Face a higher risk of osteoporosis? Tweak some lifestyle changes and explore new treatments to protect your bone health. Photo / 123rf
A new bone-strengthening drug could benefit thousands of menopausal women, but lifestyle changes can also help us stay strong as we age
Few of us think about our bones too much, until later life when they start causing issues. But like most things, it pays to nip problems in the bud while there’s still time.
One in five men and one in two women will eventually suffer a fracture over the age of 50. At age 59, I’m well aware this could one day be me. Osteoporosis runs in my family. By 65, the women of my clan are typically stooped, with a rounded upper back. Though the sometimes (horribly named) “Dowager’s hump”, or kyphosis to use the medical term, can be the result of weakening muscles, it’s often a telltale sign of a crumbling spine. So it is in my family – both my grandmothers suffered frailty fractures in later life and, after breaking a hip, sadly neither recovered.
So the recent news that a new bone-strengthening drug called abaloparatide will soon be available in Britain on the NHS was music to my ears. Particularly as I have just learnt, following a DEXA bone-density scan, that my bone density has dropped in the past five years, tipping me into “low bone density” territory (also known as osteopenia).
Abaloparatide will be made available to 14,000 postmenopausal women on the NHS, to cut their risk of fractures. The Royal Osteoporosis Society’s osteoporosis specialist nurse and nurse manager, Julia Thomson, says the new drug is a potential game-changer for those who are most severely affected.
“It’s great because it’s another option,” says Thomson. “It will probably be targeted at people who have had lots of fractures and very low bone density, who are struggling to find a treatment to suit them; it will need to be prescribed by a specialist.”
Fortunately a low bone density score – a T-score between -1 and - 2.5 on a bone density scan indicates low-bone density; a T-score of -2.5 or lower indicates osteoporosis – isn’t a calamity, says Thomson, and won’t necessarily lead to fractures, or even necessitate drug treatment. Our bones are living tissue and we can keep healthy depending on our daily habits, even in later life.
So what lifestyle changes can we adopt to keep our bones strong and healthy in midlife and beyond?
“The recommended intake of calcium is 700mg a day. It’s a bit higher if you have a diagnosis of osteoporosis – then you’re looking for 1000mg,” says Thomson. “It’s best to get dietary calcium, but if you aren’t hitting your target you can look at supplements. Your GP can prescribe them.”
Milk provides 200mg of calcium for a mug-sized portion, but you don’t need to drink milk for an adequate calcium intake.
“Green vegetables and cruciferous vegetables contain masses of calcium,” says nutrition company Zoe’s head nutritionist Dr Federica Amati. “And the other thing is tofu, which is a really good source. And if you like oily fish, anchovies and sardines are really good sources of calcium, especially when eaten with the bones.”
She also wants us to include fermented dairy such as kefir and yogurt and to up our fibre intake with a plant-rich Mediterranean diet, to feed our gut microbes.
“There’s this really cool interplay between fermented dairy, the gut biome and gut and bone health,” says Amati. Studies show that eating fermented dairy which contains calcium, protein and probiotics is associated with a lower risk of hip fracture in women. One study showed that women who ate yogurt had a 25% lower risk of hip fracture. While further research suggests a healthy gut microbiome may improve absorption of calcium in the gut.
Hence I now aim to start the day with a fibre-rich breakfast, usually steel-cut oats with apple and frozen raspberries and toasted seeds – and now I’m adding shop-bought kefir to up my prebiotic quota.
The Royal Osteoporosis Society provides a list of calcium-rich foods and has a handy calculator on its website, giving the calcium content in common foods that will help you tot up your daily intake.
Our bodies manufacture this key bone-building vitamin as light hits our skin. “Vitamin D is more worrying than calcium, as we’re more often deficient,” says Thomson. “Safe sunlight exposure is the best source, but people will need to take a supplement as they get older if they can’t get outside. In winter a 10mcg vitamin D supplement is a good idea.”
Amati advises getting outside for 20 minutes in the morning, before you slather on any SPF. “Sunscreen is great for anti-ageing but it does block vitamin D production,” she says. “What I do is go outside and give my skin a bit of exposure to the sun before it gets really hot.”
Exercise that sends a jolt through your bones will help strengthen them. “The force of the impact on the ground is hugely beneficial to the skeleton,” says Thomson.
“When your foot hits the ground your bone responds to that. I’m not going to use the word ‘microfracture’ because it isn’t as severe as that, but it kicks the bones into turning over and rebuilding. We see the opposite in astronauts who lose bone density when they are weightless. If you equate that to an older person who is very sedentary, they will also lose bone extremely quickly.”
So which exercise is best? Skipping, hopping, running, jumping all work. If you’re looking for a class at the gym, the best benefits will come from circuit training and HIIT, which include high-impact jumping exercises such as burpees and skipping.
One study showed that premenopausal women who performed 10 to 20 high-impact jumps, with 30 seconds of rest in between each jump, twice a day for four months significantly increased bone density in their hip bones compared to a group of women who did not jump. This works post-menopause too. I’ve started jogging again after a 10-year break and have just bought a skipping rope.
Unfortunately, a stroll in the park is unlikely to exert sufficient impact for maximum bone-building, though it’s certainly better than nothing. “Running is better than jogging, jogging is better than brisk walking, brisk walking is better than a stroll,” says Thomson. “But it’s really about finding what works for you and doing it regularly. Five times a week would be great.”
If you already have low bone density (osteopenia) or osteoporosis, you might worry about exercising, but it’s best to keep moving, says Thomson. According to the Royal Society of Osteoporosis, moderate-impact exercise is generally okay for those with osteoporosis and it’s probably safe to continue with high-impact exercise if you’re already doing it and haven’t had any pain or fragility fractures.
At school I was hopeless at sport, but perhaps it’s time I brushed up my backhand to join the flocks of midlifers taking up padel, the popular new tennis-like racquet sport.
“Racquet sports are really good because you’re twisting, you’re turning, you’re changing direction and changing the stress you’re putting on different parts of your bones,” says Thomson. “Any sport that does that will have similar benefits.” So squash, netball, basketball, volleyball are all good news for our skeletons.
Strength training is paramount to bone health, this much I was aware of. When tendons and muscles pull on bones they lay down more calcium and become stronger. What I hadn’t realised, though, was quite how heavy you need to go in the gym to see bone-health benefits.
“The key thing is that you have to add a significant load,” says Telegraph fitness expert Matt Roberts. “People are always surprised by how intense it really needs to be. High rep work is good for generalised fitness, but bone-building happens when you’re lifting at a level where you can only manage between four and eight reps.”
So my favourite pump class (light weights, high reps) is probably not stimulating my bones to the degree that I’d hoped.
The best bone-building moves, says Roberts, include pulling exercises such as seated rows, deadlifts and leg-presses because you’re working the mid-spine but in a controlled way, “where the muscles are pulling on the most vulnerable areas for osteoporosis, around your hips, pelvis and lower vertebrae”.
Lunges or squats with a barbell are also “gold standard”, says Roberts, though not easy to do and you need to build a baseline fitness before attempting heavily weighted moves.
Women become more vulnerable after the menopause as bone-protecting oestrogen drops off a cliff. Most will experience a rapid decline in bone density, losing up to 10% in the first five years after their last menstrual cycle. Taking HRT can help stem this flow, but not prevent it completely, as I’ve discovered. I’ve still lost 6-7% bone density in the past five years, despite using HRT patches.
“HRT was once the only treatment for bones when I started working for the Osteoporosis Society 25 years ago, and every woman was encouraged to take HRT after the menopause and recently we’ve seen a bit of a resurgence,” says Thomson. But why is HRT effective?
“We have oestrogen receptors all over the body and when levels drop at menopause, those receptors suffer. It could be the hair, the skin, the bones or vaginal tissue. And by using an [oestrogen] supplement after menopause it can help your bones because you’re not dipping down to those very low levels.”
“A very low BMI is a risk factor of osteoporosis,” says Thomson, “and certainly people with eating disorders are more at risk of fractures since being underweight can result in lower oestrogen levels, similar to after menopause. But now there is evidence that people who are at the opposite end of the spectrum and carrying a lot of weight are at risk too.”
But people with obesity have a different fracture pattern, says Thomson. “We see more ankle fractures. For light individuals the problems are in the hips and spine. So it’s best to stay in the normal weight range.”
When it comes to our bones there’s a clear link between heavy drinking and poor bone health. “If you’re drinking a lot, alcohol can have a damaging effect on the osteoclasts, the bone-building cells,” says Thomson, and obviously too much booze isn’t great for balance.
I rarely, if ever, drink beyond government guidelines, but I am partial to that warm fuzzy feeling imparted by the odd glass or two of rioja after a long week.
Sadly even this, aside from the increased cancer risk, is doing my bone health no favours. Amati suggests limiting my intake to one or two glasses with food, and only on special occasions.
The Royal Society of Osteoporosis is more lenient. “We suggest people stick to the government’s Drink Aware guidelines of 14 units a week,” says Thomson.
Similarly, smoking has an impact on the bone-building cells. " If you’re looking for motivation to stop smoking, bone health could certainly be up there,” says Thomson.
An online risk checker assessment tool is available online at the Royal Society of Osteoporosis. Speak to your GP if you are concerned and you may be referred for a DEXA scan to assess your bone strength.
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