What Is Osteoporosis? Symptoms, Causes, Diagnosis, Treatment, and Prevention

Osteoporosis is a disease in which bones deteriorate or become brittle and fragile due to low bone mass and bone tissue loss.

The condition is often referred to as a “silent disease,” because you cannot feel your bones getting weaker, and many people don’t even know they have the condition until after they break a bone.

Osteoporosis increases the risk of fractures, particularly of the hips, spine, and wrists. In fact, osteoporosis causes an estimated nine million fractures each year worldwide. (1)

In its early stages, osteoporosis generally causes no symptoms.

But in many cases the first symptom a person may have is a broken bone, often as a result of a fall, and most frequently in the spine, wrist, hips, or pelvis.

Over time, a person with osteoporosis may notice back pain, loss of height, a stooped posture, and easily-occurring bone fractures.

Learn More About Osteoporosis Symptoms

Bone is living, growing tissue that consists mostly of the protein collagen, which provides a soft framework, and the mineral calcium phosphate, which adds strength and hardens the framework.

Bone is not a static part of the body — it’s constantly being resorbed (broken down) and formed throughout your life. According to the National Institutes of Health (NIH), your entire skeleton is replaced about every 10 years, though this slows down as you age. (2)

During your childhood and teenage years, bone formation occurs more quickly than bone resorption, resulting in growth.

Osteoporosis is more likely to develop if you did not reach optimal peak bone mass during your bone-building years.

You reach your maximum bone density and strength around age 30, after which time bone resorption slowly overtakes bone formation.

Osteoporosis develops when there’s an abnormal imbalance between bone resorption and formation — that is, resorption occurs too quickly, or formation too slowly. (3)

Anything that causes your body to destroy too much bone can cause your bones to become brittle or fragile.

Women experience the most bone loss during the first few years after menopause, and they continue to lose bone from this point on. This is because estrogen (as well as testosterone) encourages bone health, so a decrease in the hormone will hasten the weakening of bones.

Numerous factors are associated with a higher risk of developing osteoporosis. Some people who develop osteoporosis have several risk factors, but others have none. Some risk factors are inherent and cannot be changed. These factors include:

• Being a woman, particularly in your postmenopausal years
• Having a family history of fractures
• Being age 50 or older
• Having small or thin bones
• Being Caucasian or Asian
• Having low estrogen levels (from menopause or missing menstrual periods) in women, or low testosterone in men
• Smoking
• Excessive alcohol consumption
• Anorexia or bulimia
• Dietary deficiencies in calcium and vitamin D
• Lack of exercise
• Long-term use of certain drugs, including glucocorticoids and some anticonvulsants

Learn More About Causes and Risk Factors of Osteoporosis

To determine whether you have osteoporosis, your doctor will assess your risk factors and perform a bone mineral density (BMD) test. The most common BMD test is called DXA (also abbreviated DEXA), or dual-energy X-ray absorptiometry. This scan is painless and is similar to having an X-ray taken, but with less exposure to radiation. (4)

T-scores, which compare a person’s bone mineral density to average values for healthy young women, are used to measure DXA outcomes. The World Health Organization (WHO) categorizes T-scores as follows:

• Normal: T-score of -1.0 and above
• Osteopenia (low bone density): T-score of -1.1 to -2.4
• Osteoporosis: T-score of -2.5 and below
• Severe osteoporosis: T-score of -2.6 and below with a history of fracture (5)

A tool called FRAX is used to assess a person’s probability of bone fracture in the next 10 years. (6) The assessment tool is available online, but you need to know your bone mineral density at the hip to use it.

The FRAX tool takes into consideration various risk factors associated with fracture — including age, sex, weight, height, previous fracture, smoking, alcohol intake, and others — as well as a person’s bone mineral density at the hip, as measured with a DXA.

Learn More About How Osteoporosis Is Diagnosed

There’s no cure for osteoporosis — once it develops, it’s a lifelong condition — but you can work to protect and strengthen your bones. The right treatment plan, including weight-bearing and muscle-building exercise, a healthy diet, and medication, can slow further bone loss.

A variety of medication and lifestyle approaches can help slow the rate of bone loss that occurs in osteoporosis.

Some drugs, called antiresorptive medications, slow the breakdown of bone. These drugs include bisphosphonates and hormone therapy. Other medicines, called anabolic drugs, promote bone formation. Human monoclonal antibodies protect bones from degradation and slow the progression of osteoporosis.

Side effects associated with bisphosphonates include gastrointestinal issues and muscle, bone, and joint pain. In extremely rare cases, bisphosphonates have been associated with jaw bone deterioration (osteonecrosis) and also carry a risk for atypical femoral fracture (a crack in the thigh bone).

New guidelines for screening and treatment were issued in 2019 by the Endocrine Society. (7) One of the new recommendations is that postmenopausal women at high risk of fracture be treated with medication (initially bisphosphonates), but that women at lower risk may opt to go on a “bisphosphonate holiday” (or temporary discontinuation) after three to five years, pending further evaluation.

You should speak to your doctor about the best strategy for you, based on your bone mineral density, estimated fracture risk, lifestyle, and any other medical conditions you may have.

Learn More About Osteoporosis Treatment

About 85 to 90 percent of adult bone mass is acquired by age 18 in girls and 20 in boys, so building strong bones during childhood and adolescence can help prevent osteoporosis later in life. (8)

There are some lifestyle choices you can make to help prevent osteoporosis, such as:

Not Smoking In addition to being harmful to the heart and lungs, smoking is also bad for bones, since those who smoke may absorb less calcium from the foods they eat.

Avoiding Drinking Alcohol in Excess People who drink a lot of alcohol are more prone to bone loss and broken bones due to poor diet and risk of falling.

Following a Healthy Diet Following a nutritious diet that is rich in calcium and vitamin D is critical to bone health.

Performing Weight-Bearing Exercise Physical activities that force you to work against gravity, such as walking and hiking, strengthen your bones and your muscles.

Healthy Diet for Osteoporosis: Calcium and Vitamin D

While a broad range of nutrients contribute to bone health, two in particular merit discussion: calcium and vitamin D.

Calcium A lack of calcium in the body over time contributes to the development of osteoporosis. Researchers have shown that low calcium intake is connected to low bone mass, rapid bone loss, and high fracture rates.

Throughout life, the body needs different levels of calcium. The body’s need for calcium is highest during childhood and adolescence because the skeleton is growing rapidly. Pregnant women and those breastfeeding also need a lot of calcium, as do postmenopausal women and older men.

As you age, your body becomes less efficient at absorbing calcium and other nutrients. Plus, the older you are, the more likely you are to take medication for various health conditions, and those drugs can interfere with calcium being absorbed into the body. (3)

The NIH notes that national nutrition surveys report that many Americans consume less than half of the recommended amount of calcium. (3) Foods that are good sources of calcium include:

• Low-fat dairy products, such as milk, yogurt, cheese, and ice cream
• Dark green, leafy vegetables, such as broccoli, collard greens, bok choy, and spinach
• Sardines and salmon with bones
• Tofu made with calcium sulfate
• Almonds
• Calcium-fortified foods, such as orange juice, soy milk, cereals, and breads

If you don’t get enough calcium from food, you may need to take a calcium supplement. Talk with your doctor about the right amount to take for your body.

Vitamin D Vitamin D helps your body absorb calcium from both food and supplements. It helps your muscles move, because nerves need vitamin D to carry messages from your body to your brain. Your immune system also needs vitamin D to fight against bacteria and viruses.

Many people get some vitamin D naturally from the sunlight — the body makes vitamin D when skin is directly exposed to the sun. But studies show that vitamin D production decreases in the elderly and those who are housebound, as well as in all people during the winter. Food sources that provide vitamin D include egg yolks, saltwater fish, and liver.

The amount of vitamin D you need varies depending on your age and, for women, whether or not you’re pregnant or breastfeeding. The Food and Nutrition Board recommends these average daily amounts in international units (IU): (9)

• Birth to 12 months: 400 IU
• Children 1–13 years: 600 IU
• Teens 14–18 years: 600 IU
• Adults 19–70 years: 600 IU
• Adults 71 years and older: 800 IU
• Pregnant and breastfeeding women: 600 IU

It’s important to note that more vitamin D does not always equal “better.” It is possible to overdose on vitamin D from excessive supplement use, which can lead to very high levels of calcium and be potentially deadly in extreme cases. Stick to the recommended dosage as much as possible, and check out the National Institutes of Health for a chart with the tolerable upper intake levels for each age group.

Learn More About Healthy Eating When You Have Osteoporosis

Bone fractures are the most serious complication of osteoporosis, and the condition itself is serious, causing death in some cases. The Bone Health & Osteoporosis Foundation (BHOF) gives the following perspective on the condition (8):

• Among hip fracture patients who are 50 or older, 24 percent die within the year following the fracture.
• Six months after a hip fracture, only 15 percent of patients can walk across a room without help.
• Of the nearly 300,000 people who have a hip fracture each year, 25 percent end up in nursing homes, and 50 percent never regain previous function.

Osteoporosis-related bone fractures most commonly occur in the spine, followed by the wrists, hips, and pelvis.

These fractures usually result from minor falls or accidents, but spinal fractures may also occur if the vertebrae (spinal bones) weaken to the point of crumbling.

While some vertebral fractures cause no symptoms, others can cause back pain and a hunched posture.

Aside from causing pain and altering your posture, osteoporosis and bone fractures can reduce mobility and affect your emotional state, resulting in depression and anxiety.

Osteoporosis also places financial burdens on individuals and society as a whole. The BHOF reports that osteoporosis-related bone breaks cost people, their families, and the U.S. healthcare system $19 billion per year. Moreover, by 2025, it’s predicted that osteoporosis will cause three million fractures in the United States, resulting in $25.3 billion in costs. (8)

Osteopenia Often Precedes Osteoporosis

Bone mineral density that is lower than normal but not low enough to be considered osteoporosis is called osteopenia.

Osteopenia shares the same risk factors as osteoporosis, and it raises the risk of developing osteoporosis. But not everyone who has osteopenia goes on to develop osteoporosis.

Generally, treatment for osteopenia includes weight-bearing exercise, adequate intake of calcium and vitamin D, and other lifestyle measures.

Learn More About Osteopenia

Secondary Osteoporosis

While the majority of osteoporosis is related to age or a decrease in hormone levels, sometimes it is caused by a medical condition or treatment that affects bone mass and causes bone loss. This is called secondary osteoporosis. Some disorders can also cause the bone marrow cavity to expand at the expense of the trabecular bone — the inner layer of bone that has a spongy, honeycomb-like structure. When this happens, the trabecular bone loses some of its strength. (10)

Diseases and disorders that can cause secondary osteoporosis may include:

• Serious kidney failure
• Cushing’s disease
• Liver impairment
• Anorexia nervosa and bulimia
• Rheumatoid arthritis
• Celiac disease
• Multiple sclerosis
• Chronic obstructive pulmonary disease (COPD)
  
• Scurvy
• Hyperparathyroidism
• Hyperthyroidism
• Diabetes
• Hypercortisolism
• Thalassemia
• Multiple myeloma
• Leukemia
• Metastatic bone diseases

The following drugs or chemicals can also cause osteoporosis:

• Corticosteroid therapy
• Lithium
• Barbiturates
• Antacids containing aluminum
• Tobacco (when used excessively)
• Alcohol (when used excessively)

Treatment for secondary osteoporosis can be complex and may focus on treating the underlying condition or disease causing it. Other methods may include those used to prevent osteoporosis from developing.

As the most common type of bone disease, osteoporosis affects approximately 10 million Americans, and another 44 million people have low bone density, which puts them at risk for the disease, according to the National Osteoporosis Foundation. (10,11)

While osteoporosis mainly affects women, men can also develop the condition. According to the Centers for Disease Control and Prevention (CDC), it affects about 25 percent (1 in 4) of women 65 and over and around 5 percent (1 in 20) of men 65 and over. (12)

Fracture prevention is a key area of focus in osteoporosis research, including the use of supplements. A meta-analysis published in December 2019 in JAMA Network Open found that fracture risk could be cut significantly by taking vitamin D and calcium supplements together, but there were no benefits observed from supplementing with vitamin D alone. (13)

Current clinical trials suggest that researchers are also looking for better ways of screening for osteoporosis, new drugs for treating it (or better ways of administering currently used drugs), and the value of various forms of exercise in treating osteoporosis and preventing falls and fractures.

Favorite Bone Health Basics

NIH Osteoporosis and Related Bone Diseases National Resource Center

Whether you’re reeling from a diagnosis or have just heard you’re at risk of osteoporosis because of a condition such as lupus or celiac disease, this resource gives you the basic information you need to understand your situation and take action.

Bone Health & Osteoporosis Foundation (BHOF)

Having your bone density tested is pretty straightforward, but understanding your results often isn’t. Luckily, the BHOF lays it out in plain terms so you know where you stand.

Favorite Osteoporosis Podcast and Videos

Bone Talk

If you like to learn from podcasts, this project of the National Osteoporosis Foundation is for you. It features interviews with doctors and caregivers as well as tips from women living with osteoporosis.

Own the Bone

Real people talk about real experiences with osteoporosis-related fractures in these videos from the American Orthopaedic Association.

Favorite Osteoporosis Online Community

American Bone Health

When you need support and answers from other people living with osteoporosis, this is the place to find them. American Bone Health has teamed up with HealthUnlocked to create a moderated, online, peer-to-peer osteoporosis community. Also look for live “Freedom from Fractures” events in your community.

Fall Prevention 101

OrthoInfo

Falls can be devastating, but they can also be prevented, as this article from the American Academy of Orthopedic Surgeons (AAOS) explains. Understanding your risk factors and making healthy lifestyle choices, including engaging in regular exercise, can go a long way toward staying upright.

Favorite Info Source for Girls

Best Bones Forever!

Help the girls in your life start healthy bone habits early with this special page on the American Bone Health website. Interested girls will learn what bones are made of, how to keep them strong, and what can weaken them.

Favorite Exercise and Osteoporosis Resources

Harvard Health Publishing

If you just need a place to start, the three exercises illustrated in this article will fit the bill, focusing on the major muscle areas that keep you upright when standing.

International Osteoporosis Foundation

For a more comprehensive set of exercise recommendations, this is the place to go. However, you may need to seek out an exercise professional to put all of these recommendations in place in your own routine.

ChoosePT by the American Physical Therapy Association (APTA)

A physical therapist (PT) can help you learn exercises that will help prevent falling and fractures, as well as exercises that will help you regain mobility and function after a fracture. Learn more about PTs and the conditions they can help with.

Favorite Vitamin D Resources

NIH Office of Dietary Supplements

While the vitamin D fact sheet on this site is written for health professionals, it still has a lot of good information for consumers who want to know what foods contain vitamin D and how sun exposure can raise your vitamin D levels. The NIH also offers a page of Frequently Asked Questions about the use and safety of dietary supplements.

Office of Disease Prevention and Health Promotion

Perhaps you don’t want an exhaustive list of foods containing vitamin D. That’s where the Dietary Guidelines for Americans 2020–2025 can help, with a list of nearly 40 common foods and their vitamin D content.

MedlinePlus

MedlinePlus aggregates links to other sources of info, so if you have a specific vitamin D question or want to dig deeper into vitamin D knowledge, check out the links here.