Updated Advice on Bone Density

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By Mary Carpenter

AFTER WRITING two previous posts (2014, 2019) on women who might be at risk for osteoporosis, Mary Carpenter’s new Georgetown University rheumatologist provided updated numbers on risks and needs for supplements and drug treatment, and   a new focus on other issues. (Note: for all recommendations made below, readers should check with their personal physicians.)

At the time of the 2019 post, a U.S. government- appointed panel of physicians recommended “against daily supplementation” with vitamin D and calcium, while my internist advised stopping both, and my gynecologist recommended maximum doses.

Diminishing bone density occurs over time when bone resorption exceeds bone formation—which is controlled by hormones, such as estrogen and parathyroid hormone, as well as by specific proteins in the bone: osteoblast cells create new bone while osteoclasts break it down.

My new rheumatologist provided clarity and specificity, updated. Her recommended dose for calcium, advising not to take less or more, was 1,200 mg—ingested over the course of each day, in at least two separate doses to maximize use by the body.  Determination of supplement amounts, however, required first measuring and subtracting dietary intake: for me, about 300mg from milk and cheese and maybe 200mg more from orange juice, a few vegetables and ice cream. For the 700mg still needed, calcium supplements should total 350mg twice a day.

For vitamin D, she advised 1,000 IU/day. By contrast, in 2019, research from the NHANES study involving more than 30,000 American adults linked vitamin D supplements of more than 400 IU/day a study with “an increased risk of death from cancer” and “increased cancer death and death from any cause,” according to the New York Times. In addition, studies showing benefits of calcium/vitamin D supplements at that time had not been controlled but observational, and they failed to assess diet, exercise and other important variables. Prescription drug treatment decisions began with my T-score, the  measurement of bone mineral content by a DEXA or DXA scan —as an indication of bone density or strength.  For women as a group, T-scores of -2.5 or below indicate a 33% chance of fracturing a hip compared with a 16% risk for those with a score of -1, the average for a 30-year-old woman. My -2.4 T-score is borderline, officially labeled osteopenia, which can signal problems ahead but is not itself cause for treatment. But adding my age, weight and race indicates higher risk, as does a broken kneecap from a fall several years ago.  Among less clear risk factors, my mother’s health was generally too poor to say what caused what; and my lifestyle habits like eating and exercise are pretty good.

With all this information, my rheumatologist used a “10-Year Fracture Risk Calculator” that placed my “risk of any fracture” at 26%—in the red danger zone on the chart, compared to the average for my age of 15%. Her advice: start medication.

Osteoporosis drug treatment typically lasts two to five years—because longer regimens can increase the risk of side effects; and because improvements in bone strength by that time can prolong bone-protective effects after stopping the medication. For higher level drugs like Prolia, early research suggested that stopping the medication risked causing greater bone loss, but recently women with sufficiently improved T-scores have been able to go off medication entirely or move to less powerful drugs.

The first-choice drug treatment is usually bisphosphonates –which can slow bone breakdown by blocking the osteoclasts, in turn allowing osteoblasts to create more new bone. Of the various forms of bisphosphonates, including pills and injectable medication, my doctor recommended yearly infusions of zoledronic acid (Reclast), preferred for anyone who has had acid reflux, also known as heartburn, when stomach acid backs up into the esophagus and irritates the tissue.

GI issues can arise during the strict regimen involved in taking bisphosphonate pills such as Fosamax: once a week, first thing in the morning, on an empty stomach—followed by sitting or standing upright for at least 30 minutes before eating.  Bisphosphonate drugs also have a small risk of side effects that include fractures of the femur and bone decay in the jaw.

The next level drug is generally Prolia, the monoclonal antibody denosumab, given by injection every six months —which slows bone loss by preventing the formation of the bone-dissolving osteoclasts. A different option is the selective estrogen receptor modulator (SERM) Evista, which produces estrogen-like effects in the body that include decreasing bone turnover. And synthetic parathyroid hormones such as Forteo increase bone density and strength.

On the other hand, high numbers of osteoporosis patients and their doctors “have turned their backs on bone-protecting medicine” — enough to cause a plateauing of hip fractures since 2012, following 10 years of declining rates. One study of 126,188 women with Medicare Part D drug coverage found fewer than one-third started drug therapy within a year of diagnosis.

The worst outcomes for osteoporosis sufferers come not from brittle bones themselves, but from the increased risk of falling—for which good balance is the best protection. “Yoga for osteoporosis”—with special series of poses and classes—focuses on balance, and not just in tree pose (standing on one leg). In her 2015 article,“12 Minutes of Yoga for Bone Health,” Jane Brody described research by Columbia University physiatrist Loren Fishman that found yoga increased bone density in the spine and femur.

“Yoga puts more pressure on bone than gravity,” Fishman told her.  “By opposing one group of muscles against another, it stimulates osteocytes, the bone-making cells.”

Despite my years-long familiarity with osteoporosis, the new rheumatologist helped by homing in on two specific recommendations, in addition to the focus on balance: working on gait and weightlifting three times a week to build bone (she does not count swimming, although others disagree). While I appreciate this clarity and specificity, as well as the prescriptions and recommendations, it often takes me years to find out how well I can handle such a regimen, especially the weight-lifting. And I am just getting started.

—Mary Carpenter regularly reports on need-to-know topics in health and medicine.