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REVERSING OSTEOPENIA

CHAPTER 1

Step 1: Baby Your Bones

Today more than ever, you must be the guardian of your own health. That means making informed decisions regarding early detection, prevention, and treatment of illness to keep yourself and your family healthy. While treating disease is critical, especially in the early stages when treatment works best, there is a compelling case supported by a host of scientific data that the prevention of any health problems should be your primary goal.

Before we talk about specific ways you can baby your bones and prevent or reverse osteopenia or low bone mass, we need to explain the epidemic problem of bone loss and how the resulting painful and disfiguring fractures can rob you of your youthful appearance and an active, productive life.

Diagnosis: Osteopenia

Patient's Name: Christie

Age: 41

Risk factors: History of low-calorie dieting, avoidance of dairy, thyroid disease

Forty-one-year-old Christie had never heard of osteopenia until she had a bicycle accident and injured her wrist. This active mother of three was riding bikes with her family when her front tire hit a curb, and shewas thrown onto the hard pavement. She broke her fall with her hands but luckily did not receive a fracture. However, because she had a history of thyroid disease, dairy allergies, and years of low-calorie dieting—all key risk factors for osteopenia—we did a bone density test at our clinic. The results of her test revealed that she had early bone loss or osteopenia with the bone density of a woman ten years older.

Patient's Name: Wendy

Age: 30

Risk factors: Family history (grandmother), excessive exercise, amenorrhea, low body weight

Wendy, age thirty, came to our clinic after her gynecologist raised concern about her low body weight and ordered a bone density test. As an avid marathon runner, Wendy was thin, muscular, and appeared to be the picture of health. But this young woman also dieted excessively and experienced amenorrhea (loss of menstrual periods)—key risk factors for osteopenia and fractures. Wendy told us that the first time she heard of bone loss was when the family discussed her grandmother's sudden death after complications from a hip fracture. "I thought thin bones were something older women got, not active people my age," she said after hearing the diagnosis of osteopenia.

Patient's Name: Janie

Age: 39

Risk factors: Early menopause (surgical), lack of estrogen replacement, sedentary lifestyle

Janie had never been an exerciser and had an early menopause with hysterectomy in her early thirties because of fibroid tumors. She discovered her bone loss problem when she and some friends took advantage of a free screening—a heel bone density test—at a mall health fair. Three of the five women were found to have low bone mass. Because Janie did not supplement with estrogen hormone therapy after her surgery, she did not receive the protective effect on bones of estrogen hormone treatment. She later had a DEXA test which confirmed she had osteopenia.

Understanding the Female Athlete Triad

The female athlete triad is a constellation of medical conditions that are becoming increasingly common in women athletes. Specifically, these are eating disorders, amenorrhea (lack of menstrual periods), and osteopenia or low bone mass. Athletes who compete in gymnastics, dancing, swimming, skating, and running are at high risk for the female athlete triad, as they strive to appear lean and fit.

We know that more female athletes have amenorrhea than women in the general population. Amenorrhea is associated with decreased estrogen levels, which may be the cause of osteopenia or low bone mass. Low-calorie diets are usually the first predictor of eating disorders. Excessive exercise or exercise obsession can be another sign of an eating disorder. Each of these three problems must be medically evaluated and treated to ensure a good outcome.

Defining Bone Loss

Are you surprised to hear that young women today are faced with bone thinning and fractures? Don't be! Osteopenia has been labeled the "young women's silent epidemic" by some experts because there are no warning signs. Such trendy behavior for young women as social drinking, smoking, drinking excessive amounts of coffee and diet colas, deprivation dieting, and lack of bone-strengthening exercise are all having a devastating effect on young bones. Even taking some forms of birth control may increase the risk of bone loss. For example, Depo-Provera (medroxyprogesterone acetate), an injectable contraceptive that prevents ovulation (the release of the egg by the ovary), causes the body to stop producing estrogen and progesterone. Both hormones are important for bone strength since estrogen slows down bone loss, and progesterone boosts bone growth.

Osteopenia is every woman's concern—no matter what her age or health status—as this is the first stage preceding full-blown osteoporosis or severe bone loss. Moreover, fractures don't wait until you have osteoporosis. The risk of fractures increases with decreases in bone density. Once you have just one fracture, you are at a greater risk for more fractures. The good news is that osteopenia can be prevented or reversed before debilitating fractures occur.

What Is Osteopenia?

Osteopenia is thinning of bones that can be detected by a simple bone density test (see page 19) long before there is the severe bone loss and fracture risk of osteoporosis. In osteopenia, the bone density is lower than normal but not yet full osteoporosis.

Many patients are confused when they hear that they have osteopenia. After all, the media has focused on full-blown osteoporosis for years with its resulting stooped posture and painful fractures. However, a diagnosis of osteopenia also means a greater risk of fractures. Studies indicate that patients with osteopenia sustain more fractures than patients with osteoporosis. It makes sense that the best time to take steps to reverse bone loss, strengthen bones, and prevent fractures is when osteopenia is found.

A Major Risk for Fractures

So, if osteopenia is a growing problem in the United States, why haven't you read much about it? Mainly, because doctors are just now beginning to learn how to deal with bone loss—just like they're learning to deal with heart disease in women. For instance, a decade ago, heart disease was not diagnosed in women until after a near fatal heart attack and loss of heart muscle. Doctors simply did not associate heart disease with women, even though it is now regarded as the single greatest health risk for women.

Today, we know that keeping a regular check on body weight, blood pressure, and cholesterol can help prevent a woman's heart attack altogether, and both doctors and patients recognize the need to take preventive measures with lifestyle changes.

Similarly, doctors are realizing that osteopenia is a major risk for the development of fractures. It is a warning sign that alerts you to take action before permanent damage is done from bone thinning. New estimates suggest that half of all women over the age of forty-five are now affected by low bone mass, including 90 percent of women over age seventy five. Moreover, those numbers continue to grow. That's why it's important to understand osteopenia and your personal risk factors in order to prevent or reverse bone loss before fractures occur.

At menopause, there is a dramatic decline of estrogen, which causes rapid bone loss, leading to devastating hip fractures. Having the strongest bones possible before you enter menopause is the best weapon against debilitating fractures. While the emphasis in the medical community has been on postmenopausal women as prime targets of bone loss awarenesscampaigns, many—including the authors!—believe the target should include younger women, especially those who have time to reverse osteopenia before it results in debilitating fractures.

Once bone has been lost in full-blown osteoporosis, treatment may not build bone that is as mechanically strong as the original bone. In other words, even if the bone density test results improve, the bone may never be as strong as it was before.. This makes the finding of osteopenia a lifesaving warning sign.

While it is more common for women to suffer from fractures after menopause because of the dramatic drop in estrogen levels and the effect on bone, the process of bone loss begins much earlier. The stage is set for osteopenia early in life—in your teens, 20s, 30s, and 40s. The problem is there are no noticeable symptoms of bone loss until you experience a sudden, painful fracture or substantial loss of height because of a vertebral fracture. By then, bones have become so weak that even mild stress like bending over, lifting a bag of groceries, or coughing can cause a fracture, horrific pain, and immobility.

We believe that the fracture you want to prevent is the first one. By identifying women with risk factors for osteopenia early in life—while they can still make lifestyle changes to strengthen bones—we might prevent millions of fractures altogether.

Imagine if all the women who suffer from painful hip fractures now could have had this lifesaving information twenty years ago! The key to living a strong life is simple: early detection and taking a few easy prevention steps to baby your bones years before bone loss and fractures occur.

Understanding Fractures

With osteopenia, bones become thin and weak, which makes them easier to break. Though painful, the break will usually heal. Yet, as long as the bones are thin and weak, they are increasingly susceptible to fractures and the subsequent immobility or even death. In fact, in adults, a grave predictor of bone problems is a previous fracture that occurred after a minor fall. If you had a fracture because of weak bones, your risk of another fracture is 2 to 20 times greater than someone who has never had a fracture.

Half of all Americans will break a bone before age sixty-five. Now, if such fractures only affected fingers or toes, it would be inconvenient but not terribly limiting. However, bone loss commonly attacks with painful vengeance, severely limiting the activities of daily life.

According to the National Osteoporosis Foundation (NOF), bone thinning is responsible for more than 1.5 million fractures each year. More than 300,000 hip fractures happen annually. While hip fracture is the most devastating fracture associated with bone loss, vertebral (spine) fracture is the most common, with over 750,000 each year.

Fractures can be painful; they also cause deformities and are expensive. For example, fractures, especially when they affect the spine, can cause deformities such as the dowager's hump. The cost of hip fractures alone—both direct (hospitalization, surgery, and doctors' visits) and indirect (lost time from work)—exceeds $17 billion annually. This cost will only skyrocket ... unless we take action early on to prevent and reverse osteopenia. The number of fractures will also escalate over the next few years as the projected population over age sixty-five increases. One study recently predicted 4.5 million annual hip fractures worldwide in the year 2050.

None of this has to happen to you. Doctors can treat and even reverse osteopenia and help you build stronger bones and end fractures forever.

Hip Fractures

"Aren't I a bit too young for a bone density test? Fractures only happen in the elderly," Suzi, a thirty-six-year-old woman with a history of eating disorders and exercise obsession, shared her concerns as we scheduled her for a bone density test. Untrue! While general bone loss among women commonly begins in the perimenopausal period (the years prior to menopause), bone loss from the hip can begin even earlier. Suzi's bone density score showed osteopenia and was lower than that of other women her age. Because of this, Suzi was at higher risk for future fractures.

If you know someone who has had a hip fracture, then you have reason to be concerned about your own bone health. Hip fractures are very serious injuries, often a turning point, beyond which independent living is no longer possible. Perhaps you have a family member who was active and living alone—until she fell and broke her hip. For those who suffer hip fracture, recovery can be difficult as they face hospitalization, surgery, and months of painful, exhausting, and expensive therapy.

The National Osteoporosis Foundation (NOF) estimates that a woman's risk of hip fracture is equal to her combined risk of breast, uterine, and ovarian cancers. Nearly one-fourth of hip fracture patients age fifty and older die in the year following their fracture, and one-fourth of those who were ambulatory before their hip fracture require long-term care afterward.

Although there are several different areas in the hip that may break,most breaks are called hip fractures. These usually require surgery, since without surgery it takes six weeks or more of bed rest for fractures to heal. With surgery, the patient can usually be up and walking within a few days.

The operation to correct these fractures is expensive, usually $35,000 to $40,000 or more. Along with this cost comes the higher risk of other serious medical problems such as blood clots, heart attack, pneumonia, and stroke. The worst cost is that many of these victims immediately lose their independence.

Studies confirm that 95 percent of hip fractures result from falls. Weight-bearing and strengthening exercises (chapter 2) and the ancient art of tai chi (see page 38) are excellent ways to keep your body toned and flexible and your bones strong, so you can stay balanced and avoid falls and fractures no matter what your age.

Spinal Fractures

Spinal fractures affect more than 50 percent of all women. Significant changes in the spine from bone thinning are common. By age seventy-five, more than 50 percent of women have had a fracture in their spine with an estimated half-million vertebral fractures occurring annually. The most common deformity from bone loss, called the dowager's hump, happens in the upper part of the spine (see figure 1.1).

Only about one-third of vertebral fractures produce symptoms. Generally, fractures in the lower spine are associated with more pain and loss of function than fractures in the upper spine, and multiple fractures are more problematic than a single fracture.

Each fractured vertebra becomes shorter, usually by about one-quarter inch, and the spine bends forward. This gradually makes the person appear stooped over and results in decreased height. The loss of height may not even be noticed until you are measured in your doctor's office. In fact, the most common cause of loss of height as we age is bone loss. The stooped-over posture can make the abdomen more prominent. One of our patients said that she went from a height of 5'4" as a young woman to 4'11" at age seventy-five with full osteoporosis (see figure 1.2).

As bones become thinner and weaker, the effort required to hold the body erect while standing or walking may be enough to cause a fracture. Bending can greatly stress the spine, often putting pressure equivalent to several times the weight of the body on the back. This pressure leads to fractures in weakened bones.

After age forty-five, the most common cause of height loss is shortening of the bones of the spine by bone thinning. However, doctors should suspect bone loss in any person—no matter what her age—who loses height. When osteopenia affects the spine, fractures can happen in one of the vertebral bones. If each fracture in the spine causes about one-quarter-inch loss of height, after many fractures there may be a loss of several inches in total height. Treatments, as described in Step 5, have been shown to greatly lower the risk of more fractures and help delay the shortening and deformity of the spine that cause the stooped posture.

When bone loss is present and weakens the bones, it is a wonder that sufferers do not experience more fractures in the spine. Science tells us that lifting an 86-pound object from the floor can place 700 pounds or more of force on the back. One fifty-one-year-old woman said that she had her first spinal fracture, along with weeks of excruciating pain, after merely opening her bedroom window. During the first week she was completely bedridden from the pain.

Fractures in the spine cause back pain that can be severe, making it difficult to stand, walk, sit, or lift. In some cases, the pain can be so excruciating as to make the smallest movement difficult and almost any position uncomfortable. It can also cause loss of independence, as we can no longer care for our families and ourselves.

Once a spinal fracture occurs, the pain may worsen when you try to walk, bend, or lift. This pain commonly makes it hard to sleep well at night. You may feel penetrating pain when you cough or sneeze. (Pain from a spinal fracture does not usually travel down the legs; so if you have this feeling, let your doctor know.)

Sometimes you may fracture more than one bone in the spine, resulting in pain that lasts longer than a few weeks. If pain is severe for longer than a few days, check with your doctor. There may be an additional problem in the spine. If you notice a change in your bladder or bowel habits, such as loss of control, then call your doctor to be sure no other serious problems are present.

Wrist and Shoulder Fractures

The wrist and the shoulder are common places for early bone loss with more than 200,000 wrist fractures annually. Fractures in these bones usually happen after a fall, such as with Christie's bicycle accident, discussedon page 1. Your doctor may find bone loss on an X ray. As we recommended to Christie, a simple bone density test, discussed on page 19, can be administered to let your doctor know if further treatment is needed to prevent the next fracture.

If you have a wrist fracture as an adult, you need to have a bone density test. The fracture is a common signal that the bones are becoming thinner; the next signal could be a hip or spine fracture.

Fractures of the wrist or shoulder may need an operation to repair, but most do not require a hospital stay and can be treated on an outpatient basis by an orthopedic surgeon. After the bones heal, you may need to see a physical therapist or do exercises at home to be sure you do not lose usage of these areas for daily activity.

Pelvic Fractures

Pelvic fractures usually happen after a fall, with an injury to the bones of the pelvis, causing great pain in the pelvis, lower abdomen, and groin areas. This often requires days or weeks in bed or the hospital. After a pelvic fracture, it is frequently hard to walk without pain. After a few days to a week, most patients can stand. Then, after a few more days, they can walk again. If you have a fracture of a bone in the pelvis, you need to have a bone density test. If bone loss is found, steps must be taken to prevent more fractures, especially a hip fracture.

The Emotional Side of Fractures

Not only are multiple fractures disfiguring and painful, they are a significant emotional burden. After one fracture you may become anxious and fearful about the possibility of others. Many people limit activity or exercise and become socially isolated. Depression and feelings of hopelessness are commonplace, especially if activities become limited.

Fracture Fast Facts

• One in two women and one in four men over age fifty will have an osteoporosis-related fracture in their lifetime.

• Osteoporosis is responsible for more than 1.5 million fractures annually, including:

- More than 300,000 hip fractures

- More than 750,000 vertebral fractures

- More than 250,000 wrist fractures

- More than 300,000 fractures at other sites

Some women with chronic pain are well aware that they are depressed. The signs are obvious: uncontrollable tearfulness, a persistent sad or anxious mood, feelings of hopelessness, guilt, or irritability, loss of interest in nearly all activities, decreased energy, difficulty concentrating or making decisions and, in severe cases, thoughts of death or suicide. Loss of self-esteem can also occur due to the disabling and disfiguring aspects of the fractures.

What Your Doctor May Not Have Told You

In a national survey of 1,000 women age thirty and older, published in the Washington Times, 7 out of 10 women said their doctors had never said anything about bone loss prevention, treatment, or detection. Less than one-fourth of women with a strong family history of thin bones said their doctor recommended early detection with a bone density test. Almost all of our patients say they'd never heard of osteopenia until we brought it up!

Other frightening findings show that more than half of the women who break a bone after age fifty—which is the number one symptom of bone loss—say their doctor has never recommended that they be tested with a bone density test. These women were untested—and untreated. We believe that a bone density test after a fracture is as important as an electrocardiogram for a woman who has suffered a heart attack or a blood glucose test for a suspected diabetic.

It's thought that the average primary care physician sees about one hundred patients each week who have various stages of bone loss. Yet doctors are so busy treating other problems that they miss unseen bone loss. In addition, until recently, there was little doctors could do to detect bone loss. Today there is something they can do. Our job as health care professionals is not just to "fix the fracture," leaving millions of women with osteopenia untreated, but to treat and reverse this early stage of bone loss.

The challenge for all of us is to detect low bone mass as early as possible, when it is most treatable. Now, with new diagnostic tools, every woman who suspects low bone mass or who has one of the risk factors for osteopenia, discussed on page 15, can quickly and inexpensively have a bone density test (see page 19).

We want you to be aware of the negative emotions that often coincide with the early stages of bone loss, fracture, and chronic pain, so you can take control. The Bone-Building Program will help to ease depression, as you become more physically active and find solutions to reverse or prevent bone loss and your risk of fractures. There are also excellent antidepressants available that both improve pain and have a positive mood effect. In fact, many chronic pain patients have received excellent relief from a combination of antidepressants and other pain-relieving drugs.

Understanding the Bone Cycle

Before we can talk about a proven program to reverse osteopenia and painful fractures, we need to explain the underlying physiology of how bone is built and lost during our lifetime.

Childhood: Bone Building Exceeds Bone Loss

Bone is not a lifeless structure. Rather, it is complex, living tissue. As if on schedule, our bodies naturally break down old bone and rebuild new bone, an intricate process called remodeling. In children, more bone is built than removed, so during this life stage, bones become larger and stronger. In fact, the skeleton may reach about 95 percent of its peak amount of bone by age twenty. Some experts believe that during childhood up to the early twenties, young women can increase their bone mass by as much as 20 percent—a critical factor in protecting against bone loss and fractures. We believe that the more bone you store, the more you will have to draw on later in life.

Age 30 to 35: Bone Loss Equals Bone Building

Around age thirty to thirty-five, the amount of bone our bodies break down begins to catch up with the amount of bone our bodies are building. Sometime during this period, the bone mass removed equals the bone mass built.

Perimenopause: Bone Loss Exceeds Bone Building

Perimenopause is the period before menopause when estrogen levels first start their decline. At this time (about age thirty-five to forty-five), the mass of bone removed may begin to exceed the mass of bone built. It is at this time that osteopenia disrupts the natural bone-building cycle, resulting in a decrease in net bone mass.

Menopause: Bone Loss Accelerates

Menopause is a normal life transition, starting with perimenopause. Perimenopause and menopause are not medical diseases. These are natural times during which your body undergoes a number of changes in metabolism, hormone production, and the length and frequency of menstrual periods, among other things.

At menopause, the hormonal changes disrupt this bone-building cycle again. Specifically, the natural decline in estrogen at menopause speeds up the breakdown of bone. During the five to ten years after menopause, there is a greatly accelerated loss of bone mass in women. Within the first five years after menopause, some women have lost up to a startling 25 percent of their bone density.

This may be difficult to comprehend for active women in midlife who take their good health for granted. Yet reports say more than 30 percent of perimenopausal women (late 30s to late 40s) have osteopenia and a startling 20 percent of women in their 40s have osteoporosis. Sadly, it is estimated that only 10 to 15 percent of those who have bone loss actually know they have it. Many women don't arrive at this knowledge until they fracture a bone, and even then many are still not aware of the problem.

How Healthy Are Your Bones?

"So, when will I have a fracture? What signs should I look for?" Lynn's concern was apparent when she was given the results of her bone density test. Then she added, "Isn't osteopenia a problem my mother or grandmother should worry about—not a thirty-eight-year-old woman with two preschoolers?"

When women ask "if" or "when" they will have a bone fracture, we always tell them that we cannot predict the hour, minute, or second a fracture might happen. Nonetheless, we can identify things they do or health conditions they have that put them at greater risk. Whether you develop osteopenia at all depends on various risk factors such as the thickness of your bones early in life, as well as your family history, age, overall health, diet, physical activity, and lifestyle later in life.

To see how healthy your bones are, put the following on your bone-building "to-do" list:

To-Do #1: Assess your personal risk for osteopenia.

To-Do #2: Schedule a bone checkup.

To-Do #3: Ask your doctor about a bone density test.

To-Do #1: Assess Your Personal Risk

Risk factors are those habits or histories that alone and together increase the likelihood you'll develop a medical condition. For instance, if you are overweight, smoke cigarettes, and have high blood pressure, your risk for heart disease is greater than a nonsmoker's who is at an optimal weight with normal blood pressure. In the case of osteopenia, some risk factors are inherited, such as a family history of bone loss and fractures. Some are tied to your individual medical history. Women with thyroid disease, those who experience an early menopause with hysterectomy, or who have irregular menstrual periods may develop osteopenia at an early age. Other risk factors are the result of lifestyle choices, such as lack of weight-bearing exercise, avoiding dairy products, or smoking.

No matter what they are, the specific risk factors for osteopenia do their damage in silence. You have no idea that you are losing bone density until you have a fracture, after which your risk for more fractures is greatly increased. We've treated many young women with osteopenia who outwardly appear be the picture of health. Many are muscular athletes, yet still have weak bones.

The good news is that early recognition of risk factors and following the 5-step Bone-Building Program can keep you from suffering with debilitating fractures in years to come.

In our practice, we've treated women ages nineteen to over a hundred. The younger our patients are, the harder it is for them to believe they are at risk for osteopenia and fractures. Maybe you're the same way. You're not old enough to have osteopenia! Or maybe you believe—mistakenly, as our patients have learned—that bone loss is a natural part of the aging process to be expected and accepted. While bone loss does happen with age, it should never be accepted and can be prevented before painful and deforming fractures occur.

As you review the following risk factors, keep in mind that risk factors for osteopenia add up. For instance, having three risk factors is definitely worse than having one or two. Still, no matter what your age, the more risk factors you address now, the more you reduce your risk for osteopenia and future fractures.

12 Signs Your Bones Need Attention

The best way to approach your personal risk of osteopenia is to get a piece of paper and write down any of the following 12 signs (risk factors) that mean your bones might need attention. After you've made your personalrisk factor list, check off those that you can control with bone-boosting changes, starting today. Talk to your doctor about the other signs or risk factors to see if further steps need to be taken to help prevent osteopenia and fractures.

1. Low body weight. Your weight influences your bone density. Some women maintain a low body weight through low-calorie dieting in order to look thin and so put themselves at increased risk for bone loss. For example, a woman who weighs less than 127 pounds is 10 times more likely to have lower bone density than a woman who weighs 150 pounds or more. The risk of bone loss increases when the percent of body fat becomes low. Women who diet excessively to maintain a low body weight often eliminate dairy products from their diet, losing their primary source of calcium—a vital source of bone strength.

2. Genetics. Did your mother or grandmother have stooped posture or height loss? This increases your risk of bone loss. Your risk of osteopenia and fractures is strong if your mother or grandmother had bone loss or fractures. The genetic predisposition may account for up to 60 to 80 percent of bone mass, while environmental factors account for the remaining 20 to 40 percent. That's why it's important to ask about your mother's and grandmother's bone health history. Families often share lifestyle habits such as diet, lack of exercise, or smoking cigarettes. You can change all of this and by doing so rewrite your bone health future.

3. Race. While non-Hispanic white and Asian women over fifty years old have a higher risk of bone loss and non-Hispanic black women over fifty have a lower incidence of bone loss, some recent findings are cause for concern for all women. When large numbers of women were tested, it was found that low bone mass is much more common than once believed in all ethnic groups, including African Americans. It is estimated that about 50 percent of white women over age fifty have osteopenia. And studies now confirm that 55 percent of Hispanic women, 65 percent of Asian women, 58 percent of Native American women, and 38 percent of African-American women have low bone mass and are at greater risk for fractures.

4. Age. The risk for bone loss increases with age. An estimated 90 percent of women over the age of seventy-five have experienced a bone fracture.

Low bone mass appears in about 50 percent of women in their 50s, 66 percent of women in their 60s, 86 percent of women in their 70s, and 93 percent of women over eighty.

5. Early menopause. The longer your body is exposed to estrogen, the lower your risk of bone loss and fractures. For instance, if you started menstruating late in your teenage years or if you experience menopause before your late 40s, your body produces less estrogen, putting you at higher risk for osteopenia.

6. Previous fractures. If you have had a fracture as an adult, your risk of more fractures is much higher. If you have a fracture in the spine (vertebral fracture), the risk is about 1 in 5 that you will have another one within a year if you don't take action. And a spine fracture can double your risk of a hip fracture! This is enough reason to have a bone density test and take lifestyle measures to reverse osteopenia.

7. Certain medications. The use of corticosteroid medications, such as prednisone or other cortisone derivatives, often leads to premature bone loss (these medications are common treatments for chronic conditions such as asthma, rheumatoid arthritis, and psoriasis). In fact, if you take these medications for more than three months, your risk for bone loss is high enough that experts recommend taking medication to prevent bone loss as well.

In addition, diuretics, antacids, chemotherapy, hormone therapy for cancer, lithium, and some medications for seizures can also sap the bones of calcium.

8. Lifestyle habits. Certain lifestyle habits such as smoking can lead to bone loss. On average, smoking doubles the risk of bone loss. The fastest-growing group of smokers in the United States are girls between the ages of twelve and eighteen. Younger women—under forty—often smoke in response to stress or to stay slim. Smokers also tend to have a higher consumption of alcohol, may be less physically active, often skimp on nutrition—all of which can lead to early bone loss. Smoking cigarettes seems to have an anti-estrogen effect on the bones, and women who smoke tend to go through menopause at least two years earlier than nonsmokers.

Excess consumption of alcohol can also lead to bone loss, since it reduces bone formation and interferes with the body's ability to absorb calcium. Drinking more than three alcoholic drinks per day can cause rapid bone loss. Moderate consumption by itself does not raise the risk.

9. Avoidance of dairy products. Calcium is the key mineral that makes up the dense structure of bone. The effect of calcium on bone health is most crucial during youth, when bones are growing quickly. In fact, it is thought that calcium deficiencies in childhood can account for a5 to 10 percent difference in peak bone mass and can significantly increase the risk for hip fracture in later life. Some studies say that less than 25 percent of adolescent females are actually getting the calcium they need each day through foods or supplements. This deficit comes at a critical time in a woman's life—just before bone mass peaks. During menopause, especially in the first few years, calcium has a less dramatic effect since the rate of bone loss accelerates during this time. Still, getting ample calcium through foods and natural dietary supplements is vital to ensure the body has enough bone-building ability.

Calcium must be replenished daily through dietary measures or supplementation or the body will be deficient. Although the optimal level of calcium intake has not been clearly established, it is recommended that daily calcium intake be at least 1,200 milligrams (mg) in premenopausal women and 1,500 mg in postmenopausal women. (See Step 3, page 60, for specific information on how to boost calcium in the diet. In Step 5, page 98, we give specific information on increasing calcium in the diet with natural dietary supplements.)

Vitamin D is usually categorized as a fat-soluble vitamin, although it actually functions as a hormone in the body. Vitamin D helps to activate calcium and phosphorus (another key mineral for keeping bones strong) into the bloodstream. This is especially important as menopause approaches. When the body is depleted of vitamin D or has an insufficient supply, the blood levels of calcium and phosphorus plummet as well. Your body turns to the bones for replenishing this mineral and bone loss increases.

10. Irregular menstrual periods. Amenorrhea (the absence of menstrual periods) and other menstrual irregularities are also associated with an increase in fracture risk (see Understanding the Female Athlete Triad, page 3). Amenorrhea can occur because of strenuous exercise, and is common in female athletes, especially gymnasts and others who train hard but keep their body weight low. Women with amenorrhea experience significant reductions in estradiol, the primary form of estrogen. In most cases, amenorrheic premenopausal women have lower bone mineral density, particularly in the spine, than women who have normal menstrual cycles. The young female athlete who appears to be in top physical condition often has the highest risk of osteopenia and fracture, particularly if she experiences an eating disorder and loss of menstrual periods.

11. Thyroid problems. Too much thyroid hormone can cause bone loss. This condition occurs when the thyroid is overactive (hyperthyroidism)or when excessive thyroid hormone medication is used to treat an underactive thyroid (hypothyroidism). A blood test called thyroid-stimulating hormone (TSH) can monitor hormone levels accurately and help women get the right amount of thyroid medication.

12. Rheumatoid arthritis. This type of inflammatory arthritis is most common in young women. It causes joint pain, swelling, and stiffness and can do permanent damage to the joints. Rheumatoid arthritis, as well as the cortisone medications often used for treatment, both raise the risk of bone thinning and fractures.

Risk Factors for Osteopenia

1. Low body weight

2. Lifestyle habits (smoking, excessive drinking)

3. Avoidance of dairy products

4. Irregular menstrual periods

5. Genetics (family history)

6. Previous fractures

7. Race (Caucasian or Asian)

8. Early menopause (surgical or natural)

9. Age

10. Certain medications

11. Thyroid problems

12. Rheumatoid arthritis

To-Do #2: Schedule a Bone Checkup

When patients schedule a visit to our clinic, we ask them to bring to the appointment a written list of any personal health concerns. We realize that it's easy to forget the problems you've had in the past or the names of medications you've taken, especially when you're busy juggling kids, a career, and other commitments. Yet, to make an accurate bone assessment, we need to know as much about your personal health history as possible. Before your visit, write down the following:

1. Any health problems or concerns

2. Symptoms you've noticed (loss of height, back pain, posture problems)

3. Past illnesses and treatment (see page 17)

4. Your family history of bone loss and fractures

5. Medications you are taking now; medications you've taken in the past

6. Your lifestyle habits (diet, exercise, smoking, alcohol consumption)

7. Your diet history (low-calorie diet, intake of dairy)

8. Questions you have about osteopenia and fractures

During the examination, your doctor will talk to you about any past or present symptoms or health problems. If your doctor doesn't ask the "right" questions, then openly volunteer any helpful information, as this may prevent you from having a fracture in the future. If necessary, your doctor might recommend a bone density test.

To-Do #3: Ask Your Doctor about a Bone Density Test

Amanda was a thin young woman who was extremely health conscious. At age thirty-one, she was a nonsmoker and vegetarian, and even grew her own vegetables in a small garden behind her condominium complex. She carefully watched her weight during pregnancy, gaining only twenty pounds, and then lost this weight within six weeks after delivery.

Amanda said she'd never given a thought to bone loss and figured that it was something only elderly women faced. Then she had a bone density scan, which clearly indicated osteopenia. Not only was Amanda thin, but her bones were thin and more fragile, putting her at double the risk of fracture. We explained to Amanda that unless she took immediate bone-strengthening steps, she could be at risk of developing fractures long before she reached an advanced age—the stress on her bones of simply picking up her preschooler could result in a fracture.

If you want to avoid having one of the more than 1.5 million fractures that occur each year from bone loss, a bone density test can help you plan ahead. The bone density test evaluates the strength of the bones in your body by measuring a small part of one or a few bones. The areas most commonly measured include:

• The hip

• The lumbar spine (in the lower back)

• The heel

The DEXA Test

The most widely used and accurate test at this writing is the DEXA (Dual Energy X-ray Absorptiometry) test of the hip and lower spine. Thissimple and accurate test can be the first step in deciding whether medications are needed to treat bone loss.

The DEXA measures bone mineral density and converts the measurement into a standardized value called a T score (see table 1.1). Higher T-score values mean stronger bones. These results show how your bone density compares to a twenty-five-year-old woman. The test is painless, takes about ten minutes, and exposes you to only a fraction of the radiation needed for a chest X ray.

Warning Signs for Osteoporosis

• Any fracture after age 40

• Bone density test T score below -2.5

• Loss of height

• Dowager's hump (curve in the upper back)

• Back pain

The heel sonogram test. If you can't get a DEXA test, another option is the heel sonogram test (see table 1.2). This test is quick, taking only three to four minutes. It's painless and often done at shopping malls and free health screenings. The heel sonogram can be done while you are sitting in a chair and is useful for letting you know if you definitely need to have the more accurate DEXA test.

There are other ways to measure bone mass and diagnose osteopenia, but they are less often used or more expensive. If you need one of these other tests your doctor can help you decide and make the specific plans for testing.

We remind patients that the T-score measurement may be different with different machines used and with different brands of machines. So, especially when you compare your T score to a previous result, keep in mind that what seems like a big difference may not actually be a real change. This is complicated, but just be sure that you talk with your doctor when you compare several T-score results over time—this may save much needless worry, especially when it appears that your bone mass has decreased. We often see patients who worry and add or change medications because of an apparent worsening of bone density test results. Many times this is simply the result of different ways of testing and not a sign of declining bone health.

Normal results: If your bone density test score is normal, this means that you are not yet at a higher risk of fracture. Take the opportunity to talk with your doctor about prevention measures, including eliminating risk factors over which you have control (see page 15). Make sure you follow Steps 2 to 5 in the Bone-Building Program, including doing the right type of exercise (Step 2), eating a healthy diet filled with bone-strengthening foods (Step 3), maintaining lifestyle habits that keep bones strong (Step 4), and taking medications, if needed, and bone-strengthening supplements such as calcium and vitamin D (Step 5).

Osteopenia: If the bone density test shows osteopenia, then steps must be taken to help prevent fractures. This goes for men as well as women, since up to 30 percent of bone loss patients are men. Your doctor might recommend calcium and vitamin D supplementation, dietary changes, increasing exercise, and, depending on your age, using specific bone-building medications (see page 111). Treatment can effectively increase bonedensity, and it is well established that if you increase your bone density, you also lower your risk of painful and disfiguring fractures. If you have relatives with bone loss and fractures yet have no other risk factors, the bone density test can put your mind at ease.

Who needs a DEXA test? You might be wondering if everyone should have a bone density test, just to play it safe. The answer is no. But in certain situations, a bone density test is absolutely critical.

The universal public health directives are vague and unclear at best.

The current recommendation by the U.S. Preventive Services Task Force (USPSTF) of the National Osteoporosis Foundation (NOF) is that women have bone density tests at sixty-five and older—when many already suffer from some form of significant bone loss. Current research estimates that only about 12 percent of women over the age of sixty-five actually have gotten a bone scan.

One fact is clear—if you don't get a bone density test, you probably won't be treated even if your bones are thinning. Then eventually you may develop a fracture, get an X ray, and discover osteoporosis. But in fact many patients who have a fracture still aren't diagnosed or treated. Many patients, even after a hip or a spine fracture, don't receive the most effective medications to prevent future fractures. This is one area that, with simple steps, you can watch over for your health. It's as simple as a bone density test.

We recommend a DEXA test if one or more of the following situations apply to you:

• A fracture

• History of eating disorders

• Amenorrhea (loss of menstrual periods)

• Around the time of menopause

• Postmenopause

• Choosing not to take estrogen at menopause

• Taking medications for other health problems, listed on page 17, which can cause bone thinning, especially prednisone or other cortisone medication

• Taking bone-strengthening medications listed on page 111. (The bone density test is used to assess the effect of treatment.)

• Taking estrogen therapy for more than a few years

• Over age thirty with rheumatoid arthritis

• Men over age seventy, especially if they smoke, have lost height, take prednisone, or have chronic bronchitis, emphysema, or other medical problem (see section on men and osteoporosis on page 133).

Dr. Harris: "While there is much enthusiasm about the new bone density tests, it's important to note that this screening is not necessary for every young woman. Key factors such as age, lifestyle habits, and family history should be taken into consideration before you have this test done."

What to Expect

What are the preparations? You will be asked to lie down on a table or sit in a chair, but you won't have to undress (see photo). No pain or needles are involved.

What happens during the scan? In the DEXA test, the machine passes over the hip and lumbar spine as you lie on the table. In the heel sonogram, you sit in a chair while the machine quickly measures the heel bone density. Both bone density tests are quick, taking only a few minutes to complete.

Is it safe? The DEXA test uses a very small amount of X ray to measure bone mass. Your exposure is much less than if you had a chest X ray or a mammogram or about as much as the amount of "natural" radiation one might receive on an airplane trip across the United States.

The heel sonogram uses sound waves, not X-ray beams, and has no long-term side effects or radiation.

How much does it cost? The DEXA scan costs about $125. Some doctor's offices offer heel sonogram tests that cost around $40, and you might even find free screening scans available at health fairs, shopping centers, and drugstores. Talk to your insurance provider to see if it is covered under your policy.

Who interprets the results? Once you get your test results, you should review these with your doctor. He or she can explain what your actual bone strength is and what options you have for prevention or treatment. Use the results as an early warning sign. It's never too early to prevent or reverse osteopenia and it's never too late to treat osteoporosis and fractures.

A Bone-Saving Fracture?

If you have already had a fracture, this may be a sign of significant or severe bone loss. It is very important that you have a bone density test, examine other risk factors, and decide with your doctor what prevention steps to take. Your signal fracture may be a blessing if it alerts you to a problem and leads you to take bone-saving action.

Bone density tests offer researchers insight into the devastation of bone loss. Using these tests, researchers have found that after a hip fracture, most patients lose even more bone and muscle, perhaps because of the forced loss of activity. Interestingly, one year after a hip fracture, some patients were found to have a 5 to 7 percent loss of bone density. In addition, the body's overall muscle mass after one year was down 5 to 9 percent. The loss of bone and muscle, along with the sudden loss of strength, may help explain why older patients experience serious problems after a hip fracture. This might also explain why so many never become independent or walk as well again.

Hip fractures also require surgery, and in patients who have a hip fracture from osteoporosis, about one-third have trouble with daily self-care and hygiene activities. Approximately one-fourth of hip fracture patients need long-term nursing home care, and there is a higher chance of death—over 20 percent the first year. Studies show that this number may increase to 50 percent or more for those over seventy-five.

Invest in Your Bones

There is a silver lining in the cloud of those sobering statistics. Using the newer methods of detecting bone loss, along with the latest prevention and medical treatments described in this book, the risk of osteopenia and fracture can be greatly reduced for most women. There is no need to suffer from a fracture—if you start investing in your bone health today.

To help determine the best course of action for you and your family, we wrote this book as the next best thing to consulting with you in person. As we explain to patients, no single approach will solve the problem of bone loss. What is called for is an individualized approach that considers all your specific risk factors. Once you've assessed your risk factors on page 15, follow the age-specific strategies in Steps 2 to 5 for ways to change those risks you can control. Ultimately, this will help you improve the strength of your bones and the quality of your life.

Copyright © 2004 by Harris H. McIlwain and