Let's Talk About Osteopenia
Half of all Americans 50+ will lose some of their bone density. It's vexing—but a wake-up call to better care for your bones.
We wouldn’t even be able to sit upright without them, so it’s ironic that most of us don’t give much thought (let alone thanks!) to our bones. We tend to take our inner infrastructure for granted until we get a wake-up call. If you’ve been told you have low bone density (also known as osteopenia), you’ve gotten yours. Rather than panic, relax and read on. We explore what’s behind weakened bones and offer strategies to strengthen them.
Our Pro Panel
We tapped some of the best bone experts in the field to bring you the most up-to-date information possible.
Kendall Moseley, M.D.
Johns Hopkins Metabolic Bone & Osteoporosis Center
Lara Than, M.D.
Department of Internal Medicine and Geriatrics
Mary Jane Minkin, M.D.
Clinical Professor of Obstetrics, Gynecology, and Reproductive Services
Yale School of Medicine
New Haven, CT
Most of the time, you won’t know until you have a bone density scan (think of it as an osteoporosis X-ray) to determine how strong or weak your bones are. The recommended age for a screening for osteoporosis is 65 for women and 70 for men. If you have risk factors for osteoporosis, your doctor may want you to have a scan sooner. Of course, many people learn they have low bone density more suddenly, when they suffer a fracture from something slight, like stumbling off a curb.
This is the process by which your body breaks down old, mature bone and releases calcium into your tissue and blood. It’s natural and necessary, but when bone resorption starts to outpace new bone formation, you’re at risk for developing low bone density and osteoporosis.
A total reversal isn’t likely, but through lifestyle changes—a calcium-rich diet, supplements, weight-bearing exercises, and medications, if you need them—you can strengthen your bones to the point that they’re at less risk for fracture. This, experts say, is the goal of osteopenia and osteoporosis treatment.
Not necessarily. You have a lower bone mass density than normal, which puts you at a higher risk for osteoporosis, but that doesn’t mean you’re destined to get it. Many physicians say osteopenia is a wake-up call for their patients to pay more attention to their bone health: boost their calcium and vitamin D intake, start exercising, quit smoking, and drink less alcohol. This plan can stave off rapid bone loss and the bone fractures that often come with it.
What’s Osteopenia, Anyway?
Let’s start at the very beginning—in utero. Your bones start forming when you’re a fetus, and they continue to do so until sometime in your 20s.
What are bones made of? At first, mostly cartilage (a resilient and smooth elastic tissue). When you’re a baby, your bones are soft and flexible, and even fuse together with other bones (fun fact: you’re born with almost 100 more bones than you have as an adult).
As you grow older, cartilage is replaced by calcium phosphate, a mineral that makes them hard. Your bones are also made of collagen, a protein that gives them some flexibility, allowing them to give a little without breaking. Bones are comprised of three types of cells:
Osteoblasts, cells that form bone
Osteoclasts, cells that break down bone (also known as bone resorption)
Osteocytes, old osteoblasts that are trapped in the bone matrix
Osteoblasts are constantly making new bone, while osteoclasts break down old bone, releasing calcium into your blood and tissue, a process called remodeling.
What’s Calcium Got to Do With Bone Density?
The amount of calcium in your bones is measured by your bone mineral density. The higher the mineral content, the denser and stronger your bones are. The lower the mineral count, the weaker, more porous (possessing holes) and more brittle your bones are.
What do we mean by brittle? Think of glass. It’s hard, but also likely to break or shatter when you drop it. Bone that’s lacking minerals becomes delicate inside and cracks into pieces from a little pressure.
Typically, when someone is diagnosed with low bone density, or osteopenia, it means they’ve lost some bone density, but not as much as someone who has osteoporosis, a bone disease that occurs as your bones weaken, thin, and become so fragile, they’re vulnerable to fracture (the medical term for a broken bone). Yep, just like a glass.
What Are the Risk Factors for Osteopenia?
So, how exactly do you wind up low bone density or osteopenia? By age 30, you’ll have reached your peak bone mass—the strongest your bones will be in your lifetime. If you had a childhood illness that affected bone formation or caused malnutrition (for example, undiagnosed celiac disease or anorexia), your peak bone mass probably isn’t as high as it could be.
Most people don’t have low bone density until mid-life, when you start naturally losing bone mass. But some factors can erode bones earlier, or accelerate loss after age 50. These include:
Being Born a Woman: Anatomy puts women at a higher risk for developing low bone density. Females bones are naturally smaller and thinner than men’s, and so women have a lower peak bone mass. So, once they start losing bone with age, there’s less to lose. Research has shown that women age 50 and older are twice as likely to have osteopenia than men.
Smaller Stature: Being a slim, petite, “small-boned” woman is associated with lower bone density levels and a higher risk of osteoporosis.
Being Caucasian or Asian: These groups tend to have far higher rates of low bone density than Latinos or African Americans. More than half of white postmenopausal women have the condition.
Genetics: Your bone quality is passed down from our parents. It’s said that up to 80 percent of your peak bone mass is determined by your genetics.
Underlying Conditions: A number of diseases can interfere with healthy bone development by impacting how your body absorbs calcium and other nutrients. Examples include:
Rare Bone Diseases: A bone disease, like those below, can certainly affect your bone density.
Osteomalacia (softening of bones due to a severe vitamin D deficiency)
Paget’s disease (which interferes with normal bone remodeling, leaving bones fragile)
Osteogenesis imperfecta, a genetic disorder that affects normal bone formation
Medications: Certain drugs can accelerate bone loss. The biggies are:
Steroids (long-term use)
Chemotherapy and other cancer drugs
Heartburn medications known as Proton pump inhibitors (Prevacid, Nexium)
Thyroid hormone (excessive amounts)
Diet: A diet chronically low in calcium and vitamin D—which helps your body absorb calcium—can affect bone density. Skimping on either nutrient during the first couple of decades of your life may cause your peak bone mass to be low. And failing to get enough calcium and D as you age will cause your bone to break down faster. Practicing a balanced, healthy approach to eating is best for your bones. Three circumstances that can leave you deficient in many nutrients and vitamins necessary for good bone health:
Having an eating disorder
Weight loss surgery
How do you know your body is low in calcium? Tell your doc if you experience any of these symptoms:
Tingling (particularly in your lips, tongue, fingers and feet)
Muscle spasms and aches
Abnormal heart rhythms
Ebbing Hormones: Yup, hormones affect bones, too. The loss of estrogen that comes with menopause can accelerate bone loss, and going through this change of life early (say, in your 40s) can up your risk of osteopenia. In men, low testosterone levels are also linked to lower bone density.
Excess Alcohol: Chronic, heavy drinking (defined as more than two drinks a night) is linked to lower bone density.
Not Enough Exercise (or Too Much!): Weight-bearing exercises like walking, dancing, and hiking, as well as resistance training put just enough stress on bones to stimulate bone formation. This is to build your peak bone mass and maintain healthy bone mass as you age. On the flip side, too much exercise doesn’t do a body good. Female competitive athletes are especially at risk for the female triad: interruption of their menstrual cycle, low calorie intake, and low bone mineral density.
How Is Osteopenia Diagnosed?
There aren’t obvious symptoms that bones are weakening, unless you break one. Most of the time, osteopenia is picked up during a routine bone density scan, or a densitometry (DXA or DEXA scan). Bone density scans are typically given to women starting at age 65 and men at age 70, but your physician or gynecologist may suggest one sooner if you have the low bone density risk factors mentioned above or a history of bone fractures.
How Does a Bone Density Scan Work?
This imaging test is like an X-ray that measures the mineral content in your bones. The higher the mineral content, the stronger your bones are. The lower the mineral content, the weaker. Results are given in what’s called a T-score, a number that tells doctors how your bones stack up to a 30-year-old’s at peak bone mass.
Above -1.0 is considered normal
-1.0 to -2.4 means low bone density or osteopenia
-2.5 and below indicates more severe osteoporosis, meaning your bones are brittle and at a higher risk of fracture
Your risk of fracture increases as your T-score dips: A 50-year old woman with a T-score of -1.0 has a 16 percent chance of hip fracture, while a -2.5 ups the risk to 33 percent, a study in the Journal of the American Medical Association showed.
You may also receive a Z-score, which compares your bone density to people your own age and gender. Think of it as an age test for your bones. Z-scores tend to be given for those under 50, for whom low bone density is not the norm. It helps doctors determine if you have an underlying condition that’s affecting your bone health.
There’s one more test your doctor may use, particularly if you’re a woman over 50: the Fracture Risk Assessment Tool (FRAX). It determines how likely you are to fracture a bone within the next 10 years. Even if you don’t have severe osteoporosis, you can have a high FRAX score. Your physician will use this when determining treatment.
So, which type of doctor should you see for low bone density? There’s no singular specialist for osteopenia and osteoporosis. Any of the following types of docs should be able to treat you:
Geriatric medicine doctors
What’s the Treatment for Osteopenia?
Most cases of osteopenia don’t require meds. Little changes to your lifestyle and diet can do a long way in beefing up your bones, as your physician will probably tell you. Start here:
Weight-bearing exercises: Exercises that require you to support your own body weight (walking, jogging, dancing, etc.) and/or resistance training helps stimulate new bone formation, which is why they’re recommended for osteopenia and osteoporosis. If your bone density is very low, you may want to avoid high-impact exercises such as running or other falling risks. Non-weight bearing activities such as swimming and biking are A-okay, as long as you’re still squeezing in weight-bearing exercise.
Dietary changes: Boosting your calcium and vitamin D levels can help slow bone deterioration.
The recommendation for calcium is 1200 mg for women over 50 and 1,000 mg for men. Ideally, you should get your daily dose through your diet. Calcium-rich foods include:
Dairy products such as milk, yogurt, and cheese
Dark leafy greens such as kale and collard greens
Sardines and salmon with bones
Fortified foods such as orange juice and cereals
Vitamin D comes from sunlight, as well as foods like:
fatty fish such as salmon, tuna, and mackerel
If you don’t think you’re getting enough D through diet, a supplement can fill the gap.
Other vitamins and nutrients that have proved helpful for bone health are:
Vitamin C (citrus fruits, red peppers, strawberries)
Vitamin K (kale, spinach)
Potassium (potatoes, raisins, bananas)
Magnesium (sweet potatoes, tomato products, artichoke hearts)
A Mediterranean style diet—lean proteins, olive oil, foods rich in omega fatty acids—is linked to a healthier bone density, too. Some studies have linked caffeine in coffee and colas to low bone density, but the evidence hasn’t been conclusive. Experts say drink in moderation to play it safe.
What Medications Are Prescribed for Osteopenia?
If your FRAX score puts you at a high risk for fracture, or you’ve already had a fracture, your doctor may prescribe medication to slow the bone loss. The goal is to prevent your osteopenia from progressing to osteoporosis.
What kind of med? Bisphosphonates are FDA-approved for preventing osteoporosis in women with osteopenia (as well as treating osteoporosis). These drugs slow down those osteoclasts, the cells that break down bone. Most are oral tablets taken weekly or monthly. Examples are:
Fosamax (alendronate), taken orally
Boniva (ibandronate), taken orally
Actonel (risedronate), taken orally
Reclast, Zometa and Aclasta (zoledronic acid or zoledronate), taken via IV
Taking meds, if your doc prescribes them, can stave off further bone damage and the breaks that it tends to bring. Giving zoledronate every 18 months for six years lowered the risk of hip fracture in women with osteopenia by 37 percent, compared to those taking a placebo drug, one study published In The New England Journal of Medicine showed. An appointment with your doc is the first step to starting on a treatment to slowing your bone loss—don’t wait to make one!
- Prevalence of Osteopenia in Women: Journal of Clinical Medicine Research. (2017). “Gender Disparities in Osteoporosis.” ncbi.nlm.nih.gov/pmc/articles/PMC5380170/
- Female Triad and Bone Density: Sports Health. (2012). “The Female Triad.” ncbi.nlm.nih.gov/pmc/articles/PMC3435916/
- Osteopenia and Fracture Risk: The Journal American Medical Association. (2001). “Identification and Fracture Outcomes of Undiagnosed Low Bone Mineral Density in Postmenopausal Women: Results From the National Osteoporosis Risk Assessment.” ncbi.nlm.nih.gov/pubmed/11735756
- Zoledronic Acid and Osteopenia: The New England Journal of Medicine. (2018). “Fracture Prevention With Zoledronate Acid in Older Women With Osteopenia.” nejm.org/doi/full/10.1056/NEJMoa1808082