More than twenty-five years ago, I first consulted with several of the individuals who developed the bone density testing machines. The hope was clear — if we could measure bone density we would be able to predict who will experience an osteoporotic fracture. The concept was quite simplistic; it assumed that the most important fracture-determining factor was low bone density. Over the last decades, bone density testing has become widespread; yet the hope for a simple, straight predictor of fracture has faded.
Today, nearly three decades later, we realize that you cannot predict who will fracture from measurements of bone density alone. In fact, recent large studies show that a large percentage of people who do fracture do not have osteoporotic bone density, but actually have only osteopenia or even normal bone density. Furthermore, many people with an osteoporotic bone density never fracture.
Most fractures occur in those who do not have osteoporotic bone density
As early as the mid 1980’s, thoughtful osteoporosis researchers noted that hip fractures could not simply be attributed to low bone mass. As Steven Cummings wrote in 1985, “Patients with hip fractures do not appear to be distinctly more osteoporotic than persons of similar age. Therefore, factors besides bone mass, such as a tendency to fall, may be important determinants of which elderly persons will have fractures; thus, measurements of bone mass might not be a reliable way to identify those at greatest risk of hip fracture.”
Over the last two decades numerous clinical trials have borne out the truth of Dr. Cummings’s early observation. For example, the US Study of Osteoporotic Fractures (SOF) looked at 8,065 women 65 and older, following them for hip fracture incidence over a five year period. Within these five years, 243 hip fractures occurred, 54% of which were in women who did not have an osteoporotic bone density at the start of follow-up. Further reports from this same Study of Osteoporotic Fractures database found that only 10% to 44% of osteoporotic fractures occurred in those with an osteoporotic bone density. As these authors summarize, “Finding effective prevention strategies for fractures in older women will require additional interventions beside [sic] preventions for bone loss, such as prevention of falls and other fracture risk factors.”
The same has been found true in other large studies of osteoporotic fractures, such as the 149,524-women US National Osteoporosis Risk Assessment (NORA) study. Over a one-year period in this large group of women (mean age 64.5), 2,259 new fractures were self-reported, including 393 hip fractures. Of those who fractured, a full 82% had a non-osteoporotic bone density (greater than -2.5 SD T-score) and a full 67% had a T-score greater than -2.0. In total, 6.4% of all women had an osteoporotic bone density. Although fracture rates were highest in this “osteoporotic bone mineral density” group, these women experienced only 18% of all osteoporotic fractures and 26% of all hip fractures.
All in all, many factors are as important, or even more important, indicators of fracture risk than is bone mineral density. For example, fracture after age 40, parental history of hip fracture, low body weight, high rate of bone resorption, deficiencies of vitamins D and K, use of steroid medications, and several other factors are stronger fracture predictors than bone mineral density.
The new fracture assessment tools: multiple risk factor assessment with and without bone density measurements
So a new question arises. How can we tell who will experience an osteoporotic fracture? We now realize that the answer lies not in any single factor like bone density, but rather in assessment of multiple risk factors. What we are already beginning to see is a series of assessment tools which allow individuals and health practitioners to sort out who is likely to fracture according to a series of important variables, not just according to bone mineral density. Further we see that the operative risk factors may vary somewhat by populations studied.
New fracture risk assessment tools: post-menopausal women
One of the best known early fracture assessment tools is the “Fracture Index.” This index was developed using data from the large US Study of Osteoporotic Fractures (SOF). In the SOF, a total of 7,782 US women aged 65 and older were studied over five years.
In the SOF, measurements over time were made of bone density and other variables which were thought to reflect upon bone strength. These variables were compared with actual fracture incidence allowing for the development of a fracture risk screening and assessment tool. With this large data base, researchers identified a seven-variable model which allowed them to make a fairly accurate prediction of the five-year risk of suffering an osteoporotic fracture for any individual.
So what were the factors and variables that seem to determine if one will facture or not? According to the SOF research, the seven most important factors were found to be:
- Bone mineral density T-score
- Fracture after age 50
- Maternal hip fracture after age 50
- Weight less than or equal to 125 pounds (57 kg)
- Smoking status
- Using one’s arms to stand up from chair
According to researchers, this simple seven-factor assessment was shown to be predictive of hip fracture, as well as other non-vertebral fractures. It is also interesting that this risk assessment was shown to be predictive of fracture likelihood with or without incorporating one’s bone density into the assessment. Subjects with the greatest number of risk factors, even without accounting for bone mineral density, had a 14-fold increase risk of fracture as compared to those with the lowest number of risk factors.
In a similar fashion, the large Women’s Health Initiative (WHI) study used its data to develop another five-year fracture risk assessment tool. This 7.6-year trial studied 93,676 women of various ethnic backgrounds, ages 50 to 79 at entry. They found that each year some 1.6% of all women suffered hip fractures. From their analysis they developed a risk assessment tool identifying 11 key risk factors (not including bone density) to predict who would fracture a hip over the next five years. This model, based on these key risk factors, was found to be of similar predictive value as the more expensive bone density tests.
The 11 key risk factors uncovered from the Women’s Health Initiative (WHI) were:
- Self-reported health
- Self-reported physical activity
- History of fracture after age 54
- Parental hip fracture
- Current smoking
- Current corticosteroid use
- Treated diabetes
New fracture risk assessment tools: identifying osteopenic women at risk for fracture
More than half of all low-trauma osteoporotic fractures among women occur in those who do not have an “osteoporotic” bone density; rather, they occur in women with an osteopenic bone density or, even in some cases, a normal bone density. Obviously in these cases we must look beyond bone density in our attempt to assess who is likely to fracture.
Data from the large NORA study attempted to identify those osteopenic women at short-term risk for fracture. In the NORA study, 57,421 post-menopausal women ages 50 to 99 were identified as having osteopenia. That means they had a bone mineral density from -1.0 to -2.5 SD T-score. In this study, bone density was measured at the heel, forearm, or hand. These women had bone density lower than that of young women, but they did not have an “osteoporotic” bone density (-2.5 SD T-score or more). Of the osteopenic women studied, 130 reported new fractures within one year of the bone density measurement.
Four risk factors were found to be the most important for identifying those at highest risk of short-term fracture. These were:
- Previous fracture
- Bone density T-score of -1.8 or less
- Self-rated poor health status
- Poor mobility
Women with a previous fracture had a one-year fracture risk of 4.1%, followed by women with T-scores of -1.8 or less or with poor health status. Nearly 2% of the women with poor mobility came to fracture within the year. About 1% of the osteopenic women not identified as being at risk experienced a fracture within the year. This 1% per year fracture incidence is the same as that found among women with normal bone density.
Other interesting findings of this study showed that being younger did not seem to protect the early post-menopausal women.
- Younger women, aged 50 to 59, who shared a similar risk profile to that of women aged 60 to 69 had a similar 1-year risk of fracture (1.6% as compared to 1.7%).
- Younger women aged 50 to 59 who were identified to be at increased risk had an absolute fracture risk of 2.6%. This was similar to that of the entire at-risk population of all ages (50 to 99 yrs).
- Younger women aged 50 to 59 with a history of previous fracture after age 45 had a 4.5% fracture risk. This is similar to the risk for women with an osteoporotic bone density.
New fracture risk assessment tools: the World Health Organization (WHO) master assessment
Over the years the World Health Association (WHO) has analyzed various large population-based studies to develop a fracture risk assessment tool based on clinical factors. This assessment tool is designed to be useful both with and without bone density measurements and indeed, this is important, as much of the world does not have access to bone density measurements. Completed in March 2008, the WHO Fracture Risk Assessment Tool identifies 10 factors found to increase fracture risk independent of bone mineral density. (See http://www.shef.ac.uk/FRAX.) The independent risk factors are:
- Weight and height
- Previous fractures
- Parental hip fracture history
- Smoking status
- Glucocorticoid use
- Rheumatoid arthritis
- Secondary disorders linked to osteoporosis, such as type 1 diabetes
- Drinking three or more alcoholic beverages per day
WHO fracture risk assessment
At age 40, a US Caucasian woman weighing 135 lbs at 5’8” with none of the WHO risk factors has a 2.3% risk of experiencing a major osteoporotic fracture within ten years. The same woman with five of the WHO risk factors has a 15% risk of experiencing a major osteoporotic fracture. At age 65, the same woman with none of the WHO risk factors has a 14% chance of experiencing a major osteoporotic fracture within ten years. This same woman at 65, with five of the WHO risk factors, has a 55% risk of experiencing a major osteoporotic fracture. At age 80, the woman with none of the WHO risk factors has a 28% chance of experiencing a major osteoporotic fracture within ten years. The same 80-year old woman with five of the WHO risk factors has a 71% risk of experiencing a major osteoporotic fracture.
Weight & Height
Number of Additional “WHO” Risk Factors
Risk % for a Major Osteoporotic Fracture within 10 Years
|40||135 lbs. / 5’8|
|40||135 lbs. / 5’8|
|65||135 lbs. / 5’8|
|65||135 lbs. / 5’8|
|80||135 lbs. / 5’8|
|80||135 lbs. / 5’8|
Does fracture risk vary by ethnicity?
This is a fascinating question which we have just begun to ask. I am confident the answer will be yes, risk does vary by ethnicity. Even with the little bit of existing research we have on the topic, we know that bone mineral density in Black women does not carry with it the same risk of fracture as it does among Caucasian women. Black women have about 30% fewer fractures at any given bone mineral density than Caucasian women. We also know that overall, Asians experience far fewer fractures than do Caucasians, yet their bone density is significantly lower.
The future of fracture risk assessment
As director of the Better Bones Foundation, I know that multi-variable risk assessments are indeed the tools of the future. I am not sure, however, whether the 7 variable model set forth by the US Study of Osteoporotic Fractures, or the 11-factor model from the Women’s Health Initiative, or even the new WHO assessment will end up being the best risk assessment tool. Yet there are a few things we do know for sure. One is that bone strength is determined by many factors, not just bone density; and many factors contribute to bone weakness. Further, every day we come to understand more about important new fracture risk factors which are yet to be incorporated in these risk assessment tools.
New risk factors: what the future might hold
As new questions are asked and new research unfolds, we are confident that many more new risk factors will become more important than bone mineral density. The new important fracture risk factors I would like to review are:
- High rates of bone protein matrix breakdown (high bone resorption rates)
- Low serum levels of vitamin D
- Low serum levels of vitamin K
- Use of various additional medications
New risk factor: high rates of bone protein matrix breakdown
Bone can be visualized as a living protein sponge matrix upon which mineral crystals are imbedded. As bone is lost, this living protein matrix breaks down and is excreted in the urine. The more bone protein fragments found in the urine, the higher the rate of bone breakdown. This is known as the rate of bone resorption. High bone resorption generally indicates a high rate of bone loss. Urine tests which measure bone resorption include the NTx, CTx, and the free deoxypryidinoline urine Dpd tests. These urine indices of skeletal turnover are as useful, or nearly as useful, as bone density in predicting fractures. They are fracture risks independent of bone density. Further, the combination of high bone resorption and low bone density is especially predictive of increased fracture risk.
New risk factor: low serum levels of vitamin D
Only recently have we begun to understand the overwhelming importance of vitamin D in fracture prevention. While it is beyond the scope of this article, suffice it to report that the vast majority of hip fractures occur in vitamin D deficient people. Among those who experience an osteoporotic fracture, vitamin D deficiency is the rule, not the exception. For example, a Minnesota hospital study of 82 minimal-trauma fracture patients ages 52-97 found that 97% of the fractures were hip fractures and that all but two of the patients had deficient vitamin D status (less than 30 ng/mL). In a large British study, vitamin D deficiency was found in 95% of hip fracture patients. Further supporting this, 78% of hip fracture patients in a Boston study were vitamin D deficient. Findings such as these have led some researchers to ask if vitamin D level is not the best predictor of fracture risk.
New risk factor: low serum levels of vitamin K
While only limited research attention has been given to the vitamin K-fracture link, the powerful role of this nutrient in fracture prevention is obvious. European researchers have shown that the marker of vitamin K insufficiency (undercarboxylated osteocalcin) strongly predicts fracture. Those with the greatest signs of vitamin K insufficiency were found to have twice the risk of hip fracture, independent of bone density. Further, a combination of low vitamin K status and low bone density increased one’s risk of hip fracture by more than five-and-a-half-fold.
New risk factor: use of various additional medications
It has long been known that the use of corticosteroids like prednisone greatly increase one’s risk of fracture. Now researchers are beginning to uncover links between other medications and fracture risk. For example, a recent British study found that those using higher doses of acid blockers (proton pump inhibitors) for more than a year had a 250% increased risk of hip fracture than non-users. Anti-depressants are another example of medications that increase fracture risk. Recently the large CAMOS 5-year Canadian osteoporosis study found that use of anti-depressants known as serotonin reuptake inhibitors (SSRI’s) was associated with increased fracture risk. Individuals using these medications, such as Prozac, Zoloft, and Paxel, for five years or more, had twice the risk of osteoporotic fracture than those not using these drugs. Further, hip bone density was 4% lower and spinal bone density 2.4% lower in those who used anti-depressants as compared to non-users.
While it is interesting to look at large studies and try to sort out the characteristics of folks at high risk for fracture, it is important to keep in mind that we can only predict relative fracture risk. We cannot foretell who will fracture. As research continues, more fracture risk factors will be uncovered and a relative weighting of their importance outlined. In the meantime, the known cluster of bone-weakening factors now include advancing age, low body weight, inadequacies of vitamins D and K, parental hip fracture, personal low-trauma fracture, selected medications, fragility and poor mobility, poor general health, high bone resorption, and low bone density.
Osteoporosis researchers in the past estimated that 35 to 50% of all Caucasian postmenopausal women experience spinal vertebral fractures. This figure always seemed high to me, and for some time I have been looking for “solid” statistics on these rather elusive spinal vertebral fractures. I call spinal vertebral fractures elusive because two thirds of these fractures are “silent” and are not even noticed by the people experiencing them. They can, however, be seen in an x-ray exam.
Now for the first time we have solid, long-term data on spinal vertebral fracture incidence among US Caucasian postmenopausal women. Data from the US Study of Osteoporotic Fractures covers a 15-year observation period looking at nearly 2,700 Caucasian women with a mean age of 69 years old at the start of the study. Over the 15-year observation period the incidence of new spinal vertebral fractures was studied carefully using x-ray exams. What researchers found was the following:
- Overall, 18.2% of all women in the study developed a spinal vertebral fracture visible on x-ray over the 15-year period.
- Fourteen percent of the women who came into the study without any vertebral fracture developed such a fracture during the 15 years.
- Only 9% of the women with normal bone density and no previous fracture came to have a vertebral fracture during this 15-year period.
- Among women with an osteoporotic lumbar spine bone mineral density, but no existing vertebral fracture at baseline, 23.3% came to fracture a vertebra during the study. An osteoporotic bone density is defined as being 2.5 standard deviations or greater below the average bone density of young women.
- Among women with an osteoporotic total hip bone mineral density T score (i.e. -2.5 T or more), but no existing vertebral fracture at baseline, 28.3% came to fracture a vertebra during the study.
- Among those women who came into the study with an existing vertebral fracture, 41% of them experienced a new fracture over the 15 years. This was true even if they did not have low bone density.
- The highest risk of fracture was among women who came into the study with osteoporotic BMD (-2.5 T or more) and also had an existing vertebral fracture at the start of the study. A full 56% of these women suffered a new vertebral fracture during the 15-year study.
- Even women with previously undetected “silent” spinal vertebral fractures at baseline had a 4-fold increased risk of experiencing a new fracture, as compared to those who had no spinal vertebral fractures at the start of the study. This was true even if they did not have low bone density.
- The strongest predictors of fracture were previous fracture, advancing age, and lower weight.
So what does all this mean? What are the important implications of this large, long-term study?
A US Caucasian woman’s risk of experiencing a spinal vertebral fracture has been overstated.
The results of this study suggest that earlier calculations of spinal vertebral fracture incidence have overestimated real fracture incidence. Over fifteen years, from age 68 to 84, only 18% of all US Caucasian women experienced a vertebral fracture. Overall, counting those who entered the study with an existing vertebral fracture, a little over 26% of all women had radiological evidence of a spinal fracture by age 84. This figure is significant, yet not as worrisome as the 35-50% estimate previously reported.
Many spinal fractures, at least in Caucasian women, occur before the age of seventy.
In this study, 14.7% of all women experienced a vertebral fracture before entering the study at a mean age of 68.8 years. During the 15-year study, a total of 18.2% ended up with a spinal fracture. Thus, nearly as many women fractured before their late 60’s as did after their late 60’s (between 68.8 and 83.8 years of age).
And just how important are these spinal vertebral fractures?
To put this study into perspective, we must remember that only one third of all spinal vertebral fractures are clinically recognized. Most are never detected by the person suffering the fracture or by his/her doctor. These fractures are not painful or troubling enough to notice. Multiple spinal vertebral fractures, however, can cause significant pain, height loss, the development of a dowager’s hump, and, if extreme, can compromise breathing, balance, and mobility.
Having one or more spinal vertebral fractures does in fact increase your risk for having others.
Another impressive finding from this long-term study is the increased risk of a new fracture for women who entered the study with an existing spinal vertebral fracture. For some time, it has been suggested that those who have experienced a spinal vertebral fracture are at greater risk for having another. In this study, the risk of experiencing a spinal vertebral fracture over the 15-year study was increased 5-fold if one came into the study having had a previous spinal vertebral fracture. Of those found to have any previous spinal vertebral fracture, 41% experienced a new spinal vertebral fracture over the 15 years. Even “silent,” unnoticed fractures indicated a 4-fold increased likelihood of other vertebral fractures. Other short-term studies have also shown that a prevalent vertebral fracture is associated with a 5-fold increased risk of sustaining a new vertebral fracture.
You should pay special attention, and be especially diligent, if you experience a fracture — any low-trauma fracture likely suggests you are more vulnerable to other fractures. As I have said, most vertebral body deformities go unnoticed, but you can have these assessed as part of your bone density test. As an “add-on” to your bone density test, you can ask for an imaging of the vertebrae to detect deformities and fractures. This is known as a measurement of “vertebral morphometry” and with this, you can see “silent” vertebral deformities and fractures.
Bone mineral density is an important risk factor, but still does not determine fracture risk by itself.
Lower densities increase fracture risk, but do not determine the risk. Keep in mind that most fractures occur in women who do not have osteoporosis based on BMD alone. Those who fracture generally have other factors contributing to bone weakness, including lower levels of vitamin D, the use of bone-depleting medications, lack of physical activity, little muscle strength, older age, low body weight, metabolic acid load, and the like. In this study, it was shown that the strongest predictors of fracture risk were previous fracture, advancing age, and lower weight. (For our fracture risk assessment click here.)
It is wise to look beyond osteoporosis medications for fracture prevention.
During the 15 years of this study, several osteoporosis medications became available. Many women in the study were given these medications over the years by their physicians. The use of such medications was significantly higher in women who had a fracture during the study (51%) than among those who did not fracture (42%). As the researchers report, the use of bone medications did not have a significant impact on study findings. Whether they used bone drugs or not, the women with previous fracture, lowest weight, lowest bone density and more advanced age had the highest rate of new fractures.
The likelihood of experiencing an osteoporotic fracture varies greatly from individual to individual depending on the number of risk factors one exhibits.
The more risk factors you have, the more imperative it is to develop an effective bone strengthening and fracture-prevention plan. It is our long-held position that the best approach to fracture prevention is a comprehensive, holistic nutrition and lifestyle program. For details on our Women’s Health Network Better Bones Package, click here.
Nearly 30 years ago, when bone density testing machines were first being developed, we thought low bone density was what mattered most in determining a person’s risk for osteoporotic fractures. Since that time, bone density testing has become the standard of health care throughout the developed nations, where fracture rates are highest.
Common variables used to determine 10-year risk of osteoporotic fracture
- Weight and height (Body mass index <21)
- History of previous fracture
- Parental history of hip fracture
- Smoking status
- Use of glucocorticoid drugs
- Rheumatoid arthritis
- Secondary disorders linked to osteoporosis, such as type 1 diabetes
- Drinking more than 3 alcoholic beverages per day
Other important factors
- Postural instability
- Poor vision
- pH balance
- Vitamin D status
- Use of proton pump inhibitors (PPI’s)
- Use of antidepressants
Nowadays, we know that rates of fracture tend to be higher in people with low bone density only in certain populations, and only under certain conditions. After following thousands of people over time, bone researchers have found that the majority of those who fracture do not have osteoporotic bone density, but actually have bone density that is osteopenic, or even normal!
What’s more, many people who, on testing, would be given a diagnosis of osteoporosis never go on to experience fracture. Clearly, the expectations we placed on bone densitometry technology as a straightforward means of predicting fracture risk have fallen short.
To illustrate this point, let’s take a closer look at the case of hip fractures in the elderly, since they are some of the most problematic types of fracture in older people.
Up until the mid-1990’s, it was widely held that many risk factors for hip fracture — weight loss, family history, and physical inactivity for instance — acted at least partly through their effects on bone density, whereas others — postural instability and sedative use — acted by influencing a person’s risk of falls. Then, in the 1990’s, a four-year study of nearly 10,000 Caucasian American women over the age of 65 revealed that all the above-listed factors exerted significant effects on the risk of fracture — after adjustment for base-line bone density.
|Heal Fractures Faster|
Our bone-building products ǀ Our Fracture Healing Kit ǀ Consult with Dr. Brown, PhD
This raised the possibility that the risk of hip fracture involved factors other than bone density and the risk of falling. Just some of the factors the researchers identified were the size, shape, and architecture of bone, as well as the type and severity of falls. Plus, the authors of the study identified independent risk factors, including low body weight, physical inactivity, a maternal history of hip fracture, use of long-acting benzodiazepines, and impaired vision.
We have also realized over the intervening years how greatly risk factors interact with each other, and have learned they can become increasingly or less important as people grow older. That’s in part why certain types of fractures are more common in certain age groups. But while we understand now that there are many variables at play in the fracture prediction equation, the reality remains that the majority of hip fractures — and the most burdensome of all osteoporotic fractures — occur within the elder segment of our population.
As foreboding as that may sound, the truth is that the longer a person lives, the more likely she/he is to experience one or more osteoporotic fractures. If there is one thing we want you to know about statistics, it is that they are only a best guess — not a sentence! Obviously, reduction of geriatric fracture is a worthwhile goal, for it would both provide our elderly with a higher quality of life and substantially reduce the healthcare costs of aging.
The good news is that both these goals lie well within our reach today. Current scientific literature nicely documents the special nutrient and lifestyle needs of elderly people. Meeting these special needs could substantially reduce the incidence of fracture in older folks. For example, the recurrence of vertebral fractures can be more than halved, and the incidence of hip fractures can be decreased by over 40%, by simply administering appropriate nutritional supplementation. Additionally, muscle mass can be increased 90% or more — even among 90-year-olds — with simple strength-building exercises! Balance can be improved and falls reduced with vitamin D therapy. And the gentle movement and breathing exercises embodied in the practices of yoga,t’ai chi, and qi gong reduce fracture risk through many mechanisms. Further, simple lifestyle modifications and attention to the special nutrient needs of the elderly can significantly reduce the incidence of falling, and thus further enhance well-being and reduce fracture risk.
While the above approach offers us a practical and effective means to reduce geriatric risk of fracture, many elements of this approach could be just as readily applied to younger populations. No matter what your age, caring for yourself by getting regular exercise, eating a healthy diet, and supplementing your nutrition appropriately can significantly minimize your fracture risk.
So it’s not just your bone density, your statistical risk of falling, or your numerical age that determine the likelihood that you will fracture. With the realization that risk of osteoporotic fracture changes over time as a result of numerous variables interacting with one another — from what we eat and drink to our genetics — bone researchers have devised various algorithms to more accurately estimate an individual’s overall risk than can be obtained by bone-density tests alone. These fracture risk assessment tools are very useful, yet the science remains a young one. Every day, we develop a broader vision as, little by little, the complex interplay of numerous factors reveals itself to our understanding.
I write more about the history and science behind these tools in my article on how we can tell who will fracture. I encourage you to check out your own risk with the Better Bones Fracture Risk and Bone Health Profile tool. You can also learn more about protecting your bones through our article on fracture prevention and fall prevention.
Please click here for information on bone processes and functions and their relationship to fracture.
What a joy it is to walk to my favorite food co-op here in Syracuse without having to dodge the ice patches. I know that many of my clients feel a new-found freedom in May as the risks of falls that come with winter has finally disappeared along with the snow.
Still, no matter what the season, falls are a major cause for bone fractures. And since many falls take place in the home, I suggest that you make fall prevention part of your spring cleaning routine.
All you need to do is take a quick overview of your home to see if you need to make any of the following environmental modifications that may help you reduce your risk of falls:
Does your house have the following to reduce your risk of falling?
• Nightlights or motion-sensitive lighting throughout home, both indoors and outdoors
• Adequate lighting in stairwells, doorways and along walkways
• Grab bars and railings as appropriate
• Non-slip mats in your bathtub and shower
• Skid-resistant material on your steps and stairs
Other tips for fall-proofing your home
• Remove any small area rugs
• Eliminate clutter: put books on shelves, clothes in a hamper, towels on a rack and shoes in the closet.
• Keep wires behind furniture (it’s getting harder to do with so many wires, but it’s very important!)
• Highlight edges of steps with bright paint or tape
• Wear shoes with non-slip soles that give support while avoiding slippers, flip flops and the like. I personally, however, like to walk barefoot when it is warm enough, as I use it as a mindful exercise to enhance body movement awareness.
• Keep a flashlight next to your bed.
• Take a few moments to stretch in bed and wake up fully before hopping out of bed.
As you review this list, I also recommend you think about what activities you can do to increase your balance, even as you age. Activities such as t’ai chi, qi gong, and yoga are excellent options, but even simple daily activities can help to increase your balance. For example, every morning I try to put on my left sock while standing on my right foot, and then vice versa. I also like to put on and tie my shoes one at a time while I’m standing, and I find it fun to practice getting up from the floor without using my hands when I am feeling fit.
What are some of the ways you get your body in balance?
For many women, a fracture is the first sign of sub-optimal bone health — and it can be pretty scary! I understand, which is why I always remind women that they have more control than they may realize to improve their bone health and to make their first fracture their last fracture.
Phyllis, a 59-year-old client from Michigan, is one wonderful example. In my book, she has met with great success after deciding to take heart and take action. Here’s her story:
How Phyllis discovered her osteoporosis
In the fall of 2010, at age 57, Phyllis had her first bone density test, inspired by a wrist fracture two years earlier. To her surprise, she found out she had osteoporosis of the hip and osteopenia of the spine.
Phyllis took action with the Better Bones approach
- Daily supplementation. Taking supplements is one of the easiest steps to increase bone health. For Phyllis, the Better Bones Builder and Omega-3 combination was the best choice.
- Creating pH balance. Through diet and our supplements she alkalized to help preserve bone.
- Enjoying “social exercise.” Phyllis expanded her exercise routine and came to see herself as a “social exerciser.” Not only did she feel much better with exercise, she also loved the community support and the social aspect of group exercise.
- Two years later her bone density test showed that she had gained bone — a whopping 19%, the trochanter part of the hip and nearly 7% in the total hip. The neck of the hip and the spine remained stable.
- What’s especially remarkable is that at 59, most women would be losing about 1% of bone mass a year. Phyllis had actually either gained significant amounts of bone mass or remained stable, depending on the site analyzed.
- Continuing success: Phyllis is maintaining her gains and her bone density as a whole remained stable — defying the natural process of aging bone loss. She also continues to search for hidden causes of bone weakening.
Do you have a success story you can share with us? We would love to hear it!
Awhile back I told you about early research connecting menopausal hot flashes to lower bone density and a higher rate of bone breakdown. These findings from Dr. Carolyn Crandall, MD made a lot of sense to me, especially given the inflammatory nature of both hot flashes and osteoporosis.
Now, the evidence of the connection between hot flashes/night sweats and bone health just got even more powerful, with new research from Dr. Crandall. In one of the first studies looking at how hot flashes and night sweats are related to fracture incidence, she found women who experience “moderate to severe” menopausal hot flashes or night sweats have almost double the risk of hip fracture in later life. The study was also a large one, including data from more than 23,000 women ages 50 to 79.
I believe this study adds to the urgency of taking care of your bones during menopause. We know that hormonal changes during menopause disrupt your body’s natural bone-building process. Your body may have less estrogen, which is needed to help preserve calcium in the body and prevent bone breakdown. The low progesterone levels common in perimenopause may also affect bone-building cells, disrupting the natural process of bone breakdown and repair.
Remember, most women lose about 10% of their bone in the 10 years around menopause, with the most loss taking place a year before menopause and the two years after that count most. Hot flashes and night sweats, weight gain, fuzzy thinking and fatigue are all clues that your hormones have started to shift, even years before your periods actually stop.
To help you put everything together, my Better Bones: Menopause Program gives you support your for bone health and relieve hormonal fluctuations that lead to menopause symptoms. You can try it now or read more in my article Bone loss in menopause.
Carolyn J. Crandall, Aaron Aragaki, Jane A. Cauley, JoAnn E. Manson, Erin LeBlanc, Robert Wallace, Jean Wactawski-Wende, Andrea LaCroix, Mary Jo O’Sullivan, Mara Vitolins and Nelson B. Watts. Associations of Menopausal Vasomotor Symptoms with Fracture Incidence. Journal of Clinical Endocrinology & Metabolism, December 2014
Are you worried about bone loss because you didn’t drink milk as a child? As I often explain to concerned clients, while calcium is an important bone nutrient, there’s a large body of evidence suggesting that milk is not central to healthy bones. In fact, in many parts of the world where milk drinking is uncommon the osteoporotic fracture rate is very low.
Now a large Swedish study suggests that drinking three or more glasses of milk a day may actually increase the risk for fracture. Even more, abundant milk usage raised the odds of an earlier death!
What the research says
Here’s what researchers discovered in the impressive study of 100,000 women and men over more than 20 years:
- There was no reduction in risk of any fracture with higher milk consumption. In fact, there was a slight increase in fracture among those with higher milk consumption
- Furthermore, those women who drank three or more glasses of milk a day had nearly a doubled risk of mortality as compared with those who consumed less than one glass a day. Specifically deaths from cardiovascular disease and cancer increased.
- There was a positive association between higher milk intake and undesirable inflammatory markers (urine 8-iso-PGF2a and interleukin 6).
- BUT, the use of fermented milk products such as yogurt, sour milk, kefir and cheese actually significantly reduced the incidence of hip fracture and death. For example, for every serving of fermented dairy consumed, women experienced a 10 to 15% reduction in both hip fracture and mortality. Eating fermented dairy was also associated with a decrease in oxidative stress and inflammation.
What does this mean for you?
First, don’t spend one minute more thinking how your current skeleton might be fitter if you drank more milk in the past.
Next, while you do want a total of 1,200 mg calcium from diet and supplements together, you don’t need to get it from milk. One idea is to move to fermented dairy as an excellent source of calcium, phosphorus, protein and life-supporting probiotics. Think yogurt, kefir, buttermilk, aged cheese. What’s more, here’s a detailed list of even more calcium-rich foods.
Michaelsson, K et al., Milk intake and risk of mortality and fractures in women and men: cohort studies. British Journal of Medicine, 2014:349, Oct 28, 2014.
Brown, Susan E. Better Bones Better Body: Beyond Estrogen and Calcium, Keats Publishing, 2000.
When most people are told they have low bone density, their greatest concern is whether they are at risk for bone fractures. That’s because many people, even many physicians, make a direct association between low bone density and fracture. But in truth, this association is weak at best. Having low bone density doesn’t mean that you are doomed to fracture, and scientists now agree you cannot predict who will fracture looking only at their bone density.
Bone density, at best, is just one of a dozen important fracture risk factors. People with very thin bone density often never experience a fracture, while people with an “osteopenic” or even a “normal” bone density may fracture with even a low-impact fall. The fact is, “thin” bone is not the same as “weak” bone — bones may be thin yet strong, or thick yet weak, or (worst case scenario) thin and weak. The latter is the group most prone to fracture.
Sadly, the fear of fractures drives many people — even some who don’t have osteoporosis — to accept prescriptions for the supposedly bone-strengthening bisphosphonate drugs, such as Fosamax, Boniva, and Actonel. These drugs may offer some short-term benefits to people with severe bone loss, but they make unhealthy long-term changes in the body. We’ve begun to see signs that these drugs don’t so much build or strengthen bone as harden it, and that can cause even greater problems over time — including the fractures the drugs were intended to prevent!
Use of such drugs is largely unnecessary for the vast majority of people, because most people’s bones can be strengthened and made denser by simple nutritional and lifestyle changes that promote the body’s natural bone-building capabilities. When you support your bones with a combination of 20 key nutrients and an alkaline diet, and include exercise and stress reduction into your daily life, your bones can work astonishing changes, becoming stronger and more flexible. And it doesn’t matter when you start — these changes work whether you’re 39 or 89.
If you have been told you’re at risk for fracture, or if you’ve already had one, I encourage you to take our bone health profile to determine how great your risk of a new fracture might be — the results could surprise you. Then, learn just what you’re up against and how to maximize your bone health by reading our articles about bone fractures — what they are, what causes them, how to prevent them, and natural ways to promote bone fracture healing.
Our most popular resources on bone fracture
- Fractures 101
Dr. Susan E. Brown, PhD offers an overview of the physiology, physics, types, and the risks of fracture.
- How can we tell who will fracture?
Take a look beyond mineral density to the new world of fracture risk assessment.
- Fracture prevention through preventing falls
Learn how to limit your risk of bone fractures by taking steps to prevent falls. Includes our recipe for strong muscles, addressing problems with balance, and simple environmental modifications.
- More Articles
The Center for Better Bones and the Better Bones Foundation
Dr. Susan E. Brown, PhD
605 Franklin Park Drive
East Syracuse, NY 13057
1-315-437-9384 — main
1-877-207-0232 — toll-free
Hours of Operation
Mon-Fri: 9am-4:30pm EST
- Mediterranean diet a special help for those with osteoporosis December 3, 2018
- Lessons from our latest retreat — why rest and rejeuvenation matter November 27, 2018
- Muscle loss with aging — are you at risk for sarcopenia? November 17, 2018
- Sweet potatoes’ alkalizing benefits are all in how you prepare them November 7, 2018
- Don’t be fooled: Vitamin D does prevent fracture November 1, 2018
- New bone drug Tymlos — is it safe? October 19, 2018
- Why you should strengthen your wrists October 8, 2018
- Osteogenic loading — a key to reversing osteoporosis September 20, 2018
- Osteopenia Treatments — What Works? September 10, 2018
Dr. Brown’s Blog Signup
Weekly wisdom from the woman who builds better bones