The seven warning signs of osteoporosis you should never ignore
By Anna Moore, The Telegraph
Many of us don’t realise we have osteoporosis until our bones begin to break. Here are the early signs, and how to prevent the condition.
It’s known as a ‘silent disease’ because, so often, it develops undetected. Osteoporosis affects one in three women and one in five men aged over 50, it’s a leading cause of disability and premature death in the UK. Yet few of us realise we have it until our bones are weak enough to break. There are excellent treatments available now, to both slow the rate that bones breakdown and speed up the process of bone renewal. Gene-based solutions might also be very close. But if we don’t recognise symptoms or seek diagnosis, we won’t access them. So what are the warning signs? And how can we know our risk?
Early warning signs
Low bone density
“Bone density is measured through a DEXA [dual energy X-ray absorptiometry] scan,” says Jill Griffin, a consultant radiographer, expert in bone health and the head of clinical engagement at The Royal Osteoporosis Society.
Quick and painless, it uses X-rays to measure the strength and mineral content of bones. “We lose bone mass from the age of 40, and a DEXA gives a measurement known as a T-Score, that shows how yours is compared to the average population.”
DEXA scans require a medical referral to access on the NHS, although they are available privately for as little as £115.
Stages of Osteoporosis:
- Healthy bone: T-score of -1 or greater
- Osteopenia: T-score between -1 and -2.5
- Osteoporosis: T-score of -2.5 or less
A better first step for early diagnosis though is to use an online tool to assess your personal risk which depends on many factors, including age, sex, weight, health, lifestyle, family history and medications. The Frax tool developed by Sheffield University uses algorithms to give the 10-year probability of an osteoporosis fracture. A simpler risk checker launched two years ago by the Royal Osteoporosis Society has already led 50,000 people to an early diagnosis.
Decreased grip strength
“Grip strength is a feature of the ageing process – your grip strength at 80 will be less than it was at 70 – but it is also linked to bone density, especially for menopausal women,” says Dr Wendy Holden, a consultant rheumatologist and specialist in bone health, osteoporosis and fracture prevention. “The less muscles you have, the less bones you have.”
Later warning signs
Back pain
“Back pain can be a sign of osteoporosis, but only when the condition has caused a bone in the back to break,” says Emma Clark, a professor of clinical musculoskeletal epidemiology at the University of Bristol. These ‘compression fractures’ usually go undetected, and occur as the vertebra weaken, hollow and start to collapse.
They range from mild to severe, are often painless or, in many cases, the pain is attributed to other causes. The Vfrac research programme developed by Prof Clark has identified some specific types of back pain that should raise alarm bells and could signify a fracture.
“In particular, there’s a type of back pain that starts when people are standing and leaning slightly forward, for example when doing the washing up,” she says. “This back pain then gets worse and worse – a crescendo of pain – until the person needs to step away, lean backwards and take the pressure off their back.”
Loss of height
“It’s normal to lose 1 or 2cm as we age,” says Dr Holden. “However it can also be a sign of collapse and compression in the spine. Anything more than 4cm needs to be assessed.”
Stooped posture
“A stoop or hunch at the top of the spine can be a sign that bones in the spine have broken and are struggling to support the weight of the body, forcing you to slope forward,” says Dr Holden.
Pelvic ‘crush’
“If you’re standing, poking into your side, you should be able to get three fingers comfortably in the space between your hip bone and lowest rib,” says Dr Holden. “If that space is reducing, it can be another sign of vertebra collapse.” A sticking out stomach might be another sign. “You don’t put on weight but your stomach looks a bit bigger as it starts to get squashed,” Dr Holden adds. “You might find you can’t eat much without feeling full.”
Fracture
Breaking bones after a minor trauma, such as a fall from standing height, is a huge red flag. “Most spinal fractures – unless you’re hit by a car or fall from a ladder – are the result of osteoporosis,” says Griffin.
While these might not be picked up, wrist and hip fractures are also common. “Wrist fractures are more likely in the younger at-risk population – aged 50 to 70 –when reflexes are strong enough to make you reach out when you fall.
Older people are less likely to do that so hip fractures are more common, as they fall sideways.
“A lot of people mistakenly think that breaking a bone when you’re older is normal,” adds Dr Holden. “It isn’t and should definitely lead to an osteoporosis risk assessment.”
How to prevent osteoporosis
“Some of your risk is down to genetics,” says Griffin. “We all have a genetically programmed bone mass peak at the age of around 25 to 30 that we can’t exceed so when bone mass starts to decline, some of us start at a disadvantage. If your parent broke a hip, your risk will be greater.” However, you can lower your risk by taking the following measures.
Don’t smoke
Nicotine slows production of bone-producing cells (osteoblasts) and decreases absorption of calcium which we need to harden and strengthen our bones.
Feed your bones
“Getting enough calcium from your diet is important and also vitamin D which helps the body absorb and use it,” says Dr Holden who recommends taking a vitamin D supplement. However, protein is also important, as well as B-12, n–3 fatty acids and numerous other bone related nutrients such as magnesium, potassium and vitamin K. “A balanced diet with fruit, vegetables, whole grains, poultry, fish, nuts, legumes, and dairy will be best for bone health.”
Exercise
“Bones get stronger when we use them” says Dr Holden. “They’re made up of living tissue.” Weight-bearing and muscle strengthening exercises are best for building bone strength – when muscles pull on your bones, the bones have to respond by renewing themselves – as well as short bursts of activity. A study found that even one minute of high intensity exercise a day leads to 4 per cent better bone health.
Stay a healthy weight
“A BMI below 19 is not good for bone health,” says Dr Holden. Lack of weight on your bones can lead to frailty, and all round loss of muscle and bone strength.
Being underweight can also reduce oestrogen levels in girls and women, and oestrogen plays an important role in bone structure. Eating disorders, such as anorexia, significantly raise osteoporosis risk.
Consider HRT
“The loss of oestrogen during menopause really speeds up bone loss,” says Dr Holden. “If you have an early menopause at 40, by the time you’re 80, your bones are closer to a 90 year olds.” If you’re in early menopause, talk to your GP about taking HRT which mimics oestrogen to assess whether it’s right for you.
Drink alcohol in moderation
High alcohol intake impacts bone cell turnover, vitamin and mineral absorption, production of hormones such as oestrogen and testosterone which play an important role in bone health, and also raises the risk of falls.
How early can osteoporosis be diagnosed?
The point at which we diagnosis and treat osteoporosis is changing. Where once, it was all dependent on bone density scores – a T Score of minus 2.5 was the magic number which showed you have osteoporosis – now that score is combined with a range of factors to assess risk of fractures, and decide whether treatment is needed.
We all lose bone mass from the age of around 35 to 40, although the rate at which we do will vary. “Someone can have osteoporosis on a DEXA scan but be at a low risk of fractures, for example if they are young,” says Prof Clark. “Treatment is not recommended in this situation, because the benefits of the medications may not outweigh the potential side effects if the individual’s risk of fracture is pretty low to start with.”
What else could be mistaken for osteoporosis?
It’s often diagnosed as ‘generalised back pain’, ‘muscle spasms’, ‘pinched nerves’ or spondylosis.
A shocking 2.6 million people in the UK have undiagnosed breaks in their spine and 80 per cent of these breaks never get diagnosed. Part of the reason is that they may not cause pain, but when they do, “people are often given painkillers and told to wait and see if it gets better,” says Griffin, “and the pain does improve if you have a fracture, but the condition that caused it is still there”.
So what lifestyle changes can we adopt to keep our bones strong and healthy in midlife and beyond?
Add fermented dairy to boost gut health
“The recommended intake of calcium is 700mg a day. It’s a bit higher if you have a diagnosis of osteoporosis – then you’re looking for 1000mg,” says The Royal Osteoporosis Society’s osteoporosis specialist nurse and nurse manager, Julia Thomson.
“It’s best to get dietary calcium, but if you aren’t hitting your target you can look at supplements. Your GP can prescribe them.”
Milk provides 200mg of calcium for a mug-sized portion, but you don’t need to drink milk for an adequate calcium intake.
“Green vegetables and cruciferous vegetables contain masses of calcium,” says nutrition company Zoe’s head nutritionist Dr Federica Amati. “And the other thing is tofu, which is a really good source. And if you like oily fish, anchovies and sardines are really good sources of calcium, especially when eaten with the bones.”
She also wants us to include fermented dairy such as kefir and yogurt and to up our fibre intake with a plant-rich Mediterranean diet, to feed our gut microbes.
“There’s this really cool interplay between fermented dairy, the gut biome and gut and bone health,” says Dr Amati. Studies show that eating fermented dairy which contains calcium, protein and probiotics is associated with a lower risk of hip fracture in women. One study showed that women who ate yogurt had a 25 per cent lower risk of hip fracture. While further research suggests that a healthy gut microbiome may improve absorption of calcium in the gut.
Hence I now aim to start the day with a fibre-rich breakfast, usually steel-cut oats with apple and frozen raspberries and toasted seeds – and now I’m adding shop-bought kefir to up my prebiotic quota.
The Royal Osteoporosis Society provides a list of calcium-rich foods and has a handy calculator on their website, giving the calcium content in common foods that will help you tot up your daily intake.
Get outside to boost vitamin D
Our bodies manufacture this key bone-building vitamin as light hits our skin. “Vitamin D is more worrying than calcium, as we’re more often deficient,” says Thomson. “Safe sunlight exposure is the best source, but people will need to take a supplement as they get older if they can’t get outside. In winter a 10mcg vitamin D supplement is a good idea.”
Dr Amati advises getting outside for 20 minutes in the morning, before you slather on any SPF. “Sunscreen is great for anti-ageing but it does block vitamin D production,” she explains. “What I do is go outside and give my skin a bit of exposure to the sun before it gets really hot.”
Hop, skip or jump
Exercise that sends a jolt through your bones will help strengthen them. “The force of the impact on the ground is hugely beneficial to the skeleton,” says Thomson.
“When your foot hits the ground your bone responds to that. I’m not going to use the word ‘microfracture’ because it isn’t as severe as that, but it kicks the bones into turning over and rebuilding. We see the opposite in astronauts who lose bone density when they are weightless. If you equate that to an older person who is very sedentary, they will also lose bone extremely quickly.”
So which exercise is best? Skipping, hopping, running, jumping all work. If you’re looking for a class at the gym, the best benefits will come from circuit training and HIIT, which include high-impact jumping exercises such as burpees and skipping.
One study showed that premenopausal women who performed 10 to 20 high-impact jumps, with 30 seconds of rest in between each jump, twice a day for four months significantly increased bone density in their hip bones compared to a group of women who did not jump. This works post-menopause too. I’ve started jogging again after a 10-year break and have just bought a skipping rope.
Unfortunately a stroll in the park is unlikely to exert sufficient impact for maximum bone-building, though it’s certainly better than nothing. “Running is better than jogging, jogging is better than brisk walking, brisk walking is better than a stroll,” says Thomson. “But it’s really about finding what works for you and doing it regularly. Five times a week would be great.”
If you already have low bone density (osteopenia) or osteoporosis, you might worry about exercising, but it’s best to keep moving, says Thomson. According to the Royal Society of Osteoporosis, moderate-impact exercise is generally OK for those with osteoporosis and it’s probably safe to continue with high-impact exercise if you’re already doing it and haven’t had any pain or fragility fractures.
Take up tennis or padel
At school I was hopeless at sport, but perhaps it’s time I brushed up my backhand to join the flocks of midlifers taking up padel, the popular new tennis-like racquet sport.
“Racket sports are really good because you’re twisting, you’re turning, you’re changing direction and changing the stress you’re putting on different parts of your bones,” says Thomson. “Any sport that does that will have similar benefits.” So squash, netball, basketball, volleyball are all good news for our skeletons.
Lift heavy – but build up slowly
Strength training is paramount to bone health, this much I was aware of. When tendons and muscles pull on bones they lay down more calcium and become stronger. What I hadn’t realised, though, was quite how heavy you need to go in the gym to see bone-health benefits.
“The key thing is that you have to add a significant load,” says Telegraph fitness expert Matt Roberts. “People are always surprised by how intense it really needs to be. High rep work is good for generalised fitness, but bone-building happens when you’re lifting at a level where you can only manage between four and eight reps.”
So my favourite pump class (light weights, high reps) is probably not stimulating my bones to the degree that I’d hoped.
The best bone-building moves, says Roberts, include pulling exercises such as seated rows, deadlifts and leg-presses because you’re working the mid-spine but in a controlled way, “where the muscles are pulling on the most vulnerable areas for osteoporosis, around your hips, pelvis and lower vertebrae”.
Lunges or squats with a barbell are also “gold standard”, says Roberts, though not easy to do and you need to build a baseline fitness before attempting heavily weighted moves. For those who live in London, Roberts runs bone-health clinics at his Knightsbridge gym.
Try HRT
Women become more vulnerable after the menopause as bone-protecting oestrogen drops off a cliff. Most will experience a rapid decline in bone density, losing up to 10 per cent in the first five years after their last menstrual cycle. Taking HRT can help stem this flow, but not prevent it completely, as I’ve discovered. I’ve still lost 6-7 per cent bone density in the last five years, despite using HRT patches.
“HRT was once the only treatment for bones when I started working for the Osteoporosis Society 25 years ago, and every woman was encouraged to take HRT after the menopause and recently we’ve seen a bit of a resurgence,” says Thomson. But why is HRT effective?
“We have oestrogen receptors all over the body and when levels drop at menopause, those receptors suffer. It could be the hair, the skin, the bones or vaginal tissue. And by using a [oestrogen] supplement after menopause it can help your bones because you’re not dipping down to those very low levels.”
Watch your weight
“A very low BMI is a risk factor of osteoporosis,” says Thomson, “and certainly people with eating disorders are more at risk of fractures since being underweight can result in lower oestrogen levels, similar to after menopause. But now there is evidence that people who are at the opposite end of the spectrum and carrying a lot of weight are at risk too.”
But people with obesity have a different fracture pattern, says Thomson. “We see more ankle fractures. For light individuals the problems are in the hips and spine. So it’s best to stay in the normal weight range.”
Drink alcohol only on special occasions
When it comes to our bones there’s a clear link between heavy drinking and poor bone health. “If you’re drinking a lot, alcohol can have a damaging effect on the osteoclasts, the bone-building cells,” says Thomson, and obviously too much booze isn’t great for balance.
Similarly, smoking has an impact on the bone-building cells. “ If you’re looking for motivation to stop smoking, bone health could certainly be up there,” says Thomson.