Reading: Osteopenia: Are You at Risk?

The last thing I expected when my doctor sent me for a bone density scan after a too-easily sustained foot fracture last year was to receive a diagnosis of osteopenia.

I shouldn’t have been surprised; after all, as many as half of women over 50 are afflicted with osteopenia or lower-than-normal bone mass. Yet I expected to be in the other half. I eat a healthy diet, exercise regularly — and passed a bone density test in my mid-40s with flying colors. How could I have weak bones now?

“I hear this at least five times a week,” says Pamela Taxel, MD, of the UConn Center for Osteoporosis. “‘I’ve been doing all these good things for all these years – how could I have bone loss?’” Unfortunately, says Dr. Taxel, professor of medicine and clinical director of endocrinology and metabolism at UConn Health, not only do genetics play a significant role in how our bones fare as we approach menopause (thanks, Mom), but bone loss is a natural part of aging.

When Bone Mass Decline Begins

Women reach peak bone density by age 30. After that, there is a slow, steady decline until about two years before menopause, when estrogen levels, which have also been on their way down, fall more rapidly. Estrogen is essential to bone metabolism; in fact, women can lose between 2 and 5 percent of bone per year during the last few years before menopause until about five years after. At that time, bone loss resumes a more gradual decline.

Yet not all women end up with osteoporosis — or even with osteopenia. So who’s at risk? “If you smoked cigarettes before age 30, you may have never reached peak bone mass, because tobacco is toxic to osteoblasts, the cells that make bone,” says Linda Russell, MD, director of the Osteoporosis and Metabolic Bone Health Center at The Hospital of Special Surgery in NYC. “If you were anorexic in your teens or twenties and didn’t get adequate nutrition, you also might not have the bone mass expected of you.”

The average Caucasian woman in the US becomes osteoporotic by age 70, according to Dr. Russell. Think of osteopenia as a precursor to osteoporosis: women with osteopenia are more likely to sustain a fracture than someone with strong, healthy bones, but women with osteoporosis have even less dense bones and thus an even higher risk of fractures. In fact, experts estimate that one in three women over the age of 50 will experience an osteoporotic-induced fracture.

Women with a family history — particularly those with mothers who have had fractures and osteoporosis; as well as those taking long-term medications that are detrimental to bone (like steroids for asthma or autoimmune diseases), aromatase inhibitors for breast cancer, or proton-pump inhibitors for reflux — are also more likely to have low bone density.

“Then there are the lifestyle factors,” notes Dr. Taxel. “Have you had enough calcium, vitamin D, and exercise in your earlier years — and throughout your life cycle — to maintain adequate bone?” It is the lifestyle choices we make that either accelerate or slow down the natural bone loss process — and that can perhaps help prevent osteopenia from progressing to osteoporosis.

The Numbers You Need to Know

Bone mineral density is measured by a special kind of imaging test called dual-energy x-ray absorptiometry (DEXA). Your T-score will determine if you have healthy bone mass, osteopenia, or osteoporosis. A score of 0 reflects the average bone density found in a healthy 25- to 30-year-old; a score of 0 to -1.0 is considered normal. A score of  -1.1 to -2.4 represents osteopenia, and -2.5 or lower, osteoporosis.

What You Can do Now

So what do you do if you have osteopenia? “Nutrition and exercise are key,” says Dr. Taxel. Calcium is needed for the bone-building process (if you aren’t getting enough, the body pulls calcium from the bones to maintain adequate blood levels of the mineral), and Vitamin D facilitates absorption of calcium in the stomach or gastrointestinal tract. “I tell my patients that D is the door that you need to open to let the calcium in,” she explains.

Dr. Taxel recommends about 1200 mg of calcium per day in divided doses (adults only absorb about 500-600 mg of calcium at once), and says it’s best to get your calcium through food, as calcium supplementation can increase the risk of kidney stones in those susceptible, and some studies suggest excess calcium may contribute to a build-up of plaques in the coronary arteries and increased risk of cardiac events.

Foods rich in calcium include leafy green vegetables like collard greens and kale; nuts and seeds, including almonds, chia seeds, and sesame seeds; fish with bones, such as sardines and canned salmon; and dairy products like cheese and yogurt. For the lactose intolerant, many dairy alternatives, like almond or cashew milk, are fortified with calcium.

Mind Your Vitamin D

Ensuring that you get adequate vitamin D is equally important. “Most people are deficient in D because they wear sunblock, and not a lot of food has Vitamin D,” notes Dr. Russell. The National Osteoporosis Foundation recommends 400 IU daily for women 50 and under, and 800-1000 IU for women over 50, though Dr. Russell says doctors often check vitamin D levels and will supplement the amount needed to get women into the normal range. Fatty fish like salmon, tuna, and mackerel are natural sources of vitamin D, and some dairy products are also D-fortified.

Do Weight-Bearing Exercise

Weight-bearing exercises — that is, activities where both feet are on the ground and your body is working against gravity — are also critical for maintaining strong bones. The National Osteoporosis Foundation advises that women do 30 minutes of weight-bearing exercise most days of the week. Running, brisk walking, dancing, and hill-climbing are all weight-bearing (though high impact activities like running might not be safe for women with osteoporosis or a history of fractures). Weight-training is also a boon to bone health.

Other lifestyle choices that protect bone: Limit alcohol, which can upset the calcium balance in the body and weaken bones. (Women should not have more than one glass per day, says Russell.) Ditto soda-drinking and eating overly salty foods — both habits have been linked to reduced bone density because they increase calcium excretion in urine. Avoid processed meats, as they contain a double whammy of both nitrates, which can remove calcium from the bones, and excessive salt. And soak your beans and grains for several hours before cooking to reduce their phytate content — phytates can interfere with calcium absorption.

Can Bone Loss Be Reversed?

What those of us with low bone mass most want to know, of course, is whether we can turn back the clock. Once you’ve lost bone density, can the damage be undone?

“If you exercise and get sufficient calcium and vitamin D, you can perhaps stabilize and slow bone loss — and may be able to prevent the progression of osteopenia to osteoporosis,” says Dr. Russell, “But without medication, it is extremely difficult to reverse bone loss.”

The most commonly prescribed medications for strengthening bones are the bisphosphonates, which include medications such as Fosamax, Boniva, and Reclast. “Every day we resorb damaged bone cells and old bone and make new bones – this is happening all the time,” explains Dr. Russell. Bisphosphonates slow bone resorption, allowing bone formation to catch up and bone density to increase. These drugs are approved for both osteoporosis and osteopenia but are commonly reserved for patients with osteoporosis because they are associated with potential long-term side effects, like rare fractures of the femur, and gastrointestinal distress.

The exception, according to Dr. Russell, is women with significant osteopenia (closer to a t-score of -2.5) who have an elevated risk of fractures. This is determined by the FRAX (fracture risk assessment) score, also calculated during a DEXA scan. “If a patient’s risk of breaking any bone in the next ten years is 20 percent or higher — or 3 percent or higher of sustaining a hip fracture  — we offer the patient medical treatment to strengthen their bones,” she says. Because these medications can’t be used for extended periods of time, she adds, doctors are increasingly offering women in their 50s with osteoporosis or significant osteopenia hormone replacement therapy, which also preserves bone density, reserving the medical therapies for later in life.

The Surprise Benefits of Yoga

Some encouraging news: Preliminary studies suggest there may be other ways to reverse bone loss without medication. Researchers at Harvard, Columbia, Rockefeller, and New York Universities found that a 12-minute daily yoga regimen, in which subjects held 12 different poses for one minute each, reversed osteoporotic bone loss. Though the 2016 study had limitations — subjects were self-selected and there was no control group — one of the researchers, Loren M. Fishman, MD, assistant clinical professor of physical medicine and rehabilitation at Columbia University Medical School, claims he has seen similar results in his own practice. “Not only does yoga prevent osteopenia from progressing, it reverses it and turns it to normal — and it takes osteoporosis and reverses it and turns it into osteopenia,” he says.

Yoga is a unique exercise, according to Dr. Fishman, because yoga opposes one set of muscles against the other, generating forces many times stronger than gravity. This creates enough tension on bones to stimulate the osteoblasts — the cells that produce bone — without creating undue stress on joints. During the more than 100,000 hours of practice by subjects in his studies, there were no yoga-related injuries, but he advises women with osteoporosis, who are more susceptible to vertebral fractures, to avoid poses requiring forward flexion while practicing yoga.

In another study, published last year, German researchers found that postmenopausal women who took daily doses of collagen peptide powder significantly increased bone mineral density in both spine and hip, though the authors acknowledged that more — and bigger — human studies are needed.

When Should You  Get Tested?

Most practicing physicians feel that women should have a baseline bone density test at menopause, or earlier if they have risk factors or a low-impact fracture while in their 40s. But experts worry that fears about side effects of osteoporosis medications are deterring women from getting bone density tests in the first place.

“It’s a real crisis in our field that many women with weak bones are not even getting considered for treatment because they aren’t getting diagnosed,” says Dr. Taxel. Osteoarthritis can falsely elevate a bone density reading; a special type of CT scan known as a QCT (Quantitative Computerized Tomography) can help diagnose osteoporosis in people with osteoarthritis.

For me, getting tested — and diagnosed with osteopenia — was a wake-up call. I’m more conscientious about making sure I’m getting adequate calcium and Vitamin D, and I’m trying to add more weight-bearing activity to my usual Pilates and weight-training regimen. I, for one, have started adding collagen peptides to my morning coffee (if it doesn’t make my bones stronger, at least my skin, joints, hair, and nails will benefit), and I plan to incorporate 12 minutes of yoga into my daily schedule. Even if it doesn’t reverse my osteopenia, as Dr. Fishman puts it, “the side effects of yoga are better balance, a better range of motion, better posture, increased strength, better coordination, and lower anxiety, all of which help to prevent falls and fractures.”  

If you want to try Dr. Fishman’s bone-building yoga poses — or join his latest study on yoga and bone health — go to sciatica.org.