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Monday, August 21, 2017

Preparing to Meet the Doctor

Making a list of important questions before seeing any doctor for
the first time or when you’re going to discuss a specific problem is
always a good idea. For some reason many people’s anxiety levels
shoot through the roof when visiting the doctor’s office, often
causing them to forget why they came in. Maybe the antiseptic
smell or the white lab coats do it, but something about the whole
environment can be frightening. Be prepared and make a list so
you don’t forget.

Everyone’s list will be a little different, but use the following basic
questions to get started:

Do you treat many patients with osteoporosis?
What kind of diagnostic tests do you usually conduct?
Will you call me when you get the results, or do I need a
follow-up appointment?
How can I reach you if I have questions?
Will my insurance pay for the tests to be done?
What is your background in treating osteoporosis? Have you
taken additional training to treat it?

You may not be comfortable asking the doctor questions, because
you were raised not to question the doctor. Don’t worry about
asking the doctor for clarification. Most doctors today are interested
in educating their patients and want you to ask questions about
anything that isn’t clear to you. So ask away! And if your doctor
doesn’t feel that way, she may not be the right doctor for you!
Before you even walk in the door, you can ask the office staff the
following questions:

What medical school did the physician attend?
Where did the physician receive her postgraduate training?
Is the physician board certified?
Does the physician’s office have its own bone density
With what hospitals is the physician affiliated? Some insurance
companies have this data available on their Web sites.
The Web might list the medical schools of the physicians who
participate in their network, for example.

Getting ready for your
first appointment

Before you go for your first appointment, put together a manila
folder of “must have’s,” so you don’t forget anything. Make sure to
put the following items in the folder:
Your list of questions

Your medical records, including blood tests done within the
last two years and consultations with other physicians
The scans from your Dual Energy X-ray Absorptiometry (DXA
scan), a specific type of test that measures your bone mineral
density (see Chapter 9 for more on the DXA scan)
Any X-rays (the actual X-rays, not just the reports)

A list of drugs you’re taking for your osteoporosis, as well as a
list of all other medications and vitamins you take with
dosages, including any over-the-counter (OTC) medications
Chapter 8: Finding (and Paying For) a Doctor to Treat Osteoporosis 123
A list of all other health issues you have, because they may
affect your doctor’s recommendations
A list of your other doctors’ names and phone numbers just in
case your doctor wants to speak with them to coordinate
your care

Making sure you’ve found Dr. Right
Finding the right doctor isn’t always easy

 Even if the doctor you’re
seeing has the best reputation in town, he may not be right for
you if:

He makes you feel uncomfortable asking questions.

He doesn’t answer your questions to your satisfaction.

He doesn’t call you back within a reasonable time when you
have concerns.

You may need more than one visit to figure out whether your new
doctor is right for you. Your first visit may be awkward for a number
of reasons: you’re nervous, the doctor is having a bad day, the
office seems disorganized with long waiting times, or the front-desk
staff is unfriendly. Don’t let one bad experience scare you away, if
you feel comfortable with the doctor otherwise.

Choosing a specialist

Many different medical specialties are available where practitioners
may choose to treat patients with osteoporosis. Your primary doctor
can help you decide which one of the following is best for you:

Rheumatologists: Rheumatologists (your co-author Dr.
O’Connor is one) diagnose and treat diseases of the bones,
joints, and muscles, including autoimmune diseases such as
120 Part III: Diagnosing and Treating Osteoporosis
lupus. Rheumatology is a subspecialty of internal medicine
and requires board certification in both internal medicine and

Endocrinologists: Endocrinologists treat diseases of the endocrine
system, which is certainly no surprise. The endocrine
system comprises the glands and hormones that control your
body’s metabolic activity. Endocrinologists treat diabetes, thyroid
problems, and pituitary diseases. Endocrinology, like
rheumatology, is a subspecialty of internal medicine.

Endocrinologists may be especially interested in osteoporosis
because endocrine problems often result in osteoporosis.
Refer to Chapter 3 for a complete discussion of risk factors.

Geriatricians: Geriatricians treat geriatric patients (also
known as senior citizens). When are you in this category?
Although most people would say “never,” the accepted definition
of “geriatric” is age 65 and above.

Because osteoporosis is often, but not always, a disease of
aging, many geriatricians have a special interest in treating it.

Gynecologists: Because women comprise the largest group of
osteoporosis patients, many gynecologists, doctors who treat
women’s health, also treat patients with osteoporosis. If
you’re a man with osteoporosis, though, you may feel a little
funny sitting in the waiting room.

Orthopedic surgeons: Orthopedic surgeons specialize in the
treatment of bones and muscles. Some are interested in treating
osteoporosis, while some aren’t.

Physiatrists: Physiatrists are often confused with everything
from psychologists to podiatrists! Physiatrists specialize in
physical medicine and rehabilitation, dealing with acute
injuries as well as chronic conditions such as arthritis and

Different Types of Fractures

Certain types of fractures are more commonly associated with
osteoporosis and other bone diseases. In this section we define
these common fracture types and the difficulties they can cause.

Falling on outstretched arms

Wrist fractures, often called Colles’ fractures, typically occur as a
result of osteoporosis. These breaks usually happen in the radius,
Chapter 7: Facing the Consequences of Bones Gone Bad 109
the ulna, or some of the other small bones in your wrist (see Figure
7-1). Colles’ fractures often occur when you fall and put your
arm out to break your fall.

Figure 7-1: A wrist or Colles’ fracture is very common in people with osteoporosis.
Darker lines show where the wrist might break.
Treatment requires casting or some other form of immobilization.
Sometimes you may require surgery. You may experience loss of
motion of your wrist, but this type of fracture isn’t nearly as devastating
as a hip or spinal fracture.

However, the occurrence of a wrist fracture is clearly a warning
sign that you may have an overall reduction in the strength of your
bones. A Colles’ fracture is therefore considered a fragility fracture,
and your doctor needs to evaluate you for the possibility of osteoporosis
or other bone disorders.

Who are more prone to wrist fractures? Among American women,
the incidence of wrist fractures increases rapidly at the time of
menopause and plateaus at about 700 per 100,000 persons per year
after age 60.
110 Part III: Diagnosing and Treating Osteoporosis
“I broke my hip! Or was it
my femur?”
What is commonly referred to as a “broken hip” is actually a fracture
of the femur, the longest and heaviest bone in your body. The
fracture is usually found at the neck of the femur, where it connects
to the pelvis.

More than 300,000 people fracture their hip each year in the United
States. In fact, hip fractures (see Figure 7-2) are the second most
common type of osteoporotic fracture.

Figure 7-2: A “hip fracture” is actually a fracture of the femur, oftentimes in the
femoral neck, which is an area that is particularly weak.

Ninety percent of all hip fractures are related to osteoporosis. Hip
fractures are devastating and can have long-term consequences. A
hip fracture
Requires a trip to the emergency room. In the United States,
in 1995, hip fractures resulted in 800,000 visits to emergency
Requires hospitalization with period of immobility. In 2003,
in the United States, there were 300,000 hospital admissions
for hip fracture (defined as a fracture of the head of the
Chapter 7: Facing the Consequences of Bones Gone Bad 111
femur) in one year. There could be more fractures not
included in this analysis.

Often requires surgery. You need a new hip or a pin in your
hip. (See Chapter 13 for more details about the surgery after
hip fractures.) Surgery on your hip can be complicated by
very serious problems including infection, pneumonia, and
blood clots in your legs or lungs.

Fractures of the femoral neck are very close to the hip joint.
As a result, doctors can’t immobilize this area with a cast.
In addition a hip fracture can lead to
Increased disability from hip surgery. One-fourth of all people
with a hip fracture become disabled in the year after their
fracture. Hip fractures result yearly in more than 7 million
days of reduced activity.

Increased chance of ending up in a long-term care facility.
Almost 75 percent of all nursing home admissions are related
to hip fractures from osteoporosis, which accounts for
approximately 6,000 admissions yearly. Almost half the
expense of hip fracture healthcare is paid to nursing homes.
(In 1995, 180,000 people ended up in a chronic care facility
because of a hip fracture.)

Reduced life expectation. Hip fracture affects your health and
ability to care for yourself (your risk of dying even!).
If you were able to get around without a walker or other aid at
the time of your hip fracture, fracturing you hip will almost
triple (2.8 times) your risk of dying in the next three months,
compared to people who don’t have a fracture.

According to one study of women older than 65, each standard
deviation decrease in bone density at the hip resulted in a 30 percent
increase in total mortality. (See Chapter 9 for more info on
standard deviations and bone density testing.)

Although we aren’t intending to scare you, we want you to be aware
that hip fractures are serious health problems that can result in
your dying sooner than you would have without a fracture. The
key is to avoid fracturing a hip. How can you stay alive longer by
being fracture free? Prevention, prevention, prevention!

Falling and hip fractures

“Grandma fell and broke her hip.” You’ve undoubtedly heard someone
say this or you’ve even said it yourself. She actually fractured
her femur, probably near the femoral neck.

112 Part III: Diagnosing and Treating Osteoporosis
Some studies show that occasionally people don’t “fall and break
their bone” at all. Instead they have a fracture of the femur from
the simple stress of putting their foot down on a step. So the fracture
causes the fall and not the other way around! How often this
actually happens is difficult to say. Nonetheless, people in the
healthcare field definitely want to prevent as many falls as possible
by changing the environment and preventing hazards.

Some people are more prone to falling than others; they have
what’s known as postural instability. Your co-author Sharon is one
of these people. If you’re one, you undoubtedly already know it.
You may walk into walls and trip over a crack in the sidewalk.

Doctors aren’t quite sure what causes postural instability, but it
may be because you have visual issues, don’t judge spatial relationships
well, can’t decipher depth perception, or have poor contrast

Whatever your reason for being spatially challenged (or as your
grandchild may say, a klutz), you need to be especially careful
when you have osteoporosis. If you’re a klutz, you know you’re
going to fall or trip sooner or later, and every fall increases your
chance for injury.

The Centers for Disease Control (CDC) statistics indicate that onethird
of all people older than 65 fall each year, and that the majority
of fractures result from falls. The good news is that most falls
occur in your own home.

Why is this good news? It’s good news, because you can control
your own environment. You can’t control the supermarket that
mops aisle one and forgets to put out a “Be Careful” sign, but you
can determine where you place your furniture and the kind of rugs
you have on your stairs. (See Chapter 13 for more on falling and
fractures.) You can also take preventive measures to avoid a fall.
(And make sure to stay off that ladder!)

Facing Fragility Fractures

Your doctor may often use the phrase “fragility fracture” when you
experience a broken bone with minimal trauma. You probably
know that experiencing a fracture with normal, healthy, strong
bones is certainly possible. For instance, a child who falls from a
tree and fractures an arm can have normal bone strength, but the
impact is still too great to withstand a break. On the other hand,
people with osteoporosis or other problems, such as osteomalacia
(adult rickets), can develop a fracture without a significant injury.

Hip fractures, vertebral compression fractures, and wrist fractures
all should alert your physician to investigate your situation carefully
and further delve into the possibility of you having lost bone
strength. In infancy, the occurrence of multiple fractures should
alert your pediatrician to the possibility of osteogenesis imperfecta.

Your doctor also may diagnosis osteoporosis if you’re unfortunate
enough to require surgery on a broken bone. During surgery, your
orthopedic surgeon can directly assess your bone quality. She may
call a consultation after the procedure because your bones appear
thin during the operation “like potato chips.” You don’t want to
hear this term when describing your bones, do you? (And to think,
you don’t get any sour cream and chive dip to go with them.)

Increasing evidence suggests that any fracture in women or men
older than 55 can be the first indication of a metabolic bone problem.
Other fractures seen in osteoporosis include rib fractures,
fractures of the arm (humerus), and pelvic bone fractures.

Finally, multiple fractures, even with significant trauma, should
alert your physician to the possibility of a metabolic bone disease
and prompt referral to a specialist.

For example, one of your co-author’s nephews experienced three
fractures over a two-year period while playing ice hockey. His doctors
started him on vitamin D supplements, because he lived in
New Hampshire, where the exposure to sunlight is variable. He
hasn’t had a fracture since!

Aging and Your Bones

bones are beautifully engineered and
marvelously efficient — until something goes awry. You first need
to understand why keeping your bones strong and healthy is so
Early detection and preventive treatment before fractures occur is
the vital key to treating osteoporosis.

Osteoporosis is somewhat similar to high blood pressure (hypertension).
For instance, if you have high blood pressure, you may
not know it, because people rarely experience any symptoms from
an elevated blood pressure. Untreated hypertension causes damage
to blood vessels over many years. But if high blood pressure is
diagnosed early, its devastating consequences (stroke and heart
disease) can be prevented.

When you develop a fracture from osteoporosis, it’s likely that you
have had the problem for years. In other words, by the time you
have an osteoporotic fracture, bone is already quite fragile. You
can lose bone at the rate of 5 percent per year (for example during
menopause) and not experience any pain at all. So unless you discover
you have osteoporosis at an early stage, before you have any
symptoms, you’ll already have weak bones at the
time of your first symptom, which can be a devastating and even
life-threatening fracture.

Don’t get the impression that as soon as a fracture occurs, no treatment
can help. Studies have shown that bone density can improve
even at later stages, and fracture rates can be reduced. A recent
estimate by the Office of the Surgeon General reports that by the
year 2020, nearly one-half of Americans will be at risk for developing
fractures, if doctors don’t make changes in their approach to
early diagnosis and treatment of osteoporosis.

Avoiding Injury While Exercising

You may be prone to initial hyperenthusiasm about exercising. Or
are you the type of person who has to be dragged, kicking and
screaming, into the gym? For people who begin any new project
with incredible amounts of misdirected enthusiasm, we need to
insert a word of warning here.

Overdoing exercise when you’re not used to it can cause muscle
damage that can permanently sideline you from the Macarena line.
Start slowly and work up to a more strenuous routine, and utilize
the gym’s trainers to help you pick the machines that will benefit
you most. Of course, the trainer can also coach you to use the
machines correctly. You can damage your muscles by exercising
incorrectly, not to mention the damage you’ll do if you drop
weights on your foot by mistake! Find out how to do exercises
properly from the beginning; your bones, muscles, and tendons
will all thank you!

Getting Down to the Nitty-Gritty:
Choosing an Exercise Routine

Sooner or later, you need to get down to business. All the running
shoes and color-coordinated outfits won’t help a bit until you start
putting them to use. To get started, pick a time, starting with 20 to
30 minutes a day, three days a week, as a recommendation. Then
pick an activity from the following list, and end your routine with
15 minutes of weight training, also known as strength or resistance

Some weight-bearing cardiovascular workouts include

Cross-country skiing


Jumping rope

 Light jogging (make sure your knees are up to this!)

Don’t let the muscleheads intimidate you

Does the thought of walking into the gym alone scare you to death? Find a friend or
drag your partner with you so you can discover how to exercise correctly together
(people typically don’t feel as foolish when they have an equally inept partner with
them) and also can cheer each other on.

Even if you go in a group of ten, you may find the gym intimidating at first. Some
gyms now cater just to women, or to the over-40 crowd, so don’t feel like the local
Beefy Studs R Us Gym Inc. is your only option. Visit a few places to get a feel for the
clientele before signing on any dotted lines.
Don’t be scared off, though, if everyone you see is fit and trim. After all, that’s what
you want to be too! Invest in a workout outfit or two if you feel conspicuous in the
sweats you’ve owned since high school. Make sure you’re comfortable in everything
so you don’t have to worry about parts of your outfit riding up or down during
your workout.

Playing tennis

 Stair climbing

Walking outside or on a treadmill

Do you want to painlessly increase your daily cardiovascular workout?

Take the stairs instead of the elevator every chance you get —
and park at the back of the parking lot, instead of circling around
looking for the spot closest to the door.

Weight, or resistance, training allows you to be specific about the
bones you want to strengthen, so you want to add exercises targeting
your hips, spine, and arms — the most frequent fracture sights
in osteoporosis. Weight training may give you a mental picture of
rippling muscles lifting a hundred pounds over their owner’s head,
but weight training can be very simple; you don’t even need to buy
weights. You can use anything that’s easy to hold, as long as you
have two of them so you work both arms equally.

Resistance training has benefits beyond bone building. A study
done at the University of Florida’s Colleges of Medicine and Health
and Human Performance showed that people working with weights
three times a week for six months were able to work out longer on
a treadmill.

When you begin resistance training, start with one- to two-pound
weights and work up gradually. If you can’t comfortably do eight
repetitions of an exercise, the weight you’re using is too heavy. If
you can do more than 15 repetitions easily, it’s too light. For some
of you, you may not be able to use any weights at all to start! Build
up at your own pace.

Follow these easy steps when using weights:

1. Take three seconds to lift the weights, and then hold in
position for one second.

2. Lower over another three seconds.

3. Breathe slowly, exhaling as you lift and inhaling as you
lower the weight.

4. Do one set of 8 to 15 repetitions (reps), starting with 8 to
12 reps and working up to 12 to 15 reps.

5. Rest for 30 to 60 seconds, and then do a second set.

Don’t forget to start with a weight you can lift only eight times.
Stay at that weight until you can lift it 12 to 15 times. Then add
weight until, once again, you can lift it only eight times. Add
more weight each time you can easily do 12 to 15 reps.
94 Part II: Keeping Your Bones Healthy

Don’t exercise the same group of muscles two days in a row —
alternate exercises to allow muscles to recover.

Setting an exercise schedule

If you try to do too much too fast, you may end up wearing yourself
out or even hurting yourself. If you overdo it at the beginning,
you may end up not doing any exercise at all in the long run.
Setting a schedule for exercise requires that you look realistically
at your schedule. If you plan to spend every lunch hour at the gym
from now until Christmas, don’t forget to factor in your once-a-week
lunch hour with your friends from high school and the garden
club’s weekly meeting.

Are you really going to avoid all lunchtime
social engagements for the rest of your life, or even for a month?

If you’re like most people, the answer is no. So be realistic. If you
can plan to spend three days a week at the gym, with some time on
the treadmill at home another day or two, you’ll still be way ahead.
Don’t feel like you need to do all your exercise at one time, either.
A walk at lunch and a bike ride with your kids after work adds up
to an hour a day, but it doesn’t feel like you’re spending all your
time exercising. Get creative — just make sure you get active!
Finding time in your life for exercise

If you’re working and your lunch hours are nonexistent, then you
need to squeeze exercise into some other time of the day. Many
gyms open early so that you can exercise before work. Going in the
morning may be a better plan than going after work, when all you
want to do is go home and collapse, if you’re motivated enough to
get up in the morning to go to the gym and make it to work on time.
If you’re a caretaker at home, finding time to get to the gym may be
difficult. Even though many gyms have childcare on-site, few have
eldercare. Being the caregiver for a parent or a disabled spouse
can affect your exercise schedule, and you may need to keep your
exercise regimen close to home.

One way to keep your family active and also spend quality time
together is to make exercise a family affair. How about bikes for the
whole bunch — and a baby carrier on the back for your youngest
member? Or just take a walk with your little guys — pushing the
stroller provides great resistance training

Developing an Exercise Plan

Having healthy bones isn’t going to do you any good if you exercise
yourself into collapse during the first week! Before you start
buying out the sporting goods store, ask yourself and your doctor
a few questions, such as:

Do I have any physical limitations on exercise? If you’ve
lived a few years, you probably have some wounded areas.
How about the hand you broke three times playing racquetball,
the knee you twisted playing football, and the foot you
had surgery on last year? Most of you have a “weak spot”
acquired from years of daily living. Try not to aggravate any
existing problems when you start exercising.

Is there any kind of exercise I shouldn’t be doing? The
restrictions may be health related. For example, if you have
exercise-induced asthma, running probably isn’t a good activity.
If you have heart problems, your doctor may not want you
undertaking certain types of exercise.

Restrictions can also be common-sense restrictions. For example,
if you live on a major highway, jogging may not be a good
choice, unless you can go to a track somewhere. Ice-skating is
impractical if you live in Hawaii, unless you have an indoor
rink nearby.

What do I enjoy doing? Suffice it to say that if you like what
you’re doing, you’ll probably keep doing it, and if you hate
what you’re doing, you’ll probably stop at the first muscle

How much will it cost? Unfortunately, cost is a major factor
in many people’s exercise plan. Gym memberships and sports
equipment can be expensive. Even walking can add up if, like
your co-author Sharon, you require expensive specialized athletic

Understanding why exercise strengthens bone

Exercise that moves your muscles stimulates your bones. As the
muscle pulls against the bone it’s attached to, it stimulates the
bone to rebuild and become dense. One reason for this is that your
bone, like every other part of you, adapts to a certain level of activity.
When you increase that activity level, you increase blood flow
to your bones, which results in increased nutrients for growth
going to your bones.

Building muscle helps build bone. Although exercise won’t completely
prevent you from losing bone, it can help slow the process.
In addition, exercise can

 Strengthen muscles and reduce pain

Improve your sense of balance and decrease your chance
of falling

Better your overall health

Utilizing weight-bearing exercise
and resistance training

Weight-bearing exercise and resistance training are both beneficial
for increasing muscle and bone mass and avoiding fractures.

Weight bearing refers to any exercise that places your full weight
on your legs. In other words, if you’re standing, you’re weight bearing!
However, if you’re just standing there, you’re not exercising.
Weight-bearing exercise means using your bones and muscles to
work against gravity when you move.

Gravity keeps you on earth instead of letting you float through the
air like an astronaut. Because gravity is holding you down, it takes
effort to move your muscles and bones against it. If you’re moving
against gravity while standing up, you’re doing weight-bearing
exercise. Some examples of weight-bearing exercise are running,
walking, stair climbing, dancing, jumping rope, jogging in place, or
playing sports, such as tennis, volleyball, or racquetball.
Meanwhile, resistance training includes any activity that involves
overcoming resistance, such as pushing, pulling, or lifting.
Some examples of resistance training are lifting weights, doing
push-ups or pull-ups, or using specially designed exercise
machines that allow you to push or pull against a set resistance

Resistance exercise helps bone grow because the tendon the bone
is attached to pulls on the bone, encouraging bone-cell activity. As
your muscles become stronger, they continue to stress the bones,
stimulating more bone-building cells to grow.
Because water doesn’t create much resistance or allow weight
bearing, swimming isn’t classified in either of these categories.
However, because water exercise is good for your heart and
muscle strength, it’s a good choice of exercise for many people,
especially those unable to bear weight on joints because of pain or
other problems.

Friday, August 18, 2017

Looking At How Your Weight Affects Your Bones

Thick or thin, fat or skinny, what’s best for your bones? Because
most other health issues say thin is better, you may assume the
same is true for your bones, but that’s not necessarily the case.
Excessive dieting isn’t good when it comes to osteoporosis.

Some studies show that thin women who are overly concerned
about their weight and diet frequently have bone density that is 6
percent lower than women of average weight. If your weight drops
below 127 pounds, your physician needs to be appropriately concerned
that you’re at higher risk for development of osteoporosis.

Clearly, obsessive dieting to the point of anorexia or amenorrhea
(lack of menstrual periods, caused by low estrogen levels) can
result in low bone density that may last a lifetime. (See Chapter 4
for more on anorexia.) Plenty of low calorie sources of calcium are
available to keep you both trim and bone-strong at the same time.

What about the other side of the coin, that is, being overweight?
“Fat” has a negative connotation in the United States and elsewhere.
And even though “fat” in the sense of true obesity is certainly
bad for your health, some fat is necessary.

 Research has shown that higher body weight can influence bone mass through
four mechanisms:

Larger mechanical loading
More muscle mass
Higher levels of sex hormones
Less bone resorption

Estrogen levels in your body are related to fat, and estrogen helps
build strong bones by decreasing bone breakdown and helping
maintain adequate levels of vitamin D.

Osteoporosis is actually less common in overweight people, but
that’s hardly a reason to gain large amounts of weight, because the
risks of obesity on many other body functions are well documented.
The bottom line for adults is that you need to discuss
your proper weight with your physician. Too much is harmful. Too
little is harmful as well.

With regard to children, weight issues may be different. Some
recent studies have shown that overweight children have lower
bone density than their normal weight peers. Their lower exercise
levels and decreased intake of calcium and increased amounts of
carbonated beverages may account for these findings.

You can help your overweight child develop better bone density
by cutting out sodas and substituting low-fat milk. Encourage your
child to be active; your child may never make the Olympics, and
may not want to play competitive sports, but cycling, weight lifting,
or just walking can pay big dividends in stronger bones. Better
yet, go out with your child when he exercises, and you’ll develop
not only stronger bones, but also a closer relationship with
your kid.

Examining the Critical Role of Vitamin D

You can’t have healthy bones unless you take in enough vitamin D.
Although you probably already know that calcium is essential to
build strong bones, you may not realize that without vitamin D,
your body can’t properly absorb or utilize calcium (see Chapter 11
for more on vitamin D supplementation).

In many parts of the world, people easily obtain vitamin D through
sunlight exposure, the main source of vitamin D. However, many
elderly housebound people, as well as those cooped up in an office
with nary a ray of sunlight exposure day after day, and those who
live where it seems the sun rarely shines, may all be vitamin D deficient,
unless they work at getting enough to compensate in their

Fortunately, many processed foods are fortified with vitamin D.
Companies began fortifying milk and cereals with vitamin D in
the 1930s to help prevent rickets, a disease caused by vitamin D

Milk is a good source of vitamin D only because manufacturers
add vitamin D to the milk. Cows’ milk alone has none! Because milk
is a good source of vitamin D, you may assume that cheese and
other dairy products, such as ice cream and yogurt, are also good
sources, but only milk is artificially fortified with vitamin D. You
won’t find vitamin D in large quantities in other dairy products, so
don’t count your daily ice cream bar as a part of your vitamin D
requirement! Vitamin D–fortified milk isn’t used in the production
of many other dairy products.

Because only certain foods are fortified with vitamin D, doctors are
recognizing more and more patients with blood levels of vitamin D
below the recommended amount. Years ago, doctors didn’t have
particularly accurate ways of measuring the amount of vitamin D
in their patients’ blood. Newer tests are more accurate.

To complicate matters, many foods have less vitamin D than they
used to have. We believe (and there is literature to back this up)
that vitamin D deficiency is becoming much more common among
adults especially those living in northern climates. One cup of milk
has about 100 International Units (IU) of vitamin D in it, but the
minimum requirement is 200 IU daily. If you have osteoporosis,
your doctor may recommend upwards of 800 IU of vitamin D daily.

So if you don’t drink milk, if you’re not exposed to enough sunlight,
and if you don’t take a multivitamin, you may be at risk for vitamin
D deficiency. Other options do exist. For example, raisin bran is
fortified with 77 IU of vitamin D, but the amount can vary from
brand to brand.

Living with lactose intolerance

Millions of people worldwide are lactose intolerant, meaning that
they can’t break down and use lactose, the main sugar found in
milk and other dairy products. These people are deficient in the
enzyme that breaks down lactose known as lactase. The symptoms
include bloating, lower abdominal pains, and loose stools after
drinking milk. As time goes by, people who are lactose intolerant
often drink less milk to avoid the symptoms.

Lactose intolerance affects all races to some degree, although
African Americans, Asian Americans, Hispanics, and Native
Americans are affected more frequently than Caucasians. For
example, some studies in the United States quote a 70 percent
incidence in African Americans and a 15 percent incidence in

76 Part II: Keeping Your Bones Healthy
Lactose intolerant people are twice as likely to suffer from osteoporosis
than people who aren’t lactose intolerant. They have a
higher rate of osteoporosis because they typically take in less calcium,
or because they don’t absorb calcium well.

You can take some easy steps to maintain your calcium intake if
you’re lactose intolerant by:

Drinking lactose-free milk, such as Lactaid. In lactose-free
milk, the lactose has been chemically removed.

Drinking soymilk. We thank comedian Lewis Black for pointing
out that soymilk is more appropriately referred to as “soy
juice” because it doesn’t come from a cow! Have you ever
seen a soy cow before? Neither have we!

Trying Ultra Lactaid tablets. Take one just before consuming
any product with lactose. These tablets often aren’t effective
in people with severe deficiencies of the enzyme.

Checking our charts in this chapter for calcium contents of
foods that don’t contain lactose. We provide plenty of alternatives,
for example, oranges, almonds, and salmon. (A yummy
spinach salad topped with orange slices, sliced almonds, and
chunks of grilled salmon sounds good right now!)

Looking for calcium-fortified drinks, such as orange juice.
Make sure you know what you’re getting by reading the label.

Eating yogurt with active cultures. Yogurts with live active
cultures contain bacteria that help digests lactose. (One cup
of yogurt contains 5 grams of lactose.)

Chopping up some cheese. Hard cheeses, such as cheddar
and Swiss, have much of their lactose broken down during the
production process. (Swiss cheese still has a gram of lactose.)

Treating corticosteroid-induced osteoporosis

Like it or not, some children need to be on daily doses of oral corticosteroids.
The treatment goal is to minimize bone damage, even
if it can’t be avoided completely. If your child takes oral corticosteroids,
ask your doctor to start with the lowest effective dose to
treat, instead of pulling out the big guns from the start.

Children on corticosteroids must maintain an adequate calcium
and vitamin D intake. This amount may be higher than the normal
recommended daily allowance, which for calcium is 400 mg for
infants aged 0 to 6 months, 800 mg for children 1 to 10, and 1,200
mg for adolescents and young adults 11 to 25. Children on corticosteroids
need to have 1,000 to 1,500 mg of calcium daily, and
400 to 800 IU of vitamin D.

Furthermore, keep your child exercising, even if you and your
doctor have to modify the exercise program for your child’s limitations.
Maintaining weight-bearing activities stimulates bone mass.
Have a baseline bone densitometry test done so your doctor can
watch for any changes. Your doctor may also want to monitor
24-hour urinary calcium, phosphorus, and creatinine (a waste
product that can help measure kidney function) levels to check
for mineral loss. Taking blood tests for osteocalcin, which helps
measure bone turnover, may also be helpful.

Corticosteroids and osteoporosis in children

The use of corticosteroids for inflammatory diseases, such as
asthma, in children is one of the biggest childhood risks for developing

Most children who develop corticosteroid-induced osteoporosis
are taking oral steroids. Although researchers and doctors haven’t
ruled out high-dose inhaled steroids as a possible cause of osteoporosis,
studies haven’t been conclusive (see “Substituting inhaled
corticosteroids” later in this section). If your child is likely to be on
oral corticosteroids long term, ask your doctor to conduct a baseline
bone densitometry to monitor any changes (check out
Chapter 9 for more on baseline testing).

One study by the National Jewish Medical and Research Center of
400 asthmatic children on daily oral corticosteroids made the following

Daily doses of 10 mg of prednisone can cause bone loss.

Thirty to 50 percent of children will have bone loss.

Bone loss in children will be mainly in the vertebrae and
radius (forearm).

Bone loss won’t have any symptoms until a fracture occurs.

Bone densitometry starting at age 5 is essential in high-risk

Bone loss is most common in children taking a daily dose of
20 mg or more of a corticosteroid. Short “bursts” or occasional
corticosteroid use doesn’t appear to cause bone loss.
Substituting inhaled corticosteroids

Although studies measuring possible bone loss in children who
have used inhaled corticosteroids have been inconclusive, some
preliminary results show less chance of bone loss and osteoporosis
if the children use inhaled corticosteroids rather than oral

Studies have shown some conflicting information, however. In
2001, studies in young women showed that inhaled corticosteroids
to treat asthma resulted in loss of bone density. Eight puffs daily
had the greatest effect. Then in 2003, further data appeared in the
literature that showed that inhaled corticosteroids in children
didn’t seem to affect bone. These preliminary results are great
news, but need to be viewed with caution, because there is conflicting

Several studies in adult asthmatics have shown decreases in osteocalcin,
a protein made by bone forming osteoclasts, in inhaled corticosteroid
users, so inhaled corticosteroids could possibly be
damaging, although not to the same extent as oral doses.

With chronic disease requiring the daily use of corticosteroids, the
best advice is to start with the smallest dose that gives good effect,
start with inhaled corticosteroids rather than oral doses if possible,
and monitor bone closely. Keep the number of puffs used daily
to a minimum. Inhaled corticosteroids for asthma are critically
important in treating this potentially life-threatening and lungdamaging

Osteogenesis imperfecta (OI)

Osteogenesis imperfecta (OI) is a genetic bone disease usually
inherited from a parent. Occasionally, OI occurs as a spontaneous
mutation with no family history. A parent with OI has a 50 percent
chance of passing the gene on to a child.

64 Part I: Understanding Your Bones
People with OI are missing a protein called type I collagen. This
protein helps make up bone, ligaments, teeth, and the white outer
part of the eyeball, the sclera. The lack of type I collagen creates
fragile bone that fractures easily, although it heals at a normal rate.
OI can range from mild to severe, and anywhere between 20,000
and 50,000 people in the United States have OI.

 Some individuals
with OI have distinctive features: They’re shorter than average.
They have a blue, gray, or purple tint to the whites of their eyes.
Some have hearing loss.

Someone with OI may have anywhere from ten fractures to hundreds
in their lifetime. Some fractures may need surgical treatment.
For example, metal rods may need to be inserted into the
long bones of the arms and legs. Spinal fusion may be necessary to
limit scoliosis. The rate of fracture often declines as OI children
become adults, but may increase again as women enter
Doctors aim treatment at maximizing function, minimizing disability,
and maintaining overall health and independence. Doctors may
prescribe an injectable bisphosphonate drug, pamidronate
(Aredia), to strengthen bones and reduce fractures.
Chapter 4: Men and Kids G Idiopathic juvenile
osteoporosis (IJO)
Idiopathic juvenile osteoporosis (IJO) is a rare disease, with less than 100 cases
reported, and occurs in previously healthy children between the ages of 4 and 16.
Most of the time, the disease goes into spontaneous remission within two to four
Children with IJO may complain of pain in their back, hips, and feet, and may have
trouble walking. Their DXA scans may show low bone density, and X-rays will reveal
fractures of weight-bearing bone or collapsed vertebrae.

Treatment of IJO is aimed at protecting bones from fracture until remission occurs,
through physical therapy and reduced activity. Doctors generally don’t use medications
unless the disease is severe and not resolving spontaneously.

Damage from IJO can result in permanent collapse of the rib cage or scoliosis, but
often the disease leaves no permanent disability. Growth may be hindered during the
active phase of the disease, but normal growth usually resumes in remission. Most
children experience complete recovery with no later recurrence.

If your child or grandchild suffers from IO, take extra care when
handling him. (Don’t avoid touching your child. Give him or her
plenty of hugs and kisses — just be gentle.) Casts are probably
going to be a way of life for your child, so make sure the car seat
and stroller you buy are big enough to accommodate them.

Little Kids Can Have Osteoporosis

Even though osteoporosis is rarer in children, it can occur. But
some diseases, such as rickets, osteogenesis imperfecta, and the
very rare idiopathic juvenile osteoporosis (IOA), can also cause
osteoporosis or bone loss in children. And some medical treatments,
such as corticosteroids to treat asthma, can also lead to
osteoporosis. This section examines these conditions in more

Rickets: A real risk for bone loss 

You may think of rickets as a disease of the past, and to some
extent you’re correct. Rickets, a vitamin D deficiency, was much
more common before the early 1920s, before milk was fortified
with vitamin D and rickets greatly decreased.

But rickets is still around, although it’s not a common disease. In
adults, rickets is known as osteomalacia (see Chapter 1 for more on
osteomalacia). Rickets and osteomalacia both have the same
causes and effects.

Some of the symptoms of rickets are
 Bone fractures
 Bone pain
 Fever, restlessness, and weakness
Chapter 4: Men and Kids Get Osteoporosis, Too 63
 Growing wings and jumping from grass blade to grass blade
(Wait, ignore that. That’s from Crickets For Dummies.)
 Muscle cramps
 Short stature
 Skeletal deformities such as bowlegs, pigeon breast, spine
curvatures, or odd-shaped skull
 Soft teeth

Rickets is a childhood metabolic disease that causes an imbalance
between bone breakdown and remodeling. This imbalance can
happen because the child isn’t taking in enough vitamin D, or
because an intestinal disease, such as celiac disease (or sprue),
is blocking the absorption of vitamin D.

Vitamin D is available from two sources: sunlight and food. In
industrial areas, pollution may block sunlight. In cold areas, sunlight
may be limited during the winter. People with dark skin
absorb less sunlight and are more prone to vitamin D deficiency.

Newborns sometimes are vitamin D deficient because their breastfeeding
mothers are. Breast milk normally doesn’t contain adequate
amounts of vitamin D, but the amount can be increased if
mom takes vitamin D supplements. Breastfed babies can also take

Sometimes children with special diets can develop rickets. For
example, a child allergic to milk and dairy products or a vegetarian
child who avoids milk products needs vitamin D supplementation
to avoid rickets. Consult with your doctor about the appropriate
amounts, depending on your child’s age.

A hereditary inability of the kidneys to retain phosphate or a
kidney disorder that causes acidosis can cause rickets. Liver
disorders can also cause problems with vitamin D absorption
or metabolism.

The female athlete triad

The female athlete triad may sound like some sort of Olympic
event, but it actually describes a serious result of eating disorders
combined with too much exercise. Young athletes involved in
sports, such as ballet, gymnastics, and figure skating, where keeping
their weight low is important, often suffer from this condition.
What causes this condition? The combination of stringent dieting
and excessive exercise results in a loss of menstrual periods,
which lowers estrogen levels. The outcome? The athlete lacks the
nutrients to grow strong bones and hormones to maintain bone,
which causes osteoporosis at a young age, leading to stress fractures
and weakened bones that can last a lifetime.

A young athlete may seem to be taking in a normal number of
calories, but the amount eaten may be far below what she needs
because of her greatly increased physical activity.

The female athlete triad isn’t an uncommon problem. In fact,
among female athletes, the syndrome may be present in as many
as 50 percent or more of athletes. If you’re a parent, grandparent,
or close friend of a young athlete, watch for these signs to see if
the child is taking training to a dangerous level:

 Loss of menstrual periods for three months in a row

 Preoccupation with eating and/or using diet pills, laxatives, or

 Frequent visits to the bathroom immediately after eating

 Menstruation not begun by age 16

 Always wearing baggy sweatshirts and pants so weight loss
isn’t evident

Girls with the female athlete triad may be put on hormone replacement
therapy to supply necessary hormones. They also need to be
under a physician’s care.

If you’re the relative, coach, or friend of a young athlete, how can
you help them avoid the trap of the female athlete triad? Follow
these three simple steps:

1. Don’t emphasize winning as the most important thing.
The benefits of sports are many, and although winning
is great, don’t seek it at the price of permanent health

2. Be aware.

Watch for the signs that your athlete is taking diet and
exercise to an extreme, and don’t wait until you notice
everything is out of hand before doing something about it.

3. Take action.

Don’t bury your head in the sand when you see signs. Don’t
assume that just talking to your athlete will fix the problem.
Enlist the help of your doctor and the coach.

Dieting and bone loss

Avoiding the “it’s in to be thin” emphasis today is difficult, especially
if you’re young and impressionable. Being severely underweight
can have devastating consequences to bone, especially
if there is an associated eating disorder, such as anorexia and

The American Psychiatric Society defines anorexia nervosa and
bulimia nervosa in the following way:
Anorexia nervosa is

 A refusal to maintain weight that’s over the lowest weight considered
normal for age and height

 An intense fear of gaining weight or becoming fat, even though

 A distorted body image

 In women, three consecutive missed menstrual periods without

Doctors and counselors direct treatment of anorexia at achieving
weight gain. When an anorexic reaches 90 percent of her normal
body weight, her period usually resumes. Estrogen therapy may
also help. Studies have shown that bone lost during this time
period isn’t easily regained, and the increased risk of fracture may
be permanent, even with treatment.

Meanwhile, bulimia nervosa is

 Recurrent episodes of binge eating, which means eating more
than needed to satisfy hunger; (minimum average of two
binge-eating episodes a week for at least three months)

 A feeling of lack of control over eating during the binges

 A regular use of one or more of the following to prevent
weight gain:
• Self-induced vomiting
• Strict dieting or fasting
• Use of laxatives or diuretics
• Vigorous exercise

 A persistent over-concern with body shape and weight
Chapter 4: Men and Kids Get Osteoporosis, Too 61
Finding out a bit more about anorexia
The following important tidbits are important to know about anorexia nervosa and
how it can affect bone development:

 Anorexia nervosa is a psychological disease that has physical consequences
lasting all through life. Around 1 out of 100 adolescents, 90 percent of whom are
female, develops anorexia.

 Anorexia can cause bone loss in several ways. Girls with anorexia stop having
menstrual periods because their estrogen levels fall too low due to a lack of body
fat. Falling estrogen levels are a prime cause for a decrease in bone density.

 Anorexics generally don’t consume an adequate amount of calories, which
results in less bone formation during adolescence, a time when up to half of
peak bone density is being achieved. In addition, anorexics often have a high
level of a glucocorticoid called cortisol, which contributes to bone loss.

 Teens with anorexia have been found to have spinal density 25 percent less
than that of healthy teens, and up to two-thirds of anorectics have bone density
more than two standard deviations below the normal on a DXA scan, a test done
to determine your bone density. (See Chapter 9 for more about DXA scans and
how to interpret them.)

Bulimics aren’t always underweight; many maintain their weight
within normal limits and don’t experience the stopping of menstrual
periods and bone loss that anorexics do.

Why Too Thin Is Bad for Bones — Especially in Teens

You may remember the teenage angst of feeling “too fat,” even
when your weight barely touched the 100-pound mark. Teens
today are as acutely aware of their weight, and many, if not most,
teenage girls want to be thin. Unfortunately, the desire to be thin
can lead to behaviors that can have disastrous consequences for
bones down the road.

Because the teen years are so important in building the bone mass
that you draw from for the rest of your life, behaviors aimed at
staying thin, such as smoking and excessive dieting, will result in
bone loss that can never be regained, even if you change behaviors
as an adult.

For example, some teenage girls see smoking cigarettes as a way
to curb their weight. One Japanese study showed teens that were
concerned about their weight were four times more likely to start
smoking. In fact, nearly

Prostate cancer and osteoporosis

Some evidence suggests that men who have prostate cancer and
are receiving androgen-deprivation therapy are at increased risk
for osteoporosis. Androgen-deprivation therapy focuses on
decreasing the level of testosterone in men with prostate cancer,
because testosterone may encourage growth of the cancerous
cells. Around 40 percent of men with prostate cancer receive antihormone
therapy as part of their treatment.

One large study showed that men who had received nine or more
doses of hormone therapy were 45 percent more likely to sustain a
bone fracture and had a 66 percent higher chance of needing hospitalization
after a fracture. Another study showed that five years
after treatment, slightly more than 19 percent of men had a fracture,
compared to 12.6 percent of men who hadn’t had any antihormone

Taking drugs to fight osteoporosis called bisphosphonates (see
Chapter 10 for more on bisphosphonates) may reduce the risk of
bone loss and consequent fractures in men taking antihormone
drugs, such as leuprolide acetate (Lupron). If you’re taking an antihormone
drug, ask your doctor about taking bisphosphonates to
help offset bone loss.

Focusing on prevention
and treatment

Outside of the use of testosterone in men, prevention and treatment
of osteoporosis in men and women is similar. Whether you’re
male or female, the best way to treat osteoporosis is to prevent it
from happening, by eating well, exercising, and by not smoking or
drinking alcohol excessively. (See Chapter 3, which covers all the
prevention measures you can take to avoid osteoporosis.)

Treating men with osteoporosis

Because osteoporosis is recognized in men less often than in women,
fewer men are put on medication to reduce the risk of osteoporosis
until the damage has already been done. However, studies are beginning
to show that the same drugs successfully used to treat women
with osteoporosis also help men (see Chapter 10 for medications
used to treat osteoporosis). The major difference in treatment in men
and women is that hormone replacement differs.

Chapter 4: Men and Kids Get Osteoporosis, Too 57
In 2001, the FDA approved use of alendronate (Fosamax) in treatment
of osteoporosis in men. Before this point in time, few studies
had been done exclusively in men. Just after that, Forteo was
approved to treat osteoporosis in both men and women.
Because many men who develop osteoporosis have low levels of
testosterone, which drops gradually as they age, they may need to
take testosterone supplements. Androgens, or male sex hormones,
such as testosterone, stimulate bone formation. Doctors may prescribe
testosterone in the form of injections, patches, or gel to
raise the testosterone to normal levels.

Although testosterone is effective in reducing calcium loss and
helping to maintain bone density, it isn’t without side effects. Men
with prostate cancer shouldn’t take testosterone, because prostate
tumors may grow larger with added testosterone. Other potential
side effects of testosterone therapy include enlargement of the
breasts, swelling of hands and feet, and erectile dysfunction.
Researchers are studying new ways to give testosterone, such as
patches, injections, under the tongue, or gel, that may bypass the
liver. When the drug doesn’t pass through the liver, the chances of
liver damage are greatly reduced. Bypassing the liver can also
result in more of the drug being available for absorption.

Don’t take testosterone replacement therapy if you have

 Breast cancer (men can get that too)
 Liver disease
 Polycythemia (an abnormal increase in the number of red
blood cells)
 Prostate cancer
Avoid DHEA (a steroid hormone that decreases with age and is
often sold as a “rejuvenation” drug in health food stores) supplements
if you’re taking testosterone, because the combination of
the two may be dangerous.

Researchers are also working to develop designer androgens that
might have the desired bony effects without increasing the risk of
prostate cancer.

Focusing on Osteoporosis in Men

Although most of the research has focused on women with osteoporosis,
researchers are slowly starting to place more emphasis on
understanding when and why men develop osteoporosis.

Men generally start adulthood with larger, heavier bones than
women, and have a higher peak bone mass. But between 15 to
25 percent of all men will develop osteoporosis, and after age 50,
6 percent will fracture their hip. Table 4-1 shows the relationship
of hip fractures in men and women more clearly:

Table 4-1 Comparing Osteoporosis-Related
Hip Fractures in Men and Women
Factor Men Women
Peak bone mass 10 to 12 percent
higher than women
Lifetime risk of 6 percent 17 percent
hip fracture
54 Part I: Understanding Your Bones
Factor Men Women
Mortality from 31 percent 17 percent
hip fracture
Sex distribution 30 percent 70 percent
of hip fractures
U.S. incidence 4 to 5 per 1000 8 to 10 per 1000
of hip fracture
at age 65

Osteoporosis begins to affect men about ten years later than it
affects women. And because both men and women are living longer,
researchers and doctors anticipate more people will have hip fractures
in the future. In fact, by the year 2050, researchers project
that men will have one half of all hip fractures in the United States.
By the age of 86, the incidence of hip fracture in men is equal to the
incidence in women, meaning that by age 86, osteoporosis isn’t a
“women’s disease” in any way.

Because osteoporosis apparently becomes an equal opportunity
disease as you age, you may be curious as to when men should
start having bone mineral density scans. All men older than 70
need a baseline scan, as well as men under age 70 who have risk
factors, such as long-term corticosteroid use or use of drugs to
treat prostate cancer. (See Chapter 9 for more information on baseline
scans, and check out the next section for more on risk factors
in men.)

Seeking answers in
the “Mr. OS” study

A seven-year study begun in 1999 by the NIH National Institute of
Arthritis and Musculoskeletal and Skin Diseases (NIAMS), along
with the National Institute on Aging and National Cancer Institute is
following 5,700 men older than age 65. The study, called “Mr. OS,” is
looking at men’s risk factors for osteoporosis and how osteoporosis
affects men specifically. Knowledge of the diseases and conditions
that can affect bone mass can help to prevent men as well as women
from reaching the point of fracture before diagnosis.

Chapter 4: Men and Kids Get Osteoporosis, Too 55
One part of the study is looking at the possible relationship
between high bone mass and prostate cancer. This increased risk
may be related to levels of hormones, such as testosterone, which
protect bone. Other findings that are being examined in the study
include the following:

 Although men sustain hip fractures less frequently than
women, their mortality rate one year after hip fracture is two
to three times higher than for women.

 Risk factors for developing osteoporosis appear to be the
same in men as in women:

• Alcohol abuse: Alcohol abuse increases bone loss.
Approximately 25 to 50 percent of men seeking treatment
for alcohol abuse have low bone mass.

• Inadequate calcium and vitamin D intake: Men older
than 50 must consume 1,200 mg of calcium and 400 to
800 International Units (IU) of vitamin D daily.

• Lack of exercise: Men, like women, need to do weightbearing
exercise 20 to 30 minutes a day three days a
week to build bone strength. (See Chapter 6 for more on

• Low hormone levels: Up to 30 percent of men with
osteoporosis have low testosterone levels and may need
hormone replacement. In one study, one-third of men
older than 70 with a fracture were hypogonadal, or suffering
from low testosterone levels. Hypogonadism is
often underdiagnosed in men because there’s no obvious
precipitating event. In women, when estrogen levels
drop and menopause begins, their menses stops and hot
flashes start. But in men, during andropause, falling
testosterone levels may not be detected. Hence,
andropause (male menopause) may be subtler than
menopause in women, because signs of andropause
might just be attributed to aging, such as lack of sex
drive or difficulty maintaining an erection.

• Prostate cancer: Chemotherapy to treat prostate cancer
and other malignancies may also lower testosterone

• Smoking: Men who smoke are two to three times as
likely to fracture vertebrae as nonsmokers.

• Use of corticosteroids for diseases, such as asthma:
Men who have osteoporosis are more likely than women
to develop the disease because of another medical
condition or because of medication they take, such as
56 Part I: Understanding Your Bones
corticosteroids. Use of corticosteroids accounts for
between 15 to 20 percent of osteoporosis in men. Men
taking these drugs need to maintain an adequate calcium
intake, have their testosterone levels checked, and
may need to take antiresorptive medications (see
Chapter 11 for more on osteoporosis medications).

Table 4-2 compares the risk factors for men developing osteoporosis
and divides them into high, medium, and less common risks

Table 4-2 Comparing the Risk Factors for
Men Developing Osteoporosis
High Risk Medium Risk Less Common
Factors Factors Causes
Corticosteroid use of Alcohol abuse Cushing disease
5 mgm or more per
day times six months
Hyperparathyroidism Anticonvulsant drugs Gastric resection
Hypogonadism Family history of Low body weight
Nontraumatic fracture Hypo- or Liver or kidney
of hip, vertebrae, hyperthyroidism disease
or wrist
Osteopenia seen Multiple myeloma
on X-ray or lymphoma
Rheumatoid or
inflammatory arthritis
Risk of falling due to
unstable gait, dementia,
or stroke

Reducing the Risks of Getting Osteoporosis

Osteoporosis isn’t just an inevitable part of getting older or a disease
that only women get. It’s a complicated disease that can have
many causes, and it’s also a disease you can prevent by being
proactive about your health.

Women do develop osteoporosis more frequently than men. So,
given the fact that if you were born a woman, you’re most likely
going to stay one your whole life, what can you do to reduce your
risk of osteoporosis? Be aware that osteoporosis is more common
in women and start early to prevent it. Use these helpful tips and
keep osteoporosis at bay:

Eat well from an early age if possible. If you’re already “over
the hill,” start eating well now, making sure you get at least
1,200 to 1,500 mg of calcium daily and 800 IU of vitamin D.
Take supplements if necessary, and medications as ordered
by your doctor. (See Chapter 5 for more on nutrition and
Chapter 11 for more on supplements.)

Exercise, exercise, exercise! It helps you build more bone
mass and protects what you already have. (See Chapter 6 for
more on the benefits of exercise at any age.)

Don’t smoke! If you already are smoking, do whatever you
can do to stop or least reduce the amount you smoke.

Limit your daily alcohol intake. Have no more than one to
two alcoholic drinks each day.

Take medications your doctor prescribes. Studies have
shown that up to half of all prescriptions written by doctors
aren’t filled or aren’t taken properly. (See Chapter 10 for more
on medications that fight osteoporosis.)

Keep other health problems closely monitored. If you have
other health problems, such as the ones listed in “Noting
Other Diseases Associated with Osteoporosis,” earlier in this
section, make sure you’re especially diligent about your diet,
exercise, and medication routines.

Know your family history. If osteoporosis runs in your family,
start working on changing history by changing your diet and

Thursday, August 17, 2017

Other Diseases Associated with Osteoporosis

Many different diseases can increase your risk of developing
osteoporosis. In many cases the medicine you take, such as
48 Part I: Understanding Your Bones
corticosteroids, to treat the disease increases your risk. In other
cases the disease itself can cause bone loss.
Some other diseases associated with increased risk of osteoporosis

Chronic kidney disease: Kidney disease raises the amount of
phosphate, a mineral that binds to calcium to maintain healthy
bones, in the blood. The extra phosphate circulates in the
blood looking for calcium to bind with, and will take calcium
from your bones if necessary to attach to the phosphate,
depleting your calcium stores.

Some people with chronic kidney disease who are on dialysis
develop a severe bone disorder known as renal osteodystrophy.
Your kidneys are critical in the metabolism of vitamin D.
When your kidneys start to fail, you become deficient in certain
important active forms of vitamin D. Technically this
condition isn’t osteoporosis. A bone biopsy in this situation
would reveal secondary hyperparathyroidism. Nonetheless,
if you suffered from renal osteodystrophy, you could develop
many fractures. A great deal of progress has been made in
recent years in prevention and treatment of this disorder.
Careful regulation of phosphorus levels and new forms of
vitamin D supplementation have greatly reduced the incidence
of this complex disorder.

Cirrhosis of the liver: Many factors associated with liver failure
can affect bone metabolism, such as the accumulation of
toxins related to the ineffectiveness of the damaged liver to
filter them out.

Ehler-Danlos syndrome: This hereditary disease affects connective
tissue and is associated with decreased bone density
and hypermobility of joints.

Hypercalciuria: People with hypercalciuria lose too much calcium
through their urine, often in the form of calcium kidney
stones. Your doctor might look for this problem by collecting
your urine for 24 hours and measuring the amount of calcium
in the urine.

Juvenile rheumatoid arthritis and rheumatoid arthritis:
People with rheumatoid arthritis are twice as likely to develop
osteoporosis as the general population; the risk is even higher
among rheumatoid arthritis patients who take corticosteroids.

Multiple myeloma: This is a cancer of blood cells that results
in bone tumors. Patients with multiple myeloma have abnormal
plasma cells in their bone marrow. These cells make substances
known as cytokines that stimulate osteoclasts and
Chapter 3: Breaking Down the Risk Factors 49
inhibit osteoblasts, thus weakening the bone. (See Chapter 2
for the lowdown on osteoblasts and osteoclasts.)

Osteogenesis imperfecta (OI): Several types of OI exist. Most
are inherited and cause very brittle bones and fractures in
childhood. OI is due to defects in the production of collagen,
an important protein in the maintenance of bone strength. (See
Chapter 4 for more information on osteoporosis in children.)

Overactive parathyroid gland: An overactive parathyroid
results in a rise in blood calcium levels, causing mental confusion,
kidney damage, dehydration, nausea, and vomiting. (See
Chapter 2 for more about hyperactive parathyroid glands.)

Overactive thyroid gland: It negatively affects bone mineral
density. (See “Avoiding excess thyroid medication” earlier in
this chapter for more information.)
The problem is that doctors and researchers don’t thoroughly
understand the mechanism in these various diseases. For example,
in people with Ehler-Danlos, the link could be genetic.

Inflammatory bowel disease

If you have a chronic intestinal problem, such as ulcerative colitis
or Crohn’s disease, your risk for developing osteoporosis is

The part of your intestine that absorbs vitamin D may be damaged
by inflammation, and therefore you become vitamin D

You may have had surgery, which removed the part of your
intestine that absorbs vitamin D.

You may be taking medications, such as corticosteroids,
which increase bone loss. (See the section “Why corticosteroids
can thin bones” earlier in this chapter.)
Your bone density may improve if your disease is in remission and
you’re no longer taking corticosteroids.

Bone loss after stomach surgery

New studies have shown that many people lose bone faster than
they can replace it in the months following bariatric surgery to
induce weight loss. Those people who lose the most weight and
those people who lose weight quickly are most at risk, with up to
an 8 percent drop in bone density six months after surgery. This
loss may be the result of less efficient absorption of calcium, to
the weight loss itself, or to the fact that vitamin D isn’t adequately
absorbed if part of the small intestine is removed.

Some people develop osteomalacia, a defect in the body’s ability to
mineralize bone, after stomach surgery. Osteomalacia (see Chapter
1 for more info) is considered to be “adult rickets” and results in
many fractures in unusual places (ribs, pelvic bones, and shoulder

Differentiating between osteoporosis and osteomalacia is important
because treatment may differ. Your doctor can perform a bone
biopsy to determine which condition is present. Bone biopsies are
simple procedures to perform, but pathologists with special training
in bone diseases need to interpret the results so that you
receive the proper treatment.

Celiac disease and bone loss

As many as 1 in 250 men and women have an inherited disease
called celiac disease, or nontropical sprue. People with celiac disease
don’t absorb adequate nutrients through the small intestine
because their intestinal lining is damaged by eaten gluten, which
is found in wheat.

Severe celiac disease can be associated with marked deficiency of
vitamin D and numerous fractures. Patients without obvious causes
of osteoporosis need to be screened for celiac disease because it’s
fairly common. Your doctor can diagnose celiac disease with a combination
of history, blood tests, and intestinal biopsies. All untreated
patients need to have frequent bone density testing and vitamin D

How Gastrointestinal Problems Can Affect Your Bones

Your bones are dependent on what your digestive system absorbs,
so anything that interferes with your absorption of calcium and
vitamin D can weaken your bones.

 Diseases that wreak havoc with your insides can also wreak havoc with your bones. Eating well is
important for development of strong bones , but eating well won’t help
your bones if your intestines aren’t absorbing the good stuff.
Vitamin D deficiency from inadequate nutrition might be more
common that originally thought. In one recent study, 45 percent of
hospitalized patients in Boston were vitamin D deficient. One
cause of vitamin D deficiency is gastrointestinal diseases, which
weren’t looked for in those cases.

Taking medications to prevent seizures

Approximately one in ten people will have at least one seizure in
their lifetime by age 75. There are different types of seizures caused
by the malfunctioning of different parts of your brain; some seizure
medications work better on one type of seizure than another. Some
anti-epileptic drugs (AEDs) are more sedating than others, and many
have been implicated in causing bone loss by interfering with your
body’s absorption of vitamin D.

Seizure medications may also interfere with female hormone levels
such as estrogen and progesterone. Some AEDs suppress ovulation,
which keeps estrogen levels from rising during the menstrual
cycle. Lower estrogen levels means a greater chance of developing

If you’re on AEDs, make sure to have a bone density test done each
year, and take at least 200 to 400 IU of vitamin D a day, along with
at least 1,000 to 1,400 mg of calcium. Also be aware of a major risk
of poorly controlled seizures: falling!

Other drugs associated with
developing osteoporosis

A large number of drugs in addition to the ones in this section are
associated with bone loss. Be aware that you may be at extra risk
for osteoporosis if you’re taking any of the following:

Vitamin A (in excess of 3,000 micrograms per day): Excess
vitamin A may cause too much bone to be reabsorbed. (See
Chapter 11 about consuming too much vitamin A.
Heparin, a blood thinner: Researchers and doctors don’t
completely understand the connection between osteoporosis
and heparin, but long-term therapy (more than four or five
months) and doses of 15,000 IU or more increase the risk of
osteoporosis. Heparin may increase the number of osteoclasts
in bone. (See Chapter 2 for more on osteoclasts.)

Drugs that lower estrogen and testosterone: Any drug that
lowers your estrogen level increases your risk of developing
osteoporosis because bone loss increases when estrogen
levels are low. For example, Lupron (leuprolide acetate) is
an anti-estrogen medicine that is used for women with
endometriosis and also for certain cancers in men, such as
prostate cancer. This drug lowers your estrogen level.
46 Part I: Understanding Your Bones

Medications that attack the virus that causes AIDS: Anti-HIV
drugs may increase your chance of osteoporosis by raising
cholesterol levels and interfering with the way the body manufactures
and uses fat.

Avoiding excess thyroid medication

Your thyroid is an important part of your body because it helps
control your metabolism. Thyroid problems come in two varieties:

hypothyroid (sometimes called Hashimoto’s disease), or too little
thyroid hormone being manufactured, and hyperthyroid (sometimes
called Grave’s disease), which is too much thyroid hormone.
(If you want the complete lowdown on thyroid disease, check out
Thyroid For Dummies by Alan L. Rubin, MD [Wiley].)

If your thyroid is underactive, you may gain weight, be tired all the
time, feel cold, or have hair loss. If you have an overactive thyroid,
you may lose weight, feel like your mind is racing, have difficulty
sleeping, be jittery, and perspire more than usual.

Hyperthyroid hormone levels can increase your risk of developing
osteoporosis. Hyperthyroid can result when your thyroid produces
too much thyroid hormone or when you take more thyroid medication
than you need to correct hypothyroidism.

A simple blood test ordered by your doctor can tell you whether or
not the amount of medication you’re taking is too much — or just

Calcium may interfere with absorption of your thyroid medication if
the two are taken too close together. Your doctor may recommend
taking your thyroid medicine in the morning and your calcium 12
hours later. You also need to avoid drinking calcium-fortified juices
close to the time you take your thyroid medicine.

Why corticosteroids can thin bones

People commonly take corticosteroids, such as prednisone, to
decrease inflammation in the body, from their eyes to their intestines.
If you have serious asthma, an autoimmune disease, severe
allergies, or arthritis, you may be taking corticosteroids every day.

Corticosteroids help many people live normal lives.
But corticosteroids are very potent medications with the following
serious side effects:

They increase calcium loss through your urine.
They decrease calcium absorption through your intestinal
They inhibit growth of new bone.
They lower estrogen and testosterone hormone levels.

Corticosteroids come in many different forms and under different
brand names. No matter how people take corticosteroids, all
routes lead to bone loss. (Some people inhale them for asthma and
other lung diseases, some inject them, some take them by mouth,
and others apply them as creams.)

The higher the dose of corticosteroid and the longer the time you
take it, the more likely you are to develop osteoporosis. One quarter
of all people who take corticosteroids for five to ten years will
suffer a fracture. Some studies have shown that you may lose up to
30 percent of bone mass after taking corticosteroids for a relatively
short time.

If you absolutely must take corticosteroids of any type long term,
doing the following is important:

Be on the lowest dose possible.
Reduce your dose slowly. Stopping or reducing your dose too
quickly can be dangerous.
44 Part I: Understanding Your Bones
Have your bone density tested every other year, or more frequently
if suggested by your doctor.
For men, check your testosterone levels.
Check your urine calcium.
Discuss your concern about osteoporosis with your doctor.

Most doctors will place you on calcium and vitamin D supplements
if you’re on chronic corticosteroids. Your doctor may
also recommend taking them every other day.

People on long-term moderate or high doses of corticosteroids
may gain weight, develop hypertension or elevated blood sugars,
and become prone to easy bruising. This condition is referred to
as iatrogenic (a disease caused by medical treatment) Cushing’s
syndrome. These people are at most risk for bone loss.

Recognizing Medications That Cause Bone Loss

Many commonly prescribed medications are a double-edged sword
for everyone, male or female. On one hand, they cure or help control
serious health problems; on the other hand, the medications
themselves can cause serious health problems.

Several commonly prescribed medications can increase your
chance of developing osteoporosis. Although we’re not suggesting
that you stop taking medications that can damage your bones, we
are suggesting that you educate yourself about your medication’s
side effects. You can take certain precautions, with your doctor
and pharmacist’s help, to decrease your risk of medication-related

Watching what you eat

We understand that watching what you eat is no fun. Even though
most people would eat a reasonably balanced diet even if they
weren’t constantly deluged with information on how what they eat
affects their health, some people would subsist mostly on cookies
and fast food if left to their own devices. This section is for you
(and you know who you are!).

Nutrition is so important to bone growth that we devote an entire
chapter to it (see Chapter 5). But we also want to throw in a few
tidbits here to demonstrate the very real connection between what
goes into your mouth and healthy bones.

Women older than 50 need at least 1,500 mg of calcium each day,
which is about 4 glasses of fortified milk (6 to 8 ounces per glass)
a day. (A glass of milk contains about 400 mg of calcium.) See
Chapter 5 for more on calcium intake.

Equally as important to ingesting enough calcium is to make sure
you’re not losing calcium from poor dietary habits. Some calcium
robbers include

High animal protein diet: High protein intake may increase
the amount of calcium excreted in your urine. Vegetables and
fruit, on the other hand, increase your potassium and magnesium
intake, which builds calcium stores. Is the current lowcarb
diet craze going to be bad news for women down the
road? One way to prevent bone loss is to make sure to eat
enough veggies in addition to high protein and also to maintain
your calcium intake at 1,200 to 1,500 mg a day.

Too much salt: A heavy hand on the saltshaker can result in
extra calcium loss.

Sodas: Recent studies indicate that drinking dark colas daily
may result in lower bone density. Both regular and diet sodas
may have this negative affect on your bones. This loss doesn’t
occur when phosphoric acid is consumed in foods that also
contain calcium. And, of course, if you’re drinking soda, you’re
not drinking something good for you — like milk or calciumfortified
juice. Sodas that contain caffeine may also increase
urine output, which can wash away vital mineral stores.

How alcohol affects your bones

When the subject turns to drinking alcohol and osteoporosis, the
information is somewhat confusing. Studies show that a moderate
intake of alcohol is good for your bones, but that heavy alcohol
use is bad for your bones. How do you know what’s “too much”
and what’s “just right” when it comes to alcohol and your bones?

The U.S. Department of Health and Human Services defines “moderate”
drinking as one drink per day for women and no more than
two drinks a day for men. A single drink is defined as 1.5 ounces
of 80 proof distilled spirits, for example, 12 ounces of beer, or 5
ounces of wine. So having a glass of wine — red or white, it’s up
to you — a day may have benefits for your bones.

One study showed that postmenopausal women who drank 16 drinks
a week had a 5 to 10 percent higher bone mass density (BMD) than
postmenopausal women who drank less than two drinks per week.
This increase in bone density may be because alcohol can help convert
testosterone to estrogen after menopause. Alcohol may also
increase calcitonin, a hormone that inhibits bone resorption, in
menopausal women.

However, excessive drinking, especially during adolescence and
young adulthood, can decrease bone growth and increase one’s
risk for developing osteoporosis later in life — true for both men
and women. Even more disturbing is the fact that studies have
shown that the effects of heavy alcohol at a young age can cause
lifelong damage to your overall health, not just to your bones.
If you haven’t gone through menopause yet, heavy drinking may
cause your periods to be irregular or to stop altogether, decreasing
your estrogen levels. Adult women older than 67 years old who
drank more than 3 ounces of alcohol a day (the equivalent of six
drinks) had greater bone loss than women who drank very little

Of course, heavy alcohol intake also puts you at risk for one of the
biggest causes of bone fracture: falling!

Smoking and osteoporosis

You know that smoking is bad for your lungs, but did you also
know that smoking is bad for your bones? Thinking that smoking,
a habit that many people want to quit because of the well-known
effects on your lungs, can also be dangerous for your bones may
be farfetched, but the facts in the following list make it crystal
clear. Studies have shown that

Smoking decreases the level of estrogen in women. Estrogen
helps keep bone healthy.
40 Part I: Understanding Your Bones

Women who smoke go through menopause at an earlier age;
estrogen levels drop during menopause.

Smokers may absorb calcium poorly; calcium is necessary to
build strong bones.

Smoking effects may begin in adolescent smokers; they may
have lower than normal bone mass and smaller bone size.

Fractures heal more slowly in smokers — true of women
and men.

By age 80, smokers have bone density 6 to 10 percent lower
than nonsmokers.

Up to one in eight hip fractures in women can be attributed to
decrease in bone density due to smoking.

Estrogen replacement therapy in menopause is less likely to
be effective in smokers than nonsmokers.

Although studies may differ on some points, the overall evidence
is clear. One of the best preventive measures you can take for your
bones is to never start smoking. But if you’re already a smoker, try
to quit. If you can’t quit, at least cut down. Your bones will thank
you! (If you need help to stop smoking, check out Quitting Smoking
For Dummies by David Brizer, MD [Wiley].)

Starting and stopping menstrual periods

The age when you had your first period and the age when you had
your last period are both contributors to your risk of osteoporosis.
Estrogen rises during your menstrual cycle, and estrogen helps
protect against osteoporosis.

So if your periods started when you were 12, and stopped when
you were 50, you got more estrogen over the years than someone
whose periods began when she was 16 and stopped when she was
40. You may not have thought at the time that your period was
good, but your bones appreciate all that extra estrogen exposure.

Assessing Your Risk Factors: Which Women Get Osteoporosis?

Many factors can contribute to your chances of developing osteoporosis.
Some factors you can influence, some you can’t. In this
section, we look at the most common risk factors and what you
can do to modify them.

Your doctor can evaluate your chances of having low bone density
based on your risk factors and request specialized testing to
screen you for osteoporosis before you actually get a fracture. (See
Chapter 9 for the specifics on testing.)

I am woman, see me shrink
When it comes to osteoporosis, being female is a definite black
mark. Men start with more bone mass, and they also lose bone
at a slower rate than women. In fact, according to the National
Osteoporosis Foundation (NOF), 80 percent of osteoporosis sufferers
are women.

Moreover, according to the American Medical Association (AMA),
between 20 and 30 percent of women who have gone through
menopause have osteoporosis, and another 30 percent have low
bone density. If you add up the percentages, you realize that the
vast majority of women are at risk. For 8 million women, osteoporosis
is a fact, and for another 15 million, it’s a looming possibility.
Why do women get all the breaks (so to speak)? In part, the risk is
due to normally thinner bones, and partly because the loss of
estrogen at menopause accelerates bone loss, especially for the
first five to seven years.

So, the biggest single risk factor for developing osteoporosis is
simply being female. And, of course, your gender is one thing
about yourself that is impossible to change.
34 Part I: Understanding Your Bones

Aging is such sweet sorrow
Another unchangeable risk of osteoporosis is age. As difficult as it
is to accept, getting older brings not only wrinkles but also the
possibility of osteoporosis. Up until her mid-30s, a woman builds
more bone than she loses. But after age 35, bone withdrawals start
to deplete her bone credit account. Here are several interesting
statistics from the AMA about age and bone fractures:

One out of two women older than 50 will have a bone fracture
related to osteoporosis.
A 50-old woman has a 14 percent risk of hip fracture over the
remainder of her lifetime.
Ninety-plus percent of hip fractures in elderly women are due
to osteoporosis.
One out of five women older than age 50 with a hip fracture
will die within one year.

Bones from Birth to Infinity

Did you know that babies actually have more bones than adults do,
because some of their bones haven’t fused yet and can be counted
as two or three? Most adults have 206 bones, but your bones at
birth numbered more than 300! Babies and young children also
have somewhat bendable bones, so they may have more greenstick
fractures, which are breaks that occur when bones bend but don’t
break completely.

This section includes a few more interesting tidbits to know about
your bones:

Bones continue to grow in length and breadth until your late
teens or early 20s. Hence bone biologists have developed the
term “peak bone mass.” This phrase refers to the amount of
bony tissue present at the end of skeletal maturation. Your
peak bone mass increases throughout adolescence and then
peaks in your early 30s. It plateaus for a while and then (for
women) starts to decline after menopause. Men start to decline
in their 60s. (You can read more about men and osteoporosis in
Chapter 4.)

Factors such as your genetic makeup, nutrition, and activity
determine your peak bone mass. Various diseases also can
affect your peak bone mass. Understanding the factors that
determine peak bone mass are critical in determining ways
to prevent osteoporosis, because if you can build stronger
bones, even though some bone is lost during aging, you may
not have enough bone loss to result in osteoporosis. (Check
out Chapter 3 for more discussion on risk factors.)

Your peak bone mass is represented in Figure 2-3 by a bone
density measurement. These graphs are different for men and
women and are different for different races. This data comes
from a large epidemiological study referred to as the National
Health and Nutrition Examination Survey (NHANES).

After you’ve achieved your peak height, your bones continue
to remodel on the inside surfaces. In fact, osteoclasts and
osteoblasts keep doing their thing. So, if the balance of breaking
down and building up is disturbed, you can lose some
bone mass.

Bones respond to forces placed upon them. For example, an
athlete who uses his right arm far more often than his left, will
develop thicker cortical bone on the right side when compared
to the left.
Figure 2-3: Standard bone density measurements determined by age, sex,
and race.
20 40 60 80
Female, White
Male, White
Female, Black
Male, Black
Female, Hispanic
Male, Hispanic
Age (years)
Standardized Total Hip BMD (mg/cm2)
30 Part I: Understanding Your Bones

Bone mass is often compared to a bank account. Up until a
certain age you’re putting more in than you’re taking out. But
as you age, your withdrawals begin to exceed your deposits,
and you begin to lose bone.

In women, bone loss accelerates after menopause because
estrogen levels drop. Women who go through menopause at
an earlier age, due to chemotherapy or hormonal disorders,
are at higher risk for osteoporosis because they have fewer
years to benefit from the protective effects of estrogen.
After you reach menopause and lose the protective benefit of
higher estrogen levels, your bone withdrawals increase dramatically.
You can lose as much as 5 percent of your bone
mass each year during the first five years of menopause.

Men also lose bone mass as they age, but at a much slower
rate, normally 0.2 to 0.5 percent per year.

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