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Molly Giles was standing in her kitchen one spring night in 2019, musing about whether to do the dishes or leave them until the morning, when a bone in her left leg snapped and she crashed to the ground, breaking her hip.

“I passed out, and I’m pretty sure I would have died if my partner hadn’t been there and called 911,” the Northern California novelist recalls.

Giles, now 81, had “bones like meringue,” her doctor rather glibly later told her. A scan several years earlier had revealed <a href="https://my.clevelandclinic.org/health/diseases/21855-osteopenia" target=_blank>osteopenia</a>, a precursor to the “silent” disease of bone density loss known as osteoporosis. But neither Giles nor her doctors followed up, and her bones grew increasingly weak until her femur “melted,” as she later described it.

Stephanie Mohan

Giles isn’t alone in failing to take bone health seriously until a crisis. Weak bones can lead to sudden fractures that can disable or even kill you. Some 20 to 30 percent of people who suffer a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6428998/" target=_blank>hip fracture</a> die within a year, usually due to a downward spiral involving decreased mobility and possible infections. Nonetheless, experts say osteoporosis remains underdiagnosed, undertreated and widely misunderstood.

“It’s just not on the radar screens for many patients and physicians,” says Andrea Singer, director of bone densitometry at MedStar Georgetown University Hospital in D.C. and a spokeswoman for the Bone Health &amp; Osteoporosis Foundation. The neglect can endure even after a serious bone break, as a 2021 <a href="https://www.milliman.com/en/insight/medicare-cost-of-osteoporotic-fractures-2021-updated-report" target=_blank>report from Milliman, a data firm</a>, revealed.

Within six months of an osteoporosis-related fracture, the risk of a second break is highest, yet according to the Milliman report, only 8 percent of Medicare beneficiaries received a diagnostic bone density scan after a fracture. That share dropped to 5 percent for African American Medicare beneficiaries, and bone experts assume even worse rates for younger patients and those who haven’t had a fracture.

“When you come in to see your doctor you may have 15 minutes, during which they’ll look at blood pressure, body weight and cholesterol, and then you may have a problem you want to discuss,” says endocrinologist and researcher Dolores Shoback at UCSF Health in San Francisco. “So osteoporosis is way down on the list and often isn’t discussed — even with older women.”

This makes it incumbent on women, in particular, to raise the question if their doctors don’t, she adds. “We have a consensus that all women over age 65 should be screened, but we’re not getting most of them, not by far.”

Health and Human Services recommends that women 65 and older <a href="https://health.gov/myhealthfinder/doctor-visits/screening-tests/get-bone-density-test" target="_blank">schedule a bone density test</a>, known as a DXA, or DEXA, for <a href="https://www.radiologyinfo.org/en/info/dexa" target="_blank">dual-energy X-ray absorptiometry scan</a> — a painless procedure that’s safer than a standard X-ray. Women 64 and younger who have gone through menopause should ask their doctors if they need one, particularly if they have clinical risk factors (see the sidebar “Know your risk profile”), including smoking, drinking more than three drinks a day, and taking prednisone or other glucocorticoid medications.

Many factors contribute to the low rates of testing, not least of which is garden-variety denial of aging. “For many patients, there’s a bit of ‘That’s not me,’” Singer says. “Osteoporosis is your grandmother’s disease, and I’m not that frail old lady.”

Osteoporosis is more common in older people, affecting an estimated <a href="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/osteoporosis-screening" target=_blank>12.3 million</a> Americans over 50 in 2020. Yet as many as <a href="https://www.ncbi.nlm.nih.gov/books/NBK499878/" target=_blank>47 million other</a> Americans of all ages are on the precipice of osteoporosis, with diagnosable osteopenia (low bone mass). Women outnumber men <a href="https://health.ucsd.edu/care/endocrinology-diabetes/osteoporosis/risk-factors/#:~:text=drugs%2C%20warfarin).-,Women%20and%20Osteoporosis,percent%20of%20all%20hip%20fractures." target=_blank>4 to 1</a> for reasons that are largely hormonal — women lose up to <a href="https://www.endocrine.org/patient-engagement/endocrine-library/menopause-and-bone-loss" target=_blank>20 percent of bone density</a> up to seven years after menopause, when bone-protecting estrogen levels decline. Women also suffer more than 70 percent of the related fractures.

But men, who tend to wait even longer to get scanned and treated, have <a href="https://pubmed.ncbi.nlm.nih.gov/12195537/" target=_blank>a higher death rate</a> after a hip fracture.

Preventing osteoporosis should begin many years before such problems might occur, experts say.

“We should start paying attention to bone health with kids and teens, when they have their peak bone mass,” Singer says. That includes consuming sufficient calcium — 1,200 milligrams in two or three doses spread out through the day for women over 50 — and up to 1,000 IU of vitamin D in your diet or supplements.

“In the older population in particular, especially the frail who get the hip fractures, you want to be sure they are getting sufficient protein intake as well,” Shoback says.

Fortunately, osteoporosis is treatable even in old age, with lifestyle changes and a wide array of medications.

Weight-bearing exercises, forcing your body to work against gravity, may help strengthen bones. This might include walking, climbing stairs or playing pickleball (or tennis). Higher-impact exercise, such as a Zumba class, may be the most effective. Muscle-strengthening activities, such as lifting weights, and balance exercises, including tai chi and yoga, can reduce the risk of fractures from falls.

Some doctors prescribe <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4520366/" target=_blank>hormone therapy</a> to replace waning estrogen, strengthen bones and reduce fractures in younger postmenopausal women. The downside is increased risks of strokes and heart attacks for women 60 or older or 10 years after menopause.

More commonly, for more than two decades, doctors have prescribed a class of drugs called bisphosphonates, with brand names that include Fosamax, Boniva and Reclast. Bisphosphonates and denosumab (Prolia), a monoclonal antibody, are known as “antiresorptives” because they target bone cells that break down and reabsorb bone tissue. Some can be taken orally every day, every week or every month; others are given intravenously, every three months.

Bisphosphonates can cause stomach upset, heartburn, and in very rare cases jawbone damage and thigh fractures. Doctors usually recommend that patients who have taken these drugs for three to five years discontinue them for up to two years, and then resume if there are no signs of problems. These medications can start reducing the <a href="https://www.hss.edu/conditions_bisphosphonates-concerns-regarding-risks-and-side-effects.asp" target="_blank">risk of fractures</a> in as soon as six months.

Another class of medications builds bones instead of slowing their destruction. These include abaloparatide (Tymlos) and teriparatide (Forteo), both of which resemble the parathyroid hormone involved in regulating the metabolism of calcium. Both require daily injections (usually self-administered) for up to two years.

One new osteoporosis medication is romosozumab-aqqg (Evenity), a monoclonal antibody approved by the Food and Drug Administration in 2019. The medication is designed to help both build bone and reduce bone loss. It requires two injections every four weeks for 12 sessions (over 48 weeks), usually at a doctor’s office. Amgen, the company that makes Evenity, warns it can have serious side effects, including increased risk of heart attack, stroke or death from a cardiovascular (heart or blood vessel) problem.

The benefits of all the bone-builders dissipate within about two years.

In a recent change, some osteoporosis specialists now recommend that people with low bone density or a recent fracture begin treatment with one of the bone-building drugs and follow up with an antiresorptive medication to try to maintain their benefits.

But bone-building drugs are expensive, and some insurance plans won’t reimburse unless a patient has already tried other medications. At that point, however, the bisphosphonates may at least temporarily <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2667901/" target=_blank>blunt the effect</a> of the bone-builders.

Scientists around the world are working on new medications and treatment approaches for osteoporosis. Some are studying stem-cell therapies that may hasten repair of fractures. Others are looking into drugs that may clear out <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8046105/" target=_blank>senescent (age-challenged) cells</a> to help new bones form.

Slowing U.S. drug development progress, however, is an FDA requirement that clinical trials measure their effectiveness by how well they can reduce fractures.

The Foundation for the National Institutes of Health and collaborating scientists have pressed the FDA to substitute measures of <a href="https://fnih.org/news/fda-approves-biomarker-qualification-plan-for-the-first-surrogate-endpoint-in-anti-osteoporosis-drug-trials/" target=_blank>bone density changes and biochemical markers</a>, which could reduce the high cost and time involved in current trials.

After Giles’s doctor compared her bones to meringue, he prescribed Fosamax, which she is still taking. She has also adjusted to using a cane and carefully scanning the ground as she walks. Her mordant wit informs both her writing — her book titles include “Wife With Knife” and “The Home for Unwed Husbands” — and her views on bone fragility and aging.

“One good thing about the fear of falling is you end up seeing a lot of great stuff on the ground, like money and cougar paw prints,” she says. “I even found a silver bracelet half-buried in dirt.”

One in 5 women ages 50 to 60 have osteoporosis, a disease that weakens bones to the point where they break easily, <a href="https://www.nia.nih.gov/health/osteoporosis#:~:text=Osteoporosis%20affects%20about%20one%20in,healthy%20during%20and%20after%20menopause." target=_blank>according to the National Institute on Aging</a>. The percentage climbs with age until, from age 75 to 84, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2685234/" target=_blank>roughly 32.5 percent of women and 6.4 percent of men are affected</a>.

Age is a significant risk factor for weak bones: Not only are bones more brittle after a woman goes through menopause, but she is also more likely to fall because of weaker muscles and medications that can cause drowsiness.

Other risk factors for women and men include being a smoker or heavy drinker, having a family history of osteoporosis; having a disease, such as HIV, that can contribute to a relatively rapid loss of bone mass; having had premature menopause; being underweight, small-framed or taking steroid medications; and having previously fallen and broken a bone.

<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4757905/" target=_blank>Race and ethnicity</a> also matter: For reasons that remain unclear, Mexican Americans account for 13.4 percent of people with osteoporosis and osteopenia, while non-Hispanic Whites account for 10.2 percent and Black Americans for 4.9 percent.

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Katherine Ellison

Many Americans have weak bones, but don’t know it

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