Not worried about your bones? You should be

Lately something interesting has been going on with popular wellness trends. Along with the usual suspects — products and activities that help boost muscle or give you more energy — more and more have to do with improving bone health. Think: weighted vests and creatine supplements. And this focus on bone health is definitely a good thing. 

For most people, unless you break one, you might not even think of your bones much at all. But ignoring your bone health — or forgetting about it completely — can have huge consequences in the years to come. That’s because once you lose bone density, it’s very hard to get it all back. This is especially important if you’re losing weight, as that can weaken your bones. With that in mind, here’s how to make sure your bones are as healthy and strong as they can be, today and for decades to come.

Your bones are a combination of protein, flexible collagen, and minerals like calcium, which gives them their firm, strong structure. And they are constantly changing, with certain cells (osteoblasts) forming new bone tissue and others (osteoclasts) breaking down old bone formation. When there’s an imbalance in those processes — too much old bone is broken down without enough new bone being formed, it can lead to weaker, more fragile bones.

Depending on your age, you might assume your bones are just fine — something to focus on down the road. But that’s not the best approach. Women reach their peak bone mass in their 20s, according to Dr. Kristi Tough DeSapri, M.D., an internist in Chicago who specializes in bone health in women. From that moment on, you’re looking at a decline. You may lose 0.5% to 1% of bone mineral density a year — and the rate of bone loss jumps to 1% to 3% for five to 10 years after menopause.

The biggest bone issues among women tend to be osteopenia (low bone mass) or osteoporosis (more advanced bone loss), according to DeSapri. But you don’t just wake up one morning and realize you have one of these conditions.

"Osteoporosis is a silent disease in the way that high blood pressure is a silent disease — you have no idea that you have it unless you're getting screened for it, and you won't know the consequences of it until something devastating happens," says Sarah Wherry, PhD, an assistant professor of Medicine-Geriatrics at University of Colorado School of Medicine. For high blood pressure, that “something devastating” is a heart attack or stroke. And for osteoporosis, that's a hip or spinal fracture.

Fractures, which are any break or crack in the bones, are no joke, often causing lasting pain and disability. A hip fracture is by far the most concerning, since nearly 30% of people over 65 who get one die within a year. “It's not that people are dying from the hip fracture itself, but rather from the complications that come with it," says Wherry. "You're going to have a lot of inflammation and mobility issues — and many people get hospital-acquired disabilities because of their inability to get up and move around." On top of that, hip fractures are common in older people who have comorbid health conditions like heart disease, diabetes, and dementia — and a hip fracture can make those much worse, Wherry adds.

Even if you recover from a hip fracture, it can still impact your ability to age comfortably. “Of the people who do survive a hip fracture, about 50% of them will lose their ability to live independently,” says Wherry. That can keep you from aging in place (staying in your current home), prevent you from continuing some of your normal activities, and interfere with your independence — all of which can have a huge impact on your mental and physical health as you get older.

What could cause old bone to get carted off faster than new bone is laid down? There are a few things that can contribute to this:

• Nutritional deficiency: Being low in vitamin D and calcium can do a number on bone health. Roughly 42% of people in the United States aren't getting enough calcium, a mineral that’s like a building block of bones. Deficiencies in vitamin D, which helps the body absorb and use that calcium, are also common. Plus, other parts of your body — your muscles, nerves, and heart — also need calcium. And when you don't get enough via your diet, your body draws on its "reserves" from your bone. 

• Sedentary lifestyle: Exercising, especially lifting weights and resistance training, creates stress on the bones that, in turn, triggers them to rebuild denser and stronger. You also want to up your overall activity levels. Research has found that regardless of how much you work out, the more sedentary you are, the worse your bone health. 

• Weight loss: Not only does losing weight cause you to lose muscle, it also reduces your bone density and increases your risk of fractures. This is due to many factors, including the hormonal changes that occur when losing weight, nutritional deficiencies that may arise from a lower-calorie diet, and the impact weight loss has on your metabolism. There’s also the fact that excess weight places a natural stress on your bones that may improve its density and strength. When you lose that weight, that is diminished.

• Menopause: “In the years leading up to menopause, your body’s production of estrogen declines, leading to a variety of physical and emotional changes,” says DeSapri. This matters because estrogen has an osteoprotective effect, meaning it protects bones from damage or deterioration.  Estrogen also helps the body absorb calcium. So when levels of estrogen drop, bone loss speeds up. “ Studies have shown that women on average lose 5% to 7% bone density in the hip, and 10% in the spine over the menopause transition,” says DeSapri. 

• Genetics: As with most health-related things, there’s a genetic component to how strong your bones are. A family history of fractures and osteoporosis increases your likelihood for both. 

• Other health issues: Medical conditions (such as rheumatologic conditions) can increase your risk of bone problems down the line, as do certain medications (like corticosteroids and aromatase inhibitors).

Getting an idea of how healthy your bones are right now can be a good idea. Remember: “There is no warning sign before a fracture occurs,” says DeSapri. But your bones are pretty hidden from view, making it tricky to check up on them. That’s where imaging scans come in. “A screening DXA, or bone mineral density scan, can help identify if you have bone loss and what your peak bone mass is,” says DeSapri. (DXA stands for dual energy X-ray absorptiometry.) It’s a “painless, low-radiation scan — similar to an X-ray — of your spine and hip, and occasionally forearm, to evaluate your bone mineral density and strength.”

But there’s a road block: “Insurance usually doesn’t cover a bone density scan for women until after menopause,” says Wherry. (It’s also a challenge to get scans for men at all, since osteoporosis is thought of as a “women’s” disease, she notes.) If your insurance won’t cover a DXA, you should still talk with your doctor about any risk factors. “If one of your parents had a hip fracture before the age of 80, you've taken medications known to influence your bone health — things like inhaled steroids or oral steroids — or you have inflammatory diseases like Crohn's disease or rheumatoid arthritis, those are all things that can increase your risk for osteoporosis,” says Wherry. And in that case, she says, it’s worth talking to your provider to see what you can do to manage and track your bone density long-term.

Once you lose bone density, it can be hard to build it back up, which is why it’s important to do what you can now to keep your bones strong. Consider these moves:

• Load up on calcium: In addition to a well-rounded diet, “incorporate adequate calcium and vitamin D in your diet, and consider supplementation,” DeSapri says. Dairy products like yogurt and milk are a good start, but sardines and greens (like spinach and collard greens) are also overlooked sources of calcium. As for vitamin D, certain types of fish, like rainbow trout, salmon, and tuna, are your best bet, as are fortified foods. If you’re deficient, your doctor might recommend a supplement.

• Up your resistance training: Get into a regular workout routine that incorporates strength or resistance training. When you move weight, you create controlled, beneficial stress for your bones, forcing them to get stronger, says DeSapri. You can also try a weighted vest to add some resistance during walks or workouts, though she warns that there aren’t any randomized studies that support a specific dose and duration to improve bone loss. (And weighted vests shouldn’t replace actual resistance-based workouts, either.)

• Kick bad habits: DeSapri recommends doing an inventory of your lifestyle — and, in particular, she recommends avoiding excess alcohol and smoking, since these can both speed up bone loss.

• Consider creatine: The research is emerging, but mixed. “Most information on creatine and nutraceuticals are anecdotal or based on small observational studies with less than 100 women,” says DeSapri. So it might be helpful if you take it for other reasons, like to build muscle, but you don’t have to do it for your bones.

For some people — like those whose bone mineral density scan come back with a low reading — your provider may recommend medications like bisphosphonates, estrogen agonists, and denosumab, which slow down the breakdown of bone, and teriparatide, which works by increasing bone formation. 

Bone health can seem like a far-off concern, but bone mass in women actually starts to decline as early as one’s 20s and 30s — and then has a steep drop-off once the menopausal transition starts. That’s because the body loses out on estrogen, which can have a protective effect on the bones. You also might have weakening bones and never know it since osteoporosis is a “silent” disease that isn’t often noticed unless you experience a fracture. The good news: Resistance training, eating more calcium- and vitamin D-rich foods, and adjusting your lifestyle habits can help keep bones strong. That can have a big payoff as you get older, keeping you healthier (and happier) in the long run.