The Battle Against Osteoporosis

Osteoporosis is a condition that I obsess about a lot because it runs in my family. If a parent or a sibling has osteoporosis, it significantly increases our risk of developing the condition. I have multiple family members with osteoporosis and two of them are directly linked to me. If that isn’t reason enough for me to take action, then I deserve the consequences that arise from ignoring the warning signs.

These are notes for myself and not to be use as a replacement for any medical advice from your doctor. Please see your health professional before engaging in any activity.

What is Osteoporosis?

Osteoporosis is a medical condition that causes our bones to become weak and brittle making them more likely to break. When allowed to progress, our bones can become so weak that even simple actions like bending or coughing can lead to a bone fracture. The word osteoporosis means “porous bone.”

Why Should We be Worried About Osteoporosis?

Osteoporosis is a silent disease because it can progress with us being none the wiser until a bone breaks. Unfortunately, by the time something breaks, the disease progression is quite advanced.

I know it is easy to dismiss a fracture as being no big deal. It’s inconvenient but we can recover and get on with our lives. Most of us think of fractures as a broken arm from falling out of a tree, or a broken leg from falling off a skateboard. They were pretty painful and quite inconvenient, but all our friends signed the cast with funny messages and we lived to tell the tale at sleepovers and parties. There were no long-term consequences from a broken bone and surely medical conditions like cancer or heart disease ought to be the ones we worry about. Then again, that only happens when we are young. In an older person, a fracture can have more serious rammifications.

When a bone breaks, especially in places like the hip or back, it can lead to loss of mobility, chronic pain, and reduced independence. All these things will reduce our quality of life and increase our risk of medical complications, especially when we are older. According to the statistics, 20–30% of older adults will die in the first year after a hip fracture. The outcome depends on age, health status, and speed/quality of treatment and rehab.

Why is there a risk of death and reduced quality of life after a fracture when we are older?

• Complications from surgery – surgery is often require to fix a broken hip. Surgery, especially in older adults, is associated with higher risks.
• Loss of mobility – reduced mobility from being bedridden comes with its own set of problems. Immobility can result in pneumonia (lying down too much), blood clots (poor circulation), bedsores, and muscle wasting (lack of muscle use).
• Complicates pre-existing medical conditions – older individuals suffering a fracture may already have a number of existing medical conditions which are exacerbated by the trauma of a fracture.
• Reduced function and independence – many people who suffer a fracture often do not regain their pre-fracture level of function. The loss of independence is associated with depression, social isolation, reduced willingness to recover, and malnutrition.
• Infections – after a surgery and having to stay at a hospital increases the risk of infections like UTIs (urinary tract infections), sepsis (infections of the blood), and nosocomial (hospital acquired infection).
• Cognitive decline – older patients can suffer from delirium due to pain, anesthesia, infection, disrupted sleep, side effects from medications, and being in a hospital environment. While delirium is usually temporary, it can increase the risk of long-term cognitive decline or unmask underlying dementia. Cognitive decline is also the result of reduced physical activity and social interaction, both of which are important for cognitive stimulation. Stress, depression, and the inflammatory response from the fracture can further aggravate a vulnerable cognitive state.

I haven’t needed to be convinced to worry about Osteoporosis. I grew up with a living example that made me wary. Studying about my genetic risk factors only serve to fuel my determination not to end up like that.

Testing for Osteoporosis

The DEXA scan is the main test for osteoporosis. It is used to measure bone mineral density at the spine and hip. It is usually recommended for women 65 and older and men 70 and older, although individuals with risk factors for osteoporosis are also encouraged to get tested as early as age 50.

Risk factors for osteoporosis include:

• Family history of osteoporosis or hip fractures
• History of fractures with minimal trauma
• Early menopause (before age 45)
• Low body weight or BMI < 19
• Smoking, excessive alcohol intake, or certain medications (e.g., corticosteroids)
• Certain diseases (e.g., rheumatoid arthritis, celiac disease, lupus)

Results from a DEXA scan are reported as a T-score and a Z-score. The T-score compares our bone mineral density (BMD) to the peak bone density of a healthy, young adult (typically age 30), of the same sex.

• Normal: T-score ≥ -1
• Osteopenia (low bone mass): T-score between -1 and -2.5
• Osteoporosis: T-score ≤ -2.5

The Z-score compares our bone mineral density (BMD) to what’s expected for someone of the same age, sex, and body size as us.

• Z-score ≥ -2.0: BMD is considered within the expected range for your age.
• Z-score ≤ -2.0: “Below the expected range for age”, which may indicate secondary osteoporosis (i.e., bone loss caused by another condition, not just aging).

The Z-score is not used to diagnose for osteoporosis. It is usually used for premenopausal women, men under 50, and children/adolescents because their bone density is expected to be different from young adult peak.

Getting Base Line DEXA Scores

In women, bone mass most rapidly in the four to five years around menopause, when estrogen plummets, then slows and continues through the rest of life.

“Given that about 20% of women over age 50 have osteoporosis and 50% have low bone mass, getting a first scan around this age may be beneficial for people with risk factors,” says Walker, “because we have a chance to slow the loss before it gets worse.”

“When Should I Get a Bone Density Test?” – Columbia Doctors

I have always been conscious of my bone density, especially with my family history, so I finally got myself a set of baseline DEXA Scores. The results were good – above average for my age which is a good position to be starting in. I was glad to see that my efforts to build and preserve bone mass have not been in vain. Nevertheless, transitioning into menopause with a strong family history for osteoporosis means I cannot afford to slack off now. If anything, I need to be even more diligent with bone-preserving/building exercises as my estrogen levels start to dip.

Working Out for Bone Health

There are two ways to build and preserve bone mass – weight bearing exercises (e.g. impact exercises like hiking, jogging, dancing) and resistance exercises (e.g. strength exercises like lifting weights and bodyweight exercises). Both impact exercises and strength exercises are beneficial for building and preserving bone, but each affects bone health in slightly different and complementary ways. It is especially important to keep up these exercises to maintain and increase bone mass during perimenopause.

Resistance/Strength Training – 2 to 3 Times a Week

What strength exercises do for our bones:

• Stimulates bone growth by placing mechanical load on bones through muscle contractions.
• Especially effective for areas where the muscles pull strongly on bones (e.g. hips, spine, arms).
• Helps maintain or increase bone density, especially in older adults.

The standard recommendation is to use free weights or resistance bands to target 2 to 3 sets of 8 to 12 reps. However, Vonda Wright, a pioneering orthopedic sports surgeon, expert in human performance, and authority in women’s health says we need to lift heavier especially as we age because:

• Bones respond to load – they adapt to the amount of stress placed on them (Wolff’s Law). Light resistance (like walking or lifting 2-lb weights) is not enough to stimulate new bone formation. We need heavier loads like squats, deadlifts, and overhead presses to place meaningful stress on the spine, hips, and long bones and stimulate bone-building cells (osteoblasts).
• It builds muscle mass to support bones – strong muscles pull on bones during movement and this, in turn, stimulates bone growth. When we lift heavier, it requires greater muscle recruitment, which enhances bone remodeling.
• It protects against falls and fractures – lifting heavy also improves core strenght, balance, and joint stability. Protecting against falls prevents fractures.
• It counters age-related bone loss – once we hit 30, our bone mass starts to decline. Bone loss is even faster during perimenopause and menopause when estrogen drops. Lifting heavy is the best way to reverse or slow down this bone loss.

Vonda’s strength training recommendation:

• Compound Lifts: Squats, deadlifts, bench press, overhead press (4 sets of 4 reps, lifting heavy). 
• Supporting Lifts: Biceps, triceps, lats, deltoids (4 sets of 8 reps, lighter weights). 
• Frequency: 3 times per week. 
• Definition of “Heavy”: The weight that allows you to perform 4 to 6 repetitions with good form, until fatigue sets in after 4 repetitions.

If you haven’t been doing strength exercises regularly, I would suggest building up to this slowly. Going from zero to hero, especially at this age, is not recommended. Vonda says that if you’re starting with body weight exercises, it could take 6 to 9 months to build up to this.

Weight-Bearing Aerobic Exercise – 3 to 5 Times a Week

Impact exercises are important for stimulating bone formation through ground reaction forces. Repeated impacts create micro-stress that encourages bone remodeling and strengthening. Some examples of Weight-Bearing/Impact exercises include:

• Brisk walking for at least 3 hours a week following Vonda Wright’s recommendation. This could be four sessions of 45 minute walks or six sessions of 30 minute walks. I have been targeting a walk after dinner as part of my own effort to beat the insulin spike.
• Boxing – which also offers some mild resistance training from hitting a punching bag although this will not be as effective as training with weights or even body weight. The classes I attend usually include a functional round which serves to add a body weight resistance training component. I especially like this class because it also targets VO2 Max which is important for cardiovacular health and longevity but more about this another time.
• Other activities like climbing stairs, hiking, skipping, and dancing.
• Sports like basketball, tennis, and pickle ball (particularly popular these days) are also good choices.

It’s worth noting that impact exercises are especially beneficial for the hip and spine; and may be more effective than strength training at maintaining bone density in premenopausal women. That said, it doesn’t mean we can ignore our resistance/strength training entirely either.

Balance and Core – Daily or at Least 3 Times a Week

Balance and core exercises may not specifically target bone mass, however, they are important for fall prevention. Since falls are one of the major causes of bone factures, we should also work on reducing our fall risk. Exercises like the following will help:

• Tai Chi
• Yoga
• Planks, side planks
• Single-leg stands

If time constraints are a concern, because who has time to do so many workouts in a week, we can select exercises and workouts that achieve more than one goal. Exercises that build strength and train balance like the single leg Romanian Deadlift are great for loading the bones of the femur, pelvis and lumbar spine; building the muscles of the glutes and hamstrings; training balance and proprioception from having to balance on one leg; and improving ankle and foot stability which are important for fall prevention.

Other Considerations for Building/Preserving Bones

Aside from working out, there are a few other things to take into consideration.

• Consuming enough calcium – since calcium is the main mineral in bone.
  • Aim for 1000 mg/day (1200 mg/day if you are a woman 50 and above).
  • Best sources are from dairy, like milk, yoghurt and cheese. For lactose intolerant individuals, dark green leafy vegetables are a good alternative, like kale, bok choy, and broccoli. Don’t eat spinach because it contains oxalates that affect calcium absorption.
• Getting enough Vitamin D – since Vitamin D is essential for calcium absorption.
  • Aim for 600 to 800 IU a day.
  • Our skin can make Vitamin D through exposure to the sun. To get our daily requirement, we would need about 10 to 30 minutes of sunlight exposure. This may vary depending on our skin tone, time of day, season, where we live, amount of skin exposed, and age (older people make less Vitamin D).
  • A good rule of thumb to follow is that our body can produce 10,000–25,000 IU of vitamin D from full-body sun exposure for 15–30 minutes in strong sun.
  • It is important to be aware that short, frequent exposure is safer (we should not allow our skin to burn) and Vitamin D synthesis stops once our skin has made enough.
  • If sunlight exposure is an issue, we can also consume Vitamin D from fatty fish, like salmon and sardines. Vitamin D supplementation is another alternative.
• Consuming enough protein – because protein supports collagen matrix in bone.
  • Aim to get about 0.8 to 1.2 g/kg of body weight a day. This can vary for older adults and/or athletes.
  • Best food sources include meat dairy, legumes, tofu, eggs, and nuts.
• Getting enough of other key nutrients – Magnesium, Vitamin K2, Zinc, and Potassium.
  • Magnesium (nuts, whole grains, and leafy greens) supports bone structure, regulates calcium and Vitamin D, and reduces bone loss.
  • Vitamin K2 (fermented foods like natto and certain cheeses) is important for directing calcium to our bones and teeth and away from our arteries. Studies also suggest that it could improve bone density, especially in postmenopausal women.
  • Zinc (meat and pumpkin seeds) supports bone formation and inhibits bone breakdown.
  • Potassium (bananas, potatoes, and oranges) may neutralise acid load and reduce calcium loss from the bone which has a beneficial effect on bone density. 
• The following habits can also negatively impact bone mass:
  • Smoking
  • Excess alcohol – no more than 2 drinks/day
  • Excess salt and soda which can leach calcium from bones
  • Caffeine – less than 3 cups a day if calcium intake is low
• Monitor hormone levels – estrogen for women and testosterone for men.

The Role of Estrogen

While listening to this podcast on The Hidden Truth About Estrogen, Dr Avrum Bluming (author of Estrogen Matters) said:

Young bones don’t break as often as old bones because of the collagen fibers within them. This isn’t about the calcium or the phosphorus. This is about the infrastructure. It’s about being able to bend without breaking. Calcium and Vit D doesn’t prevent hip fracture. Within one year of a hip fracture, 21% of women die from the sequel of the fracture.

Bone mineral testing is a poor test for predicting significant bone fracture but we use it because there’s nothing else. Within 5 or 6 years of stopping estrogen, your bones become as fragile as they would be if you had never taken estrogen.

This really got my attention because I am going to lose estrogen through menopause. Estrogen plays a critical role in maintaining bone health, particularly through its effects on collagen fibers, which are not only essential for bone strength but also its flexibility.

• Estrogen promotes the synthesis of type I collagen, the main collagen type in bone matrix. Type I collagen provides structural integrity and tensile strength to bone.
• Estrogen also reduces the activity of matrix metalloproteinases (MMPs) – enzymes that break down collagen and other extracellular matrix components. This helps preserve the existing collagen network in bone. Enhances Osteoblast Activity:
• Estrogen supports the activity of osteoblasts (bone cells that produce new bone and collagen). This contributes to balanced bone remodeling.
• Estrogen suppresses osteoclasts (bone cells that break down bone and degrade collagen).
• Estrogen helps to maintain a healthy balance between bone formation and breakdown.

Estrogen levels being to decline in perimenopause. When estrogen drop, collagen production decreases and degradation increases. This contributes to reduced bone density and increased fragility. Postmenopausal women can lose up to 20% of their bone mass within 5 to 7 years of menopause if not addressed. One of the ways to address this is through hormone replacement therapy (HRT) but this is a very long discussion best saved for another day.