How to Build Stronger Bones

You can't feel your bones getting weaker. That's what makes osteoporosis so tricky to detect—and why understanding risk factors, getting screened, and improving your bone health matter so much.

Osteoporosis occurs when bone density decreases, and the internal structure of bone deteriorates. This causes bones to become weaker and more likely to fracture. In post-menopausal women and older men, osteoporosis is the main cause of fractures of the hip, wrist, and spine. It’s sometimes called a “silent” disease because you often don’t know you have it until you break a bone or a screening test reveals it.

Columbia endocrinologist Marcella Donovan Walker, MD, discusses risk factors and the importance of diagnosis, as well as ways to reduce your risk.

What happens when you have osteoporosis?

In people with osteoporosis, a fracture can result from a minor fall or even an everyday activity like lifting a window. These are called fragility fractures.

Compression fractures (breaks in a vertebra that cause it to collapse) are the most common osteoporotic fractures. They can cause back pain, loss of height, and a stooped posture. But they can also be asymptomatic, often going undiagnosed. Losing more than an inch and a half of height can be a sign of an undiagnosed vertebral fracture and should be discussed with your doctor.

What raises the risk of osteoporosis and fractures?

Gender, age, family history, hormonal changes, low weight, and certain medications and medical conditions may all contribute to your osteoporosis risk.

• Age: As we get older, we break down more bone density than we rebuild. Bone loss is particularly accelerated at the time of menopause in women, putting women at higher risk for developing osteoporosis.
• Some medical conditions: Certain conditions, such as diabetes, rheumatoid arthritis, some cancers, and some gastrointestinal or hormonal diseases, may increase your risk.
• Some medications: Long-term reliance on certain medications, including steroids, as well as certain drugs for cancer and epilepsy, may lead to higher risk.
• Family history: A family history of osteoporosis and a parental history of hip fracture increase your risk.
• Falls: Most fractures result from falls. So, factors that increase fall risk—such as poor balance, muscle weakness, and poor vision—can also increase risk of fracture.
• Prior fracture: If you have had a fragility fracture, you are at greater risk for more fragility fractures in the future.

Many providers, including Dr. Walker, use a fracture risk assessment tool called FRAX, which evaluates risk factors including age, gender, weight, alcohol consumption, smoking, and bone density, among others, to gauge someone’s risk of having a fracture.

How is osteoporosis diagnosed?

Osteoporosis can be diagnosed based on having certain fractures alone (like a compression, hip, or wrist fracture) if they occur with little or no trauma.

Otherwise, because osteoporosis is “invisible,” doctors may check your bone density using a DXA scan (short for dual-energy X-ray absorptiometry, and pronounced “dexa”), which is a quick, non-invasive test that uses low-dose radiation. This scan provides a “T-score” that determines if you have osteoporosis or osteopenia (a common precursor to osteoporosis).

“Getting evaluated is important because you can’t treat what you don’t know you have,” says Dr. Walker. Treatment options may range from adopting healthy habits (such as exercising and eating well) to physical therapy to starting medications that reduce the incidence of fracture. Your provider will monitor your osteoporosis on an ongoing basis.

“Lifestyle modifications may be enough for some people. For others, in whom the risk of fractures may be higher, medication may be required,” Dr. Walker says. “Every patient is different, and we weigh risk factors carefully in making treatment decisions.”

How can you reduce your risk of osteoporosis?

There are plenty of ways to promote bone health, including:

• Get screened: If you are a woman age 65 or older, a man age 70 or older, or a younger person with risk factors, ask your doctor to order a bone density scan.
• Get moving: “Almost any exercise will help maintain muscle mass as we age. Find something you enjoy and do it,” says Dr. Walker. Exercise can help slow age-related bone loss and maintain muscle mass, coordination, flexibility, and balance. Try weight-bearing and resistance exercises, such as walking, jogging, and weight training. But check with your doctor first to ensure these are safe for you.
• Prioritize calcium and vitamin D in your diet: Bones are mostly made of calcium and act as the body’s calcium reservoir, so if you don’t get enough from your diet, the body will take it from your bones. In addition, “if you are vitamin D deficient, your body can’t adequately process your dietary calcium,” Dr. Walker says. Young men and pre-menopausal women should get about 1,000 mg of calcium a day, ideally from food. Post-menopausal women and older men should get about 1,200 mg. For vitamin D: 600- 800 IUs daily is recommended by some guidelines, depending on age. Personal needs may vary, so ask your provider what’s right for you.
• Embrace healthy habits: Avoiding smoking and limiting alcohol intake are also important factors in lowering osteoporosis risk.

Although some risk factors are beyond your control, healthy lifestyle choices can be powerful tools in lowering osteoporosis risk.

Marcella Donovan Walker, MD, is a professor of medicine at the College of Physicians and Surgeons, Columbia University in the Division of Endocrinology.