In a recent post, Beauty is Bone Deep, I commented on the health effects of trying to obtain a thin physique for the sake of an unrealistic beauty ideal. But there are many women who try to gain weight rather than lose it, often to no avail. They don’t have an eating disorder or anorexia — they simply can’t gain a single pound.

Now, many women out there will read this and think, “Gee, that’s a problem I wish I had.” But the struggle to gain weight is actually harder than the struggle to lose it. If you search the internet, you’ll find most information on weight gain is for bodybuilders and focuses on building bulky muscle, but that’s not something most women really want. And contrary to the suggestions some of my underweight clients hear, eating cheeseburgers, ice cream and cookies 24/7 does not help, and it’s a highly acidifying, bone-damaging way of life as well.

It’s true that some people are naturally thin, and if you eat a varied diet with good nutrition, get sufficient (but not excessive) exercise, and have good coping methods for stress, being thin need not be a concern for your bones. But for many women, thinness has the following implications for their health — and their health care:

• Small-boned, thin women are more likely to be handed a diagnosis of osteopenia or osteoporosis. As I noted in my blog post about BMD testing bias, DEXA scans don’t actually measure bone density, they measure bone area — and if you are naturally thin and small, your bones will likely fall below the standard used to assess bone density, leading to a diagnosis of osteopenia or even osteoporosis. At this point, many women are offered bone drugs and warned that they have a high fracture risk — without any real indication that they have a significant issue with bone loss or bone weakness at all.

• Underweight women have less social support for their weight-related health concerns. As I mentioned earlier, the common response to women who can’t gain weight in our overly weight-conscious society is envy — not empathy. There are very few recommendations offered for women seeking to gain weight, other than suggestions that they pack their diet full of junk food (and we already know what’s wrong with that approach!) Thin women may also face social stigmas of the sort experienced by obese women — that is, the message that there “must be something wrong with you” and hints that perhaps they’re mentally unstable or have some sort of eating disorder. While there are certainly women with eating disorders that make them excessively thin, there are many others who have a healthy relationship with food… but still can’t gain weight.

• Women with naturally small and “thin” bones have less leeway when they reach the menopause transition. Menopause for most women is accompanied by a certain amount of bone loss, related to the hormonal changes that naturally accompany this life stage. If your bones are small to begin with, you have less “wiggle room” when it comes to how much bone you can afford to lose. Now, that doesn’t mean you’ll automatically develop osteoporosis, but it could mean you need to pay attention to factors that can limit your bone loss — factors I discuss at greater length in my article on bone loss in menopause.

When it comes to thin women and bone health, I want everyone to know three specific points:

First, if your bones are small and “thin”, it doesn’t mean they’re weak — even if you’ve had a DEXA scan that indicates you’re in the osteopenic or osteoporotic range. Fracture risk is a combination of multiple factors, and bone density is just one of those — so take our Bone Health Assessment to get a better sense of where you stand when it comes to fracture risk.

Second, if you are at risk of fracture, there are steps you can take to reduce that risk — and they don’t necessarily involve bone drugs. We offer both quick tips on how to prevent weak bones as well as comprehensive information on key nutrients for bone health and how to change your lifestyle for better bones in our articles.

Finally, understand that osteoporosis and bone fractures are not inevitable for thin women. No matter how many scary osteoporosis statistics you hear, if you assess your risk factors and take steps to reduce them, your bones will respond as Nature meant them to — no matter how old (or young) you are!

In an upcoming blog post, I’ll offer some specific tips for how underweight women can gain weight, so stay tuned!