6 Steps to Reduce Fracture Risk
- Fracture a hip with osteoporosis and you have a 20-40% chance of dying in a year.
- The bone density myth that has people focusing too much on their T-score.
- Modifiable risk factors are in your control. Change them and change your risk.
By Dr. John Neustadt
Osteoporosis is a bone disease marked by declining bone density and weakening bones. Osteoporosis can be a silent disease for many years, as bone gradually becomes more fragile. One of the most dangerous consequences of weakening bones is an osteoporosis fracture. Since osteoporosis makes bones more fragile and easier to break, osteoporosis fractures are also called fragility fractures.
Fractures resulting from osteoporosis are surprisingly common. Approximately 1 in 2 women and 1 in 5 men will experience an osteoporosis-related fracture in their lifetime.
Osteoporotic fractures are not like the broken bones you had in grade school. The aging body doesn’t heal as readily as the 8-year-old. Of every 3 osteoporotic fractures that occur in adults, 1 will require hospitalization. For those people with osteoporosis who break a hip, there’s a 40% chance of dying in 6 months. The risk of dying isn’t just increased in the months following the fracture. The risk of death is increased for the next 5 to 10 years.
If you’re one of the lucky ones who survives a fracture, breaking a bone inevitably reduces physical function. We always hope the disability will be temporary, but there’s a 50% chance you won’t regain the same level of independence you had before the fracture, and 20% of people who survive require long-term care.
Given the pain and disability that fragility fractures cause, it’s important to learn what you can do to reduce your fracture risk.
In this article I dispel the myth of bone mineral density and teach you what the research shows are natural ways you can reduce your risk.
The Bone Density Myth
Bone mineral density is a measurement of the amount of minerals in the bone. A person’s bone density is determined by a bone density test, which is a special type of radiology technique called a dual-energy x-ray absorptiometry (DXA) scan. The DXA scan is a standard tool used for osteoporosis screening, diagnosis and ongoing monitoring. Results are reported as a T-score, which is a number that indicates how different a person’s bone density is compared to healthy women in their 20s.
Bone mass increases steadily through childhood and young adulthood, to reach peak bone mass around age 30. After about age 40, bone mass declines at a gradual rate in both men and women. For women, the fastest rate of bone loss occurs for approximately 10 years after menopause.
While measurements of bone mineral density are the way osteoporosis and pre-osteoporosis (osteopenia) are diagnosed, the question remains: how well does bone mineral density predict fracture risk?
Conversations with healthcare providers unfortunately tend to focus primarily on a person’s bone mineral density test results. Low bone mineral density increases fracture risk, but not as dramatically as most people think. While bone density tests are important, most healthcare providers are either unaware or simply don’t tell their patients that bone density predicts less than half of people who will break a bone.
While most people think low bone density is the most important risk factor for predicting osteoporosis fracture risk, that myth was debunked in the 1990s. One important study is The Rotterdam Study, which tracked thousands of US adults over the age of 55, monitoring them for bone mineral density and non-spinal fractures (e.g., hip, wrist and upper arm). The researchers discovered that bone density tests predict only 44% of fractures in women and only 21% in men.
But what The Rotterdam Study and other studies also found out was that the risk of breaking a bone was greater for people who don’t even have osteoporosis. Most fractures occurred in people with osteopenia. The reasons for this are unclear, but it’s possible that people with osteoporosis are proactively working to reduce their fracture risk.
Based on this and other studies, the World Health Organization (WHO) and the American College of Obstetricians and Gynecologists (ACOGS) correctly concluded that fracture risk depends on factors largely other than bone mineral density.
Since more than half of fractures in aging adults occur in people without a diagnosis of osteoporosis, it’s time to look beyond bone density to other indicators of fracture risk and what you can do about them.
Fracture Risks You Control
The World Health Organization (WHO) and other medical groups, such as the American College of Obstetricians and Gynecologists (ACOG) established risk factors for osteoporosis fractures that have remained relatively consistent over the years. Many risk factors are out of our control and are called “non modifiable” risks. For example, being female increases your risk, as does simply getting older. If you’ve had an osteoporotic fracture in the past, you’re at increased risk for a future fracture. If one of your parents had an osteoporotic fracture, if you entered menopause before the age of 45 or if you are underweight also increase your risk.
Other risk factors, however, are called “modifiable” risks because you can do something about them. For example, cigarette smoking, excessive alcohol consumption, low amounts of calcium, vitamin D and vitamin K, and never exercising increase risk for osteoporosis and fracture. These modifiable risk factors are what lay the foundation for a proactive approach to fracture risk reduction, an approach we have summarized in the following 6-step action plan.
6-Step Action Plan to Reduce Your Fracture Risk
The 6-step plan described here is designed based on research showing that these actions reduce the risk for the most debilitating outcome of osteoporosis: fractures. You may read elsewhere about medications, vitamins, or supplements that increase bone mineral density, but always ask the question: does the research specifically show that it reduces fracture risk?
Step 1: Hazard-Proof Your Home
The number one risk for fracture is falling. Simple changes that reduce your risk of tripping over something in your home, or slipping and falling are important to make. You can wear slippers or shoes that have non-slip soles; tuck electric cords away; secure loose rugs to the floor; place non-slip mats in the shower (or install a seat in the shower); and keep the home well-lit, including a lamp you can reach before you get out of bed.
Step 2: Stop Smoking
Smoking cigarettes is strongly associated with osteoporotic fractures. Smoking alters the blood supply to bone and also exposes the body to cadmium and other heavy metals that are toxic to bone.
A 2015 study looked at the effects of smoking as well as smoking cessation on fracture risk. Researchers followed 1033 women for 10 years, beginning at the age of 75 years old. They found that both former smokers and current smokers had a 31% increased risk for osteoporotic fractures overall, but women who quit smoking had a significantly lower risk of vertebral fractures than women who continued to smoke.
Step 3: Follow a Mediterranean Diet
Food provides the building blocks for excellent health. A whole-foods diet is naturally rich in the vitamins, minerals, proteins and phytonutrients has been shown to grow stronger bones and reduce fractures. The most studied dietary pattern is the Mediterranean Diet. Over the past fifty years this way of eating has been shown to reduce the risk of cardiovascular disease, diabetes, osteoporosis, cancer, death from cancer and death from other causes.
A 2017 review article found that following a Mediterranean Diet was associated with an increased bone density and a 21% decreased risk of hip fracture. Their analysis further showed that the more someone adheres to the diet the greater the benefit.
The Mediterranean Diet is essentially the opposite of the Standard American Diet. It’s low in processed foods, fried foods and red meat. Instead, it emphasizes fruits, vegetables, grains, legumes, nuts and healthy oils such as olive oil. Following a Mediterranean Diet means eating lean proteins such as chicken and fish a few times a week, and eating red meat only a couple times a month. Transitioning to a Mediterranean Diet will give your body a good foundation to maintain strong, healthy bones.
Step 4: Exercise
To evaluate the effect of exercise on fracture risk, researchers followed 9704 women, aged 65 and older, for an average of 7.6 years. They found that women who participated in more leisure time, more sport activity, more household chores, and fewer hours of sitting per day had a significantly reduced risk for hip fractures. When compared to no activity, vigorous or moderate physical activity reduced the risk of hip fracture by 42% and spinal fracture by 33%.
Most experts recommend a combination of balance and strength training to reduce the risk of falls and fragility fractures. An expert panel of clinicians published exercise recommendations in 2014 for people with osteoporosis, concluding that aerobic exercise should not be done without also including balance and strength training. Not all exercise is appropriate for everyone. Prior to starting an exercise routine, you should check with your healthcare provider to discuss appropriate and safe levels of exercise you.
Step 5: Moderate Alcohol
If you drink alcohol, it’s important to understand the link between the amount and type of alcohol you’re drinking and your risk for osteoporosis fractures. Research shows that drinking too much alcohol increases your risk of fracture while drinking alcohol in moderation can reduce people’s risk.
Researchers analyzed 33 studies that looked at the link between drinking and fractures. They concluded that people who consume 2 or more drinks per day have a 39% increased risk of hip fracture.
Drinking less alcohol protected bones. Compared to people who didn’t drink alcohol at all, those who drank an average of half to one alcoholic beverage per day had a 20% reduced risk of hip fracture compared to non-drinkers.
And a second study confirms the results. When more than 100,000 postmenopausal women were evaluated for their drinking habits and fracture risk, researchers discovered that women who drank an average of 3.3 glasses of wine per week (approximately 0.5 glasses per day) had a 22% lower risk of hip fracture than women who did not drink alcohol at all. This study is interesting in that it concluded that the reduced fracture risk was seen in women who drank wine and not hard alcohol.
If you drink alcohol, limit your intake to 3-3.5 drinks per week.
Step 6: Take Bone Building Dietary Supplements
There are many nutrients in bone health dietary supplements; however, only a few nutrients have been shown in clinical trials to grow stronger bones and reduce fractures. These are calcium, vitamin D, vitamin K2 (as MK4) and strontium. While you may not decide to take them all, these are the ones supported by clinical trials.
Calcium and Vitamin D
Calcium and vitamin D have long been heralded as the most important nutrients for bone health, and the Food and Drug Administration (FDA) has approved calcium and vitamin D for the prevention of osteoporosis.
Calcium. An extensive systematic review was published in 2015 that looked at 52 studies comparing calcium intake to fracture risk. Researchers found that most studies reported no relationship between calcium intake from foods and fracture risk. Of the 26 randomized controlled trials of calcium supplementation, there was evidence that calcium supplementation reduced the risk of total fractures by 11%. When specific fracture locations were examined, calcium supplementation reduced the risk of spinal fractures by 14% but did not reduce the risk of wrist or hip fractures.
Vitamin D. Because calcium and vitamin D work synergistically to support bone health, most clinical trials evaluate the combination of these 2 nutrients. A randomized controlled trial of 2532 adults over the age of 65 found that supplementation with 1000 mg of calcium and 400 IU of vitamin D for 3 months reduced fracture risk by 16% when compared with placebo. A 2015 meta-analysis of 8 randomized controlled trials (involving 30,970 participants) concluded that calcium plus vitamin D supplementation produced a 15% reduction in total fracture risk and a 30% reduction in hip fracture risk. In line with these studies, a 2014 review of 53 studies concluded that supplementation with calcium and vitamin D produces a statistically significant reduction in the risk for hip fractures, spinal fractures, and overall fractures.
Overall, studies show that calcium and vitamin D supplementation reduces the risk of osteoporotic fractures by approximately 15-16%.
Strontium is another mineral that can be deposited in bone and contribute to bone mineral density. A certain form of strontium, called strontium ranelate (SR), has been extensively researched and is approved as a treatment for osteoporosis in most of Europe.
In the strontium ranelate for the treatment of osteoporosis (STRATOS) trial, researchers evaluated the ability of different amounts of SR to reduce fractures in 353 post-menopausal women with osteoporosis. The most interesting results were in volunteers who took either SR 500 mg /day or 2.0 grams/day. Studies like this are called dose-response studies and are interesting because they provide data that help us learn the best amount to take.
After two years of taking SR, the people taking less SR (500 mg/day) had fewer fractures than those taking 2.0 grams/day, 29% reduced fracture risk versus only a 23% reduction, respectively. Interestingly, while bone density increased in both groups, those taking 2.0 grams/day had their bone density increase the most, and yet they suffered more fractures. A second study gave SR 2.0 grams/day to 1,649 postmenopausal women for 3 years. Unlike the first study, these women experienced 41% fewer fractures.
A few cautionary notes about strontium. Strontium has an atomic mass greater than calcium. As such it attenuates the X-rays from a DEXA scan to a greater extent than calcium. Unless the radiologist corrects for this, the DEXA scan will not provide an accurate measure of BMD. Strontium may also interfere with calcium absorption. Thus, if you take strontium make sure to take it away from calcium. Finally, the form of strontium used in clinical trials (strontium ranelate) is not available in the United States. The form available in dietary supplements in the US is strontium citrate. Although the strontium citrate form helps grow stronger bones, clinical trials have not been performed on strontium citrate.
Vitamin K2 (as MK4)
Vitamin K is an essential nutrient with many important functions. For bone health, vitamin K is required for deposition of calcium in bones and for the formation of bone collagen. Vitamin K2 is available as a supplement in two forms: MK7 and MK4. It is important to distinguish between these 2 forms because only MK4 has been shown to reduce the risk of fractures in clinical trials of people with osteoporosis.
More than 28 human clinical trials have been conducted in over 7,000 participants using 45 mg/day or more of MK4. While most of those studies looked at changes in bone density or laboratory markers for osteoporosis risk, many studies also evaluated the most important outcome—fractures. An analysis of seven clinical trials on the effect of MK4 on fracture risk reported that supplementing with 45 mg/day of MK4 reduced spinal fractures by 60%, reduced hip fractures by 77%, and reduced overall fractures by 81%. MK4 (45 mg/day) is the only amount of MK4 shown to grow stronger bones and reduce fractures, and has been so well studied that it’s been approved by the Japanese Ministry of Health since 1995 for osteoporosis and osteoporosis bone pain.
You may already be following many of the recommendations listed here. While not all risk factors for osteoporosis fractures are within your control, I hope this action plan inspires you to take practical steps to reduce those risks you can control. Whether you have osteoporosis, osteopenia or your bone mineral density is in a healthy range, you have the power to reduce your fracture risks.
Arunakul M, Niempoog S, Arunakul P, Bunyaratavej N. Level of undercarboxylated osteocalcin in hip fracture Thai female patients. J Med Assoc Thai. 2009;92. [article]
Avenell A, Mak JC, O’Connell D. Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men. Cochrane Database Syst Rev. 2014(4):CD000227. [article]
Berg KM, Kunins HV, Jackson JL, et al. Association between alcohol consumption and both osteoporotic fracture and bone density. Am J Med. 2008;121(5):406-418. [article]
Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR. Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA. 2009;301(5):513-521. [article]
Bolland MJ, Leung W, Tai V, et al. Calcium intake and risk of fracture: systematic review. BMJ. 2015;351. [article]
Bolster MD. Osteoporosis. Merck Manual. Accessed September 6, 2017. [article]
Bonjour JP. Protein intake and bone health. Int J Vitam Nutr Res. 2011;81(2-3):134-142. [article]
Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res. 2007;22(3):465-475. [article]
Cockayne S, Adamson J, Lanham-New S, Shearer MJ, Gilbody S, Torgerson DJ. Vitamin K and the prevention of fractures: systematic review and meta-analysis of randomized controlled trials. Arch Intern Med. 2006;166(12):1256-1261. [article]
De Laet C, Kanis JA, Odén A, et al. Body mass index as a predictor of fracture risk: a meta-analysis. Osteoporos Int. 2005;16(11):1330-1338. [article]
FRAX Fracture Risk Assessment Tool. https://www.sheffield.ac.uk/FRAX/tool.jsp. Accessed September 6, 2017. [article]
Giangregorio LM, Papaioannou A, Macintyre NJ, et al. Too Fit To Fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. Osteoporos Int. 2014;25(3):821-835. [article]
Gregg EW, Cauley JA, Seeley DG, Ensrud KE, Bauer DC. Physical activity and osteoporotic fracture risk in older women. Study of Osteoporotic Fractures Research Group. Ann Intern Med. 1998;129(2):81-88. [article]
Jeremiah MP, Unwin BK, Greenawald MH, Casiano VE. Diagnosis and Management of Osteoporosis. Am Fam Physician. 2015;92(4):261-268. [article]
Kanis JA, Johansson H, Oden A, et al. A family history of fracture and fracture risk: a meta-analysis. Bone. 2004;35(5):1029-1037. [article]
Kanis JA, Johnell O, Oden A, De Laet C, Jonsson B, Dawson A. Ten-year risk of osteoporotic fracture and the effect of risk factors on screening strategies. Bone. 2002;30(1):251-258. [article]
Karinkanta S, Piirtola M, Sievänen H, Uusi-Rasi K, Kannus P. Physical therapy approaches to reduce fall and fracture risk among older adults. Nat Rev Endocrinol. 2010;6(7):396-407. [article]
Kubo JT, Stefanick ML, Robbins J, et al. Preference for wine is associated with lower hip fracture incidence in post-menopausal women. BMC Womens Health. 2013;1336. [article]
Larsen ER, Mosekilde L, Foldspang A. Vitamin D and calcium supplementation prevents osteoporotic fractures in elderly community dwelling residents: a pragmatic population-based 3-year intervention study. J Bone Miner Res. 2004;19(3):370-378. [article]
Lim HS, Lee HH, Kim TH, Lee BR. Relationship between Heavy Metal Exposure and Bone Mineral Density in Korean Adult. J Bone Metab. 2016;23(4):223-231. [article]
Malmir H, Saneei P, Larijani B, Esmaillzadeh A. Adherence to Mediterranean diet in relation to bone mineral density and risk of fracture: a systematic review and meta-analysis of observational studies. Eur J Nutr. 2017[article]
Melton LJ, 3rd, Chrischilles EA, Cooper C, Lane AW, Riggs BL. Perspective. How many women have osteoporosis? J Bone Miner Res. 1992;7(9):1005-1010. [article]
Meunier PJ, Slosman DO, Delmas PD, et al. Strontium ranelate: dose-dependent effects in established postmenopausal vertebral osteoporosis–a 2-year randomized placebo controlled trial. J Clin Endocrinol Metab. 2002;87(5):2060-2066. [article]
Meunier PJ, Roux C, Seeman E, et al. The effects of strontium ranelate on the risk of vertebral fracture in women with postmenopausal osteoporosis. N Engl J Med. 2004;350(5):459-468. [article]
Office of the Surgeon General US. Bone Health and Osteoporosis: A Report of the Surgeon General. 2004. [article]
Pisani P, Renna MD, Conversano F, et al. Major osteoporotic fragility fractures: Risk factor updates and societal impact. World J Orthop. 2016;7(3):171-181. [article]
Schuit SC, van der Klift M, Weel AE, et al. Fracture incidence and association with bone mineral density in elderly men and women: the Rotterdam Study. Bone. 2004;34(1):195-202. [article]
Siris ES, Chen Y-T, Abbott TA, et al. Bone mineral density thresholds for pharmacological intervention to prevent fractures. Arch Intern Med. 2004;164(10):1108-1112. [article]
Svejme O, Ahlborg HG, Nilsson JÅ, Karlsson MK. Low BMD is an independent predictor of fracture and early menopause of mortality in post-menopausal women–a 34-year prospective study. Maturitas. 2013;74(4):341-345. [article]
Takiar R, Lutsey PL, Zhao D, et al. The associations of 25-hydroxyvitamin D levels, vitamin D binding protein gene polymorphisms, and race with risk of incident fracture-related hospitalization: Twenty-year follow-up in a bi-ethnic cohort (the ARIC Study). Bone. 2015;7894-101. [article]
Thorin MH, Wihlborg A, Åkesson K, Gerdhem P. Smoking, smoking cessation, and fracture risk in elderly women followed for 10 years. Osteoporos Int. 2016;27(1):249-255.
Weaver CM, Alexander DD, Boushey CJ, et al. Calcium plus vitamin D supplementation and risk of fractures: an updated meta-analysis from the National Osteoporosis Foundation. Osteoporos Int. 2015. [article]
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