By Daniel G. Graetzer, Ph.D.
Faculty Member, School of Health Sciences
and Kristjana Cook, M.S.
2022 Master’s Degree Graduate, Sports and Health Sciences
Osteoporosis is a disease which causes bones to lose density and become porous, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases. As a result, the bones become more fragile, which drastically increases the risk of a fracture.
Like the foundation of a house, a robust, resilient skeletal system is the foundation for lifelong vitality and health. Osteoporosis is a “silent” disease that degenerates the entire skeleton. It generally has no warning signs until a broken bone occurs – typically in the hip, spine, or wrist –after a fall or sudden impact.
People of All Ages Can Suffer from Osteoporosis
The stereotypical image of osteoporosis brings to mind a stooped granny hobbling with a cane. But while advanced age and gender are certainly factors in an increased risk for osteoporosis, it is a disease that can affect both men and women of all ages.
In recent years, there has been more recognition that populations other than the elderly are vulnerable to osteoporosis. The American Medical Society for Sports Medicine has indicated a distinct connection between bone density and low energy availability in athletes, both elite and recreational. Similarly, Army Times says that male and female military recruits can also suffer from osteoporosis, which is often recognized only after a recruit suffers a stress fracture.
While a gradual loss of bone tissue normally begins occurring midway through someone’s life, there are other reasons for an accelerated loss of bone mass, including:
- Lifestyle choices
- Certain medications
- Poor nutrition
- Insufficient weight-bearing activity
As a result, bone quality can sink to dangerous levels. In fact, for U.S. women age 55 and older, bone fractures due to osteoporosis lead to more hospitalizations and greater healthcare costs than heart attacks, strokes, or breast cancer.
Fortunately, bone loss is both preventable and treatable if risk factors are identified early. In addition, patients should be educated on necessary diet, exercise, and lifestyle modifications for rebuilding bone density and halting further bone loss.
Who Is at Risk for This Disease?
There are various groups that are at the highest risk for osteoporosis. These groups include:
- Women and men over the age of 50
- Women without regular menstrual cycles
- Elite and recreational athletes
- Military recruits
Osteoporosis in People Over 50
The integrity of the 206 bones in the human skeleton is constantly changing, and bones are strongly affected by the aging process. People may think of bone as hard and lifeless, but in fact, bone is living tissue providing critical structural support for muscles and protecting vital organs.
But bones will only adapt to stimuli they are given. As people age, they have a tendency to become less physically active. However, weight-bearing exercise such as running, walking, jumping, and resistance training are vital in maintaining adequate stress on bones to promote new bone growth and slow age-related bone mineral loss, according to Harvard Medical School.
Because bone tissue degenerates in the absence of physical stress, weight-bearing exercises can help people to develop and maintain skeletal strength. Weight-bearing exercises like walking, jogging, low-impact aerobics, weightlifting, and ballroom dancing are generally more effective than non-weight-bearing exercise such as swimming or biking, though these forms of aerobic exercise are excellent for maintaining one’s overall health.
Repeated muscular contractions during weight training may actually be the most effective method of the stimulating of bone function. The key is the degree of mechanical loading that flexes the bone regardless of whether the weight comes from barbells, babies, full grocery bags or garbage cans.
A protocol from The Bone Clinic in Australia, based on successful clinical trials that involved targeted weightlifting interventions in men and women over 50 with a diagnosis of osteoporosis, has shown great effect. Osteoporosis patients who did just two sessions per week of resistance training along with jumping built their bone density back into the healthy range for older adults, according to the American Society for Bone and Mineral Research.
Rapid and severe bone loss often occurs during prolonged periods of disuse, such as hospitalization or bed rest due to injury. However, bones are remarkably adaptable to stimulation, so bone density can begin to rebuild once someone resumes physical activity.
Older adults, especially the elderly, who begin an exercise program should take care to progress slowly and give their bodies time to adapt. In addition, they should seek to incorporate a variety of weightbearing activities during exercise sessions. Changing from a sedentary lifestyle to regular, moderate activity will greatly reduce the chance of several degenerative problems, such as cardiovascular disease, cancer, osteoarthritis, and Alzheimer’s disease.
The Centers for Disease Control and Prevention note that regular, weight-bearing exercise prescribed for patients with osteoporosis may worsen the condition of osteoarthritis (inflammation of the joints and surrounding tissues). It is common for people to have one or more of these diseases at the same time, especially in older populations.
Osteoporosis in Women Without Regular Menstrual Cycles
According to the U.S. Department of Health and Human Services Office of Women’s Health, one in four women over the age of 65 are affected by osteoporosis. Similarly, the Bone Health and Osteoporosis Foundation states that one in two of these women will sustain a fracture directly related to low bone density.
The influx of estrogen at the start of puberty is the primary metabolic pathway with which mineral deposits in the bone begin to accumulate. Estrogen also protects bone from being reabsorbed.
At the onset of menopause, estrogen levels drop, according to the Endocrine Society. As a result, bone regeneration is stalled and the protection against bone depletion is reduced.
Natural menopause is not the only cause for the loss of a menstrual cycle. Surgical procedures, such as a hysterectomy, can also cause a rapid decrease in estrogen production, explains Medical News Today. It can also happen due to conditions such as disordered eating, anorexia, or bulimia or through any kind of restricted-calorie diet combined with excessive exercise.
Osteoporosis in Elite/Recreational Athletes and Military Recruits
In 2017, British Olympic hopeful Bobby Clay was diagnosed with osteoporosis at age 18 after snapping the bones in her foot while pushing off from the wall in a swimming pool. Clary recounted on the Olympics Channel podcast that she found out she had the bone density of someone 70 years her senior. Her condition was the result of overtraining, chronic under-fueling and athletic amenorrhea, as well as eliminating any exercise beyond running.
In recent years, the incidence of low bone mineral density in young athletes due to overloading the body through repetitive, single-sport training along with the underconsumption of vital nutrients has become more widely recognized. Radiology Medicine notes that both recreational and professional athletes have come forward with stories of chronic bone stress injuries, exposing the alarming frequency of early osteopenia, a herald to potential osteoporosis.
According to American Family Physician, the combination of restricted eating and excessive activity can create a condition called relative energy deficiency in sport (RED-S), which can affect both male and female athletes of all ages and skill levels. It is frequently linked to low bone density, which is especially concerning during adolescence and the peak years of bone development in young adulthood.
Research published in Frontiers in Nutrition observes that military recruits are another population that is plagued with stress fractures, and new studies are beginning to recognize the prevalence of RED-S and the Female Athlete Triad in young military personnel. Recruits are often under high levels of stress as they adapt to new environments and the new physical demands placed on their bodies in basic training.
Many recruits are told to lose weight to meet military standards, and they may not be counseled on safe weight loss habits. This need to lose weight can result in haphazard calorie restriction and dieting; at the same time, these recruits are suddenly engaging in levels of strenuous physical activities to which their bodies are not accustomed.
Unfortunately, cases of RED-S and the Triad are rarely diagnosed until a trainee sustains a fracture during basic training. Low bone density may only be detected if a physician orders a bone mineral density scan.
Osteoporosis in Patients with an Eating Disorder or Disordered Eating
There are significant links between disordered eating and osteoporosis, according to the National Institutes of Health. Any time food is restricted or whole food groups are eliminated, vitamin and nutrient consumption is compromised.
If people do not supply their bodies with the necessary vitamins and nutrients, the body’s systems are forced to extract calcium and other minerals from existing tissues, including the bones. In addition, when there is not enough available energy to the body, the body begins to conserve energy any way it can, which include stopping reproductive processes like menstruation.
The dual challenge of insufficient nutrition and low levels of estrogen wreak havoc on the bones. According to Eating Disorder Hope®, about 30% of people with anorexia nervosa have osteoporosis, no matter what age they are, and up to 90% of those with eating disorders have osteopenia. Osteopenia is a bone density level lower than normal for a person’s age.
What Can Be Done to Prevent and Treat This Disease?
The best prevention for osteoporosis and osteopenia is to maximize the potential for peak bone density during adolescence and young adulthood, says the International Osteoporosis Foundation. Bone becomes stronger when it is stimulated to grow, and children and adolescents who participate in vigorous physical activity that stimulates the skeletal system in a variety of ways are likely to build stronger bones.
Maintaining a sufficient level of physical activity throughout one’s lifespan is also vital for keeping bones strong and healthy. Focusing on weight-bearing exercise and resistance-based training are the most effective methods of building stronger bones.
Diet is another critical method for optimizing bone development. Along with eating enough to sustain activity levels, striving to eat a variety of fruits and vegetables with essential vitamins and minerals is the best medicine.
According to the Bone Health and Osteoporosis Foundation (BHOF), calcium and Vitamin D are especially important to consume as a part of one’s diet. Including calcium-rich foods such as dairy products and dark leafy greens, along with foods high in Vitamin D like fatty fish and eggs, helps the body to absorb these nutrients.
The New York State Department of Health says that FDA-approved medications are occasionally used to treat severe osteoporosis, but an informed dialogue with a physician of the benefits and risks of these medications is advisable. Web MD notes that hormone replacement therapy for post-menopausal women is another treatment worth considering, but studies on the effects of synthetic estrogen on maintaining and building bone density are still ongoing.
Prescriptions for oral contraceptives to “re-start” a period in pre-menopausal women are not universally advised by physicians. The artificial menstrual cycle brought on by the pills can mask amenorrhea without treating or addressing the underlying cause.
Osteoporosis Will Continue to Be a Major Health Problem in the US
The BHOF states that osteoporosis will continue to be a major health problem in our aging society and its treatment expected to cost billions of dollars for surgery and rehabilitation, according to a recent systematic review. Unfortunately, bone deterioration usually occurs silently over many years and is often not discovered until an individual falls and breaks a bone.
Fortunately, osteoporosis is both preventable and treatable. A balanced diet adequate in calcium and vitamin D, a regular program of weight-bearing exercise, and pharmaceutical interventions prescribed by a physician can be helpful in preventing people from suffering the pain of broken bones due to osteoporosis.
About the Authors
Daniel G. Graetzer, Ph.D., received his B.S. from Colorado State University/Fort Collins, MA from the University of North Carolina/Chapel Hill, and Ph.D. from the University of Utah/Salt Lake City and has been a faculty member in the School of Health Sciences, Department of Sports and Health Sciences, since 2015. As a regular columnist in encyclopedias and popular magazines, Dr. Graetzer greatly enjoys helping bridge communication gaps between recent breakthroughs in practical application of developing scientific theories and societal well-being.
Kristjana Cook, M.S., earned a bachelor’s in anthropology from The George Washington University in 1996. In 2022, she earned her master’s in health sciences with a concentration in exercise science and human performance from American Public University, maintaining a 4.0 GPA. Her capstone project, written under the direction of Dr. Graetzer, was “Reframing the Female Athlete Triad and Reconsidering Mindsets and Training Methods for Female Distance Runners Across the Lifespan.” Kristjana is an American Council on Exercise (ACE) Certified Personal Trainer and a certified Road Runners Club of America (RRCA) Level 1 Running Coach. She has also been a participant in the Boston Marathon multiple times.