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10 Risks for Osteoporosis — and Its Early Warning Signs

Know the habits that can weaken your bones — and how to spot the changes early on

Hand clasping opposite wrist with bone drawing overlaid
Illustration by Fiona McDonnell; Getty Images

I got my wake-up call about bone health 15 years ago. I was enjoying a stroll around my neighborhood with my dog, Gunther, when I tripped over a crack in the sidewalk. As I fell, I thrust my right hand forward, and when I hit the ground, the pain and swelling in my wrist were immediate. After five decades, I had broken my first bone. ​

That incident gave me a crash course in bone health. First, I was sent for a bone density test, which revealed that my bones had thinned to the point of osteopenia (think of that as a precursor to osteoporosis, not unlike prediabetes is to diabetes). Then a blood test showed that my vitamin D levels were extremely low, which doctors told me was making it hard for my bones to access the calcium they so desperately needed. Suddenly, without a prior clue, I discovered I was on the express train to osteoporosis.

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photos of people with drawings of their bones overlaid on top that are cracking or breaking
Illustration by Fiona McDonnell; Getty Images; Stocksy

Osteoporosis is often called a silent disease because people who have it may not know until a bone breaks. But it’s not entirely silent, says Andrea Singer, M.D., director of bone densitometry at MedStar Georgetown University Hospital and chief medical officer of the Bone Health & Osteoporosis Foundation (BHOF). These are some of the most common — and surprising — signs that might mean you need a bone check:

  • You’re getting shorter. Losing height is one of the most common signs that your spine might be shrinking. Measure yourself annually so you can spot this early.
  • Unexplained back and neck pain. Back pain could have many causes, including a compression fracture or collapsed vertebra in your spine.
  • Poor posture. If you feel uncomfortable when standing straight or notice a hunch in your upper back, it could be a sign of spinal bone loss or fracture.
  • Shortness of breath. If your spine is starting to compress because of bone loss or fracture, your lung capacity may be reduced. Shortness of breath can be a symptom of several other serious issues too; always get it checked.
  • Brittle fingernails. Nails that break easily might indicate you don’t have enough collagen in your diet. If your nails have vertical ridges, this could mean you’re not getting enough calcium from what you eat or drink, or your body may not be properly absorbing calcium.
  • GI issues. Bone loss is connected to several gastrointestinal conditions, such as celiac disease and inflammatory bowel disease, both of which can inhibit nutrition absorption. In addition, some GI issues require treatment with steroids, which also lower bone density.
  • Dental Issues. Tooth loss can be a sign of bone loss in the jaw area, and may additionally indicate bone loss and decreased bone density in other areas of the body. Pay close attention to this sign if you’re losing teeth too easily.
  • Weaker grip strength. Having low grip strength is associated with a decrease in muscle strength, an increase in frailty and a heightened risk of falling and fracturing bones. Grip strength can be easily measured in a doctor’s office or at home with a simple tool called a hand dynamometer.
  • Weight loss. Being a serial dieter, or losing significant weight or having rapid weight loss, increases your risk for bone loss.
  • Broken bones. The most obvious signal of all: Fracturing a bone is a pretty clear sign that your bones are getting weaker.

Know the risks

Paying attention to these early warning signs of bone decline is important; so is knowing your risk of developing the bone-weakening diseaseCertain factors can increase the likelihood of developing osteopenia and osteoporosis. Some of them are within your control. Others are not, but you need to be aware of them, too.

1. Age. As you age, your body tends to lose some bone density. But osteoporosis is not inevitable, and it can be slowed or halted with lifestyle changes — exercise and a bone-healthy diet, for example — and medications.  

2. Gender. Women are four times as likely to develop osteoporosis as men are, and about half of women and one quarter of men over age 50 will break a bone because of osteopenia or osteoporosis.  

3. Smoking. Yet another reason to try to kick the habit: Studies have shown a direct relationship between tobacco use and decreased bone density, according to the National Institutes of Health (NIH). 

4. Heavy drinking. Excessive alcohol consumption interferes with the balance of calcium, according to the NIH. Heavy drinking can also cause hormone deficiencies that can lead to weaker bones.

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5. Menopause. This is when bone loss sets in with a vengeance. And women lose the most bone — up to 20 percent or more — during the first 10 years after menopause, notes Margaret Nachtigall, M.D., a reproductive endocrinologist and clinical associate professor at NYU Langone Health and a founding member of the North American Menopause Society (NAMS). She says it may be appropriate for women at an increased risk for osteoporosis to consider hormone therapy (HT) during menopause. “Hormone treatment can help activate bone growth cells and therefore help restore bone or prevent bone loss,” she explains. But, although she said HT may be beneficial for some women, she cautioned that it isn’t for everyone; discuss your situation with your health care provider.

6. Poor dietary habits. Getting insufficient amounts of calcium, vitamin D and protein can increase the risk of osteoporosis.

7. Breast cancer. Fragile bones and fractures are more common in women who have been treated for breast cancer, partly because breast cancer treatment may trigger early menopause, says nurse practitioner Eva E. Meyers, of the National Breast Cancer Foundation Medical Advisory Council.

8. Physical inactivity. Just like exercise builds stronger muscles, it also builds stronger bones. 

9. Family history. While research is ongoing, many studies have indicated that a family history of osteoporosis suggests that you’re also at higher risk for the disease, especially if a parent has had a hip fracture. A look at literature focusing on twins and families shows that between 25 and 85 percent of the variation in bone mass and other skeletal traits is inherited, but the why behind this continues to be studied.

10. Body type. The thinner you are, the thinner your bones, and the higher your risk for fracture is. While a healthy body mass index (BMI) is often better at lowering risk for certain health issues such as type 2 diabetes, it seems that a higher BMI protects both men and women against osteoporosis. According to Nachtigall, having more weight to carry around helps keep bones dense, and having a very low BMI is considered a risk for bone loss. 

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It's also important to note that long-term use of certain medications may increase your risk for developing osteoporosis, the NIH says, including glucocorticoids (a class of steroid hormones); antiepileptic medicines; proton pump inhibitors (used to lower stomach acid); thiazolidinediones (which treat type 2 diabetes); and selective serotonin reuptake inhibitors (SSRIs), used treat depression and anxiety. Medications that affect hormone production to treat breast and prostate cancer are also on the list.

Test your bones

When I took my tumble, I had several risk factors for bone disease: I’m a woman; I was over 50; I wasn’t exercising; I wasn’t paying attention to my vitamin or mineral intake; I had gone through menopause and wasn’t taking any form of hormone therapy, so my estrogen levels were low, low, low. And despite all of those risk factors, until I experienced my fracture, no doctor had ever recommended a bone density test.

Bone density, the concentration of minerals in your bones, is easy to check with a special X-ray called a DEXA (dual-energy X-ray absorptiometry) scan. BHOF recommends DEXA testing for anyone age 50 and older who has broken a bone or has risk factors for osteoporosis, and for women age 65 and older and men age 70 and older regardless of risk factors. If that’s you, talk with your doctor about getting a bone scan as part of your next overall checkup.

The Calcium Connection

For optimum bone health, the Bone Health & Osteoporosis Foundation recommends that women over age 50 and men over 70 get 1,200 milligrams (mg) of calcium daily, while women age 50 and younger and men age 70 and younger should get 1,000 mg. But they strongly recommend that you aim to get your calcium from food first and supplement with pills only if necessary.​​

“Studies have shown that diets low in calcium are low in other essential nutrients, such as phosphorus, magnesium, iron, protein and zinc,” says Joan M. Lappe, a professor of medicine and professor of nursing at the Osteoporosis Research Center at Creighton University in Omaha, Nebraska. Some reports suggest that low-dietary-calcium intake is a “marker” for multiple nutrient inadequacies and for a low diet quality. ​

Calcium supplementation alone can do nothing to correct the other nutritional inadequacies. These are some reliable sources of calcium and many other crucial nutrients as well.​​

  • Dairy. One cup of milk has about 300 mg, while most cheese offers around 200 mg per ounce.​​
  • Whey protein. Known as a protein boost, a scoop of whey protein also contains around 50 mg of calcium.​​
  • Yogurt. One cup of low-fat yogurt delivers about 415 mg of calcium and is a great source of probiotics and protein. Greek yogurt has more protein than regular yogurt but less calcium.​​
  • Canned salmon and sardines. Thanks to their edible bones inside, these fishy options offer a lot of calcium: a 3-ounce can of sardines has more than 300 mg; 3 ounces of canned salmon provide more than 180 mg.​​
  • Fortified beverages. Calcium-fortified orange juice has 350 mg per cup, while 1 cup of unsweetened almond milk may contain close to 450 mg of calcium; check the label.​​
  • Dark leafy greens. Most greens are packed with nutrients and range roughly from 100 to 300 mg of calcium per serving, depending on the type and preparation. But some veggies, such as spinach, are high in oxalates, which can slow the absorption of calcium when eaten raw. Either cook them or swap them for alternatives such as kale, collard greens, bok choy and chard.​​
  • Tofu. Firm tofu made with calcium sulfate offers about 250 mg of calcium per 1/2 cup; soft tofu has about half that amount. ​
  • Chia seeds. These powerful little seeds can be used in just about anything; 1 tablespoon gives you about 75 mg of calcium.​​
  • Almonds. Many nuts provide calcium, and almonds lead the pack, with about 95 mg per 1/4 cup. 

There are also a few new testing options that, when used with DEXA, can capture a more complete picture of bone health. All can be done while getting your bone density test, and they are usually covered by Medicare and insurance.

  • Trabecular Bone Score (TBS): The most promising is TBS, a new technology that works with the DEXA and looks at the microarchitecture of the bone, offering a better fracture risk assessment than measuring bone mineral density alone. According to E. Michael Lewiecki, M.D., director of the New Mexico Clinical Research & Osteoporosis Center, including TBS with FRAX (see below) could change treatment decisions. TBS is an add-on computerized analysis of the same DEXA scan, so there’s no additional time or X-ray exposure.
  • The Fracture Risk Assessment Tool (FRAX®): This tool is a fracture risk calculator that is included in the software of most DEXA tests. According to Singer, it was developed to calculate 10-year probabilities of hip fracture and major osteoporotic fracture. You can do a self-test, as well. Access the test here.
  • Vertebral Fracture Assessment (VFA): VFA is a sideways image of the spine with DEXA that may detect previously undiagnosed vertebral fractures (VFs), which are the most common type of osteoporotic fractures. Lewiecki says the VFA is a very useful tool because discovering a VF can change the assessment of fracture risk and influence treatment decisions.​​

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