The best ways to maintain strong bones as you age

If you’re a woman 50 or older who undergoes a bone density test, there’s a one-in-two chance the results will indicate you have osteopenia. If so, your immediate question will probably be: What does that mean? Is that the same thing as osteoporosis?

Here’s the first thing you need to know: Osteopenia is not osteoporosis. The latter is most definitely a disease, one in which bones have become thin, brittle, and porous. Affecting women far more than men, osteoporosis leads to bones so fragile that fractures can occur with everyday acts like bending over or coughing. 

What is osteopenia?

Osteopenia, which affects some 44 million Americans, many times the 10 million Americans who have osteoporosis, refers to bone density that’s lower than normal but not low enough to be considered osteoporosis.

“I don’t even like the term ‘osteopenia’ says Risa Kagan, a San Francisco obstetrician-gynecologist who’s on the medical advisory board of the nonprofit educational organization American Bone Health. “I prefer to talk about ‘low bone mass,’ because I think we should downplay this as a disease state.”

No matter what you call it, here’s what you need to know.

What to make of your bone density screening

Both osteoporosis and osteopenia are determined by a quick and painless DXA (dual energy x-ray absorptiometry) bone density test. The test yields a “T-score,” a measurement of how your bone mineral density (BMD), compares to “normal,” or the BMD of the average, healthy 30-year-old. 

According to definitions set by the World Health Organization in 1994, bone mass that is 25% or more below normal (a T-score of -2.5 or lower) indicates osteoporosis. 

In addition to increasing your risk of fractures, osteoporosis can cause chromic back pain, loss of height, and stooped posture. Falls for seniors with osteoporosis can be catastrophic, leading to hip fractures that will mean death within a year for 20% of those who are hospitalized. Many more will lose their independence; 90% of people who were able to take the stairs unassisted before a hip fracture will be unable to climb five steps 12 months later.

Osteopenia falls somewhere between normal and osteoporosis. It’s defined as 10% to 25% below the bone mass of the average 30-year-old, or a T- score between -1.0 and -2.5.

Why osteopenia treatment may mean it’s not a dire diagnosis 

A T-score that lands a post-menopausal woman in osteopenia territory isn’t, on its own, a predictor of developing osteoporosis. For one thing, as Kagan points out, everyone’s bone density is different and your T-score, even if it’s below that young adult mean, might be peak bone density for you. 

“Women will come into my office holding their test results and saying, ‘I have a disease,’” Kagan says. “I’ll tell them, ‘we don’t know that, because we don’t know where you began.’ Your bone density today might be as good as it’s ever been.’”

What’s more, women start losing bone density as they enter peri-menopause, and the decrease continues throughout the next few years, for a bone density loss of between 10% and 20%.

“Some women are rapid bone losers, some are slow bone losers,” Kagan says. “In any case, by the time they reach their early 60s, most women do not have normal bone density.”

What you can do to treat osteopenia

Kagan believes it’s most useful to see that “osteopenia” conclusion on your lab report as a “call to action.” 

“Our goal is to protect and preserve whatever bone density you have,” she says. That leads to the sometimes challenging question of whether to treat osteopenia with medication. 

A group of medications called bisphosphonates, including Fosamax and Boniva, are the most common type of drug prescribed. These stop or slow down bone loss. The FDA has just approved a new osteoporosis drug called Evenity, which builds new bone density, but it may also slightly increase the risk of heart attacks and strokes.

Some doctors, as the Harvard Health Letter notes, have become concerned about “overmedicating” people who have osteopenia. “The fracture risk is low to begin with,” the newsletter says, “and research has shown that medication may not reduce it that much. We also don’t know if the medications might have some long-term effects.” 

Loren Fishman, a physiatrist—that’s a specialist in physical and rehabilitative medicine—who’s an assistant clinical professor at New York’s Columbia Medical School, is one osteoporosis expert who takes an adamantly anti-medication stance. 

“I consider all osteoporosis medicines protective but undesirable,” he says, pointing to “never-ending side effects” that may include gastric upset, flu-like symptoms, and, in rare cases, fractures of the upper thigh bone and osteonecrosis, a breakdown of the jawbone. 

How to bone up on osteopenia

When it comes to deciding on what treatment to choose after a diagnosis of osteopenia, Kagan suggests women do some homework to become better educated. She points to the websites Americanbonehealth.org, NationalOsteoperosisFoundation.org, and Menopause.org as reliable sources of information. 

As Fishman notes, a T-score doesn’t provide a full picture of your risk of suffering a debilitating fracture. “Although bone mineral density does correlate with fracture risk, it’s not the only relevant factor,” he says. “Posture, balance, number of falls, and bone quality are all extremely pertinent aspects.”

Two free online resources can help evaluate your 10-year probability of a major osteoporotic fracture. Both the Fracture Risk Assessment Tool (FRAX) and the similar Fracture Risk Calculator assess this risk by looking at factors that include age, ethnicity, height, weight, your history of fractures, along with that of your parents, medical conditions, and lifestyle habits like smoking and alcohol consumption.

Kagan advises that if you’re at all uneasy with your doctor’s recommendation on whether or not to take medication, seek a second opinion from someone who specializes in bone health, perhaps an endocrinologist or a gynecologist with a focus on menopause.

“This should be a process of what we call ‘shared decision-making,” she says, “where you and your physician jointly reach a decision about what’s best for you.” 

Easy lifestyle habits and diets that can boost bone health

There’s pretty much universal consensus in the medical world that there are a few things you can all do—whatever your T-score—to protect your bones in midlife and beyond. This includes quitting smoking, curbing excessive drinking, and eating a healthy diet rich in the nutrients that have bone-boosting nutrients, calcium, and Vitamin D, with ample amounts of magnesium and protein. 

As this guide from the National Osteoporosis Foundation shows, sardines and salmon, collard greens and cruciferous vegetables, low-fat dairy and juices, and foods fortified with calcium and Vitamin D are your fracture-preventing friends.

The National Osteoporosis Foundation recommends women 50 and older consume 1200 milligrams of calcium daily and 800 to 1,000 international units of Vitamin D. If you’re not getting this amount from food or, in the case of Vitamin D, from exposure to sunlight, consider filling the gap with a supplement. 

Exercise is another critical piece of preserving and protecting your bones. That includes regular weight-bearing exercise. The Harvard Health Letter recommends at least 30 minutes on most days, noting that “if your feet touch the ground during an exercise it’s probably weight bearing. Running and walking are weight bearing. Swimming and biking are not.” 

Kagan recommends exercises that improve balance and encourages her patients to try brushing their teeth while standing on one leg.

Fishman’s own research suggests that a regular yoga practice can be an effective way to build bone. “Yoga puts more pressure on bone than gravity does,” he says. “By opposing one powerful muscle against another, stimulates osteocytes, the bone-making cells. And the only side effect of yoga is better balance.” 

His prescription doesn’t involve twisting yourself into a pretzel or 90-minute classes. As this video by Fishman shows, the 12 poses can be completed in as many minutes.

Finally, if a bone-density screening indicates osteopenia, schedule a follow-up test in two years. DXA machines vary, so try to return to the facility where you had the first screening done for the easiest and most accurate comparison.