Critical Mass

By staff June 1, 2005

When Sarasota resident Shirley Darling was a little girl, her mother made her sleep without a pillow to keep her posture arrow straight. "She was always telling me and my brother to sit up," recalls the 80-year-old former nurse.

So when Darling noticed her spine starting to curve about eight years ago, she headed straight for an internist and requested a bone density test. He denied her request and sent her home with a clean bill of health.

"He was a very good doctor," Darling insists. "But he goofed on that one." One month later, a rheumatologist confirmed what Darling suspected, that her poor posture was caused by osteoporosis.

With that news, Darling joined the estimated 10 million Americans over the age of 50 who have the condition, which sucks mass from bones, leaving them so weak and brittle that the simple act of sitting can crush an entire pelvis like soapstone.

Although Darling's bone density test showed that her spine had been painlessly succumbing to compression fractures for years, the news could have been worse. The American Academy of Orthopaedic Surgeons (AAOS) says osteoporosis contributes to about 700,000 spine fractures and about 250,000 wrist fractures every year. The U.S. Department of Health and Human Services (HHS) attributes 1.5 million fractures to weak bones that cost nearly $18 billion in medical care. Hip fractures alone account for nearly 300,000 hospitalizations annually, with individual costs reaching more than $80,000.

Risk factors for osteoporosis include smoking and alcohol abuse, but 80 percent of its victims are women, and race is not a factor. AAOS says as many as 49 percent of Mexican-American women 50 years and older have low bone density. And while only 10 percent of African-Americans over the age of 50 have osteoporosis, between 80 and 95 percent of all fractures in African-American women over the age of 64 are related in some way to osteoporosis.

The reason seems to lie in the amount of estrogen a woman produces. Estrogen is crucial to maintain bone mass, but by the time women reach menopause, estrogen drops to one-tenth the levels of pre-menopausal women. In the five to seven years following menopause, women can lose up to 20 percent of their bone mass.

But men are also at risk. "Bone health is dependent on sex hormones [like estrogen in women and testosterone in men]," says Dr. Suhail Khoury, of the Khoury Institute in Sarasota. Although men continue to produce the testosterone that protects their bones until late in life, by the time they reach their 70s, both men and women are losing bone mass at about the same rate.

Approximately one in eight men will eventually experience an osteoporosis fracture. Women suffer hip fractures nearly three times as often as men, but men are nearly twice as likely to die within a year of having the same type of fracture. "A lot of it has to do with recovery," says Dr. Erik Herman, of Kennedy White Orthopedics in Sarasota. Some 20 percent of all hip fracture patients die within a year of the fracture, and 20 percent will end up in nursing homes.

Herman cites complications from hip surgery, including blood clots and pulmonary embolisms, but he says the main problem is immobility. "You lose a significant amount of strength lying in bed," he says. This leaves patients prone to pneumonia and secondary complications that are more dangerous than the initial fracture.

For years, the first line of defense against osteoporosis was hormone replacement therapy. The National Institutes of Health maintains that replacing estrogen and progestin in older women can reduce the rate of hip and spine fractures by 34 percent by increasing bone density and prevent further bone loss, but not everyone agrees with that assessment.

"Bone density is not directly related to fracture," says Khoury. According to Khoury, who has a Ph.D. in physiology, bone efficiency depends on elasticity and plasticity. "If you hit a dried-up tree limb, it breaks," he explains. "A fresh, green limb will bend, even if it's half the size of the dry limb." Mass, he says, plays a big role in preventing fractures, but not the ultimate role.

Don't rely too much on calcium, either. "Calcium is the [substance] needed to prevent bone loss," says Khoury. "But it will not stop the loss. It will slow it down, by 20 to 30 percent, but the process continues."

Between 1993 and 1998, more than 27,000 healthy, postmenopausal women who enrolled in a government study to determine the effects of HRT on preventing bone fractures and other disease were ordered off their drug regimen early when safety monitors noticed a spike in the rate of breast cancer among participants. The rate of heart attacks, stroke, and blood clots in the lung and legs also increased.

Doctors now prescribe hormones for osteoporosis only in extreme cases. Instead, they've turned to medications like Fosomax and Actonol, which belong to a class of drug called bisphosphonates. "They're the only medications that actually raise bone mass," says Herman, who's seen a significant reduction in the bone fractures of his patients who use the two drugs.

Patients with osteoporosis who are suffering severe menopausal symptoms can also try Evista, one of a new group of drugs called estrogen receptor modulators. These drugs mimic the effects of estrogen on bones without damaging breast tissue or raising the risk for uterine or ovarian cancers.

Khoury believes the most effective method for deterring osteoporosis is prevention, but few doctors devote much of their practice to treating the condition because it is not financially feasible. Most osteoporosis patients are on Medicaid or Medicare, which have steadily decreased physician reimbursement.

Unfortunately, HHS predicts that if nothing is done soon to address the problem, within 15 years, weak bones and low bone mass will afflict half of all Americans over 50. This could cause the number of hip fractures in the United States possibly to triple by 2040. And because a fracture is the first sign someone is at risk, up to four times as many men and nearly three times as many women may have osteoporosis without even knowing it.

"It's a shame we can't prevent this 100 percent," says Khoury. "We have the knowledge and the ways to diagnose it and the medications to treat it." He insists, "Osteoporosis should not exist as a social problem. It should not be a punishment for getting old."


The National Institutes of Health says that because the average woman acquires 98 percent of her bone mass by the age of 20, building strong bones in childhood and adolescence can be the best defense against developing osteoporosis late in life. Here are five other ways to protect yourself.

  • Exercise. The U.S. Department of Health and Human Services (HHS) maintains that half of all Americans don't exercise enough to strengthen their bones. Children and teens should get at least an hour of physical activity every day. Adults should get at least 30 minutes a day. "I can never emphasize enough to my patients to stay physically active," says Dr. Erik Herman of Kennedy White Orthopedics in Sarasota. "The older you are, the more immobility is going to cause you problems."
  • Diet. Try to consume 1,000 to 1,500 mg a day of calcium, and 400 to 800 units of Vitamin D. Milk, leafy green vegetables, soybeans, yogurt, cheese and fortified orange juice are all good sources of calcium. Be aware that not all calcium supplements are the same. Calcium phosphate has the highest available absorption rate, 40 percent. A good over-the-counter product is Posture D, which also contains magnesium.
  • Testing. HHS recommends that every woman over the age of 65 and anyone who has had a bone fracture over the age of 50 get a bone density test. This simple test is painless and takes less than 10 minutes.
  • Balancing acts. Supplement aerobic exercise and strength training with balance activities like tai chi. (The American Academy of Orthpaedic Surgeons claims tai chi decreases falls among seniors by 47 percent.) Remove small rugs that can be tripping hazards. Install grab bars around tubs and showers and non-slip mats inside them. Avoid medications that could cause drowsiness and lead to falls.
  • Moderate your vices. Avoid smoking and heavy alcohol use. Both habits leech valuable bone mass from your body.


Testing for osteoporosis is a simple, painless procedure, thanks to DEXA scans that produce the same amount of radiation as 10 minutes in the sun. Getting them read correctly is another matter. Never allow a scan of just your ankle or wrist to determine if you have osteoporosis. The condition usually manifests itself first in the hip and spine, so insist on a full body scan. Make sure your scans are read by a qualified doctor in a certified facility that tests its machinery for accuracy. Then make sure your doctor compares the scan's score to the actual X-ray image. Conditions like osteoarthritis leave calcium deposits that a DEXA scan will read as healthy bone. If your doctor relies solely on the computer score, you could be sent home with a "normal" reading, when in fact you're a walking fracture waiting to happen.


Before you begin any drug regimen for osteoporosis, make sure you actually have the condition. "We have 64 other illnesses that can cause osteoporosis," says Dr. Suhail Khoury, of the Khoury Institute in Sarasota. Among them are hypothyroidism, liver disease and multiple myeloma, an incurable cancer of the blood. It can even be induced by anti-seizure drugs, cortisone and heparin, a popular blood thinner. Says Khoury, "If you miss [a proper diagnosis], you may be missing someone with cancer."


The span of your arms should be the same as your height. If it's larger, you've already lost height and may be developing osteoporosis. Get a bone density test to make sure. And here's a good reason to defy society's obsession with thinness: Khoury says that overweight people suffer less from osteoporosis, because the extra weight they carry increases their bone mass. "A big risk factor is a body weight of less than 127 pounds for women," he says.

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