Keys to Healthy Bones

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A new surgeon general's report warns of a coming osteoporosis crisis. Simple lifestyle changes you make now can help keep you from becoming part of the problem.

A NEW REPORT from the US Surgeon General says Americans need to pay more attention to our bones. Making lifestyle changes today, according to the report, can help prevent widespread incidence of the bone-weakening disease osteoporosis in the coming years.

The 400-page report, the first from the surgeon general to address bone health, says some 10 million Americans age 50 and older already have osteoporosis, with another 34 million at risk. By 2020, as the population ages, those numbers are projected to grow to 14 million plus 47 million more at risk--one in two Americans over 50. Osteoporosis affects men and women of all races, though it's four times as common in women.

The report calls osteoporosis a "silent" condition, because many Americans are unaware that their bone health is in jeopardy. Four times as many men and almost three times as many women actually suffer from osteoporosis than are aware of having the disease.

"Osteoporosis isn't just your grandmother's disease," says US Surgeon General Richard H. Carmona, MD, PhD. "We all need to take better care of our bones. The good news is that you are never too old or too young to improve your bone health. With healthy nutrition, physical activity every day and regular medical checkups, Americans of all ages can have strong bones and live longer, healthier lives. Likewise, if it's diagnosed in time, osteoporosis can be treated with new drugs that help prevent bone loss and rebuild bone before life-threatening fractures occur."

"Lifelong bone health starts with healthy lifestyle choices that are also very good for your overall health," says Bess Dawson-Hughes, MD, president of the National Osteoporosis Foundation and director of the Bone Metabolism Laboratory of the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University. "But it needs to start early. You can't just ignore this for years and then start to shape up later."

Assessing your risk
How do you know if you're at risk for osteoporosis? While everyone should be aware of the importance of healthy bones, scientists have identified several key factors that put a person at increased risk of osteoporosis, says Dr. Dawson-Hughes:

• Suffering a bone fracture as an adult

• Being unusually thin

• Smoking

• Having a family history of the disease.

Other potential risk factors include heavy alcohol use, poor diet, use of steroids, early onset of menopause and severe weight loss (since bone loss tends to occur in parallel with weight loss--unfortunately, the reverse may not be true). The National Osteoporosis Foundation recommends that post-menopausal women under age 65 with one or more of these risk factors should get a bone-density test, as should all women 65 and older. The recent surgeon general's report called for bone-density testing in women over 65 and for anyone who breaks a bone after age 50.

A recent study by researchers at Tufts and other institutions cast a spotlight on fractures after 50 as a warning sign of osteoporosis. The study, on which Dr. Dawson-Hughes was corresponding author, followed the care of patients over age 51 who had been seen at a hospital for an acute fracture. Researchers found that few of these patients received treatment for osteoporosis; only 36 percent of the women and 7 percent of the men even discussed the disease with their primary care physician.

"Primary care physicians are in a position to help patients reduce their risk of re-fracture by taking prescription osteoporosis medications and by increasing vitamin D and calcium in their diets," says Dr. Dawson-Hughes. "These patients just need a bit of counsel."

For these patients and others at risk for osteoporosis, a bone-density test can help diagnose and determine the right treatment. According to Miriam E. Nelson, PhD, director of the John Hancock Center for Physical Activity and Nutrition at Tufts and author, with Sarah Wernick, PhD, of Strong Women, Strong Bones, bone density is the single best predictor of future fractures--it accounts for up to 80 percent of the strength of your bones. Several different tests are used to gauge bone density, she notes: "All these tests are safe, painless, quick (no more than 10 to 20 minutes) and precise." After an initial bone-density test, follow-up tests will be scheduled based on your condition.

Don't assume that if you don't have an obvious risk factor for osteoporosis that you're out of the woods. Post-menopause, says Dr. Dawson-Hughes, estrogen levels drop. If you're not on hormone-replacement therapy--which has been shown to have its own downsides--you can expect some degree of bone loss, especially in the spine and central skeleton.

Got milk?
The best-known prevention step against osteoporosis is of course getting plenty of calcium--it's also probably the easiest lifestyle step to achieve. According to the National Osteoporosis Foundation, depending on your age, the right amount of calcium is between 1,000 and 1,200 milligrams daily. "With three servings of dairy daily and a balanced diet, most people easily meet their calcium needs," says Dr. Dawson-Hughes. And eating and drinking your calcium, not popping a pill, is the preferred way, she adds: "Start there and make up any deficiency with calcium supplements. That's why they're called 'supplements'--they're meant to be a supplement to a healthy diet."

In addition to dairy products, you can boost your calcium intake by eating green vegetables such as broccoli, collard greens, mustard greens, turnip greens and kale. Shrimp and oysters are also rich in calcium. These days, given the increased awareness of the importance of calcium, you can even find it added to products ranging from orange juice to breakfast cereal.

If you don't or can't eat dairy products, says Dr. Dawson-Hughes, then you will have to pay close attention to make sure you're getting enough calcium in your diet. And you may want to take a calcium supplement.

Don't forget the D
The emphasis on calcium to build strong bones sometimes obscures the importance of another essential ingredient in bone health and osteoporosis prevention: vitamin D. Dr. Dawson-Hughes explains, "Vitamin D promotes the absorption of dietary calcium. You need an adequate vitamin D level to make use of the calcium."

Recent research also suggests other ways vitamin D can combat osteoporosis, she adds, such as an association between vitamin D levels in the blood and improved muscle function in lower extremities. That in turn can reduce your risk of falls, and vitamin D is likewise associated with reduced risk of falls. In the elderly, especially, falls can lead to fractures. The surgeon general's report noted that about 20 percent of individuals with a hip fracture end up in a nursing home within a year, and another 20 percent of senior citizens suffering hip fractures die within a year. Hip fractures account for 300,000 hospitalizations annually, according to the report.

Another study by Dr. Dawson-Hughes and her colleagues followed men and women age 65 and older for three years. Those who took vitamin D and calcium supplements experienced significant increases in bone density and decreases in fractures. But when the subjects stopped taking calcium and vitamin D supplements, the majority of these bone benefits were lost in as little as two years.

Unlike calcium, says Dr. Dawson-Hughes, it's difficult to get enough vitamin D through your diet alone. Exposure to the sun can cause the body to form its own vitamin D, but of course many people have cut back on their sun exposure for fear of skin cancer. In any case, at high latitudes, such as Boston, sun exposure doesn't promote vitamin D synthesis in the winter. That's why vitamin D levels and bone density vary with the seasons, peaking during the summer months and dropping to a low in spring until the days begin to lengthen again.

Moreover, the standard recommended level of 400 IU of vitamin D daily is probably not enough, especially for the elderly, says Dr. Dawson-Hughes. She expects the National Academy of Sciences to raise that recommendation to at least 800 IU, which is what she suggests older adults take daily. Don't try to boost your vitamin D by taking "extra" multivitamins, she warns--among other things, you'll get too much vitamin A. Instead, she suggests buying inexpensive vitamin D supplements with 400 IU and taking those plus a multivitamin containing 400 IU.

You can also get out in the sun a little in the summer--up to 15 minutes before you should apply sunscreen. "It's good to get a minimal amount of sun," says Dr. Dawson-Hughes. "It doesn't take a lot to get vitamin D production, without getting enough to be toxic in terms of skin cancer."

Exercising your bones
The third key to osteoporosis prevention is weight-bearing exercise. "Weight bearing," Dr. Dawson-Hughes explains, means any activity done in a full standing-upright position. Brisk walking or jogging counts, for example, as would exercising with free weights or any of the standard walking-like exercise machines at the gym, such as Nordic Trac, elliptical or stepping machines. Bicycling or swimming, however, while otherwise good aerobic exercise, won't help build bone health.

Your bones can benefit from day-to-day activities such as gardening (think hoeing, raking, shoveling). Activities such as Tai Chi may also be helpful; exercises that promote balance can help ward off falls. The relationship between duration and intensity of exercise and osteoporosis prevention isn't entirely clear, adds Dr. Dawson-Hughes.

How much exercise do you need? The surgeon general's report suggests being physically active for 30 minutes a day.

A good start on weight-bearing exercises can be found in the book Growing Stronger: Strength Training for Older Adults, published by the Friedman School of Nutrition Science and Policy at Tufts University and the US Department of Health and Human Services' Centers for Disease Control and Prevention (CDC). You can find an interactive Growing Stronger Program based on the book online at nutrition.tufts.edu/growingstronger, where you can also download the contents of the book for free.

Does all this sound like too many do's and don'ts? Keep in mind that the key steps for preventing osteoporosis--eating right and exercising--are the same advice you'd want to follow anyway to live healthier longer. "Thirty years ago, doctors thought weak bones and osteoporosis were a natural part of aging," notes Dr. Carmona. "But today we know they are not. We can do a lot to prevent bone disease."

Getting Into Your Bones
Resources for learning more about osteoporosis prevention and treatment and bone health:

• A free, four-color, magazine-style "people's piece," The 2004 Surgeon General's Report on Bone Health and Osteoporosis, is available by calling toll-free (866)-718-BONE or visiting www.surgeongeneral.gov.

• National Osteoporosis Foundation, 1232 22nd St. NW, Washington, DC 20037, (202) 223-2226, www.nof.org

• Growing Stronger, nutrition.tufts.edu/research/growingstronger

• Strong Women, Strong Bones by Miriam E. Nelson, PhD, with Sarah Wernick, PhD (Perigee, $14.95)

• Exercises for Osteoporosis by Dianne Daniels (Hatherleigh Press, $14.95)

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