FIVE. Prevention and Going Forward
I'm worried that my daughter, who is 40, will get osteoporosis. How can she prevent this from happening to her?
If you have already been diagnosed with osteoporosis, you are right to be concerned. Family history is certainly a risk factor for osteoporosis. But what you have learned from your own diagnosis can truly help your daughter.
Making exercise a habit is critical to keeping bones strong through midlife and beyond.
Women beginning midlife should make themselves aware of all the risk factors for developing osteoporosis. First, at the age of 40, unless she is one of the 1% who experience premature menopause (natural and total cessation of menstrual periods before the age of 40), she is likely to still be making the necessary estrogen to protect her bones. She should continue to take adequate calcium and vitamin D for her age, which means 1000 to 1200 mg of elemental calcium and 400 IU of vitamin D per day. This may mean assessing her diet and supplementing it if she does not get enough calcium through dairy products and other foods (see Table 4 in Question 47). If she smokes, she should stop. If she drinks excessive alcohol, she should stop that, too. Equally important, she should develop an exercise routine that puts the necessary stress on her bones for them to continue to remodel appropriately. Making exercise a habit is critical to keeping bones strong through midlife and beyond (see Questions 43-45).
If your daughter is 40 and also has asthma or one of the autoimmune disorders that require treatment with steroids, she needs to be aware that steroids can cause significant bone loss. She should consult her clinician about taking a medication that will help her maintain her bone density.
What about my granddaughter? She is only 16. Should I also worry about my grandson?
The importance of reaching peak bone mass cannot be overemphasized. Ninety percent of peak bone mass is reached by age 20 to 30. One of the periods of greatest bone growth occurs at the beginning of puberty (the other period is in infancy to toddlerhood). Boys must take in at least 1000 mg of calcium per day and girls must take in at least 850 mg of calcium per day in order to reach peak bone mass; however, the recommended intake of daily calcium is even higher: 1300 mg for both boys and girls aged 9 to 18 years. Recommended daily intake of vitamin D for boys and girls in this age group is 200 IU.
You should encourage your grandchildren—male and female—to do all the things that everyone at any age needs to do to have good bone health. Convincing teens to drink milk instead of soda sometimes feels like a losing battle. They should be encouraged to drink 2 to 3 glasses of skim or 1% milk per day, or get enough dairy products in their diet to get the calcium required for bone development and for them to reach their maximum height. Teens especially tend to drink soda or other non-nutritious beverages, and some drink as many as six cans of soda per day. Regrettably, they sometimes begin drinking alcoholic beverages or start smoking at an early age. These poor health habits can harm their bone development.
Although teens often get good sources of dietary calcium by eating cheese on pizza or cheeseburgers, low-fat dairy products should be encouraged as well, such as yogurt, puddings, and low-fat cheese. Because of the high sugar and fat content of many popular foods, adolescents need to get the necessary calcium for bones without increasing their risk of obesity. They can also get calcium from fortified orange juice, cereals, and even Calci-Fresh chewing gum, which contains calcium. Vitamin D is available in fortified dairy and cereal products. An added incentive for your granddaughter is that diets higher in calcium and vitamin D have recently been shown to help prevent premenstrual syndrome (PMS).
Urging teens and helping them to quit smoking is another challenge. Smoking cessation programs are often not successful, even in the face of gory lung cancer photos. But studies in teens have shown they are more responsive to messages about ugly stained teeth and bad breath as a result of smoking than negative health consequences. Pictures of osteoporotic bones are not likely to make teens quit smoking either, especially if they think this couldn't happen to them until they're much older. But still, making an effort to focus on the future negative impact on their appearance, particularly the hunched back, may have a positive result.
Many teens have cars now, so unless they are on sports teams at school, they are less likely to be getting a significant amount of exercise. They should be reminded of the benefits of walking to a friend's house, and few teens have to be encouraged to go to the mall to walk around. Thirty to sixty minutes of moderate exercise per day should be their goal. Exercise routines developed in adolescence are more likely to be carried into adulthood.
The sport of weight-lifting has gained increasing popularity among young adults. Weight-lifting is different from strength training. Strength training uses free weights, one's own body weight, machines, or elastic bands to exert resistance on muscles. While strength training does increase strength and puts appropriate stress on bones, it does so without increasing muscle mass in children and adolescents who have not reached puberty. Strength training should be encouraged in all age groups and is appropriate for children and adolescents as long as they can follow directions and receive adequate adult supervision. Improving strength will depend on the intensity, frequency, duration, and type of strength training. Weight-lifting, the competitive sport of lifting weights with specified technique and movements, should not be started before the completion of puberty. Adolescents should be advised against using anabolic steroid supplements to put on muscle mass, as they actually cause bone to break down and weaken.
There are certain children and adolescents who are at special risk for not reaching their peak bone mass and for developing osteoporosis. Diseases and conditions that put them at risk include anorexia nervosa and bulimia, gastrointestinal diseases that affect their intestinal absorption such as gluten or lactose intolerance, chronic kidney and liver diseases, amenorrhea (no menstrual periods), autoimmune disorders that require treatment with steroids, and endometriosis that is treated with GnRH analogs (see Question 92). These young people should be monitored carefully for bone development and bone mass.
Strength training should be encouraged in all age groups and is appropriate for children and adolescents as long as they can follow directions and receive adequate adult supervision.
A study done recently showed that if teens get the recommended amount of calcium, their high-protein, high-salt, and high-phosphorus diets don't interfere with bone development. If, however, their soda intake substitutes for other sources of calcium, they are not likely to get the calcium they need.
I wasn't prepared to hear that my teenage daughter might have osteoporosis. When we went to see an orthopedic specialist about her stress fractures, he asked if she had been exercising excessively. She had complained of severe back pain ever since she started running but he wasn't convinced at first that the amount of her running added up to stress fractures, which were diagnosed on MRI. Then he asked about any eating disorders, her periods, and the amount of calcium and vitamin D she was getting. Since she has never had an eating disorder or lost her periods from over exercising and she has a healthy diet, the doctor went on to ask about our family history. My mother has osteoporosis and I also have bone loss. We are both on treatment, she with Actonel, and I with Fosamax. Both of us take calcium and vitamin D supplements. Because of her family history and the stress fractures, my daughter was sent for bone mineral density testing of her spine and hips, which showed she did have osteopenia. She is being treated with extra calcium and 800IU of vitamin D. She is also going for intensive physical therapy and strength training so that she will eventually be able to tolerate high impact sports again. My daughter has always been a good milk drinker, so I've never been concerned that she wasn't getting enough calcium and vitamin D, but now we can remind each other about calcium and exercise!