Osteoporosis prevention

Osteoporosis — a condition that affects bone density — is common in Australia, however, there are steps you can take to prevent getting osteoporosis.

Osteoporosis prevention involves several lifestyle measures to address any risk factors you may have for osteoporosis. There are also medicines that can be used to help prevent osteoporosis in certain at-risk people.

Because osteoporosis increases your risk of bone fractures, reducing your risk of falling is also important.

Bones are made up of minerals, such as calcium, which give them their structural strength and make them dense. When bone mineral density is low it means the bones are porous and not as strong. As people age, their bone mineral density (BMD) decreases, leading to an increased risk of osteoporosis.

Bones reach their maximum density when we are aged about 30, so it is important before that time to do everything you can to give your bones the best opportunity to be as dense as possible. In our early 30s, bones start to slowly lose density. Once women reach menopause, BMD is lost rapidly for the next 5 to 7 years, so it is important to take action to try to maintain BMD for as long as possible after that.

Some people have risk factors for osteoporosis that cannot be changed, including being female, having Caucasian or Asian heritage, being small or thin-boned, having a family history of osteoporosis or needing to take steroid medicines for medical conditions.

Other risk factors are due to lifestyle factors and include having a poor diet that lacks calcium, drinking too much alcohol, and having low physical activity.

Lifestyle measures to help prevent osteoporosis

There are several simple lifestyle measures that can reduce your risk of developing osteoporosis and help maintain healthy bones well into old age.

Eat lots of calcium-containing foods

Low calcium intake is associated with low bone mass. Appropriate calcium intake can help reduce the rate of bone loss. Men younger than 70 years and women younger than 50 years should aim for at least 1000 mg of calcium per day; and women older than 50 years and men over 70 years should aim for 1300 mg per day.

Good sources of calcium include:

  • milk;
  • yoghurt;
  • cheese;
  • almonds;
  • dark green leafy vegetables such as broccoli; and
  • fish with bones such as sardines and salmon.

Dairy foods are the best source of calcium, so to get enough calcium from food you should aim for at least 3 serves of dairy products each day.

Take a calcium supplement

Your doctor may recommend taking a calcium supplement (e.g. Caltrate, Cal-Sup, Citracal) to boost your calcium intake but there may be risks as well as benefits. Calcium supplements are usually only recommended if your dietary intake is inadequate. Doses of 500 mg to 600 mg per day are usually recommended.

Remember that supplements based on calcium carbonate should be taken with or after food as they need gastric acidity to help increase their absorption, and not to rely on supplements at the expense of a good diet.

Calcium supplements may cause constipation and bloating.

Get out in the sun

Vitamin D, which is synthesised in the skin through exposure to sunlight, plays an important role in helping to absorb calcium and also in the general health of bone. The amount of sun exposure needed to make adequate vitamin D for healthy bones depends on:

  • your skin type;
  • the season;
  • where you live in Australia; and
  • the amount of skin you have exposed.

Many Australians have low vitamin D levels, particularly in winter and early spring.

To maintain adequate vitamin D levels during winter, many Australians need to spend some time outdoors in the middle of the day. In summer time, you should avoid sun exposure in the peak UV period which is between 10 am and 2 pm (11 am and 3 pm during daylight saving summer time) because of the risk of skin cancer. Sun exposure during the mid-morning or mid-afternoon is recommended in summer.

Older people who live in nursing homes, people who spend little time outdoors, those with naturally dark skin and those who cover their skin for cultural reasons are most at risk of vitamin D deficiency.

People with low vitamin D levels may need vitamin D supplements – talk to your doctor for advice on testing and supplements. Vitamin D supplements may also be recommended to prevent osteoporosis in people taking corticosteroid medicines.

Exercise regularly

Bone is living tissue which, like muscles, gets stronger with weight-bearing exercise. Walking, hiking, running, jogging, weight training (resistance exercise) and tennis are all beneficial because they force you to work against gravity.

The earlier you start building an exercise programme into your life, the larger your bank of bone mass will be, making you less susceptible to osteoporosis later on. However, very high levels of exercise in young women, such as that done by ballerinas or elite athletes, can lead to their periods stopping which can increase osteoporosis risk.

Weight-bearing exercise can slow the rate of bone loss, and even increase bone mineral density in the spine and hips in women who have been through menopause.

You are never too old for exercise, because it will also help you build muscle, and improve your posture and balance, which may prevent falls when you are older.

Maintain a healthy bodyweight

Low bodyweight is a risk factor for osteoporosis. Women who lose so much weight that their periods stop, such as those with eating disorders like anorexia, do not have sufficient circulating oestrogen to maintain bone density.

After menopause, when levels of oestrogen fall naturally, women have a much higher rate of osteoporosis than men of similar age. Having your periods stop for more than 6 months before the age of 45, other than during pregnancy, is a risk factor for getting osteoporosis.

Drink alcohol only in moderation

Alcohol interferes with calcium absorption, so high alcohol intake increases the risk of osteoporosis. The National Health and Medical Research Council’s guidelines say that for both men and women, limiting alcohol to no more than 2 standard drinks a day reduces the risk of alcohol-related harm.

Stop smoking

Smoking may affect your ability to absorb calcium from your diet — it certainly does contribute to weak bones.

Manage your medicines

Long-term use of some medicines, including anticonvulsants, heparin, corticosteroids and some diuretics, can contribute to bone loss. You should talk to your doctor about whether any of your medicines may contribute to your risk of osteoporosis.

Medicines used to prevent osteoporosis

Some people may need to take medicines to reduce their risk of developing osteoporosis. This includes some women after menopause and also some people taking long-term corticosteroid medicines.

Bisphosphonates

Bisphosphonates can slow bone loss, improve bone density and reduce the risk of fractures.

Bisphosphonates include:

  • alendronic acid (brand name Adronat, Fosamax);
  • risedronate (e.g. Actonel); and
  • zoledronic acid (brand names include Aclasta, Osteovan) which is given as a once-yearly infusion.

Bisphosphonates can be used to preserve bone mass in certain people who have to take corticosteroids long term, and some can also be used to prevent osteoporosis in postmenopausal women who have low bone mass.

Bisphosphonates can give some people stomach upsets and should be taken on an empty stomach to minimise side effects. Also, people are advised to stay upright for 30 minutes after taking risedronate and alendronic acid, as these medicines can sometimes irritate the oesophagus (gullet). Once-weekly bisphosphonate formulations are available which reduce the risk of gastrointestinal side effects.

Certain people may also be able to take a dose of risedronate once a month, which may be more convenient.

Other side effects of bisphosphonates may include musculoskeletal pain and fatigue.

Bisphosphonates can — rarely — cause osteonecrosis (death of bone) in the jaw. This risk is generally confined to people with underlying cancers taking large doses.

Raloxifene

Raloxifene (brand names Evifyne, Evista) belongs to the class of medicines called selective oestrogen receptor modulators (SERMs). Raloxifene can prevent post-menopausal bone loss and has been shown to reduce spine (backbone) fractures. It is only for use by women after the menopause.

Raloxifene may make hot flushes worse and may cause leg cramps and increase the risk of blood clots. There is evidence that it may reduce the risk of breast cancer.

Hormone replacement therapy (HRT)

Hormone replacement therapy (HRT), or oestrogen/progestin therapy, is effective for the prevention of osteoporosis and fractures in postmenopausal women. However, because of the risks associated with long-term HRT use, including breast cancer and thrombosis (blood clots), HRT is not recommended for routine osteoporosis prevention.

HRT may be used to prevent osteoporosis in certain women younger than 60 years who are at high risk of osteoporosis and are considering taking HRT in the short term to relieve menopausal symptoms.

The risks and benefits of taking HRT need to be assessed on an individual basis for each woman and vary depending on age, the type of HRT and other factors. Your doctor will be able to advise you on whether it is right for you.

Tibolone

Tibolone (brand names Livial, Xyvion) is a medicine that can be used for preventing bone mineral density loss in postmenopausal women at high risk of fractures.

(Tibolone is also used for short-term relief of menopausal symptoms.)

Tibolone aims to replace the body’s natural sex hormones which are reduced after menopause. Tibolone is sometimes given to women who have had their ovaries removed, because it is the ovaries that produce sex hormones in women. Tibolone may improve libido. It takes 3 months of treatment to obtain the full benefit of tibolone. 

Side effects of tibolone may include: vaginal bleeding or spotting; headache; dizziness; itching; weight gain; abdominal pain; breast tenderness; and rash.

Use of tibolone carries an increased risk of stroke, breast cancer and endometrial cancer (cancer of the lining of the uterus).

Tibolone is usually only used short-term, and only continued while the benefits of treatment outweigh the risks.

There may be other medicines that are available for the prevention of osteoporosis. Talk to your doctor about your options.

Reducing your risk of falling

If you are older or already have osteoporosis, having a fall and breaking a bone can have a dramatic effect on your quality of life, so it is important you try to avoid this.

Weight-bearing exercise will improve your muscle strength, and exercises such as Tai Chi or yoga can improve your balance.

You should ensure your house is free from loose mats, badly placed power cords and uneven surfaces that could cause you to trip over. Also, check that the lighting in your home is sufficient throughout and that any rails or steps are securely fixed.

Make sure too that you minimise the chance of falls by having your eyesight checked and that your eye glasses, if you wear them, are adequate.

Some medicines, such as sedatives, antihistamines and blood pressure medicines, can make you dizzy or interfere with your balance, so it is important that your doctor reviews all of your medications regularly.

Last Reviewed: 18 August 2016
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References

1. Preventing osteoporosis (published March 2014; amended June 2014). In: eTG complete. Melbourne: Therapeutic Guidelines Limited; 2016 Mar. http://online.tg.org.au/complete/ (accessed Aug 2016).
2. Osteoporosis Australia. Prevention (updated 25 Jun 2014). http://www.osteoporosis.org.au/prevention (accessed Aug 2016).
3. Guidelines for preventive activities in general practice, 8th edition. East Melbourne: Royal Australian College of General Practitioners (RACGP), 2012. http://www.racgp.org.au/your-practice/guidelines/redbook/osteoporosis/ (accessed Apr 2016).
4. National Health and Medical Research Council. Australian Guidelines to Reduce Health Risks from Drinking Alcohol, 2009. https://www.nhmrc.gov.au/health-topics/alcohol-guidelines (accessed Aug 2016).
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