoking altogether, radically changing a diet to include adequate calcium and Vitamin D intake, and starting a regular exercise program often present quite a personal challenge.  When designing a treatment plan, it is advisable for the patient to honestly discuss with the physician any impediments to completing the treatments.  For example, if a patient experiences lack of balance or dizziness while exercising, discussing this with the physician and tailoring the treatment plan to address this problem will help the patient follow through on the exercise plan.  While the changes in a patient’s behavior are often difficult to undertake, they are definitely worth it when one considers the negative consequences of sustaining an osteoporosis-related fracture.

Most osteoporosis treatment plans will include a combination of some or all of the following lifestyle and health changes to slow bone loss and, ideally, rebuild bone strength in an effort to prevent a fracture:

• Osteoporosis medications
• Calcium and Vitamin D requirements
• Regular weight-bearing exercise
• Stopping smoking, alcohol abuse
• Monitoring osteoporosis

Osteoporosis medications

If a DEXA scan shows bone loss, the treating physician may prescribe an osteoporosis medication. These medications work to either slow/stop further bone loss or to increase bone formation.

The choice of osteoporosis medication to prescribe is based on a number of variables, including the gender of the patient, the type of osteoporosis (primary or secondary), the age of the patient, the number of years a female patient is post-menopause, and the preferred method of drug administration (by mouth, by injection, etc.). Currently, the medications approved by the U.S. FDA for the prevention and/or treatment of osteoporosis include:

• Bisphosphonates – e.g., Alendronate (e.g., brand name Fosamax), Ibandronate (e.g., brand name Boniva), Risedronate (e.g., brand name Actonel).
  • Alendronate is approved for the prevention and treatment of postmenopausal osteoporosis. Alendronate also is approved for treatment of glucocorticoid-induced osteoporosis in men and women and for the treatment of primary osteoporosis in men. It is taken orally once per day or once per week.
  • Ibandronate is approved for the prevention and treatment of postmenopausal osteoporosis. It is taken as a once-a-month pill.
  • Risedronate is approved for the prevention and treatment of postmenopausal osteoporosis. It is also approved for use by men and women to prevent and/or treat glucocorticoid-induced osteoporosis. It is taken orally once per day or once per week.

  Side effects for bisphosphonates are generally mild to moderate and usually do not require stopping treatment, such as gastrointestinal problems (e.g., constipation, difficult or painful swallowing, chest pain), abdominal or musculoskeletal pain (e.g., joint pain, back pain), nausea, heartburn, or irritation of the esophagus. Serious side effects, while rare, can include osteonecrosis of the jaw (death of bone tissue, which can result in toothache, loose teeth, jaw pain, etc.) and of visual disturbances – these issues should be reported to the healthcare provider immediately.⁶

  To avoid damage to the esophagus and to ensure that food or other oral medication doesn’t interfere with absorption, bisphosphonates should be carefully taken according to the instructions. These instructions include taking the drug in the morning upon waking and during a specific time period before eating. The drug should be taken with a glass of water, and the person should remain upright for a specific time period after taking it. These drugs should not be taken by people who cannot stand or sit upright or who have disorders that prevent esophageal emptying into the stomach.⁷

• Calcitonin – e.g., Miacalcin, Calcimar, Fortical. Calcitonin is a naturally occurring hormone involved in calcium regulation and bone metabolism. It is approved for use in postmenopausal women, and is taken as an injection or nasal spray.

  Calcitonin taken as an injection may cause an allergic reaction. A skin rash or hives requires medical attention. Other side effects may occur and should subside as your body adjusts to the medicine; a doctor should be consulted if these symptoms persist or are bothersome: diarrhea; flushing or redness of face, ears, hands, or feet; loss of appetite; nausea or vomiting; pain, redness, soreness, or swelling at place of injection; stomach pain; increased frequency of urination; chills; dizziness; headache; pressure in chest; stuffy nose; tenderness or tingling of hands or feet; trouble in breathing; weakness. Side effects for calcitonin taken by nasal spray are uncommon but may include nasal irritation, backache, bloody nose, and headaches.⁸

• Estrogen/hormone therapy – either estrogen alone (e.g., Estraderm, Ogen, Premarin) or estrogen and progestin (e.g., Activella, FemHrt, Prempro) are used together to manage symptoms of menopause. They have also been shown to decrease the risk of fractures in the hip and spine in postmenopausal women. However, given recent findings that certain types of hormone replacement can increase a patient’s risk of certain cancers, stroke or heart attack, patients are currently advised to consider other osteoporosis medications.

• Selective Estrogen Receptor Modulators – Raloxifene (e.g., Evista). This class of drugs was developed to provide the benefits of estrogens without their disadvantages. Approved for postmenopausal osteoporosis, Raloxifene is taken orally once a day.

  Most side effects of Raloxifine are mild, and include hot flashes and leg cramps. A rare but serious side effect is blood clots in the veins (deep vein thrombosis). A physician should be notified immediately if the patient has pain in the calves (lower part of legs), leg swelling, sudden chest pain, shortness of breath, if coughing up blood, or if changes in vision occur.⁹

• Parathyroid hormone – Teriparatide (e.g., Forteo), the only approved treatment for osteoporosis that increases bone formation (rather than slows bone loss). It is approved for the treatment of osteoporosis in postmenopausal women and men who are at high risk for a fracture. Teriparatide is self-administered as a daily injection for up to 24 months.

  The most common side effects of teriparatide include nausea, leg cramps and dizziness. They may also include: pain, headache, weakness, diarrhea, and depression. A doctor should be notified if any of these symptoms are severe or do not go away. While rare, more serious side effects can occur, and medical help should be sought immediately if any of the following occur: chest pain; fainting; difficulty breathing; fever, sore throat, chills, and other signs of infection; upset stomach; vomiting; constipation; lack of energy; or muscle weakness.

  Forteo carries a strong caution from the FDA. In the pre-approval studies of Forteo using rats, there was an increase in the incidence of osteosarcoma, a rare but serious cancer of the bone. It is possible that people treated with Forteo could be at increased risk for developing this cancer. Patients are advised to speak with their doctors about the risks of taking this medication. Because of this risk, teriparatide is usually not used to prevent osteoporosis, to treat mild osteoporosis, or by people who can take other medications for osteoporosis. Patients should not use teriparatide unless they have osteoporosis and at least one of the following conditions is met: they have already had at least one bone fracture; their doctor has determined that they are at high risk of fractures; or they cannot take or do not respond to other medications for osteoporosis. Patients should tell their doctors if they have or have ever had a bone disease such as Paget’s disease, bone cancer or a cancer that has spread to the bone, or radiation therapy of the bones. The doctor can order certain tests to see if teriparatide is appropriate for the individual. People who are prescribed Forteo should receive an FDA-approved medication guide that explains the benefits and risks and gives other advice about how to use the treatment properly.

Calcium and Vitamin D requirements

Sufficient amounts of calcium are required for bone strength. The body uses calcium for the heart, blood, muscles and nerves. Without the proper amount of calcium intake, the body will strip calcium from the bones where it is stored, causing the bones to get weaker. It is estimated that 55% of men and 78% of women over age 20 in the U.S. do not get enough calcium in their diet¹¹. It is important to note that since the human body cannot produce its own calcium, adequate calcium intake is vital.

Calcium intake
The recommended amounts of calcium for adults are as follows¹²:

• For pre-menopausal women 25-50 years old and post-menopausal women on estrogen replacement therapy: 1,000-1,200 milligrams of calcium per day. 1,500 milligrams of calcium per day is recommended for pregnant or lactating women.
• For postmenopausal women less than age 65 not on estrogen replacement therapy: 1,500 milligrams of calcium per day.
• For men ages 25-65: 1,000 milligrams of calcium per day.
• For all people (women and men) over age 65: 1,500 milligrams of calcium per day.

Correcting a calcium deficiency has several components:

• Eating a diet rich in calcium that provides the recommended daily amount of calcium to help bone strength and weight loss. Calcium is especially prevalent in dairy products, dark green leafy vegetables (e.g., broccoli, kale, turnip greens, Chinese cabbage), beans and peas, calcium-set tofu, seeds, nuts and some fish. Many foods may also be fortified with calcium, such as orange juice, cereal and breakfast bars. Nonfat powdered dry milk can be added to many mixes and meals as another way to enhance their calcium content.
• Adding calcium supplements if daily diet cannot be altered to provide adequate levels of calcium. Even though calcium supplements are available without a prescription, a health professional (e.g., doctor, dietician, pharmacist) should help patients determine what form, what compound, what amount of elemental calcium (varies across supplements), etc., is best for them. Usually, absorption of calcium supplements is most efficient at individual doses of 500 mg or less and when taken between meals.
• Limiting foods known to cause the body to excrete more calcium than normal. Notable substances include sodium and chloride (found in table salt) and caffeine (primarily found in coffee, tea and soft drinks).
• Addressing a vitamin D deficiency. Vitamin D helps with absorption of calcium from the gastrointestinal tract and with resorption of calcium in the kidneys that would otherwise have been excreted. Like calcium, it is estimated that most people do not get enough vitamin D. Data from the Institute of Medicine suggest that more than 50% of younger and older women are not consuming recommended amounts of vitamin D¹³.

Vitamin D intake
The recommended amounts of vitamin D for adults are as follows:

• For people over 50 (and postmenopausal women): 400-800 i.u. of vitamin D per day. For people over 65 or 70, at least 600 i.u. is usually recommended.
• For people 25-50 years old (and premenopausal women): 400 i.u. of vitamin D per day.

Correcting a vitamin D deficiency has several components:

• Eating a diet rich in vitamin D. This is more challenging than calcium as vitamin D is found naturally in only a few foods, like fatty fish (e.g., salmon), liver and cod liver oil, and egg yolks. However, vitamin D fortified foods, such as many types of milk, cereal, bread, and orange juice, are widely available.
• Exposing the body, primarily the face, hands and arms, to sunshine. With direct exposure to sunlight, vitamin D is manufactured in the skin. Ten to fifteen minutes of sunshine two to three times per week will satisfy the body’s need for vitamin D. However, as people age they are less able to make vitamin D through the skin. Additionally, sunscreen reduces the body’s ability to absorb sunlight needed to manufacture vitamin D.
• As necessary, taking a vitamin D supplement. Calcium supplements and multivitamins also can contain vitamin D, so patients are advised to read all labels carefully, and if necessary, to discuss intake with their physician or pharmacist. Since excessive doses of vitamin D can be harmful, patients are advised to talk with their doctor about the right intake for their particular situation. The Institute of Medicine recommends no more than 2,000 i.u. per day.

Appropriate intake of calcium and vitamin D is crucial in the prevention and slowing of bone loss, but can be difficult to achieve on a daily basis. Careful planning and tracking are often necessary to ensure the individual is getting adequate amounts across all sources.

Regular weight-bearing exercise

The importance of exercise in the fight against osteoporosis cannot be underestimated. Lack of regular exercise can make good changes in diet have little effect on bone mass. Starting the right kind of exercise in combination with other preventive measures like appropriate calcium intake, can help build bone mass especially in high risk fracture sites like the wrist, hip and spine.

Putting stress on the bones fights fractures
The key here is “weight bearing exercise” – which means exercise one performs while on their feet that works the bones and muscles against gravity. Popular forms of weight bearing exercise include:

• Walking
• Jogging
• Stair climbing
• Dancing
• Hiking
• Volleyball
• Tennis
• Certain types of weight lifting/resistance exercises (e.g., squats)

The particular form of exercise will depend on the person’s overall physical health, the extent of bone loss, and whether the person already regularly engages in physical activity. It is recommended that individuals speak with their physician about the appropriate types of exercise to include in their osteoporosis treatment plan, especially people who have been sedentary most of their adult life or who are already diagnosed with low bone mass (termed “osteopenia”) or osteoporosis. Certain movements, like those that require twisting of the spine or bending forward from the waist (like sit-ups or toe touches), and most high-impact exercise, can put certain people at risk for fracture and should be avoided.

Recommendations on frequency of exercise needed to increase bone density vary. Depending on one’s diagnosis and doctor-recommend activity restrictions, typical exercise routines that are recommended may range from:

• 20-30 minutes of aerobic exercise 3 to 4 times weekly, to
• 30 minutes of moderate physical activity every day plus strength training 2 to 3 times per week.

Many patients benefit from working with an exercise specialist (trained in exercise physiology, physical education, physical therapy, or a similar specialty) to learn the proper progression of exercise, how to stretch and strengthen muscles safely, and how to correct poor posture habits. This is particularly true for those with relatively advanced osteoporosis (who are most at risk for a fracture) and those who are starting a new exercise program. The exercise specialist should be familiar with the special needs of people with osteoporosis.

Stopping smoking, alcohol abuse

Two lifestyle habits, considered diseases in certain cases, that are important to eliminate are smoking and excessive use of alcohol.

Smoking in any amounts has a detrimental effect on bone density. Alcohol intake of greater than 3 ounces per day (about six typical drinks) has been shown to increase bone loss. If one considers that studies have shown that people who smoke are more likely to drink than nonsmokers and that people who drink are more likely to smoke than nondrinkers, it is no surprise that stopping either activity (or both) can be particularly difficult. Patients with either of these problems are advised to address these factors as part of their osteoporosis and fracture prevention plan and seek appropriate medical treatment as necessary.

Smoking and osteoporosis
Smoking impacts a person at risk for developing osteoporosis in several ways¹⁴. In studies, smoking has been shown to:

• Reduce blood supply to the bones
• Slow the production of bone-forming cells
• Impair the absorption of calcium
• Reduce the protective effect of estrogen replacement therapy

Because those who smoke have weakened bones, they are more likely to experience exercise-related injuries, such as fractures or sprains. When they do sustain a fracture, it takes longer to heal. If surgery is required to repair a fractured bone, then a person who smokes is more likely to have a longer recovery period and greater risk of complications following the surgery than one who doesn’t smoke.

While it is very difficult for many individuals to quit smoking, for a person at risk for osteoporosis quitting smoking is definitely worth the effort as it will greatly reduce the risk of sustaining a fracture.

Excessive alcohol and osteoporosis
The effect of moderate alcohol use on bone health is unclear, and some studies suggest moderate alcohol intake (usually defined as up to one drink per day for women and up to two drinks per day for men) is beneficial. However, the damaging effects of heavy alcohol use are fairly consistently supported. Although alcohol’s damaging effects on bone are most striking in people who drink heavily during adolescence and young adulthood, research has shown that elderly women (between the ages of 67 and 90) who consumed an average of more than 3 ounces of alcohol per day (the equivalent of six typical alcoholic drinks) had greater bone loss than women who had minimal alcohol intake (Hannan et al. 2000).¹⁵

The exact way alcohol affects bone isn’t entirely understood, but it seems to interfere most with bone formation. As with smoking, excessive alcohol use has a wide range of damaging health effects for any person, but is particularly damaging for persons at risk for osteoporosis.

Monitoring osteoporosis

A final, important component of any osteoporosis treatment plan is regular monitoring and follow-up to ensure that the treatment plan is working effectively and make adjustments as necessary. Both follow-up bone density testing and physician checkups are recommended.

Periodic bone density testing
Some doctors recommend periodic bone density testing, usually DEXA bone scans, such as every 1 to 2 years for people diagnosed with osteoporosis or at risk for developing osteoporosis. Periodic DEXA scans for these patient populations allow both:

• Overall assessment of the change in the patient’s bone density and whether he or she is considered to have low bone mass or full blown osteoporosis, and;
• Monitoring of the effectiveness of osteoporosis treatments, which informs the physician if the patient’s osteoporosis medications and lifestyle changes are effective in slowing bone loss and/or rebuilding bone mass.

The use of DEXA bone scans to monitor treatment is considered by some to be controversial, because the change in bone density over time is slow and can be less than the error rate of the machine itself. The use of periodic bone density testing in an individual patient’s treatment will depend on the preference of the treating physician, the coverage by the patient’s insurance company or by Medicare, and by the patient’s overall risk for osteoporosis.

Regular osteoporosis follow-up with a physician
The good news about osteoporosis is that to a large extent it is preventable and treatable. However, an individual’s personal plan to prevent and treat osteoporosis may include multiple components and challenging lifestyle changes. In order for osteoporosis prevention and treatment to be successful, the patient will need to practice diligent follow-through and seek regular care by the treating physician or healthcare team. This may be accomplished by incorporating a discussion, exam and diagnostic tests focused on bone mass into the patient’s regular annual exam, or by scheduling a periodic appointment focused solely on bone mass/osteoporosis.

The key is making sure that follow-up takes place so that the elements of the osteoporosis prevention and treatment plan can be adjusted as needed to slow/stop bone loss to the maximum extent possible for weight loss and healthy living.

The single most important thing to remember is that even after osteoporosis has been diagnosed it is possible to slow bone loss and build bone density. Those at increased risk for osteoporosis do not have to accept the disease and the risk of osteoporosis-related fractures as their inevitable fate.

Osteoporosis and the fractures it causes are largely preventable and treatable and scores of patients have successfully held it at bay.