Osteoporosis Risk Factors

Osteoporosis is a disease where the density and quality of your bones are reduced, as a result of age and various osteoporosis risk factors. The word “osteoporosis” literally means “porous bone.”

Your risk of a bone fracture increases as your bones become more porous and weakened. In serious cases of osteoporosis, even minor stresses — not just major falls or accidents — can cause bone fractures. Think coughing or sneezing, or bending or reaching for something. Fractures due to osteoporosis are most common in the hip, wrist, or spine.

In this article, we’ll discuss different osteoporosis risk factors, including merely having arthritis. It’s important to understand how arthritis and osteoporosis are connected, so you can ensure you’re getting appropriate testing and, if necessary, treatment.

The Connection Between Osteoporosis and Arthritis

In rheumatoid arthritis (RA) there’s often “local bone loss” where there is joint inflammation in the knees, hands, wrists, ankles or wherever the inflammation occurs in this autoimmune inflammatory condition, says Stephen Honig, MD, Associate Professor of Rheumatology and Director of the Osteoporosis Center at NYU Langone Health.

“Because of the release of inflammatory substances [in inflammatory arthritis], the bone next to the joint is often affected as well,” he said.

When people talk about the link between arthritis and osteoporosis, they’re generally talking about the inflammatory types of arthritis, which includes rheumatoid arthritis, psoriatic arthritis, systemic lupus erythematosus, and mixed connective tissue diseases, like scleroderma and polymyositis, says Dr. Honig.

Although bone loss is typical with aging, people with rheumatoid arthritis and other chronic inflammatory diseases often have systemic inflammation, which is associated with generalized bone loss, according to research in the journal Seminars in Arthritis and Rheumatism.

In addition, corticosteroid medications that people with arthritis commonly take to reduce inflammation and pain also increase your risk of developing osteoporosis (more on this below).

In osteoarthritis (OA), pain occurs due to wear and tear on joint tissue. It often involves the knees, hips, lower back, and small joints of the hands. This wearing away of the joint’s cartilage due to overuse of the joints or injuries of the joints leads to impaired flexibility, bone spurs, and swelling of the joint. Although some medical experts and researchers believe there is an association between bone mineral density and osteoarthritis, others see the two issues as distinct, but related through similar risk factors, such as age.

A 2021 study on the causal link between RA and osteoporosis found no evidence that RA is causally linked to osteoporosis but related to secondary effects from medications and reduced physical activity. However, yet another study in 2021 found strong evidence for a genetic connection between RA and osteoporosis. Clearly, more research is needed.

Osteoporosis Risk Factors

Here, familiarize yourself with other osteoporosis risk factors. Discuss these with your physician and learn what to do if you’re at an increased risk of osteoporosis.

Your Biological Sex

Women are more likely to develop osteoporosis than men (although men do get osteoporosis too). Women’s bones are smaller and thinner than men’s bones, which make them more fragile. And loss of the hormone estrogen after menopause cause lead to accelerated bone loss in women, which explains why women are even more at risk of osteoporosis as they age, according to the Bone Health and Osteoporosis Foundation. This is why it’s suggested that women get screened for osteoporosis earlier than men — age 65 for women and age 70 for men.

Your Age

Your bones are not an inanimate skeleton; rather, they contain living tissue made from cells that are constantly being broken down and then replaced with new tissue. When you’re a child and a young adult, your body replaces old bone faster than it breaks down old bone, which causes your bone mass to increase. But after about age 30, which is considered peak bone mass, your body doesn’t replace old bone as quickly. Over time, this can increase the risk of developing osteoporosis.

Also, as you get older your ability to absorb and use calcium and vitamin D decreases; these nutrients are an important part of the bone rebuilding process.

What’s more, cognition issues and balance problems that are more common in older adults could lead to falls and fractures, which then also increase your risk of complications from osteoporosis.

Your Weight

Excessive thinness or a history with an eating disorder like anorexia could put you at risk of developing osteoporosis earlier.

Studies have shown that a low body mass index (BMI) is related to osteoporosis and increased fracture risk. Women who have extremely low body weights (from eating disorders like anorexia) may also stop producing estrogen, a hormone that’s important for building and maintaining bone density. In some people, rheumatoid arthritis can cause weight loss, which could also affect your osteoporosis risk.

Your Medications

One of the biggest reasons someone with inflammatory arthritis is at a higher risk of osteoporosis is taking corticosteroid medication to manage symptoms. “With any patient who’s on long-term and high-dose corticosteroids, you have to worry about steroid-induced osteoporosis and fractures,” says Dr. Honig. Steroids are also used to help treat common arthritis comorbidities, such as lung disease and chronic obstructive pulmonary disease (COPD). “Taking corticosteroids can result in weakening of the bones,” he says. Taking an oral dose of 5 mg or so daily would predispose someone to systemic osteoporosis, says Dr. Honig.

Your History of Fractures

You might blame a weak ankle from sports injuries decades ago, but if you have a history of fractures, or even if you’ve only broken one bone in your lifetime, you’re at a higher risk of developing osteoporosis. If you’re over age 50 and have broken a bone, there’s a solid chance that fracture is related to osteoporosis.

Your Family History

Aside from your own history of fractures, if your parents have a risk of fracturing bones, particularly in the hips, or a parent has been diagnosed with osteoporosis, let your doctor know this information as well. A family history of hip fracture in parents was associated with a significant risk of all osteoporotic fractures in their children, according to the Centers for Disease Control and Prevention.

Your Smoking Status

If you were a regular cigarette smoker or still smoke on occasion, you’re at an increased risk for a fracture due to lower bone density and it may take longer for your bones to heal after a fracture. Research has found a direct relationship between smoking cigarettes and a decrease in bone density. Smokers also tend to be thinner and women who smoke may hit menopause earlier, which increases other osteoporosis risk factors. Quitting smoking, which is healthy for a million other reason, can also help limit bone loss and decrease your fracture risk.

Your Diet

Have you avoided dairy or dark greens most of your life? A diet that’s low in calcium (from such food sources as dairy products, fortified cereals and drinks, and dark leafy greens) could make you more at risk of developing osteoporosis. Your body needs the mineral calcium to make healthy bones and keep them strong. Your body can’t make calcium on its own; you only get it from foods and supplements. If you struggle to hit the recommended 1,200 mg of calcium daily, talk to your doctor about whether you could benefit from taking calcium supplements.

The 2021 position statement of the North American Menopause Society, which identified the risk factors for osteoporosis and discussed ways to mitigate it, also recommended an adequate intake of protein.

When to Screen for Bone Mineral Density

If you suspect you have a high risk of osteoporosis because of your risk factors, ask your doctor about this, and whether and when you should get a bone mineral density screening test. This test measures how much calcium and other essential minerals are in your bone and can determine whether you have osteoporosis (and the degree to which you have it), or osteopenia, a precursor to osteoporosis.

The scan will be performed using dual-energy x-ray absorptiometry (DEXA), which uses low-dose x-rays.

For patients without osteoporosis risk factors, guidelines from the U.S. Preventive Services Task Force (USPSTF) recommend that women should have their first bone density test at age 65. The Bone Health and Osteoporosis Foundation suggests men should get screened for osteoporosis at age 70.

For patients without osteoporosis risk factors, guidelines from the U.S. Preventive Services Task Force (USPSTF) recommend that women should have their first bone density test at age 65. The National Osteoporosis Foundation (NOF) suggests men should get screened for osteoporosis at age 70.

Experts agree that people with osteoporosis risk factors do need bone density screening at a younger age, but there are no set rules for exactly when to start osteoporosis screenings. The decision is up to you and your doctor. Some doctors may recommend you get one as soon as you’re diagnosed with inflammatory arthritis for a baseline; others may take a more conservative approach.

How to Prevent Osteoporosis

There are things you can do to improve your health right now if you are at increased risk of developing osteoporosis:

Do Weight-Bearing Exercise

Being upright and active is an important component of maintaining bone strength. While you don’t need to follow a rigorous strength-training routine to keep your bones strong, doing weight-bearing exercises — like walking — regularly will help build and maintain bone mass. According to the Mayo Clinic, weight bearing exercises, plus strength training, flexibility and balance exercises can be recommended for people with osteoporosis.

Get Enough Bone-Boosting Nutrients

Make sure you have adequate amounts of calcium in your diet, says Dr. Honig. “If not, taking a vitamin D supplement can help, especially in the wintertime when it can be difficult to get enough vitamin D from the sun in certain areas of the country.” Your body needs vitamin D to help you absorb the calcium in your diet and store it in your bones. Vitamin D also helps support muscles that surround those bones to help prevent falls.

You lose calcium daily through your nails, skin, hair, urine, sweat, and face. That’s why you need to replenish it with a healthy diet and/or supplement. Daily calcium intake of 1,000 mg (milligrams) for men and women up to age 50 is suggested by The Institute of Medicine. Women over 50 and men over 70 should increase that to 1,200 mg each day. Getting at least 800 to 1,000 international units (IU) of vitamin D is recommended daily.

How Osteoporosis Is Treated

Osteoporosis treatment is designed to prevent fractures. “We try to estimate the risk of fracture over a period of time and then determine whether medications are needed,” said Dr. Honig. “It’s an ongoing process. You may not need treatment in year one, but in two or three years, you may need treatment.”

Your doctor may prescribe medication that prevents bone loss and helps build bone. “The vast majority of drugs help prevent bone loss and strengthen bones by making them harder,” said Dr. Honig. Those could be traditional bisphosphonate medications, such as risedronate (Actonel), alendronate (Fosamax), or zoledronate (Reclast), which are taken orally, or RANK ligand inhibitors such as denosumab (Prolia), which is an injection to help prevent bone loss.

Some hormone-related drugs called selective estrogen receptive modulators (SERMs) also help prevent bone loss among people at high risk for osteoporosis, such as raloxifene (Evista).

“Talk to your physicians about what your fracture risk is and all the thing that go into an increased fracture risk,” said Dr. Honig. “Then you can have an informed discussion about whether taking osteoporosis medication is suggested or not.”

Ha J, et al. Body mass index at the crossroads of osteoporosis and type 2 diabetes. The Korean Journal of Internal Medicine. October 28, 2020. doi: 10.3904/kjim.2020.540

Liu Y, et al. Rheumatoid arthritis and osteoporosis: a bi-directional Mendelian randomization study. Aging. May 18, 2021. doi: 10.18632/aging.203029

McClung M, et al. Management of osteoporosis in postmenopausal women: the 2021 position statement of the The North American Menopause Society. The Journal of the North American Menopause Society. September 2021. https://journals.lww.com/menopausejournal/Abstract/2021/09000/Management_of_osteoporosis_in_postmenopausal.3.aspx

Straub R, et al. Evolutionary medicine and bone loss in chronic inflammatory diseases – a theory of inflammation-related osteopenia. Seminars in Arthritis and Rheumatism. October 2015. doi: 10.1016/j.semarthrit.2015.04.014

Yu X, et al. Rheumatoid arthritis and osteoporosis: shared genetic effect, pleiotropy and causality. Human Molecular Genetics. October 13, 2021. doi: 10.1093/hmg/ddab158

Interview with Stephen Honig, MD, Associate Professor of Rheumatology and Director of the Osteoporosis Center at NYU Langone Health

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