10 warning signs your bones need help

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Osteoporosis is painful, crippling--and very, very sneaky. But both you and your doctor can learn to recognize 10 frequently overlooked tip-offs--and safeguard your bones

For months, Susan James (not her real name) suffered from nagging back pain that wouldn't go away. Her gynecologist suspected osteoporosis, so he recommended a bone-density test. But her orthopedist (bone specialist) told her it was a waste of time, so she didn't get one.

PHOTO (COLOR): You feel great, but how are your bones? Here's how to tell.

"I thought if the orthopedic doctor says nothing is wrong, then nothing is wrong," recalls Susan, 61, who went back to skiing and tennis, her two passions.

But when the pain got worse, she contacted a few more doctors: first, a back specialist who found inflammation but didn't take it seriously, and then a urologist who ruled out kidney stones, which she had had in the past.

Finally, her gynecologist talked her into the bone scan. The result? Susan had severe osteoporosis of the spine, and osteopenia, or low bone density, of the arms and hips.

How Osteo Gets Overlooked
Susan's weak bones might have been diagnosed sooner if her doctors had paid attention to her history of kidney stones, which in certain cases can be a risk factor for osteoporosis, says Susan's doctor, Marjorie Luckey, MD, director of the Osteoporosis and Metabolic Bone Disease Center at the St. Barnabas Ambulatory Care Center in Livingston, NJ.

That, combined with her age, her back pain, and her low intake of calcium-all warning signs of osteoporosis-should have signaled her orthopedist that she really needed that bone-density test.

Susan's story is not uncommon. The National Osteoporosis Foundation (NOF) in Washington, DC, estimates that more than 28 million Americans-80% of whom are women-have low bone density or osteoporosis, and that half of all women will have an osteoporosis-related fracture in their lifetime. What's going on?

Well, for one, osteoporosis is "nobody's disease," says Robert Lindsay, MD, president of the NOF. Since it doesn't "belong" to any one medical specialty, not enough doctors learn about the disease or test for it. Plus, advances in testing and treatment have come along so fast in the last decade that many doctors haven't kept up.

Add to that a long list of symptoms and warning signs (some, such as kidney stones, are so unusual that many doctors haven't encountered them) and there's plenty of opportunity for missed diagnoses.

That may soon change. Late last year, for the first time, the NOF issued guidelines to help doctors, no matter what their specialty, diagnose and treat osteoporosis. (See "Take This to Your Next Appointment" on p 112 to learn how you can get information about the guidelines.)

But if your doctor still isn't vigilant, you should be. Here, Prevention reveals 10 of the most frequently overlooked warning signs that your bones are in trouble-which should send you for a bone scan.

1. You're Thinner Than Normal
What many people think of as a plus really isn't: Low body weight puts you at increased risk for osteoporosis and fractures.

In fact, low body weight is probably the single most important risk factor for osteoporosis and increased risk of fractures, says Steven Cummings, MD, a professor of medicine and epidemiology at the University of California, San Francisco.

PHOTO (COLOR): Back pain that occurs on exertion could be a warning.

The NOF says that you have "low body weight" if you're an average-size woman who weighs less than 127 pounds. If that sounds a little vague, try thinking of it this way: You are potentially "osteoporosis-thin" if you weigh less than you should for your body type.

According to Dr. Lindsay, the following are the chief reasons why you're more prone to fractures if you're thin:

• You have less padding of muscle and fat to protect your bones. • You have thin bones, which are more vulnerable to injury. • You tend to make less bone-building estrogen after menopause.
If you're trying to be thin by dieting frequently, you're also at risk, warns Dr. Lindsay. When you lose weight, you lose fat, muscle, and bone. The first two may come back, but the bone could be gone forever.

2. Your Backache Won't Quit
Persistent back pain could be a sign that you have a spinal fracture, one of the symptoms of osteoporosis.

By the time Susan was finally diagnosed, her osteoporosis of the spine was so severe that she was close to a spinal fracture. In fact, without treatment she's about "16 to 20 times more likely to have a spinal fracture within the next five years than the average woman her age," says Dr. Luckey.

Spinal fractures occur when the bones in your back become so weak that they fracture and collapse. They can happen without warning-even during ordinary activities such as bending over to pick up a newspaper.

The pain can be severe, requiring a long recuperation. But sometimes all you feel is a dull, aching pain across the middle of your back and bottom of your shoulder blades. Unlike muscle pain, it doesn't go away with time and rest. Typically, the only way to ease the pain is to lie down, says Dr. Lindsay.

Having one spinal fracture puts you at greater risk for another and for hip fractures. And multiple fractures make it more likely you'll suffer chronic disability.
"If you are a postmenopausal woman and think you're getting a little round-shouldered and you've got some back pain, talk to your doctor and ask, 'Do I have osteoporosis?' " advises Dr. Lindsay.

3. You're Shorter Than You Used to Be
A spinal fracture can also steal inches from your height. When a bone in your back fractures, it literally collapses onto itself, causing you to shrink, explains Dr. Lindsay.

PHOTO (COLOR): If you're lactose intolerant, switch to calcium-fortified orange juice.

For some, loss of height happens gradually. For others, it happens quickly following an acute episode, with sudden back pain that can be quite severe and disabling.

Multiple fractures can also cause the spine to form a C curve, causing the disfigurement known as dowager's hump. This can trigger pain in the ribs and abdomen, as the lower ribs close in on the upper abdomen.

Not all height loss is caused by osteoporosis. As you age, the disks in your back lose their elasticity, causing your frame to shift downward. Gravity also takes its toll, and it's not uncommon to lose anywhere from 1/2 to 1 inch in height between the ages of 60 and 80. "But any loss of height that's more than that should be investigated," says Dr. Lindsay.

4. You Break a Bone
Breaking a bone as an adult doesn't mean you have osteoporosis. But it could be a warning sign that your bones are weak, says Dr. Lindsay.

In fact, someone who has had a fracture after age 40 is twice as likely to suffer a further osteoporotic fracture than someone who has not. "Obviously, the thing that causes a fracture is an injury of some sort, but if your bones are thin, then any injury is more likely to cause one," says Dr. Lindsay.

5. You Use Steroids
Many people with rheumatoid arthritis, asthma, lung disease, and other chronic illnesses rely on corticosteroids such as prednisone or dexamethasone for relief from their symptoms. And they work well. But taken over two or three months, they can also cause rapid bone loss that can lead to osteoporosis.

While steroid inhalers, usually used for asthma, can cause a small degree of bone loss and probably a small increase in your risk of fractures, steroids in pill form are the main bone robbers, says Dr. Cummings, because they generally come in higher doses.

PHOTO (COLOR): Combining aerobic and weight-bearing exercise can help you ward off osteoporosis, no matter what your risk factors are.

Steroids interfere with your body's ability to form new bone. They also interfere with the absorption of calcium by impeding the biochemical actions of vitamin D, Dr. Cummings explains.

Bone loss is most rapid in the first three to six months of treatment; taking almost any dose for more than two or three months can be harmful to your skeleton. But the effects of 10 mg or less per day of a steroid can usually be offset in part by supplementing from the start of treatment with a daily dose of 1,500 mg of calcium and 600 international units (IU) of vitamin D, says Dr. Cummings.

For steroid dosages greater than 10 mg per day, your doctor may recommend a more aggressive approach to stave off bone loss. At these doses, steroids can decrease bone mass by 10 to 20% and increase your risk of fractures by as much as threefold.

"Anyone who has been told by their doctor that they need steroids and have to stay on them for whatever reason should ask, 'Is this going to affect my skeleton? And does this mean I need a bone-density test now to make sure I'm not already at risk?' " says Dr. Lindsay.

6. You Have Thyroid Troubles
If you have hyperthyroidism, which is a condition caused by overproduction of the thyroid hormone thyroxine, you may want to schedule a bone-density test right away. Thyroxine speeds up the body's metabolism, so it breaks down bone faster than the body can make it, says Baha Arafah, MD, an endocrinologist with University Hospitals of Cleveland and professor of medicine at Case Western Reserve University.

Ironically, having hypothyroidism can also put your bones in jeopardy, says Dr. Arafah. That's because doctors may prescribe a synthetic version of thyroxine to treat hypothyroidism, which is caused by an underproduction of the thyroid hormone. When the prescribed dose is too high, the end result is the same: The body breaks down more bone than it builds.

Although bone loss can happen to anyone with too much thyroxine, women who have other osteoporosis risk factors such as being peri- or postmenopausal have an even greater risk, says Dr. Arafah.

If you're taking thyroxine, your doctor should be monitoring your dosage once or twice a year with a simple blood test. If not, ask for one. Prevention recommends you ask your doctor about the thyroid stimulating hormone (TSH) test.

7. You're Being Treated for Endometriosis
Endometriosis is an often painful disease of the reproductive system in which pieces of the uterine lining break away through the fallopian tubes and implant themselves outside of the uterus.

Most doctors believe it's the treatment of the disease-not the disease itself-that leads to osteoporosis, says Prevention advisor John Bilezikian, MD, director of the Metabolic Bone Diseases Program at Columbia-Presbyterian Medical Center in New York City. The drug that doctors prescribe most often to treat endometriosis-gonadotropin-releasing hormone (GnRH)-essentially shuts down the reproductive system over time, thereby reducing estrogen levels. Bone breaks down more rapidly when estrogen levels drop, explains Dr. Bilezikian.

"It's an effective therapy for endometriosis, but when used long term, it leaves women with an estrogen deficiency, and that's a big risk factor for osteoporosis," he says. That's why he recommends not taking the medication for more than six months.

8. You Smoke
Perhaps the Surgeon General should add another warning to cigarette packs: If you smoke, you double your risk of suffering an osteoporotic fracture.

Smoking harms bones in several ways. First, smokers tend to be thin, and thin frames usually mean thin bones. Smoking has also been linked with earlier menopause. That means you're getting less estrogen during your important bone-building years.

Smoking may also reduce your ability to absorb calcium. And if you started smoking at an early age, you may have put yourself at risk for osteoporosis later in life-even if you kicked the habit as an adult, says Clifford J. Rosen, MD, professor of nutrition at the University of Maine and the director of the Maine Center for Osteoporosis Research in Bangor. That's because cigarette smoke is thought to damage bone cells and prevent new bone growth. And smoking at a young age coincides with the time of life when your body builds the most bone.

9. You Have Kidney Stones
Studies have shown that kidney stones place some-but not all-people at higher risk for osteoporosis, says Dr. Luckey, who sees many patients with a history of kidney stones in her practice. People who are at risk are those who excrete too much calcium into their urine, or who are advised to avoid calcium, explains Dr. Luckey. When the body becomes calcium deficient in either of these ways, it dissolves bone to replenish its supply and keep the blood calcium levels normal.

Fortunately, only a minority of stone-formers are also calcium excreters, says Dr. Bilezikian. To find out if you're one of them, ask your doctor for the results of your urine calcium test, a simple urine test taken by some people with kidney stones.

If your urine calcium level is high, then you may be at risk for osteoporosis. You and your doctor can then work out a plan to lower that risk. This may include cutting back on salt, drinking lots of water, and even taking extra calcium or prescription drugs under certain circumstances.

10. You Can't Drink Milk
Milk and other dairy products provide a major boost of bone-building calcium to most American diets. People who are lactose intolerant may not be able to stomach milk-literally.

Lactose is a natural sugar found in milk and other dairy products. Before the body can absorb it, an enzyme called lactase must break it down. If your body has little or no lactase enzyme, you have trouble absorbing lactose. The result: bloating, gas, and sometimes diarrhea.

Many people avoid these unwelcome symptoms by staying away from dairy altogether. And that's fine-as long as you're getting your calcium from other sources including supplements, says Dr. Bilezikian.

Many people with lactose intolerance can eat yogurt and cheese, both good sources of calcium. There's also good evidence you can build up to as much as 3 cups of milk a day by starting with small amounts-1/4 to 1/2 cup one to three times a day-taken with meals, and working up gradually.

Take This to Your Next Appointment

If your doctor hasn't talked to you about osteoporosis, mention the Physician's Guide to Prevention and Treatment of Osteoporosis during your next office visit. New from the National Osteoporosis Foundation (NOF), the guidelines cover the prevention, diagnosis, and treatment of the disease. Below, we've highlighted some of the key recommendations.

Who should get a bone-density test? All women age 65 and older; all postmenopausal women under age 65 who have one or more risk factors for osteoporosis (besides menopause); postmenopausal women with fractures; women who are considering treatment for osteoporosis; and women who have been on hormone replacement therapy (HRT) for prolonged periods. Prevention recommends that you also get a bone-density test if you're in your 30s or 40s with one or more risk factors.

What's a T-score? This is the way the results of your bone-density test will be reported. A T-score represents how you compare to the "mean" bone density for "young normal" adults, which is a T-score of 0. Optimal bone mass is a T-score of +1 or above; low bone mass or osteopenia is a T-score between -1 and -2.5; osteoporosis is a T-score at or below -2.5.

Who needs treatment? Women with T-scores below -2 in the absence of risk factors; below -1.5 if other risk factors are present.

Food and Drug Administration-approved medications: HRT, alendronate (Fosamax), calcitonin (Miacalcin), and raloxifene (Evista).

Note: The NOF's Physician's Guide is not available to consumers. However, your doctor can request a copy by calling 800-400-1079, and you can call this number to receive an upcoming patient guide tentatively planned for late 1999.

Three Easy Steps to Stop Bone Loss

Get 1,000 mg of calcium daily-or 1,500 mg if you're 50-plus or have low bone density. These foods contain high-impact calcium:
8 ounces of milk-300 mg
Dannon Light Yogurt (8 ounces)-350 mg
8 ounce glass Tropicana Pure Premium Plus calcium-fortified orange juice-350 mg
8 ounce glass Health Valley Fat-Free Soy Moo soy milk-400 mg
1 cup Light 'n Lively cottage cheese-400 mg
1/2 cup Edy's or Dreyer's Fat-Free Frozen Yogurt-450 mg
Get 400 international units (IU) of vitamin D daily, or 600 IU if you're 70-plus.
Taking D will help you absorb calcium.

3 Exercise at least five times a week. Include the following in your program:
• 1 hour of weight-bearing aerobic exercise such as walking, or
• 30 minutes of resistance training such as weight lifting, or
• some combination of the two

Spirit of women

Free or Low-Cost Bone Testing!
Prevention has been working with our "Spirit of Women" network, representing nearly 100 hospitals across the US, to help provide you with free or low-cost bone screenings. Turn to p 29 for a listing of the hospitals offering the tests, as well as schedule information.

The "Spirit of Women" Osteoporosis Screening Program is sponsored through an educational grant from Merck & Co., Inc., and by funding from Viactiv Soft Calcium Chews, a new chewable calcium source from Mead Johnson Nutritionals.

In the News: 4 Hidden Risks

These risk factors didn't make our list of hidden warning signs because the research is too preliminary, but they're worth a closer look:

Chronic depression. Elderly women who are depressed may be more susceptible to osteoporosis because they secrete more cortisol, a hormone associated with bone loss.

Premature graying. For reasons unknown, going gray at an early age may be a risk factor for osteoporosis. Two years ago, researchers in New Zealand found a link between premature graying and bone loss. In a study of 293 healthy postmenopausal women, scientists found that women who went gray in their 20s tended to have lower overall bone density than those who turned gray later in life. The same was true for women who turned mostly gray by age 40.

Tooth loss. Having low bone density puts you at an 86% greater risk of gum disease, the major cause of tooth loss when you're over 35. And since tooth loss may reflect poor bone health in healthy postmenopausal women, some researchers believe it may become the earliest warning sign of osteoporosis.

Menopausal symptoms. A study at the University of Pittsburgh recently found that premenopausal women who have symptoms of menopause, including irregular menstrual cycles, may have greater bone loss and perhaps a higher risk of osteoporosis than women who don't have them.

Are You at Risk?

In this article, we've uncovered "hidden" risk factors-that is, things that increase your risk for osteoporosis that you may not know about. Here's a list of the most common risk factors, according to the National Osteoporosis Foundation. Some appear on our list as well:

1. Female
2. Advanced age
3. Being thin (less than 127 pounds
for an average-size woman)
4. Caucasian
5. Cigarette smoking
6. Fractures as an adult
7. History of fractures in first-degree relative
8. Inadequate physical activity
9. Lifetime of inadequate calcium consumption
10. Poor eyesight
11. Poor health or frailty
12. Recurrent falls
13. Dementia
14. Alcoholism
Get Tested: Know Your Options

The gold standard in bone-density testing is the Dual Energy X-Ray Absorptiometry (DEXA or DXA) of the spine and hip. If this test isn't offered near you, you have other options:

QCT (quantitative computed tomography of the spine)
p-Dexa (of the forearm)
PIXI (peripheral instantaneous x-ray image of the heel and forearm)
SXA (single energy x-ray absorptiometry of the heel and forearm)
accuDEXA (of the middle finger)
RA (radiographic absorptiometry of the middle three fingers)
US (ultrasound of the heel)
Ask your doctor to help you find a bone-density testing facility near you.

Bragging Rights

You heard it here first: Long before the National Osteoporosis Foundation introduced its new Physician's Guide to Prevention and Treatment of Osteoporosis (see "Take This to Your Next Appointment" on p 112), Prevention brought you the nation's first comprehensive screening guidelines in "Size Up Your Bones...Now!" on p 74 of the Feb 1996 issue.

We told you who should get a bone-density test, when, and which tests were best. And we highlighted the major risk factors for osteoporosis and told you how to keep your bones healthy.

If you've never had a bone-density test (and you think you should), bring it up at your next doctor's appointment. And tell 'em Prevention sent you.

~~~~~~~~

By Julie A. Evans

While researching this article, Contributing Editor Julie Evans discovered that she has several of the hidden warning signs of osteoporosis.

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