A doctor has just diagnosed you or a family member with osteoporosis. What does this mean, and what should you do about it? In this article we will address these basic questions.
To begin, we must learn a bit about our bones. The bones of our skeleton are made up of many different cells, proteins, and minerals like calcium. Bones have a thicker outer region, and an inner cavity that contains bone marrow. The hard outer parts provide support for our bodies, while the inner marrow creates fresh blood cells that are vital for life.
Our bones are living structures, constantly remodeling depending on how they’re used. There is always new bone being built up and old bone getting broken down, like a life-long renovation project. Many individuals assume that their bones are susceptible to “wear and tear” or simply “wear out” over a lifetime. The reality is that bones – just like muscles – grow and adapt when given the right challenge, but also waste away if left unused.
In childhood and adolescence, more bone gets built up than gets broken down. This helps us grow to our full adult size. The physical stress of lifting weights causes bones to build up even more and become thicker and stronger over time. Despite what many people believe, childhood and adolescence is an excellent time to begin strength training to build as much bone as possible early in life, as this leads to healthier bones in older age. The idea that lifting weights will stunt a child’s growth is not true (for more, see here).
Bones that are not exercised regularly tend to break down more than they build up, leading them to become thinner and weaker over time. This is one of the many dangers from a life spent on the couch. When individuals are never exposed to loaded exercise, like lifting weights, bones do not receive the stimulus that keeps them strong. Similarly, when astronauts spend long periods of time in space without any gravity, their skeletons are deprived of the normal challenges that maintain strong bones.
What is Osteoporosis?
Osteoporosis describes bones that have become much thinner and weaker than normal. Some individuals are diagnosed with a milder form known as Osteopenia, which may progress to osteoporosis if it is not addressed. It becomes much easier for an individual with osteoporosis to break a bone – known as a “fracture”. For example, a ground-level fall that would not be a problem for most adults may result in a severe hip fracture for someone with osteoporosis. Hip fractures often require surgery to repair. The rehabilitation process is often long and difficult and can have lots of dangerous complications that increase the risk of death, especially in older adults. Fractures also commonly affect the spine, wrist, and many other areas. For this reason, it is worth doing everything we can to build up as much bone strength as we can earlier in life – but it is never too late to start, either.
How is Osteoporosis Diagnosed?
Osteoporosis does not cause symptoms – for example, having aches and pains in the bones or joints does not mean that an individual has the condition. Unless it is found through screening tests, osteoporosis is often found after someone experiences a fracture.
Factors that can increase the risk of osteoporosis and fractures include things like older age, smoking, alcohol use, and having very low body weight. Women are more prone to develop osteoporosis than men, especially after menopause (or if the ovaries stop working or are surgically removed earlier in life). But men with certain medical conditions can develop osteoporosis too, particularly those with extremely low testosterone levels (i.e., less than 200 ng/dL) or who have been treated with testosterone blockers for prostate cancer.
Other issues like severe vitamin D deficiency, thyroid or parathyroid hormone problems, kidney disease, intestinal diseases, and other medical conditions can affect bone strength as well. Long-term use of oral steroid medicines (like Prednisone) or high-dose inhaled steroid medicines may be necessary to treat certain diseases but can contribute to osteoporosis too. Nasal steroid sprays for allergies do not cause problems.
Not everyone needs to get tested for osteoporosis – most people are at such low risk that testing is a waste of time and resources. But those who are at higher risk, for example those who have the conditions mentioned above, may benefit from a screening test. The typical recommendation is to check all women over age 65 for osteoporosis. This involves a special type of X-ray called a DEXA scan. Women below age 65 or men who have certain conditions may benefit from DEXA testing but should discuss their individual situation with a doctor to see whether it is worthwhile.
Osteoporosis: What should you do about it?
There are several ways we can influence bone strength. These include diet, exercise, and other habits like alcohol and smoking.
A basic healthy diet includes:
- Plenty of fruits and vegetables
- Plenty of fiber (beans, lentils, oats, whole grains, fruits & vegetables)
- Palm-sized portions of protein at each meal to support muscle and bone
- Unsaturated fats (oily fish like salmon, mixed nuts like walnuts and almonds)
- Little animal-based saturated fats (butter and fatty red meats)
- Little to no ultra-processed foods (most packaged sweets and snacks)
This diet will promote general health, and paying attention to the intake of calcium and protein can be especially helpful for bone health. Calcium-rich foods include leafy green vegetables, dairy products like milk and yogurt, tofu, beans, and other calcium-fortified foods.
Quitting smoking and reducing or eliminating excess alcohol intake can be much easier said than done, but can provide profound health benefits on the physical and mental health, as well as bone strength.
Exercise may be the most important thing people can do to reduce the risk of osteoporosis, to improve osteoporosis if it is already present, and to reduce the risk of falls and fractures in people with osteoporosis. While we often encourage people to do any form of exercise they enjoy, not all forms of exercise will provide the same benefit for bone strength.
Bones need to experience a lot of force in order to build up and get stronger. Exercises that do not put much weight on the bones (like swimming, “aqua-aerobics”, or bicycling) will not provide the same benefit as exercises that put higher forces on the bones (like lifting weights). And for individuals who do lift weights, lifting very light weights for very high repetitions will not provide the same benefit as lifting heavier weights for fewer repetitions.
There are no magic exercises or programs required for osteoporosis; we recommend any program that provides sufficient load to the spine, shoulders, hips, and legs. This can involve machines, dumbbells, barbells, or other forms of high-intensity resistance. Our Beginner Prescription may be a helpful place to start.
Lots of people are told that osteoporosis means that their bones are “brittle” or “fragile” – and this can cause a lot of fear and anxiety over their risk of breaking a bone. Ideally doctors would not use this language when describing the situation to patients, and instead emphasize how our bones are living things that can respond and re-build when challenged.
It is understandable to be confused if you are told your bones are “fragile”, and then hear that you should lift heavy weights, because it might seem that using heavy weights could cause a fracture. Of course, what is “light” or “heavy” depends on the person, and all beginners should start out using lighter weights at first, but these should progress and become heavier over time. We have studies of high-intensity weightlifting programs in older patients with osteoporosis showing that they can re-build their bone strength without causing dangerous fractures during exercise. A good coach can help provide guidance through the process, but it is important to remember that the exercise needs to be intense enough and progress over time to be effective for strengthening bones.
There are some individuals who might be eating a healthy diet, exercising regularly, and lifting weights, but still have osteoporosis. In these situations, it is helpful to talk with a doctor about your situation. They will use your health information to estimate your risk of a fracture (often using a tool called FRAX), and discuss this risk compared to the potential benefit of vitamin D supplements and anti-osteoporosis medications. Some medicines work by preventing bone breakdown, while others directly promote bone building – and the best option will vary between people. These medicines should be used alongside healthy diet and weight-bearing exercise while being monitored by a doctor over time.
Osteoporosis can be a frightening diagnosis, although it is a condition that often responds to things that are under our control. There are multiple behaviors that can prevent osteoporosis and improve our bone health, including dietary changes and lifting weights. Even if a person successfully addresses these lifestyle changes, sometimes medications may still be needed. This should not be viewed as failure, but simply as another tool to reduce the risk of complications in the future. Your bones are living tissues, and providing them with the stimulus they need to build up and remain strong is essential regardless of your age or athletic background. You are not destined to be fragile. A diagnosis of osteoporosis does not mean that you should give up on physical activity. It is a call to action and a condition that you have the power to improve.
Thank you to Tom Campitelli, DTM, DTFP, for his assistance in editing this article.