Osteoporosis: understanding the silent disease

Osteoporosis is the most common bone disease in the United States, but unlike most other diseases you may have heard about, you might not even know you have it.

Osteoporosis is often called the silent disease because many people affected by it are unaware until something catastrophic happens. Read on to bone up about what osteoporosis is and how you can fight it.

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Bones, like the rest of your body, are living, growing, and always changing. Parts of your bone are being broken down by cells called osteoclasts, while others are being built up by cells called osteoblasts.

This process allows you to get taller when you’re young, heal microbreaks that you pick up during everyday life, and reshape your skeleton to your physical demands. It also allows you to control the amount of calcium in your bloodstream.

This entire process is called bone remodeling and requires the careful balancing of osteoclast and osteoblast activity. Every year of your adult life, around 10% of your skeleton is broken down and rebuilt (Langdahl, 2016). 

So what happens when this process goes wrong? Hint: it’s almost all in the name—“osteo” meaning bone and “porosis” meaning porous.  Osteoporosis causes your bones to lose their strength through the loss of bone mineral density and bone quality.

The osteoclasts that break down bone are much more active than those trying to build bone back up. Under a microscope, osteoporotic bone will have much larger empty spaces within them, almost like a honeycomb. The resulting fragility makes you much more likely to get bone fractures.

Osteoporosis is a widespread problem, affecting around 10 million Americans and 200 million people worldwide. It’s estimated that 1 in 3 women and 1 in 5 men will suffer a fracture due to osteoporosis in their lifetimes.

Studies have shown that certain groups of people are more likely to get osteoporosis than others. These groups are (Sözen, 2017):

• Females: Roughly 80% of people affected by osteoporosis are females.

• Older adults: You reach peak bone mass in your twenties. After that, bone density naturally goes down with age. This is especially true in women after menopause when estrogen levels drop, and bone loss increases because of it (Lee, 2013). 

• White, Asian, or Hispanic people: People who identify as Black have consistently been shown to have high bone mineral density and lower rates of osteoporosis. In one study of nearly 200,000 post-menopausal women, 12% of Native American women, 10% of Asians, 10% of Hispanics, 7% of whites, and only 4% of Blacks had osteoporosis.  

• Smaller, thinner people: People with lower body mass index (BMI), a measurement of height compared against body weight, tend to have higher rates of osteoporosis. Having a lower BMI typically means that you’re thinner compared to other people at your height.   

• Family history of osteoporosis: People with a family history of osteoporosis have been shown to have lower bone mineral density. And unfortunately, the more family members you have with osteoporosis, the lower your bone mineral density is likely to be. 

• Smokers: Smoking tobacco is known to decrease bone mineral density, increase the risk of osteoporosis, and increase the risk of fracture.

• People with alcoholism: Studies have shown that excessive alcohol intake is associated with low bone mineral density.

People on chronic glucocorticoid medications may also be at risk for osteoporosis. Glucocorticoid medications are among the most commonly used medications in the United States. Common ones include prednisone, dexamethasone, and hydrocortisone.

These medications decrease inflammation and calm your immune system. This is helpful if you have an autoimmune disease, which is when your immune system attacks normal parts of your body. Examples of diseases where glucocorticoids are used include asthma attacks, multiple sclerosis, rheumatoid arthritis, lupus, and inflammatory bowel disease.

Unfortunately, long-term use of glucocorticoids is known to decrease bone density, and fracture risk is doubled in people that are taking them. Although the exact length of treatment and dose that would cause osteoporosis isn’t known, the American College of Rheumatology considers three months of treatment to qualify as long-term glucocorticoid treatment and enough to start taking steps to prevent osteoporosis (Buckley, 2017; Briot, 2015). 

Most people with osteoporosis won’t know they have it until they get an osteoporosis-related fracture. Just think of a wooden house with termites—you might not know anything’s wrong until the house starts falling apart.

The type of fracture that often happens in osteoporosis is called a fragility fracture. Fragility fractures are fractures that occur when a person falls from a standing height or less, without a major trauma like a car accident. These minor mishaps might cause a bump or bruise in a healthy person, but in osteoporosis, it can put you in the hospital.

Another sign of osteoporosis is back pain, caused by fractures in the vertebrae of the spine. In osteoporosis, you can get what’s called a compression fracture where bones in your back crumple with as little as a cough or lifting a heavy box. 

These spinal fractures can lead to loss of height over time as well as a stooped posture from a hunched back, which is what healthcare providers call kyphosis. Hip fractures and vertebral fractures are the most common fractures that happen because of osteoporosis. 

If you’ve had a fragility fracture—again, a fracture from minor fall—you automatically qualify for the diagnosis of osteoporosis. If you didn’t have a fracture, osteoporosis can be detected through screening with imaging tests. In many people, osteoporosis is diagnosed through a bone density test called a DEXA scan. Also called DXA, DEXA stands for dual-energy X-ray absorptiometry. In this test, two x-ray beams are pointed at portions of your skeleton. The density of your bones can be calculated based on how much of each beam your bone absorbs. Typically, the hip and the spine are the two areas that are scanned because they are the most frequent places where fractures from osteoporosis happen.

Before you get too worried about the radiation that a DEXA scan will expose you to, be reassured that the dose is extremely low. A DEXA scan delivers around 0.001 mSV of radiation, around 1/100th the dose of a chest x-ray. In comparison to a DEXA scan, a flight from New York to Los Angeles will give you around 35 times the amount of radiation (CDC, 2015; Mettler, 2008). After you get a DEXA scan, the images will be interpreted by a radiologist using the help of a computer program that analyzes the images. You’ll get what’s called a T score. A T score compares your bone mineral density against a healthy thirty-year-old of the same sex and ethnicity as you.

A zero would mean that you’re exactly the same (bone density-wise) as a healthy young person. As the score goes into the negatives, your bone density is lower and lower. The World Health Organization (WHO), using the T score, has defined normal as being between +1 and -1. -1 to -2.5 is what’s called low bone mass (also called osteopenia), and at this point, you would be considered at risk for developing osteoporosis. Lower than -2.5 means you are formally diagnosed with osteoporosis. Who should be screened for osteoporosis? Experts agree that all women over the age of 65 should get a bone mineral density test. In men, there’s a bit of debate—some experts don’t think routine screening is necessary, while others think that men should be screened at age 70.

In younger men and women, most experts think that screening should be done in men and women between ages 50-65 that have risk factors for osteoporosis. Major risk factors include:

• Previous fractures

• Family history of fractures due to osteoporosis

• Smoking

• Chronic glucocorticoid medication use 

• Rheumatoid arthritis

• Type 1 diabetes

• Untreated hyperthyroidism

• Hypogonadism (low estrogen or testosterone levels) or premature menopause

• Malnutrition including disorders that prevent absorption of nutrients

• Liver disease

• Excessive drinking

If you’re worried about osteoporosis, talk to your healthcare provider about your concerns—they’ll be able to evaluate whether or not you need to be screened and what the best next steps are if you need to be treated.

Let’s say you’ve been diagnosed with osteoporosis. What now? First of all, don’t panic.

There are a number of effective, U.S. Food and Drug Administration (FDA)-approved medications to help treat osteoporosis and decrease fracture risk. Let’s walk through a few categories of osteoporosis treatments that your healthcare provider might recommend.

First, your healthcare provider will be sure to recommend lifestyle and diet changes. Getting exercise and enough calcium and vitamin D in your diet is key to stopping osteoporosis. Quitting smoking and excessive drinking are two more steps that will help.

Sometimes osteoporosis is caused by another medical condition. If you have a condition that’s preventing you from getting the nutrition you need to maintain bone mass, like an eating disorder such as anorexia nervosa or a disease that causes malabsorption, such as celiac disease, that will need to be treated.

In men, low testosterone can be a contributor and would be treated with testosterone replacement. Hyperthyroidism (where your thyroid is producing too much hormone) is another cause of osteoporosis and would need to be treated with anti-thyroid medications, thyroid surgery, or radioactive iodine. Other conditions that might cause osteoporosis include kidney failure, liver impairment, and diabetes.

Bisphosphonates are usually the first type of medication that healthcare providers will use to treat osteoporosis. Bisphosphonates work by slowing down osteoclasts, the cells that break down bone.

This allows your osteoblasts to build up more bone to increase your bone density and decrease your risk of fracture. Common bisphosphonates include etidronate (brand name Didronel), alendronate (brand name Fosamax), ibandronate (brand name Boniva), zoledronic acid (brand name Reclast), and risedronate (brand name Actonel).

In men with osteoporosis, bisphosphonates were able to decrease the risk of vertebral (spinal) fractures by 63% and all other fractures by 40%. In women with osteoporosis, bisphosphonates were able to decrease the risk of vertebral (spinal) fractures by 40-60% and all other fractures by 20-40% (Nayak, 2017).

Bisphosphonates have few side effects. The most common are bone, joint, or muscle pain. If you take bisphosphonates as a tablet, you might also get nausea, heartburn, difficulty swallowing, ulcers, or irritation of the esophagus (the tube that connects your mouth to your stomach). 

Rare side effects include osteonecrosis of the jaw, a condition where the jaw bone is exposed and begins to starve from a lack of blood, and atypical femur fractures, where the long bone in the thigh breaks without major trauma. These rare side effects usually occur only after 3-5 years of bisphosphonate use and only in around 1 in 10,000-100,000 patients. 

Another class of medications that can be helpful in women are selective estrogen receptor modulators or SERMs. One of the major reasons post-menopausal women are at such a high risk for developing osteoporosis is that they lose their estrogen production from their ovaries.

Without estrogen, osteoclast cells go into overdrive. SERMs mimic estrogen in order to slow down the breakdown of bone. They’ve been shown to decrease the risk of spinal fractures and also might be helpful in reducing breast cancer risk. One common SERM is called raloxifene (brand name Evista). 

Finally, there are a few other medications that are usually reserved for people that can’t get bisphosphonates or have special medical cases, such as people with kidney disease or people with severe osteoporosis. These medications include denosumab, teriparatide, and abaloparatide.

These medications tend to be much more expensive than bisphosphonates. Denosumab (brand name Prolia and Xgeva) is an injectable monoclonal antibody, which means that it’s an artificial antibody targeted against a particular molecule. In this case, denosumab is targeted against RANKL, a protein that stimulates the growth of osteoclasts, the cells that break down bone. By shutting off RANKL, fewer osteoclasts develop, and thus the bone is able to become denser.

Teriparatide and abaloparatide are two medications that mimic a hormone in the body called the parathyroid hormone. These medications stimulate osteoblast activity, which causes those cells to build more bone. You might also hear them called anabolic, or bone growing, medications.

You may have also heard of another medication called calcitonin. Calcitonin is a hormone that inhibits osteoclasts. It’s currently not used in most patients because bisphosphonates are more effective.

If you don’t have osteoporosis, there are steps you can take to prevent yourself from getting it and to maintain healthy bones.

To prevent yourself from losing bone mass, make sure you’re getting adequate exercise, nutrition, and stop smoking or drinking excessively. Let’s go into each of these in more depth.

Exercise

It's recommended that everyone get at least 30 minutes of moderate physical activity most days of the week. This can include things as simple as brisk walking, lifting weights, or even working around the house or yard.

The science backs this up—researchers have consistently found that weight-bearing and resistance exercise programs improve bone mineral density. A study analyzing 25 different clinical trials found that exercise programs prevented or reversed a 1% loss of bone mass per year in women both before and after menopause. 

Another study analyzed trials of weight-bearing exercise in men and found that exercise improved bone mineral density in men over 30. The most important thing to do is to be consistent and pick something you enjoy. It doesn’t appear that exercising more intensely makes your bones more sturdy.

What matters is sticking with the exercise program. Studies have shown that the benefits of exercise on bone health go away when you stop. One last thing to note is that non-weight-bearing exercises like swimming and cycling, while great for your heart and muscles haven’t been proven to help with osteoporosis.

Nutrition

Having a diet with sufficient calcium and vitamin D makes it less likely that you’ll develop osteoporosis. Calcium and vitamin D supplementation has been shown to reduce the risk of fracture by 15% overall (Weaver, 2016).

The National Osteoporosis Foundation recommends 1,000 mg of calcium intake daily for women 50 and younger and 1,200 mg for women over 50 (NOF, 2018). For men, the recommendation is 1,000 mg of calcium daily if you’re 70 and younger and 1,200 mg if you’re over 70.

For vitamin D, the recommended daily intake is at least 400-800 international units (IU) a day if you’re 50 and younger and at least 800-1,000 IU daily if you’re over 50. You can get calcium from food or through calcium supplements.

Great ways you can get more calcium in your diet are dairy products, seafood, and fresh vegetables, especially collard greens, kale, soybeans, and broccoli. Vitamin D is a little bit different. It’s rare to find a lot of vitamin D in food unless it’s been added by the manufacturer.

Your skin can produce vitamin D through reactions to sunlight. However, many people don’t make enough vitamin D on their own. It’s estimated that around 42% of people in the United States are deficient in vitamin D. If you’re deficient in vitamin D. Usually, the best way to get enough of it is to take a supplement (Parva, 2018).

You might see two different types of vitamin D on the market, D2, and D3. Both can increase your vitamin D levels, but some studies say that D3 is more effective (Tripkovic, 2012).

Quit smoking

Smoking has been shown to cause low bone density and increase the risk of fractures. Studies have shown that quitting smoking can stop bone loss associated with smoking. 

Cut down on drinking

Studies have shown that people who drink more than two alcoholic beverages daily are at increased risk for fractures. Outside of just osteoporosis, excessive drinking increases the risk of heart disease, stroke, pancreatitis, cirrhosis, head and neck cancer, liver cancer, breast cancer, and colon cancer. 

Remember, your healthcare provider is your best resource for navigating your bone health—make sure to tell them about your concerns so that they can help you figure out a game plan. Always let them know about any dietary supplement you’re planning on taking so that they can help you avoid any dangerous interactions or side effects. 

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How we reviewed this article

Every article on Health Guide goes through rigorous fact-checking by our team of medical reviewers. Our reviewers are trained medical professionals who ensure each article contains the most up-to-date information, and that medical details have been correctly interpreted by the writer.

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Current version

November 11, 2019

Written by

Jefferson Chen, MD

Fact checked by

Chimene Richa, MD

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About the medical reviewer

Chimene Richa, MD

Dr. Richa is a board-certified Ophthalmologist and medical writer for Ro.