Here are some ways to keep your bones in the best possible shape

By Hallie Levine,

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In the past 18 months, some of your medical care — including supporting your bone health — may have fallen by the wayside. In the first few months of the pandemic, for exam­ple, about a third of health-care providers in one survey said they had pushed off bone density screenings.

Even before the pandemic, an esti­mated 10 million Americans older than 50 had osteoporosis, a disease in which bone loss can hike fracture risk, according to some data. An additional 43 million people in the United States, including 16 million men­, had low bone mass (osteo­penia), putting them at increased risk for osteoporosis.

The resulting fractures can be serious, even deadly: Research shows they’re respon­si­ble for more hospitalizations than breast cancer, heart attacks or strokes among women 55 and older. “We’ve reached a global crisis when it comes to the care of osteoporosis,” says E. Michael Lewiecki, director of the New Mexico Clinical Research & Osteoporosis Center in Albuquerque.

To help you keep your bones in the best possible shape, here’s the latest thinking on screening, lifestyle strategies and when medication is the best option.

Stay up to date on screening

A bone density test — a low-dose X-ray known as a DEXA scan ­— can tell you and your doctor how strong your bones are. It’s painless and quick: You lie on an exam table for about 15 minutes while specific bones are scanned.

Women are about twice as likely as men to break a bone because of osteoporosis, according to the National Osteoporosis Foundation. So women 65 and older should have a baseline screening, accord­ing to draft recommendations from the U.S. Preventive Services Task Force.

But younger women with osteoporosis risk factors should also get scanned, says Andrea Singer, director of bone densitometry at MedStar Georgetown University Hospital in Washington, D.C., and an NOF spokeswoman. Risk factors may include a smoking history, use of steroid medications, autoimmune disorders such as rheumatoid arthritis, certain types of past fractures, chronic heavy consumption of alcohol, and having diabetes, thyroid disease or early menopause.

When to screen is a bit more complicated for men. “People thought osteoporosis was just a disorder of postmenopausal women, and it is only in the past 20 years that osteoporosis in men has been recognized,” says Robert Adler, an endo­cri­nol­ogist at Virginia Commonwealth University in Richmond. And it can have serious effects on men, in whom fractures tend to occur about 10 years later than they do in women, he says. In 2016, the latest year for which figures are available, 381,000 men on Medicare experienced osteoporosis-­related bone fractures. Of that number, 91,000 — almost a quarter — died within a year.

The NOF recommends that all men have a baseline bone density test at age 70, but George Abraham, president of the American College of Physicians, advises discussing it with your doctor sooner if you have osteoporosis risk factors like those above, or low testosterone or documented loss of height.

Both women and men who have a normal scan (results are given as a “T-score”) might not need another for up to a decade. Those with osteopenia need a follow-up scan between three and five years later, and for diagnosed osteoporosis, repeat testing every two years.

And if you break a bone, it’s important to have another scan to check your bone strength — but this doesn’t happen often enough. The NOF found that only 5 percent of men and 9 percent of women ­using traditional Medicare received a scan within six months of a fracture.

Eat for stronger bones

While some studies suggest that carrying extra pounds may be bone-protective, some other research has found that a change in weight — a gain or a loss ­— may increase the risk of a fracture.

But a diet that supports strong bones also tends to help you maintain a normal weight. A study published in the American Journal of Clinical Nutrition in 2018 found that a diet rich in produce, nuts, whole-grain cereals, olive oil and fish increased bone density in the femoral neck — near the top of the femur — in people with osteoporosis over 12 months. Such diets help control inflammation, which may have a protective effect on bones, Lewiecki says. And they provide plenty of magnesium and potassium, which are associated with better bone density in older adults.

Also important is calcium, which helps to build and preserve bones. Women younger than 50 and men younger than 70 need at least 1,000 mg of calcium per day, and women older than 50 and men older than 70 should consume 1,200 mg daily. Ideally, your calcium should come from food, says Stephen Honig, direc­tor of the Osteoporosis Center at NYU Langone Health in New York. (A cup of skim milk has about 300 mg; a cup of cooked fresh kale has 94 mg.)

Vitamin D is important because it helps the body absorb calcium. The NOF recommends that adults older than 50 get 800 to 1,000 international units daily. Fortified dairy and cereal contain vitamin D. And your skin makes it in response to sunlight, but it can be hard to get enough this way, so ask your doctor about assessing your blood levels of vitamin D.

Pay attention to protein, too. “Studies have shown inadequate amounts of protein are associated with increased fracture risk, which makes sense, because it makes up a hefty portion of your bones,” Lewiecki says. Men older than 50 need 56 grams a day; women older than 50, 46 grams. (Three ounces of chicken without skin has about 22.8 grams.) If you’re a vegetarian, make sure to get enough plant protein, such as legumes and nuts.

And limit alcohol and caffeine because drinking a lot of either has been linked to bone loss. The National Institute of Arthritis and Musculoskeletal and Skin Diseases recommends no more than one alcoholic drink a day for women, and two for men, and the NOF advises fewer than three cups of coffee a day for everyone.

Get the right exercise, too

Being physically active may help you maintain bone density, even after menopause, when density typically drops.

Weight-bearing moves such as walking and resistance training are ideal. Try to get 30 to 60 minutes of moderate activity (like brisk walking) or 20 to 30 minutes of vigorous aerobic activity daily, along with 10 to 15 minutes of resistance exercises (you can use light dumbbells, resistance bands or your own body weight). Along with balance training, this can help prevent falls, too, by strengthening the muscles that help keep you on your feet.

For specifics, the National Institute on Aging has an exercise plan for older adults that incorporates balance, cardio and strength: Go to NIA.NIH.gov and search for “four types of exercise.” (If you’ve already had a spine fracture or you have osteoporosis, talk with your doctor and possibly a physical therapist before doing resistance training, Adler says.)

When to start and stop meds

If you receive a diagnosis of osteoporosis (or osteopenia with a high fracture risk), your doctor may recommend medication to cut your chance of a bone break. But which type and how long you’ll need it vary. Most people start with bisphosphonates, such as alendronate (Binosto, Fosamax), ibandronate (Boniva) and risedronate (Actonel, Atelvia), which slow bone breakdown. For severe osteoporosis, some experts advise starting with self-injectable anabolics, such as abaloparatide (Tymlos) and teriparatide (Forteo), which build bone.

Because bisphosphonates can cause stomach upset, heartburn and, in very rare cases, thigh fractures or jawbone damage, they aren’t advised for longer than five years. Anabolics, which may cause dizziness, leg cramps and nausea, aren’t usually prescribed for more than two years because their long-term effects are still unknown.

After this time, your doctor will prescribe a bisphosphonate or, if you don’t respond to bisphosphonates, the drug denosumab (Prolia). This can increase bone mass, but its benefits subside once you stop using it.

After five years on a bisphosphonate, most people should be assessed to see whether they need to take a break from the medication, Adler says. But about two years ­after stopping, if a scan shows ­decreased bone density, your doctor may put you back on a bisphosphonate.


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