A disease characterized by low bone mass and
structural deterioration of bone tissue, leading to bone fragility and an
increased risk of fractures of the hip, spine, and wrist. Men as well as
women are affected by osteoporosis, a disease that can be prevented and
Osteoporosis is not the same as osteomalacia, which is demineralization
of bone due to vitamin D deficiency. However, the two conditions may be
present simultaneously, causing severe bone weakness.
Osteoporosis is a natural part of aging. By
the age of 70, bone density of the skeleton has typically fallen by about
one third. For hormonal reasons, significant osteoporosis is much more common
in women than in men. Also, for reasons unknown, black people are less affected
than white people or Asians.
To reach optimal peak bone mass and continue building new bone tissue as
you age, you should consider several factors.
An inadequate supply of calcium over a lifetime
contributes to the development of osteoporosis. Many published studies show
that low calcium intake appears to be associated with low bone mass, rapid
bone loss, and high fracture rates. Nutrition
surveys show that many people consume less than half the amount of calcium
recommended to build and maintain healthy bones. Good sources of calcium
include low-fat dairy products, such as milk, yogurt, cheese, and ice cream;
dark green, leafy vegetables, such as broccoli, collard greens, bok choy,
and spinach; sardines and salmon with bones; tofu; almonds; and foods fortified
with calcium, such as orange juice, cereals, and breads. Depending upon
how much calcium you get each day from food, you may need to take a calcium
Calcium needs change during one's lifetime. The body's demand for calcium
is greater during childhood and adolescence, when the skeleton is growing
rapidly, and during pregnancy and breastfeeding. Postmenopausal women and
older men also need to consume more calcium. Also, as you age, your body
becomes less efficient at absorbing calcium and other nutrients. Older adults
also are more likely to have chronic medical problems and to use medications
that may impair calcium absorption.
Vitamin D plays an important role in calcium
absorption and in bone health. It is made in the skin through exposure to
sunlight. While many people are able to obtain enough vitamin D naturally,
studies show that vitamin D production decreases in the elderly, in people
who are housebound, and for people in general during the winter. Depending
on your situation, you may need to take vitamin D supplements to ensure
a daily intake of between 400 to 800 IU of vitamin D. Massive doses are
Like muscle, bone is living tissue that responds to exercise by becoming
stronger. Weight-bearing exercise is the best for your bones because it
forces you to work against gravity. Examples include walking, hiking, jogging,
stair climbing, weight training, tennis, and dancing.
Smoking is bad for your bones as well as for your heart and lungs. Women
who smoke have lower levels of estrogen compared to nonsmokers, and they
often go through menopause earlier. Smokers also may absorb less calcium
from their diets.
Regular consumption of 2 to 3 ounces a day of alcohol may be damaging to
the skeleton, even in young women and men. Those who drink heavily are more
prone to bone loss and fractures, because of both poor nutrition and increased
risk of falling.
Medications that cause bone loss
The long-term use of glucocorticoids
(medications prescribed for a wide range of diseases, including arthritis,
asthma, Crohn's disease, lupus, and other diseases of the lungs, kidneys,
and liver) can lead to a loss of bone density and fractures. Bone loss can
also result from long-term treatment with certain antiseizure drugs, such
as phenytoin (Dilantin) and barbiturates;
gonadotropin-releasing hormone (GnRH) drugs used to treat endometriosis;
excessive use of aluminum-containing antacids;
certain cancer treatments; and excessive thyroid hormone. It is important
to discuss the use of these drugs with your physician and not to stop or
change your medication dose on your own.
Osteoporosis is often called the "silent disease" because bone loss occurs
without symptoms. People may not know that they have osteoporosis until
their bones become so weak that a sudden strain, bump, or fall causes a
hip to fracture or a vertebra to collapse. Collapsed vertebrae may initially
be felt or seen in the form of severe back pain, loss of height, or spinal
deformities such as kyphosis (severely stooped posture).
Following a comprehensive medical assessment, your doctor may recommend
that you have your bone mass measured. A bone mineral density (BMD) test
is the best way to determine your bone health. BMD tests can identify osteoporosis,
determine your risk for fractures (broken bones), and measure your response
to osteoporosis treatment. The most widely recognized bone mineral density
test is called a dual-energy X-ray absorptiometry or DXA test. It is painless
– a bit like having an X-ray – but with much less exposure to
radiation. It can measure bone density at your hip and spine.
Bone density tests can:
- Detect low bone density before a fracture occurs.
- Confirm a diagnosis of osteoporosis if you already have one or more
- Predict your chances of fracturing in the future.
- Determine your rate of bone loss, and/or monitor the effects of treatment
if the test is conducted at intervals of a year or more.
A comprehensive osteoporosis treatment program includes a focus on proper
nutrition, exercise, and safety issues to prevent falls that may result
in fractures. In addition, your physician may prescribe a medication to
slow or stop bone loss, increase bone density, and reduce fracture risk.
The foods we eat contain a variety of vitamins, minerals, and other important
nutrients that help keep our bodies healthy. All of these nutrients are
needed in balanced proportion. In particular, calcium and vitamin D are
needed for strong bones, and for your heart, muscles, and nerves to function
Exercise is an important component of an osteoporosis prevention and treatment
program. Exercise not only improves your bone health, but it increases muscle
strength, coordination, and balance, and leads to better overall health.
While exercise is good for someone with osteoporosis, it should not put
any sudden or excessive strain on your bones. As extra insurance against
fractures, your doctor can recommend specific exercises to strengthen and
support your back.
Currently, alendronate, raloxifene, risedronate, and ibandronate are approved
by the U. S. Food and Drug Administration (FDA) for preventing and treating
postmenopausal osteoporosis. Teriparatide is approved for treating the disease
in postmenopausal women and men at high risk for fracture. Estrogen/hormone
therapy (ET/HT) is approved for preventing postmenopausal osteoporosis,
and calcitonin is approved for treatment.
- Bisphosphonates – Alendronate (Fosamax), risedronate (Actonel),
and ibandronate (Boniva), are medications from the class of drugs called
bisphosphonates. Like estrogen and raloxifene, these bisphosphonates
are approved for both prevention and treatment of postmenopausal osteoporosis.
Another bisphosphonate, zoledronic acid (Reclast), is approved for the
treatment of postmenopausal osteoporosis. Alendronate is also approved
to treat bone loss that results from glucocorticoid medications like
prednisone or cortisone and is approved for treating osteoporosis in
men. Risedronate is approved to prevent and treat glucocorticoid-induced
osteoporosis and to treat osteoporosis in men.
Alendronate, risedronate, and zoledronic acid have been shown to increase
bone mass and reduce the incidence of spine, hip, and other fractures.
Ibandronate has been shown to reduce the incidence of spine fractures.
Alendronate is available in daily and weekly doses. Risedronate is available
in daily, weekly, and twice monthly doses. Ibandronate is available
in a monthly dose and as an intravenous injection administered once
every three months. Zoledronic acid is available as an intravenous injection
administered once yearly.
Side effects for oral bisphosphonates include gastrointestinal problems
such as difficulty swallowing, inflammation of the esophagus, and peptic
Side effects for intravenous bisphosphonates include flu-like symptoms,
fever, pain in muscles or joints, and
headache. These side effects can occur
shortly after receiving an infusion and generally stop within two to
There have also been rare reports of osteonecrosis of the jaw and of
visual disturbances in people taking oral and intravenous bisphosphonates.
Some bisphosphonates are marketed with calcium and vitamin D supplements.
These nutrients are important for everyone, and people should include
adequate amounts of them in their diets.
- Raloxifene – Raloxifene (Evista) is approved for the prevention
and treatment of postmenopausal osteoporosis. It is from a class of
drugs called estrogen agonists/antagonists,
commonly referred to as selective estrogen receptor modulators (SERMs).
Raloxifene appears to prevent bone loss in the spine, hip, and total
body. It has beneficial effects on bone mass and bone turnover and can
reduce the risk of vertebral fractures. While side effects are not common
with raloxifene, those reported include hot flashes and blood clots
in the veins, the latter of which is also associated with estrogen therapy.
Additional research studies on raloxifene will continue for several
- Calcitonin – Calcitonin
(Miacalcin, Fortical) is a naturally occurring hormone involved in calcium
regulation and bone metabolism. In women who are at least 5 years past
menopause, calcitonin slows bone loss, increases spinal bone density,
and may relieve the pain associated with bone fractures. Calcitonin
reduces the risk of spinal fractures and may reduce hip fracture risk
as well. Studies on fracture reduction are ongoing. Calcitonin is currently
available as an injection or nasal spray. While it does not affect other
organs or systems in the body, injectable calcitonin may cause an allergic
reaction and unpleasant side effects including flushing of the face
and hands, frequent urination, nausea,
and skin rash. The only side effect reported with nasal calcitonin is
- Teriparatide – Teriparatide (Forteo) is an injectable form
of human parathyroid hormone. It is approved for postmenopausal women
and men with osteoporosis who are at high risk for having a fracture.
Unlike the other drugs used in osteoporosis, teriparatide acts by stimulating
new bone formation in both the spine and the hip. It also reduces the
risk of vertebral and nonvertebral fractures in postmenopausal women.
In men, teriparatide reduces the risk of vertebral fractures. However,
it is not known whether teriparatide reduces the risk of nonvertebral
fractures. Side effects include nausea, dizziness and leg cramps. Teriparatide
is approved for use for up to 24 months.
- Estrogen/Hormone Therapy –
Estrogen/hormone therapy (ET/HT) has been shown to reduce bone loss,
increase bone density in both the spine and hip, and reduce the risk
of spine and hip fractures in postmenopausal women. ET/HT is approved
for preventing postmenopausal osteoporosis and is most commonly administered
in the form of a pill or skin patch. When estrogen – also known
as estrogen therapy or ET – is taken alone, it can increase a
woman's risk of developing cancer of the uterine lining (endometrial
cancer). To eliminate this risk, physicians prescribe the hormone progestin
– also known as hormone therapy or HT – in combination with
estrogen for those women who have not had a hysterectomy. Side effects
of ET/HT include vaginal bleeding, breast tenderness, mood disturbances,
blood clots in the veins, and gallbladder disease.
The Women's Health Initiative, a large Government-funded research study,
recently demonstrated that the drug Prempro (estrogen combined with
progestin), which is used in hormone therapy, is associated with a modest
increase in the risk of breast cancer, stroke, and heart attack. The
WHI also demonstrated that in patients who had a hysterectomy, estrogen
therapy alone was associated with an increase in the risk of stroke,
but not of breast cancer or cardiovascular disease. A large study from
the National Cancer Institute indicated that long-term use of estrogen
therapy may be associated with an increased risk of ovarian cancer.
Estrogen therapy is approved for treatment of menopausal symptoms but
should be prescribed for the shortest period of time possible. When
used solely for the prevention of postmenopausal osteoporosis, any ET/HT
regimen should only be considered for women at significant risk of osteoporosis,
and nonestrogen medications should be carefully considered first.
Preventing falls is a special concern for men and women with osteoporosis.
Falls can increase the likelihood of fracturing a bone in the hip, wrist,
spine, or other part of the skeleton. In addition to the environmental factors
listed below, falls can also be caused by impaired vision and/or balance,
chronic diseases that affect mental or physical functioning, and certain
medications, such as sedatives and antidepressants.
It is important that individuals with osteoporosis be aware of any physical
changes that affect their balance or gait, and that they discuss these changes
with their health care provider. Here are some tips to help eliminate the
environmental factors that lead to falls.
- Use a cane or walker for added stability.
- Wear rubber-soled shoes for traction.
- Walk on grass when sidewalks are slippery.
- In winter, carry salt or kitty litter to sprinkle on slippery sidewalks.
- Be careful on highly polished floors that become slick and dangerous
- Use plastic or carpet runners when possible.
- Keep rooms free of clutter, especially on floors.
- Keep floor surfaces smooth but not slippery.
- Wear supportive, low-heeled shoes even at home.
- Avoid walking in socks, stockings, or slippers.
- Be sure carpets and area rugs have skid-proof backing or are tacked
to the floor.
- Be sure stairwells are well lit and that stairs have handrails on
- Install grab bars on bathroom walls near tub, shower, and toilet.
- Use a rubber bath mat in shower or tub.
- Keep a flashlight with fresh batteries beside your bed.
- If using a step stool for hard-to-reach areas, use a sturdy one with
a handrail and wide steps.
- Add ceiling fixtures to rooms lit by lamps.
- Consider purchasing a cordless phone so that you don't have to rush
to answer the phone when it rings, or so that you can call for help
if you do fall.