We tend to think of our bones as hard and unchanging, like the bones we find on our dinner plate. But actually, they are living tissues that undergo constant change and renewal, just like our other organs. Cells called osteoclasts break bone down, and cells called osteoblasts build it back up, just as if you were remodeling your house a room at a time. The osteoblasts build up living tissue and reinforce it with minerals like calcium, magnesium, boron, and manganese.
Normally, these two processes–resorption and formation of bone–are closely linked so that bone stays strong. Quite a few factors can upset the balance, though. If the osteoclasts race far ahead of the osteoblasts, bone density can drop and eventually the bones are not strong enough. A minor fall can result in a broken hip, which can be catastrophic for an older person.
Osteoporosis, a condition of weakened bone, is responsible for 1.5 million fractures each year, including 300,000 hip fractures.766 The National Institutes of Health (NIH) estimates that 10 million Americans currently have osteoporosis. Two million of them are men. While osteoporosis is thought of as a women’s issue, it is not limited to women.
There’s no shortage of controversy surrounding osteoporosis. Perhaps the first issue is just how many people should be concerned about it. According to the NIH, 34 million people have low bone density. Add that to the 10 million who have been diagnosed with osteoporosis, and you come up with 44 million Americans for whom “osteoporosis is a major public health threat.”767 That’s more than half of the population over 50 years of age.
Lumping those 34 million who have low bone density together with those who have already been diagnosed with osteoporosis certainly makes for a larger potential market for the drugs that have been developed to prevent or treat bone loss. Some public health researchers have criticized this tactic by calling it “-disease-mongering.”768 Instead of characterizing osteoporosis or low bone density as a risk factor for fracture, calling it a disease implies that it requires treatment.769 The critics claim that this tactic mobilizes fear (and helps sell drugs) rather than promoting understanding and positive action.
The availability of bone density screening is a two-edged sword in this respect. On the one hand, it is helpful for those who are truly at risk to find out before they break a hip or develop debilitating back pain from vertebral fractures. Unfortunately, many of those being screened are not those who need it most. An analysis of nearly 44,000 women on Medicare found that the oldest women, ages 81 to 85, were only half as likely to be screened as women ages 66 to 70. The older women, however, are far more likely to have reduced bone density, even osteoporosis, putting them at risk of a fracture.
Increasingly, middle-aged women are being screened for bone density. The scoring system is a bit complicated, since it is based on standard deviations below the bone density of a young person at peak bone mass. Most of us don’t have the grounding in statistics to make much sense of “standard deviations,” so if the doctor does not explain carefully what the numbers mean, women often end up confused and alarmed. Critics point out that defining osteoporosis as bone density that is 2.5 standard deviations (T score -2.5) below the mean for a young person practically guarantees that approximately 30 percent of postmenopausal women will be diagnosed with this condition, whether they are truly at risk for osteoporosis or not.
When it comes to preventing broken hips and painful spinal fractures, there is no single treatment that stands head and shoulders above the rest. Each has benefits and disadvantages. People at risk for osteoporosis will need to think about the issues that might affect their treatment and their ability to stick with the program.
Even when the primary goal is prevention by getting adequate calcium and vitamin D together with exercise (and we strongly encourage that for everyone who can do it), the studies show that nutritional supplements are effective only if people actually take them all the time. Surprise! So consider whether you will take a pill or an injection every day, or if you’re better off with once-a-week or even once-a-month therapy.
Consider combining Evista or Menostar with one of the bisphosphonate medicines, such as Actonel or Fosamax. Some research shows that combining these treatments can increase bone density more than either one alone.804 We don’t know whether the combination also reduces the risk of fractures synergistically. There are, of course, costs associated with taking more than one drug. But if the therapy you are using does not seem to be working adequately, this option might be worth discussing with your doctor. There isn’t any advantage in combining Forteo with other medicines.
There are a couple of other treatments to watch for, although they are not currently available in the United States. A new hormone replacement therapy called Angeliq has been introduced in Europe. It contains a lower dose of estrogen (1 milligram per day of estradiol) along with a different type of progestin called drospirenone.805 We can’t tell at this point whether it would be safer than the usual HRT or how effective it might be at preventing fractures. Another new drug is called Preos. Like Forteo, it is based on parathyroid hormone.806 Not enough information is available at this time to tell if it would offer any significant advantages.
- A lifetime of healthy living, with plenty of physical activity and adequate intake of calcium and vitamin D, is the best osteoporosis preventive. It’s (almost) never too late to start. But if you already have had fractures, check with your doctor before you begin a new exercise program! You don’t want to make things worse.
- Bone density screening can be a useful tool for determining who may need treatment for osteoporosis. It is underutilized for those most at risk, women of more than 80 years of age.
- Don’t bother with calcium supplements alone. Make sure they are paired with adequate vitamin D. Your skin can manufacture its own D with roughly 15 minutes of sun exposure three or four days a week. If you shun the sun, you should be getting a minimum of 700 IU of vitamin D3 a day; 1,000 IU daily might be even better, but don’t go overboard because vitamin D can be toxic at very high doses.
- Evista can do double duty, reducing the risk of both osteoporosis fractures and breast cancer. If you are concerned about both issues, discuss this possibility with your doctor.
- The bisphosphonates are fairly similar in side effects and efficacy, though alendronate (Fosamax) may have an edge. Consider one of these medicines unless you have had problems with your esophagus (such as bleeding or trouble swallowing) or expect to need dental surgery.
- Forteo builds bone, but its long-term benefits and risks are unknown. As a daily injection, it is less convenient and more expensive than most other treatments.
- Miacalcin might be a good choice for a person who already has osteoporosis and vertebral fractures. It may ease back pain as well as increase spinal bone density.
- Menostar offers an alternative for women. This ultra-low-dose estrogen patch can increase bone mineral density and may not cause the harm associated with conventional HRT.