Six Myths of Osteoporosis | New Light on Bone-density Controversies

Many studies show how simple lifestyle changes—like regular exercise—can reverse thinning of bones.

Few things are more  disconcerting for women over 50 than the specter of osteoporosis and osteopenia. Even men are not exempt from the brittle bone disease—one out of four people with osteoporosis are men.

The statistics indeed are sobering. Ten million Americans have osteoporosis, another 34 million have pre-osteoporosis, or osteopenia. About 24 percent of people over 50 who have a hip fracture die within a year after having the fracture, and an estimated 25 percent end up in a nursing home.

Yet, take a look behind the curtain, and you might be surprised at what you find. Our knowledge about how to treat and prevent osteoporosis is still developing, and there are numerous controversies.

The issues around the side effects of osteoporosis drugs are well known. An FDA advisory panel recently called for greater warnings on osteoporosis drugs, and urged the FDA to look into why the drugs are prescribed for women with osteopenia, for whom studies show the drugs provide questionable benefit.

However, there are numerous other controversies around current practices in diagnosis and prevention of osteoporosis. Here are six myths about osteoporosis and osteopenia to consider.

MYTH #1: Your grandmother’s osteoporosis is your osteoporosis

In your mother or grandmother’s time, osteoporosis was defined as “a disease where bones fracture as the result of little impact, because they have become thin, brittle, and weak.”

That changed in 1994, when a study group working under the World Health Organization published new guidelines for the classification of osteoporosis based on the so-called T-scores. The WHO standards defined osteoporosis as bone density  minus 2.5 standard deviations and for osteopenia minus 1.0 to 2.5 standard deviations below the average bone mass density (BMD) of healthy 30-year-old white females.

Everyone loses bone mass as they get older. The question is, what is normal bone loss, and what is cause for concern? Under the new WHO guidelines, millions of women age 50 and over became classified with a potentially serious condition. Researchers involved in the classification noted that the thresholds were “somewhat arbitrary” and intended for epidemological studies, not as a clinical threshold.

Particularly controversial was the classification of osteopenia. In a 2003 article in the New York Times, Dr. Steven R. Cummings, a leading osteoporosis researcher, noted that  “there is . . . no basis whatsoever” for using one standard deviation as the cut-off for osteopenia. As a consequence of this definition, however, “more than half of the population is told arbitrarily that they have a condition they need to worry about.”


MYTH #2: DXA scans providea reliable picture of bone mineral density

The gold standard for measuring bone mass density (BMD) is the DXA scan, or dual-energy x-ray absorptiometry. Yet, as Finnish researcher Dr. Teppo Järvinen and colleagues note in a 2008 article in the British Medical Journal, DXA scans can “underestimate or overestimate bone mineral density by 20 to 50 percent.”

In other words, someone with a BMD T-score of minus 1.5 (classified as osteopoenia), could have a true value between minus 3.0 and 0—that is, ranging from clear osteoporosis to normal. Further, when a different DXA scan machine is used on the same person, the number of people classified as having osteoporosis varies from 6 to 15 percent.

MYTH #3: Bone mass density  provides a reliable measure of fracture risk

A 50-year-old woman with a bone mass density classified as osteoporotic has a much lower risk of having a fracture within the next five years than an 80-year-old woman with the same bone density.

One reason for this variation is that bone strength is related more to the quality of the bone—its internal structure—than to bone mass. Bone density tests fail to capture this important, but poorly understood factor which declines with age.

Recent re-evaluation of pivotal clinical trials “has brought into question our long-held idea that increases in bone density parallel increases in bone strength and reduction in fractures, and that therapeutic improvement in bone density is the mark of success,” writes Dr. Angelo Licata in a 2009 article in the Cleveland Clinic Journal of Medicine. “Bone strength or resistance to fracture is more complex than density alone.”

MYTH #4: Osteoporosis is the largest risk factor for fractures

Bones don’t just break—even for those with osteoporosis. In fact, the largest single risk factor for fractures is not osteoporosis, but falling! According to Järvinen, falling is the main cause of over 90 percent of hip fractures.

Falls become more common as we grow older, because we lose balance, coordination, and muscle strength. If falling indeed is the strongest single risk factor for fractures, it would seem important to focus not just on thinning bones, but on the factors that help reduce the risk of falling. Yet these are largely overlooked in current osteoporosis prevention efforts.

In fact, the simplest way to determine your risk of fractures may be your assessment of how well you balance. In a study of Swedish twins aged 55 and above, twins who said that their balance was impaired had three times the risk of suffering a hip fracture over the next five years, even if they did not have osteoporosis. Approximately 40 percent of all hip fractures were attributable to impaired balance, irrespective of whether the person had osteoporosis.

MYTH #5: Dowager’s hump is caused by osteoporosis

Vertebral fractures caused by osteoporosis have long been considered to be the cause of the so-called Dowager’s hump, or hyperkyphosis, which develops in many older people. Characteristically, the partially drug company-sponsored National Osteoporosis Foundation tends to refer to the condition as “spinal deformity.”

Recent studies, however, have found that six out of ten people with hyperkyphosis do not have vertebral fractures. More commonly, hyperkyphosis appears to be linked to degenerative disc disease, another common companion of the aging process. Hyperkyphosis is also linked to loss of muscle strength, particularly in the back extensor group.

An estimated 20 to 40 percent of older adults will eventually develop hyperkyphosis, the health consequences of which dwarf those of osteoporosis. Millions of people with osteoporosis never incur a fracture. People with hyperkyphosis, on the other hand, are living with the consequences of the condition every day.

Hyperkyphosis has been linked to numerous health issues, including  increased risk of falls and fractures (independent of osteoporosis), restricted breathing due to the compression on the lungs, reduced quality of life (greater anxiety and depression), impaired mobility, reduced ability to manage simple daily tasks, and increased mortality.

MYTH #6. Osteoporosis is an isolated condition

Osteoporosis doesn’t exist in isolation. It is part of a larger syndrome of aging, which includes several degenerative processes: loss of bone mass, loss of muscle mass (sarcopenia), loss of balance and coordination, degenerative disc disease, global posture deterioration and overall loss of structural health, and loss of flexibility and range of motion.

Together, these degenerative processes account not just for an increase in fractures, but for the vast majority of functional limitations we develop as we get older: aches and pains, limited mobility, overall frailty, and gradual inability to function independently. However, as we shall see below, even though they can’t be prevented entirely, their progression can be slowed to a considerably degree.

Writing Your Own Prescription for Healthy Aging

There are numerous efforts to find more precise diagnostic efforts and better treatments for osteoporosis. However, with 11 percent of women over 55 on osteoporosis drugs, the financial stakes are high.

“An informal global alliance of drug companies, doctors, and sponsored advocacy groups portray and promote osteoporosis as a silent but deadly epidemic bringing misery to tens of millions of postmenopausal women,” writes Pablo Alonso-Coello and colleagues in a 2008 article in British Medical Journal. He characterizes the status quo as disease mongering—transforming a risk factor into “a medical disease in order to sell tests and drugs to relatively healthy women.”

Efforts at preventing osteoporosis miss the mark if a narrow focus on BMD causes us to overlook the many other important things we can—and must—do to empower ourselves to take greater charge of how well we age. The degenerative processes of the aging syndrome are inevitable, yet we have considerable control over when and to what degree they develop.

Thousands of studies document the power of simple lifestyle changes, particularly exercise and healthy diet, to reverse not just thinning bones, but all of the degenerative conditions associated with the aging syndrome. Old age (limited mobility, frailty, difficulty performing daily tasks) may hit in your 60s, 70s, 80s, or even 90s. The choice, to a large extent, is yours.

Strength training is an important component of preventing osteoporosis. But to prevent the overall aging syndrome, you need a broader focus and a wide variety of exercise activities from balance training and coordination to maintaining flexibility, aerobic capacity, and so on. Holistic movement forms like dance, yoga, and tai chi are particularly useful for creating the kind of whole-body, mind-body exercise that trains not just muscles, but coordination and mental sharpness as well. Only in this way can we accomplish sound prevention, not just of fractures, but overall frailty and loss of function, and write our own prescription to ensure health in old age.     

NOTE: Nothing in this article should be construed as medical advice. Osteoporosis is a serious condition. Please consult with your doctor if you suspect you have osteoporosis.

Terry Smith is a body worker and movement therapist and Eva Norlyk Smith is a health writer and movement therapist. They teach the Healthy Body, Healthy Back course and a course entitled Beyond Bones—The 7 Keys to Successful Aging. This is an excerpted version of a larger report on osteoporosis controversies. For the full, annotated report, reach the authors at Fairfieldwellness@gmailcom.