Cartoon illustration showing osteoporosis and lupus
Credit: Tatiana Ayazo

At least five million people worldwide are thought to be living with some form of lupus, a chronic autoimmune disease. Lupus occurs when your body’s immune system mistakenly attacks healthy tissues and organs. While it can impact any part of the body, lupus most often affects the skin, joints, or internal organs like the kidneys or heart 

Meanwhile, osteoporosis is a condition that impacts your bones. It causes bones to become weak, brittle, and break more easily. And it’s common: Osteoporosis is thought to affect over 200 million people across the globe. 

If you have lupus, chances are you’re already taking steps to protect your skin and joints, but here’s why you should find ways to preserve your bone health, too. 

The Link Between Lupus and Osteoporosis 

Overall, having one chronic illness tends to increase your risk of developing another. And that seems to be the case with lupus and osteoporosis. “Osteoporosis can be a coexisting disease process in patients with lupus,” says Nilanjana Bose, MD, a rheumatologist at Lonestar Rheumatology in Houston.  

The following factors are thought to play a role. 

Inflammation 

Simply having lupus has been linked to bone loss. Research shows that people who have lupus are at an increased risk of bone fracture. And women with lupus may be up to five times more likely to experience osteoporosis-related fractures. 

This increased risk of osteoporosis may be related to inflammation. Lupus is an inflammatory disease, meaning it leads to inflammation throughout the body. “The inflammatory cytokines involved in lupus can lead to bone loss,” explains Bose. That’s because this inflammatory process increases bone resorption and reduces bone formation.   

Medication 

Steroid drugs are commonly used to control underlying inflammation and treat lupus. Though they come with side effects — including an increased risk of osteoporosis 

“Patients with lupus usually have exposure to steroids, and steroids are a risk factor for bone loss,” says Bose. In fact, research shows that steroid use is a major risk factor for low bone mass. 

Bone loss often is most rapid in the first six months of steroid use and slows after 12 months. However, research shows that even long-term, low-dose steroid use in people with lupus can still lead to decreased bone mineral density. 

Lifestyle 

“Sometimes when people who have lupus hurt and don’t feel well, they don’t eat well and exercise, and that can be a significant issue as well,” says Bose. That’s because not keeping up with a healthy lifestyle can further increase osteoporosis risk. 

Research shows that being deficient in vitamin D — an essential nutrient for building strong bones and preventing osteoporosis that’s gained through exposure to natural sunlight and consumption of fortified foods — is also common in those with lupus.  

Osteoporosis Risk Factors  

Many other risk factors play a role in the development of osteoporosis. These can be broken into two groups: uncontrollable and controllable risk factors.  

Uncontrollable risk factors for osteoporosis include:  

  • Gender: Osteoporosis is more common in women, especially in perimenopausal women. 
  • Ethnicity: Osteoporosis is more common in Caucasian and Asian women. 
  • Age: The older you get, the higher your risk of developing osteoporosis. 
  • Family history: If an immediate family member, like a parent, has osteoporosis, your risk of developing it increases. 

Controllable risk factors, or those you can modify, include: 

  • Medications: Long-term use of steroids or anticonvulsants can contribute to osteoporosis. 
  • Diet: Low calcium and vitamin D intake may contribute to osteoporosis risk. 
  • Inactivity: Not exercising regularly, or being inactive, can weaken your bones. 
  • Weight: Being underweight (or having a small body frame) can impact bone health. 
  • Smoking: Smoking cigarettes makes you more prone to osteoporosis and bone fractures. 
  • Alcohol: Excessive alcohol consumption impacts how the body absorbs calcium and vitamin D, both of which are critical for healthy bone development. 

By familiarizing yourself with the many risk factors tied to osteoporosis, you can have an informed conversation with your health care provider about your personal risk and what you can do to protect your bones. 

Osteoporosis Symptoms  

Osteoporosis is sometimes referred to as a “silent” condition. That’s because it often has no symptoms.  

As it progresses, it can lead to symptoms like  

  • Back pain 
  • Sudden back pain 
  • Joint pain 
  • Changes in posture 
  • Stooping or loss of height 

But most people aren’t aware they have osteoporosis until they fracture or break a bone. That’s why it’s so important to be aware of osteoporosis and take steps to protect your bone health. 

Tips to Manage Lupus and Protect Your Bones 

These strategies can help you manage lupus and keep bones healthy. 

Eat a Healthy, Nutritious Diet 

Research shows that poor dietary habits can contribute to the progression of osteoporosis —but following healthier eating habits may help decrease disease progression.  

For optimal bone health, plan to eat a well-balanced diet full of fruits, vegetables, fish, whole grains, and legumes. Research shows a low-calorie, low-protein diet that focuses on fiber, polyunsaturated fat, vitamins, minerals, and polyphenols may help regulate immune system activity in people with lupus. 

Aim to get plenty of calcium and vitamin D — which can be found in dairy products like milk, cheese, and yogurt — to help preserve bone strength. “Vitamin D actually has a role not only in bone health, but also in lupus,” says Bose. One study suggests that taking high doses of vitamin D can improve disease activity and fatigue in people with lupus.   

Women ages 50 and under and men ages 70 and under should aim to get 1,000 mg of calcium each day and increase intake to 1,200 mg each day once women reach age 51 and men reach age 71. The recommended vitamin D intake is 400-800 IU a day for most adults under age 50, and 800-1,000 IU a day for those 50 and up. Talk to your doctor before taking any new supplements.  

Stay Active 

Not only does regular exercise help you improve balance and reduce your risk of falls — it also helps your body absorb calcium and vitamin D, emphasizes Bose. Research shows that staying active may also help improve underlying inflammation related to lupus. Regular exercise may also help improve lupus symptoms. 

Incorporating a mix of activities into your workout plan is best to promote overall health. If you experience lupus-related joint pain, stick with low-impact activities that are easier on the joints. And for osteoporosis, weight-bearing activities are especially important. Research has found that resistance exercises in particular, such as weightlifting, can help preserve both bone and muscle mass.  

Maintain a Healthy Weight 

Being overweight or obese can make it more challenging to manage lupus. And one study found that women with lupus are more likely to be affected by obesity compared to the general population.  

Meanwhile, being underweight can weaken bone health and increase your risk of osteoporosis. And researchers are starting to uncover a link between illness-related involuntary weight loss with lupus.  

Aim to reach and maintain a healthy weight to promote optimal health. 

Quit Smoking 

Smoking is bad for your overall health on many levels — including bone health. Smoking can contribute to weakened bones and increase fracture risk. Findings show that smoking may also trigger or accelerate the disease process in lupus.    

What’s more, many people who smoke also partake in other habits that impact lupus and bone health, like decreased activity levels and poor diet. 

If you smoke, it’s best to quit. Findings from one study show that quitting may help increase bone mass previously lost due to smoking.  

Ask your doctor if you need help with quitting. You may benefit from the use of a smoking cessation aid.  

Moderate Alcohol Use 

Research shows that chronic, excessive alcohol consumption increases osteoporosis risk. Heavy drinking has also been linked with a decrease in bone density and weakened bones.  shows that chronic, excessive alcohol consumption increases osteoporosis risk. Heavy drinking has also been linked with a decrease in bone density and weakened bones.  

What’s more, excessive alcohol consumption has also been linked to other lifestyle habits that affect bone health, including smoking and poor eating habits. 

If you do drink, be sure to so in moderation: That means one drink a day for women, and two for men. Some research shows that drinking in moderation may provide protective benefits against lupus. 

When to Talk to Your Doctor About Bone Health 

Because there are often no symptoms of osteoporosis until a bone breaks, routine screening can help prevent osteoporosis. Screening is easy and only takes five to 10 minutes. Early detection can help you take proper steps to prevent fractures and promote bone health.  

Routine screening for osteoporosis should be done:  

  • After age 65 for women, 70 for men, or sooner depending on your personal risk factors 
  • Every one or two years, or more often depending on your health  
  • After a bone fracture in those over age 50 
  • When taking new medication associated with low bone mass or bone loss 

Talk to your doctor at your next health exam about getting screened for osteoporosis.  

This article was made possible with support from Amgen. 

American Bone Health. How Often Should I Get Tested? https://americanbonehealth.org/bone-density/how-often-should-i-have-a-bone-density-test/  

American College of Rheumatology. Lupus. https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Lupus  

Bone Health & Osteoporosis Foundation. Evaluation of Bone Health/Bone Density Testing. https://www.bonehealthandosteoporosis.org/patients/diagnosis-information/bone-density-examtesting/  

Bone Health & Osteoporosis Foundation. Osteoporosis Exercise for Strong Bones. https://www.bonehealthandosteoporosis.org/patients/treatment/exercisesafe-movement/osteoporosis-exercise-for-strong-bones/  

Bultink IE. Bone Disease in Connective Tissue Disease/Systemic Lupus Erythematosus. Calcified Tissue International. September 2017. https://link.springer.com/article/10.1007/s00223-017-0322-z  

Cleveland Clinic. When (and Why) Should I Start Screening for Osteoporosis?  https://health.clevelandclinic.org/when-and-why-should-i-start-screening-for-osteoporosis/  

Gracanin AG, et al. [BONE MINERAL DENSITY IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS–OUR RESULTS]. Reumatizam. 2018. https://pubmed.ncbi.nlm.nih.gov/26882799/  

Hassanalilou T, et al. Role of vitamin D deficiency in systemic lupus erythematosus incidence and aggravation. Autoimmunity Highlights. December 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5743852/  

Hong AR, et al. Effects of Resistance Exercise on Bone Health. Endocrinology and Metabolism (Seoul). December 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6279907/  

Islam MA, et al. Immunomodulatory Effects of Diet and Nutrients in Systemic Lupus Erythematosus (SLE): A Systematic Review. Frontiers in Immunology. July 2020. https://pubmed.ncbi.nlm.nih.gov/32793202/  

Katz P, et al. Impact of obesity on functioning among women with systemic lupus erythematosus. Arthritis Care & Research. October 2011.  https://pubmed.ncbi.nlm.nih.gov/21702085/  

Kiyota Y, et al. Smoking cessation increases levels of osteocalcin and uncarboxylated osteocalcin in human sera. Scientific Reports. October 2020. https://www.nature.com/articles/s41598-020-73789-4  

Lupus Foundation of America. How lupus affects the bones. https://www.lupus.org/resources/how-lupus-affects-the-bones  

Lupus Foundation of America. Lupus facts and statistics.  https://www.lupus.org/resources/lupus-facts-and-statistics  

Mayo Clinic. Osteoporosis. https://www.mayoclinic.org/diseases-conditions/osteoporosis/symptoms-causes/syc-20351968  

Molina E, et al. A prescription for exercise in systemic lupus erythematosus. Lupus. December 2021. https://pubmed.ncbi.nlm.nih.gov/34903093/  

National Institute of Arthritis and Musculoskeletal and Skin Diseases. Osteoporosis. https://www.niams.nih.gov/health-topics/osteoporosis 

New York State Department of Health. What You Should Know About Steroids and Osteoporosis. https://www.health.ny.gov/publications/1985/index.htm  

NIH National Institute on Alcohol Abuse and Alcoholism. Alcohol and Other Factors Affecting Osteoporosis Risk in Women. https://pubs.niaaa.nih.gov/publications/arh26-4/292-298.htm  

NIH Osteoporosis and Related Bone Diseases National Resource Center. Exercise for Your Bone Health. https://www.bones.nih.gov/health-info/bone/bone-health/exercise/exercise-your-bone-health 

NIH Osteoporosis and Related Bone Diseases National Resource Center. Smoking and Bone Health. https://www.bones.nih.gov/healthinfo/bone/osteoporosis/conditions-behaviors/bone-smoking