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How to boost bone health and reduce risk of osteoporosis and fractures
Imagine not being able to cough, sneeze or be hugged for fear of your bones breaking.
This is the reality faced by people with severely weak bones.
Fragile bones can creep up on you and are often not recognised until they break.
A small trip and fall can be catastrophic, with a broken hip leading to a rapid deterioration in health.
Today, millions of Australians live with poor bone health, and the "silent disease" of osteoporosis is expected to lead to one fracture every 30 seconds by 2033.
And this is not just because we have an ageing population.
We talked to experts about bone health and how to keep them strong for as long as possible.
It's a common misconception that fragile bones are an older woman's problem.
According to the Royal Australian College of GPs, one in two or three women will suffer an osteoporosis-related fracture over their lifetime.
But one in every three or four men suffer the same, and younger people can also develop weak bones.
We can think of our body's skeleton as a bank transaction account, where old bone is "withdrawn" or removed and replaced by "deposits" of new bone.
Ideally we'd keep that bone bank balance high by stimulating new bone growth or preventing its loss with the right combination of diet and exercise — and, where needed, medications.
When we are young and our skeleton's growing — especially during puberty — it's relatively easy to increase your "bone bank" balance.
But as an adult, you eventually start losing bone faster than it's replaced, and eventually this can increase fracture risk.
Some experts such as exercise scientist David Scott from Deakin University are concerned the sedentary lifestyle of many children could leave them with a low bone bank balance as they enter adulthood, and may create problems later in life.
"We're just worried that children are not accumulating bone," Dr Scott says.
Bone and muscle strength in women peaks at 30 before declining, especially around menopause when there is a massive drop of oestrogen, which is a hormone important for bone health.
So if you hit menopause without a good balance in your bone bank, you have fewer reserves to draw on at a time you need it.
Other risk factors include:
While going for a daily stroll can be good for your general health, a different kind of exercise is required when it comes to bone health.
Bone cells are only triggered to grow or repair when they experience a certain amount of stress and strain, which is why gentle walking, cycling or swimming does little to increase bone strength.
"The prevailing wisdom is if you want to make your bones stronger, you have to work hard," Chris Maher, an expert in musculoskeletal health at the University of Sydney, says.
Strong bones need weight-bearing impact — think of forceful jumping, running or hopping.
One study that got men to hop on one leg found that leg had stronger bones than the other after 12 months.
Muscle strengthening exercises — such as weights or resistance bands, push ups, sit ups or squats — are essential for strong bones too.
Because our bones adapt to exercise, experts advise doing impact and resistance exercises in a way that pushes yourself.
Some emphasise "exercise snacking" — brief bouts of high-intensity exercise — that can be done in ad breaks, while taking a break from computer work, or waiting for the kettle to boil or the bus to come.
Even taking the stairs instead of the lift, carrying shopping instead of using a trolley, or squatting instead of bending when you get something from a bottom drawer can help.
But high-intensity exercising may require supervision, especially if you are older, so talk to a qualified health practitioner before embarking on a routine.
Professor Maher says while there are fears about exercise causing damage to older people, this should not stop them from doing appropriate exercise.
Ask your GP to see if you qualify for a scan of your bone mineral density, which is the most common measure of bone strength, and subsidised visits to see a professional such as an exercise physiologist, who can tailor an exercise prescription that is suited to your individual needs.
Check Healthy Bones Australia or the Royal Australian College of GPs for more tips on exercises to improve or maintain bone health.
While exercise is accepted as an essential part of maintaining bone health, there is a debate over how much it can reverse bone loss, especially in post-menopausal women, although even if it slows down the rate of loss this is a benefit.
Exercise can also improve strength and balance, which can also help prevent falls.
Osteoporosis is a condition of very low bone mineral density.
But if you have osteoporosis, that doesn't automatically mean you'll get a fracture.
Only a third of "fragility fractures" — those that result from a small impact such as falling over — are in people with osteoporosis, Monash University endocrinologist Susan Davis says.
Most fractures occur in people with osteopenia, whose bone density is low, but not low enough to qualify for an osteoporosis diagnosis.
Even people with normal bone density can get fragility fractures. This is because there is more to stopping fractures than bone mineral density.
The size, shape and structure of bones, referred to as bone "micro-architecture", can also affect how strong they are.
While the jury is still out on how much exercise can boost bone architecture, one thing is for certain: most fractures due to fragile bones are caused by falls.
Activities that increase your strength, stability, mobility and balance will keep you on your feet and less prone to falls.
Experts say there is good evidence tai chi helps balance, and perhaps dancing or gardening do too.
Researchers are currently looking into whether yoga can also help.
Strong bones need the right balance of nutrients including vitamin D and calcium.
Vitamin D helps us absorb calcium, which is needed to build bone.
While some foods such as fatty fish and milk can provide vitamin D, the main source of this nutrient is exposure to sunlight.
One in four Australians are deficient in the vitamin because they don't get enough sunlight exposure. This might be because a lack of sun in winter at low latitudes in the southern states, because they have darker skin or because they habitually cover themselves.
Supplements can help boost vitamin D levels, but the idea that the more vitamin D you take the better is a myth.
While not having enough vitamin D can lead to weak bones, having too much can be a problem too.
"We see people who are profoundly deficient and people on high doses who are on too much," Professor Davis says.
Some people take many times the recommended amount, risking the development of kidney stones.
While we're on diet, Australians in general don't tend to get enough dietary calcium either.
And some older people don't tend to eat enough protein, which — along with exercise — is important to stop muscles wasting, which is also linked to bone loss.
According to the RACGP guidelines for maintaining bone health and preventing fractures:
Dairy foods are rich sources of both calcium and protein.
Australian dietary guidelines recommend three serves of dairy a day for most people, and four serves a day for women over 51. Other sources of calcium include: firm tofu, almonds, sesame seeds, tinned fish, some green leafy vegetables, dried figs, and calcium-fortified non-diary milks.
Thanks also to Gabrielle Stokes, Monash University; Belinda Beck, Griffith University; Maria Fiatarone Singh, University of Sydney and Robin Daly, Deakin University for assistance in producing this article.
