Osteopenia

Osteopenia is a condition where your bones lose density and become weaker than normal, though not weak enough to be classified as osteoporosis. About 40 million Americans have osteopenia, and it typically develops after age 50, though the exact timing depends on how strong your bones were when you were younger.

Table of contents

• What is osteopenia?
• Symptoms
• Causes and risk factors
• Diagnosis
• Prevention and treatment
• Living with osteopenia

What is osteopenia?

Osteopenia is the loss of bone density — the amount of minerals like calcium in your bones. When you have low bone density, your bones lack enough minerals, which makes them weak^[1]. Your bones are made of living tissue that constantly changes. To keep them strong, your body breaks down old bone and replaces it with new bone^[1].

Think of osteopenia as a midpoint between having healthy bones and having osteoporosis. With osteopenia, your bones are weaker than normal, and your risk of getting osteoporosis and having broken bones increases. With osteoporosis, your bone density loss worsens and you become much more prone to fractures if you slip or fall^[1].

Your bones are usually at their densest when you’re about 25 to 30 years old. You lose bone density naturally as you age. Bone density loss affects roughly one-third of adults over age 50. Osteopenia, if it happens at all, usually occurs after age 50^[1]. The exact age it starts depends on how strong your bones are when you’re young. If they’re hardy, you may never get osteopenia. If your bones aren’t naturally dense, you may get it earlier^[1].

The good news is that osteopenia is not inevitable. Diet, exercise, and sometimes medication can help keep your bones dense and strong for decades^[1].

Symptoms

You probably won’t notice any symptoms if you have osteopenia. That’s why doctors often call it a “silent disease”^[1]. Decreasing bone density doesn’t cause pain^[5]. Most people who have osteopenia don’t have symptoms^[4].

However, you could break a bone more easily after a minor fall or bump^[1]. Often, people don’t know they have an issue with bone loss until they fall and break a bone^[10]. One possible indicator that something may be awry is height — people lose an average of an inch in height as they age, but if it’s more than that, it could signal a problem^[23].

Causes and risk factors

Peak bone mass is normally achieved by the third decade of life. Most people reach peak bone mass around age 30. After that, your body breaks down old bone faster than it builds new bone^[1]. This means you lose some bone density, and your bones may become more brittle^[5].

While it is estimated that hereditary factors dictate up to 80% of our ability to achieve and maintain optimal bone density levels, modifiable factors contribute to the rate of natural bone mass reduction into adulthood. These include weight-bearing exercises, nutrition status (adequate calcium and vitamin D daily intake), body mass, and hormonal balance^[3].

Some people are genetically prone to osteopenia, with a family history of the condition. You’re also more likely to get it if you’re a woman. Women have lower bone mass than men. Also, women live longer, which means their bones age more, and they usually don’t get as much calcium as men^[1].

Hormone changes that happen at menopause increase the chance of having osteopenia for women, and men with lower testosterone levels have higher odds of getting it^[1]. Women who had surgery to remove their ovaries before menopause are also at increased risk^[1].

Other risk factors include being of White or Asian descent, having an early menopause (before age 45), and having hyperthyroidism^[4]. Adults older than 50, people who smoke or use tobacco products, and people who regularly drink alcohol (more than two drinks per day) are at higher risk^[10].

Medical conditions that can lower your bone density or worsen osteopenia include diabetes, chronic kidney disease, malnutrition, a calcium or vitamin D deficiency, hormonal imbalances, eating disorders like anorexia, and autoimmune diseases that affect your bones like rheumatoid arthritis^[10]. Untreated celiac disease can damage the small intestine by eating foods with gluten, which can starve your body of nutrients needed to keep bones strong^[1].

Medications that can increase your osteopenia risk include diuretics, corticosteroids (steroids like hydrocortisone or prednisone), medications used to treat seizures (such as carbamazepine or gabapentin), hormone therapy for cancer, anticoagulants, and proton pump inhibitors that treat acid reflux^[1][10]. Chemotherapy and exposure to radiation can also play a role^[1].

Diagnosis

In order to diagnose osteopenia, your doctor will do a bone density test^[4]. The main way to determine your bone density is to have a painless, noninvasive test called dual-energy x-ray absorptiometry (DXA or DEXA) that measures the mineral content of bone^[2]. This scan measures bone density in your hips, spine, and wrist^[4].

The measurements, known as T-scores, determine which category — osteopenia, osteoporosis, or normal — a person falls into^[2]. Osteopenia, as defined by the World Health Organization, is a T-score between -1 to -2.5, while values less than -2.5 are diagnostic for osteoporosis^[3]. The lower your score, the higher your risk of bone breakage^[4].

Fracture risk increases as bone mineral density declines. But there isn’t a huge difference between, say, a -2.3 T-score and -2.5, although the former would be labeled osteopenia and the latter, osteoporosis. The label matters less than the number^[2].

According to the U.S. Preventive Services Task Force, all women over 65 years old should have a bone density test. Women under 65 years old should be tested as well if they’re at high risk^[4]. Postmenopausal women younger than 65 years who are at increased risk for an osteoporotic fracture as estimated by clinical risk assessment should also be screened^[2].

If your bone density results fall into the osteopenia category, your doctors will probably schedule you for a bone mineral density test every two to five years^[2]. Because the difference in bone density between two tests must be at least 4 to 5 percent to be a reliable indication of change, women with osteopenia and no other risk factors should wait five to 10 years before being retested^[14].

Prevention and treatment

You can’t always avoid osteopenia. No matter what you do, bone mass decreases over time^[4]. However, there are some things you can do to lower your risk and keep your bones as healthy as possible.

Diet and nutrition

For strong bones, you need a diet rich in calcium and vitamin D^[1]. Bones rely on calcium to get stronger, and your body needs vitamin D to absorb calcium. Aim for 1,000 IU of vitamin D and 1,000 milligrams of calcium per day^[2]. Try to get as much calcium as you can from food, such as dairy products, sardines, and leafy greens^[2].

High-calcium foods include dairy products such as yogurt, low-fat milk, and cheese; green vegetables such as broccoli and collard greens; sardines and salmon with bones; and tofu^[1]. Your body makes its own vitamin D when sunlight hits your skin. If you spend a few minutes outdoors in the sunshine each day, you get at least some of the vitamin D you need^[1]. Good food sources include fish such as salmon, tuna, and mackerel; fish liver oils; beef liver; cheese; egg yolks; and fortified breakfast cereals, juices, milk products, yogurt, and margarine^[1].

If you’re not getting enough calcium in your diet, ask your doctor if you should add a low-dose calcium supplement to make up the gap^[2].

Exercise

Like muscles, bones get stronger when you use them^[1]. Bones get stronger when we exert force on them by using our muscles. Weight-bearing exercise — such as resistance (strength) training or body-weight exercises — is an effective way to do this^[2].

The best moves for bones are weight-bearing exercises that force your body to work against gravity. That includes walking, stair climbing, dancing, and lifting weights^[13]. If your feet touch the ground during an exercise, it’s probably weight bearing. Running and walking are weight bearing. Swimming and biking are not^[2].

Simply walking at a brisk pace reduces the likelihood of osteoporosis. Aerobic and balance exercises help reduce the risk of falling and suffering a fracture^[2]. Not getting enough weight-bearing exercise (at least 30 minutes on most days) accelerates bone loss^[2].

Lifestyle changes

If you smoke, try to quit. Studies show a strong link between cigarette smoking and lower bone density^[1]. If you drink alcohol, do it in moderation. That means no more than one drink per day for women and two daily drinks for men. Too much beer, wine, or liquor can mess with the balance of calcium in your body and change how your body makes hormones and vitamins for healthy bones^[13].

Cut back on salt and caffeine. Both may make your body lose more calcium and bone. Caffeinated coffee and sodas have been linked to osteopenia, so try to cut back or switch to the decaf kinds^[13].

Medications

In some cases, especially if you’ve already broken a bone, your doctor may prescribe medicine to lower your chances for osteoporosis and prevent more fractures^[13]. Medications that can treat osteopenia or prevent osteoporosis include bisphosphonates, which slow your body’s natural process of breaking down bones. You may keep the level of bone you have or even get a small boost of bone density^[13]. These include alendronate, ibandronate, risedronate, and zoledronic acid^[13].

However, pharmacologic treatment for fracture prevention depends on fracture risk and patient preference^[14]. Not everyone with osteopenia needs medication. Women with osteopenia and no other risk factors may not require drug treatment^[14].

Living with osteopenia

Falls are much more likely to cause fractures when you have osteopenia. Lower your risk of falls by getting rid of obstacles in your home that may cause you to trip, such as loose rugs or electronic cords; adding railings to your shower or bathtub walls; limiting your use of sleep medications; and wearing your glasses or contacts if you need them^[13].

Having osteopenia does not mean you will definitely develop osteoporosis. With proper care and attention to bone health, many people can prevent osteopenia from progressing. If you have osteopenia, your bone density is lower than average, but it can be managed^[10]. Visit a healthcare provider for regular checkups. They’ll tell you when you’ll need your bone density tested^[10].