Osteoporosis: Know Your Risk-and How to Lessen It

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"Are you at risk for osteoporosis? If you're a woman, the answer is yes. All women are vulnerable to osteoporosis, and our vulnerability increases as we get older. But sex and age aren't the only risk factors for the disease. The full list is much longer."
So begins a chapter in Strong Women, Strong Bones (G.P. Putnam's Sons), the third in the Strong Women book series written by Miriam Nelson, PhD, associate chief of the Human Physiology Laboratory at Tufts (and one of this newsletter's editorial advisors).

Whereas Dr. Nelson's first book, Strong Women Stay Young, focused on increasing body strength in general, and her second, Strong Women Stay Slim, proposed a sound program for weight control, this latest work zeroes in on the nuts and bolts for avoiding--or at least mitigating--the ravages of osteoporosis. The brittle-bone disease afflicts an estimated 28 million Americans--men as well as women.

One of the most important steps you can take, Dr. Nelson says, is to know just how many risk factors for the disease you have. It's not that you need to count them up to know you should be eating right and exercising to protect your bones, she comments. But, she notes, "information often is an unexpectedly powerful motivator." That is, the better you know how likely you are to break, say, a hip bone or some other bone down the line, the more likely you will be to make lifestyle changes that will help protect you from such an outcome.

With that in mind, Strong Women, Strong Bones offers an extensive checklist for you to see just how high your risk is. Some things on the list you cannot change: your racial heritage, for instance, or at what age you entered menopause. But there are many risks you can do something about.

Following, in an adaptation from Dr. Nelson's book, is that checklist. Also included are tests you can take to see how good your balance is and whether you're likely to fall--along with exercises you can do to improve your balance and thereby avoid falling. That, in turn, will further diminish the chances of your breaking a bone, even if your skeleton has already thinned considerably.

The Osteoporosis Risk Checklist
Check all that apply. The more unavoidable risk factors you have, the more important it is to minimize the risks you can control.

1. My mother has (or had) osteoporosis. 2. My father has (or had) osteoporosis. 3. One or more siblings has (or had) osteoporosis.
It is now believed that peak bone mass is determined 60 to 70 percent by genetic factors. So if either or both of your parents or any of your siblings were ever diagnosed with osteoporosis (or suffered fractures, lost more than an inch and a half of height, or developed a hunched-over posture--all of which suggest the presence of osteoporosis), you're at elevated risk, too.

4. I broke a bone when I was 40 or older.
Studies consistently find that women who suffer fractures after age 40 either have osteoporosis or are at elevated risk of developing it. This is true regardless of which bone was broken.

5. I have symptoms of a spinal fracture, such as loss of height of more than an inch and a half, a stooped posture, or chronic pain in the middle or upper back. 6. I'm Caucasian or Asian.
The lighter your skin, the greater your risk for osteoporosis. Broken down by race, here are the proportions of women over 50 who have the disease.

Caucasians and Asians: 30 percent Hispanics: 16 percent Blacks: 10 percent

7. I began to menstruate at age 15 or older.
Women who reach menarche (the beginning of menstruation) relatively late are at higher risk for osteoporosis. They have less lifetime exposure to bone-saving estrogen.

8. I frequently have menstrual irregularities that aren't caused by pregnancy or impending menopause.
Menstrual interruptions or irregularities indicate reduced estrogen exposure, which means elevated risk for bone loss. A young woman who doesn't menstruate month after month can lose as much bone as a postmenopausal woman.

9. I'm in menopause. 10. I reached menopause before age 45. 11. I entered menopause prematurely because my ovaries were removed.
All women are at increased risk of bone loss after menopause--but the risk is even higher for those who go through the change of life early. The earlier a woman stops menstruating, the less lifetime estrogen exposure she has.

12. I'm tall and very slender.
Slender women generally have less bone mass than healthy-weight or heavy women, so they're particularly vulnerable to fractures--especially if they're also tall. The longer the bones, the easier it is for them to break.

13. I've been a yo-yo dieter.
Frequent cycles of losing and then regaining 15 or more pounds puts you at increased risk for osteoporosis. That's because most people lose bone along with fat when they lose weight. The more times you lose weight, the more times you lose bone.

14. I've suffered from an eating disorder.
Anorexic women lose their menstrual cycles and, thus, the bone-building benefits of estrogen. They also consume very little calcium. As for bulimics, their purging of food leads to calcium shortfalls.

15. I have rheumatoid arthritis.
People with this disease have what is known as extra osteoclast activity, which results in bone loss. Osteoclasts are cells involved in the dissolving of bone.

16. I have a thyroid disorder.
Hyperthyroidism, or an overly active thyroid, stimulates the bone-dissolving action of the osteoclasts.

17. I have a disorder of the parathyroid.
The parathyroid glands--four tiny glands in the neck--secrete parathyroid hormone. But too much of that hormone can increase osteoclast activity and thereby quicken bone loss.

18. I have type 1 diabetes that is poorly controlled.
People with type 1, or "juvenile," diabetes who are able to keep their blood sugar under control don't seem to be at elevated risk for osteoporosis. But those who have difficulty regulating their blood sugar are more likely to develop the disease.

19. I suffer from a chronic digestive disorder.
Digestive problems such as a food allergy, colitis, or Crohn's disease make it harder for the body to absorb calcium.

The next five questions are about medications that can decrease bone density. If you take any, ask your doctor whether there's an alternative drug; if not, whether the dose can be reduced; and whether your bone density should be monitored while you're on the treatment. 20. I take a steroid.
Steroids such as prednisone and cortisone lead to decreased absorption of calcium, increased urinary excretion of calcium, increased bone dissolving, and inhibited bone formation.

21. I take medications for seizures.
Anticonvulsants used to treat epilepsy and other seizure disorders reduce the availability of vitamin D, which is needed for the body to absorb calcium as efficiently as possible.

22. I take a diuretic other than thiazide.
Diuretics other than thiazide increase calcium output in the urine.

23. I take a gonadatropin-releasing agonist such as Lupron.
Fibroid tumors and endometriosis are treated with these agents, which reduce the body's estrogen levels.

24. I take an antacid that contains aluminum.
Antacids, both the over-the-counter and prescription, sometimes contain aluminum, which increases loss of calcium through the urine.

The next seven questions zoom in on lifestyle factors over which you have complete control. 25. Most days I'm sedentary, spending fewer than 30 minutes at moderate-to-vigorous physical activity.
Women who engage in any kind of regular exercise have stronger bones; they also have better balance and coordination, which reduces their risk of falling.

26. My daily diet typically does not include four servings of calcium-rich foods, nor do I take a calcium supplement.
There's a strong relationship between lifetime calcium intake and bone density. Women who consume fewer than 600 milligrams of calcium daily--the amount in two cups of milk--are at especially high risk for osteoporosis.

27. I'm exposed to the sun for fewer than 10 minutes a day, and I don't get vitamin D from supplements or fortified foods.
Vitamin D--which comes from sun exposure, the diet (milk is by far the best source), or supplements--is essential for calcium absorption. Note that as we get older, our body's ability to make vitamin D via sunlight is greatly diminished. And in the wintertime, sun exposure simply can't be sufficient in the northern third of the country. Thus, for some people, it becomes very important to drink milk or at least take a multivitamin supplement that contains D.

28. Most days I don't eat five or more servings of fruits and vegetables.
Women who consume plenty of produce have higher bone density. Especially helpful for bone health are citrus fruits, which contain vitamin C, and green leafy vegetables, which provide vitamin K. Both nutrients are It essential for proper bone formation.

29. On average, I consume more than seven alcoholic drinks a week.
Alcohol decreases bone-building activity in the body. Excess alcohol intake is also associated with poor nutrition as well as with poor balance, increasing the risk for falls and fractures.

30. I drink more than four cups of caffeinated coffee per day.
Caffeine consumption over 400 milligrams daily--the equivalent of about four cups of coffee--doubles the risk for hip fracture, according to some research. Caffeine has a diuretic effect, which increases excretion of calcium in the urine.

31. I'm a current or former smoker.
Women with a smoking history have significantly lower bone density and are much more likely to suffer fractures than those who never lit up. That's because smoking decreases estrogen levels. Indeed, women who smoke tend to go through menopause earlier. But if you've kicked the habit, congratulations. Your fracture risk is considerably lower, though not as low as that of someone who never smoked.

Improving Your Balancing Act (To reduce your risk of falls--and fractures)
You could have osteoporosis, but there's a good chance you'll never suffer from it if you don't fall. That's because about 90 percent of osteoporosis-related hip fractures, more than 90 percent of wrist and pelvic fractures, and about 50 percent of spinal fractures result from falls. It used to be thought that the poor balance that often leads to falls didn't become a problem until age 70 or so. But we now know it starts much earlier. In fact, balance begins to deteriorate by the time a woman reaches her mid 40s. Changes are subtle and occur slowly, becoming more obvious by the mid 60s. Each year about a third of women over age 65 and half of women 80 and older experience a fall.

Even fear of falling presents problems. Curtailing activity to avoid falls not only diminishes quality of life, it also leads to inactivity. That only causes further weakness and deterioration in balance, which further increases the risk of falls-and fractures.

How good is your balance? Take the following five tests to find out. It's helpful to have a stopwatch or a clock with a second hand. For the more advanced tests, which are performed with your eyes closed, you'll need a spotter-someone to stand nearby and steady you if necessary. It's also important that you do all tests near a counter, so you can catch yourself if necessary.

Note that the tests are arranged by degree of difficulty, so if you can't do one, don't go on to the rest-you could fall and hurt yourself. And if you can't stand with your feet side by side and touching for 10 seconds (without using your hands on the counter for support), don't attempt any of them.

Test 1: Tandem Stand Stand to the side of the counter and put your hand on it for support. Position one foot directly in front of the other; the heel of the front foot should be just touching the toes of the foot in back. Try to distribute your body weight evenly on your two feet. Steady yourself and let go of the counter. Hold this position for 10 seconds, without the aid of your hands.

Test 2: One-Legged Stand Stand to the side of the counter with your feet together. Put your hand on the counter for support. Shift your weight to one foot. Bend the other knee to bring that foot up in back. When you're balanced on one leg, let go of the counter-but keep your hands poised so you can catch yourself if necessary. Hold this position for 10 seconds.

Test 3: Tandem Stand with Eyes Closed This is the same as Test 1-except with your eyes closed. You will be surprised at how much more difficult it is!

Test 4: Tandem Stand with Eyes Closed and Head Turning This is the same as Test 3 except that during the 10 seconds, you should slowly turn your head to the right, then slowly turn it all the way to the left, then return to face front.

Test 5: One-Legged Stand with Eyes Closed This is the same as Test 2-except with your eyes closed.

Dr. Nelson says she'd expect a fit, healthy woman under age 35 to score "excellent" with a little practice; a woman between 35 and 50, "good"; and an older woman, "fair," although many active women in their 50s and 60s, and even 70s and 80s, do better.

If you're not where you'd like to be regarding balance, improve your balancing ability--and decrease your risk of falling and breaking a bone-with the following three exercises. Research shows that balance training can reduce falls in older men and women by about 50 percent.

Note that if you scored "poor" or "very poor" on the balance tests, you should have a spotter nearby when you perform these moves. Also, discuss your balance problems with your doctor-sometimes there's a treatable cause. And if an illness such as a bad cold is affecting your ears, or if a medication is impairing your balance, don't do the exercises until you're better. Finally, wear sturdy shoes during your balance workout; make sure you're near a counter to catch yourself if necessary; and, if you find yourself teetering, stop and regain your balance before starting again.

Try to do these balance-training exercises at least three times a week
A. Mountain Pose and Sway Stand with your feet close together, touching if possible, knees slightly bent. Distribute your body weight evenly between the balls and heels of your feet. Keep your arms straight down at your sides, with your hands relaxed. Your shoulders should be down and gently drawn back; your head should be high. Tuck the bones of your pelvis under, moving them slightly forward and up. Hold this position for a minimum of 30 seconds up to 2 minutes, breathing evenly. Release the pose by stepping one foot out to the side so that your feet are hip-width apart.

To increase the challenge, after holding the position for at least 30 seconds, add postural sway. Visualize the soles of both feet anchored to he ground. Very slowly move your entire body slightly forward, then slightly to the left, to the back, and then to the right and to the front again. The full circle (forward, left, back, right, forward) should take about 1 minute. During the sway, your entire body should remain relaxed and straight. Don't bend at the hip or back-only your ankles should bend.

B. One-legged Stork Stand to the side of a counter or wall with your feet hip-width apart. Your knees should be slightly bent. Hold the counter or touch the wall lightly with one hand for support; hold your other arm straight out to the side. Bring one knee up slightly, about 6 inches, (Unreadable) back straight. Point your toes of (Unreadable) and turn your knees out to the side by rotating your hip. Place the bottom of your foot against your opposite shin. Hold this position for a minimum of 30 seconds up to 2 minutes. Release the pose by lowering your knee and returning to the starting position.

C. Tandem Walk Police use the tandem walk to test for drunk driving. It's not sufficiently challenging for those with good balance. Add it to your balance program if you could do only balance test 3 or less.

Find a hallway with a clear wall where you can walk at least 10 to 20 steps while holding onto the wall. Place one hand on the wall at shoulder height for support. Focus your eyes on a location straight ahead. Keep your head up, and don't look at your feet. Now, place one foot in front of the other so that the heel of your front foot touches the toes of your back foot, forming a straight line.

Don't lock your knees. Walk toe to heel in tandem style for approximately 10 to 20 steps. Move your hand along the wall "to help you remain balanced. Turn around carefully and walk back again, toe to heel, for 10 to 20 steps. Repeat the walk one more time.

Reprinted from STRONG WOMEN, STRONG BONES by Miriam E. Nelson, Ph.D., with Sarah Wernick, Ph.D. with permission of G.P. Putnam's Sons, a member of Penguin Putnam, Inc. Copyright 2000 by Miriam E. Nelson, Ph.D. with Sarah Wernick, Ph.D.

Your Balance Score
If the highest test you
could pass was Your balance is

Test 5 Excellent
Test 4 Very good
Test 3 Good
Test 2 Fair
Test 1 Poor
Unable to pass any test...Very poor
PHOTO (BLACK & WHITE): Tandem Stand

PHOTO (BLACK & WHITE): Mountain Pose

PHOTO (BLACK & WHITE): Tandem Walk

PHOTO (BLACK & WHITE): One-legged Stork

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