As side effects go, this one flew below the radar. Hope White, 45, knew she needed strong doses of steroids

to wage her battle against a particularly virulent case of lupus. But she didn’t give much thought to the fact that those treatments to combat her auto-immune disease would make her susceptible to weakened bones.

In fact, when her doctor suggested that she — a young black woman — could acquire osteoporosis — a condition that hits mostly aging, white women — she was almost amused.

“I’m too young,” White remembers saying after her doctor recommended a bone density test to check for the disease. “I’m not white, and I’m not frail.”

Fortunately, her doctor insisted and ordered the first of three bone tests. Sure enough, White was diagnosed with osteoporosis.

Like most people, White didn’t pay much attention to the

health of her bones. Fortunately, the Surgeon General did and in 2004 delivered a sobering report that more than 10 million people across the country had osteoporosis and another 34 mil-lion were at risk.

And the costs were — and remain — significant. Treatment for fractures resulting from osteoporosis amounts to about $18 billion a year, and fractures are just the beginning of the medical problems. Twenty percent of older people who sustain osteoporo-sis-related hip fractures die within a year, and those who survive can experience a downward spiral in their health.

Most at risk are thin, older white and Asian women, but men and black women are not exempt.

Although more prevalent in people over the age of 50, osteoporosis can strike at any age. The disease also tends to

run in families. Osteoporosis, or porous bones, is characterized by a decrease

in bone density that leaves those affected more vulnerable to life-threatening fractures. Bone density refers to the amount of calcium, other minerals and protein packed in bone.

According to Dr. Sherri-Ann M. Burnett-Bowie, an endo-crinologist at Massachusetts General Hospital, on average, black women have a higher bone density than white women, but that does not offer complete immunity. The National Osteoporosis Foundation (NOF) has determined that 5 percent of black women aged 50 and older as compared to 20 percent of white and Asian women aged 50 and older are estimated to have osteoporosis. But Burnett-Bowie cautioned that some experts estimate the prevalence among black women is closer to 11 percent.

The frequency in men is smaller — 4 percent and 7 percent in black and white men, respectively.

The threat of osteoporosis is greater in blacks than expected, White learned, largely because of the long-term use of medica-tions, such as steroids, to treat illnesses prevalent among African Americans. Asthma, arthritis, lupus and some cancers are examples of diseases where some of the treatments increase the risk of devel-oping osteoporosis.

Indeed, there’s not much amusing about osteoporosis at all. Studies have indicated that death rates following osteoporosis-relat-ed hip fractures are higher in blacks than in whites. Complications of pneumonia, blood clots and poor circulation take a hefty toll.

Misperceptions are part of the problem. Because many blacks believe that osteoporosis is not a threat, they are not looking for it, and worse, some doctors aren’t looking for it either.

In one study, doctors from the Johns Hopkins School of Medicine found that significantly fewer African American women were tested for osteoporosis than their white counterparts, a surpris-ing statistic given that both groups evaluated shared similar risks.

Another group of researchers found more bad news. Many blacks treated at Howard University Hospital were not tested for the disease — even in the presence of bone fractures commonly associated with osteoporosis.

Bone is composed of collagen — a type of protein — and calcium, which combine to give bones strength and flexibility.

Dr. Sherri-Ann M. Burnett-Bowie, an endocrinologist at Massachusetts General Hospital, readily admits aging bones come with the territory.

“If we live long enough,” Burnett-Bowie said, “chances are we will eventually suffer some bone loss.”

And that means trouble for those who choose to ignore the risks and fail to take preventive measures to combat osteopo-rosis, or low bone density, and other bone diseases.

The key is to start early in life when bones are developing in strength and size.

To further that goal, the federal Of-fice on Women’s Health, for instance, has developed a program called “Best Bones Forever!” that encourages girls to get active

in their health at an early age and consume foods high in calcium and vitamin D to maintain healthy bones throughout their lives.

That’s because one of the biggest cul-prits in bone deterioration — and one of the most modifiable — is the lack of calcium and vitamin D. National nutrition surveys indicate that most people consume less than half of the minimum recommendations. “Both men and women should consume enough calcium and vitamin D throughout life,” Burnett-Bowie said. “Not just when you get older. Additionally, while osteopo-rosis affects women predominantly, roughly one-third of broken bones due to osteoporo-sis occur in men.”

Calcium is the most common mineral

More calcium, vitamin D key to healthy bones

On average, black women have a higher bone density than white women, but that does not offer complete immunity.

Dr. Sherri-Ann M. Burnett-Bowie

BE Healthy™

White, continued to page 4

Bones, continued to page 4

VOL. 4 • NO. 9 © May 2010

Sponsored by Boston Public Health Commission

Hope White, shown above and with her son, Narai (left) was diagnosed with osteoporosis after long-term treatment with steroids for lupus. (Ernesto Arroyo photos)

Bo

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ssAfter about age 30, you begin to slowly lose bone mass. This loss

accelerates the first few years following menopause, and continues at a slower pace in older men and women.

Rapid LossAfter menopause

Active GrowthChildren and teens

Less Rapid LossSeniors

Slow LossMid-30s

Osteoporosis:Aging bones need youthful attention

Bones are living tissue that are constantly built up and torn down for repairs. During childhood and throughout the 20s, the body banks bone

tissue. But right around age 30, the advantage shifts and the body begins to lose more bone than it builds. In time, bones become increasingly porous, often growing weaker and more fragile, which sets the stage for disabling fractures. This condition is called osteoporosis and affects eight million American women and two million men. Often, the very first clue is a broken bone.

“You can do a lot to prevent osteoporosis or slow its advance,” says Dr. Karen Boudreau, Medical Director of Medical Innovation and Leadership at Blue Cross Blue Shield of Massachusetts. “One very important step is exercis-ing regularly. Strength exercises actually help prevent bone loss, and may even build bone slightly over time. Talk to your doctor about other measures that will help, too.”

What kind of exercises should you do?Balance exercises help you avoid falls that can cause

fractures. Weight-bearing exercises stress bones by forcing the body to work against gravity. Walking, jogging, climbing stairs, and dancing are all good examples — plus, they offer aerobic benefits to keep your heart and lungs strong, too. However, these activities mostly strengthen bones in your

lower body. Strengthening exercises for the upper body, such as the three described at right, will help keep those bones strong, too.

The National Institute on Aging (www.nia.nih.gov) has many excellent tips and a full set of upper and lower body strength exercises in its booklet on exer-cise. Click on “Publications” and look for “Exercise & Physical Activity: Your Everyday Guide.” Or you can order a free copy of the full publication by calling 1-800-222-2225.

Tips for safe strength training • Before starting, talk to your doctor if you have any health problems, joint surgeries, or injuries, or aren’t usually active. The strengthening exercises depicted are recommended by the National Institute on Aging

for people of all ages and abilities. • These exercises use resistance to build strength in

muscles and bones. The resistance can be supplied by body weight (see chair dips), hand weights or resistance bands, which are long, wide stretchy strips you wrap around your hands.

• Resistance bands come in strengths from light to heavy. You can buy them at sports stores and many pharma-cies. At first, choose light resistance or none at all. If you can’t do eight repetitions of an exercise (which should feel hard, but not very, very hard), use lighter resistance. When you can do two sets of 10-15 repetitions, move to heavier resistance.

• Start with two sessions a week. While walking, jog-ging, climbing stairs and dancing are activities you can do every day, your muscles need a day to recover from strength-ening exercises. If you do strengthening exercises Tuesday, wait until Thursday to repeat.

• Don’t hold your breath during exercises. It can raise your blood pressure.

• Count to three as you lift or push. Pause, then count to three as you return to the first position.

• Listen to your body. You shouldn’t feel pain when you do these exercises, though mild muscle soreness a day or two afterward is normal.

A blend of balance and strength

1. Face a wall, standing a little further than arms’ length away, feet shoulder-width apart.2. Lean your full body forward and put your palms flat against the wall at shoulder height, shoulder-width apart. 3. Slowly breathe in as you bend your elbows to lower your upper body toward the wall in a slow, controlled motion. Keep your feet flat on the floor.4. Hold for 1 second. 5. Breathe out as you slowly push yourself back until your arms are straight.

3 strengthening exercisesWarm up first by walking or marching in place for five minutes. Cool down afterward with some stretches. For each exercise, try to do 10-15 repetitions (that’s one set), rest, then do another set of 10-15 repetitions. If that’s too hard, do whatever you can and work toward these goals over time.

1. Stand with your feet shoulder-width apart. 2. Hold weights straight down at your sides, palms facing forward. Breathe in slowly.3. Breathe out as you slowly bend your elbows and lift the weights toward your chest. Keep your elbows at your sides.4. Hold for 1 second.5. Breathe in as you slowly lower your arms.

1. Sit in a sturdy chair with armrests with your feet flat on the floor, shoulder-width apart.2. Lean slightly forward, keeping your back and shoulders straight. 3. Grasp the chair arms with your hands next to your sides. Breathe in slowly.4. Breathe out as you use your arms to push your body slowly off the chair.5. Hold for 1 second.6. Breathe in as you slowly lower yourself back down.

*Adapted from Exercise & Physical Activity: Your Every-day Guide from The National Institute on Aging.

Heel-to-Toe Walk*1. If necessary, hold onto a counter for balance during this exercise. 2. Put one foot directly in front of the other as if on a tightrope while walking forward 10 steps. 3. Try it in reverse. 4. Repeat two to three times.

Chair Dips*

Wall Push Up*

Arm Curl*

Balance exercises

Balance exercises and activities like yoga and tai chi help prevent falls that can cause serious injuries. Practice these two exercises daily to improve balance.

Single Leg Stand*1. If necessary, hold onto a sturdy chair or counter dur-ing this exercise. 2. Stand on one foot for 30 seconds or longer. 3. Switch feet and try again. 4. Repeat two to three times.

BE Healthy • http://behealthy.baystatebanner.com2

The information presented in BE HEALTHY is for educational purposes only, and is not intended to take the place of consultation with your private physician. We recommend that you take advantage of screenings appropriate to your age, sex, and risk factors and make timely visits to your primary care physician.

May is National Osteoporosis Awareness and Prevention Month

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A closer look

As bone weakness progresses, the bones in the spine collapse which can result in pain, reduced height and kyphosis, a severe curvature of the upper spine. Extreme cases of kyphosis can impede breathing.

Watch your step!Most falls occur in the home, but there are things you can do to avoid them.

• Clear clutter off the floor.

• Tack down carpets firmly and secure loose wires along the walls.

• Keep items you often use within reach. Don’t use step stools.

• Use non-slip mats in the tub or shower.

• Use brighter light bulbs, especially along stairs.

• Add handrails to staircase.

• Wear shoes with non-slip soles.

• Have your eyes checked.

• Review your medications with your doctor, especially if they make you sleepy or dizzy.

Questions & Answers

BE Healthy • http://behealthy.baystatebanner.com 3

Lisa Michelle Owens, M.D.Medical Director

Brigham Primary Physicians atFaulkner Hospital

Should black women get screened for osteoporosis given the fact that its incidence is higher in white and Asian women?

1Yes. Black women should be screened for osteoporo-sis because although the disease occurs less frequent-ly, they could have other risk factors for osteoporosis depending on their medical history or habits. For in-stance bone weakness results from excessive alcohol consumption, smoking and long-term use of certain medications. Osteoporosis also runs in families.

If a person is diagnosed with osteo-penia — reduced bone density — is it possible to prevent its progression to full-blown osteoporosis?

6The rate at which a person progresses from osteo-penia to osteoporosis is variable and depends on genetics, medications and a person’s medical history. It may be possible to maintain or increase bone health through weight bearing exercise and a diet rich in calcium and vitamin D. In other situations, doctors may start a person with osteopenia on medication to decrease the rate of bone loss.

Why is exercise recommended to prevent bone weakness? 7

Even though our bones may lose some density as we age, an exercise program will increase muscle strength, improve balance and help individuals avoid falls — and it may help keep bones from getting weaker.

Should men get screened for osteoporosis?

Is osteoporosis a normal part of aging? 3

Normally, bone density increases during childhood and reaches a peak by around age 25 to 30. Bone density then is maintained for about five to 10 years. After age 35, both men and women will normally lose 0.3 to 0.5 percent of their bone density per year as part of the aging process. A decrease in bone density is a normal part of aging; however, the rate at which individuals lose bone density as a part of the aging process is variable.

Why is vitamin D necessary for bone health?4

Vitamin D allows for the absorption of calcium, which is a major building block of bones. So significant is its role that when levels of vitamin D fall, the body takes the cal-cium from bones to make it available for other functions of the body. That is why it is recommended to consume the recommended daily allowance of both calcium and vitamin D.

Why does the threat of osteoporosis increase after menopause? 5

Estrogen is important in maintaining bone density in women. When estrogen levels drop after menopause — including early menopause — loss of bone density accelerates. During the first five to 10 years after meno-pause, women can suffer up to 2 to 4 percent loss of bone density per year.

2Yes. The National Osteoporosis Foundation recom-mends that all men aged 70 and older should get screened. Men with low testosterone levels are particularly at risk and should receive a bone mineral

What impact does smoking have on bone health? 8

Studies have shown a direct relationship between tobacco use and decreased bone density. Smoking weakens the bones and is considered to be a risk factor for osteoporosis. It is not known whether a decrease in bone density is due to smoking itself or to other risk factors. For example, in many cases smok-ers are thinner than nonsmokers, tend to drink more alcohol, may be less physically active, and have poor diets. Women who smoke also tend to have an earlier menopause than nonsmokers. These factors place many smokers at an increased risk for osteoporosis apart from their tobacco use.

density test. In addition, research has shown that the 1-year mortality rate after hip fracture in men is twice that in women.

Are you at risk for fractures? You could be and not know it ― you cannot feel your bones get weaker.

Ask yourself the following questions.Are you 65 or older?Did you break a bone after the age of 50?Did your mother have osteoporosis?Did you go through menopause before the age of 45?Do you smoke or have more than two alcoholic drinks a day?Are you sedentary?Do you get less than the recommended amounts of vitamin D and calcium every day?Are you taking certain drugs, such as prescription steroids or antiepileptic medications?If you have answered “yes” to any of the questions, talk to your doctor about a possible risk for osteoporosis.

Bones are far from lifeless matter, and in fact, are in constant change removing the old and developing the new.

During childhood and teenage years, bone development exceeds the pace of bone removal, resulting in larger, heavier and denser tissue. This process continues until young adults reach peak bone mass when bones reach their maximum strength and density.

Osteoporosis develops when bone removal occurs too quickly or bone replacement occurs too slowly. Developing strong bones in childhood is key. If a child or teen does not reach optimal bone mass, osteoporosis is more likely.

Bone deterioration accelerates in women in the first few years following menopause. Accord-

ing to the NOF, women can lose up to 20 percent or more of their bone density during the first five years after menopause.

There are generally no symptoms of osteoporosis. If the spine is affected, some might experience back pain. Others might experience only a decrease in height due to compression of the bones that comprise the spine. Extreme cases can result in spinal deformities, such as kyphosis, a severely stooped posture.

More often than not, those suffering from the disease became aware of their problem when they experience what is aptly named a “fragility fracture.” They occur after a very mild trauma, such as an unexpected bump or a trip and fall from a low height. While bones in the wrist, hip or spine are usually impacted the most frequently, any bone can be affected.

The gold standard detection for osteoporosis is the DXA test (dual energy X-ray absorptiom-etry), a low dosage X-ray that measures bone

mineral density (BMD) in the spine and hip. The DXA can confirm a diagnosis of

osteoporosis and detect those who are at risk. A common finding of the test is osteopenia, or reduced bone density — a precursor to osteo-porosis. The NOF recommends a BMD for all women aged 65 or older and all men aged 70 or older as well as younger people with several risk factors for osteoporosis. Women who experience early menopause, for instance, are particularly vulnerable, as the loss of estrogen accelerates bone loss.

So important is a BMD that Medicare pays for it every two years.

The good news is that bone loss can often be stopped and even reversed through a regimen of exercise and adequate amounts of calcium and vitamin D. More severe cases might require prescription drugs. “Anyone who has had a fragility fracture requires medication,” Burnett-Bowie said. “Because they are much more likely to have another fracture.” Additionally, if an individual has had a significant decrease in bone density on serial DXA tests, medical therapy may be prescribed.

A web-based test to determine the likeli-hood of a fracture called FRAX — Fracture Risk Assessment Tool — was developed by the World Health Organization. Analysis of the results of the DXA test and risk factors will determine whether the probability of an osteoporosis-related fracture is significant enough to warrant medical therapy.

Fortunately for White, her DXA indicated that she was at low risk for a fracture.

White takes two kinds of calcium com-pounds — including one that contains vitamin D — three times a day after every meal.

She pays more attention to her diet and consumes more calcium-rich foods, such as leafy greens and dairy products.

She admits she was a bit inconsistent when it came to exercising, but now makes an effort to work out on the treadmill at her gym at least twice a week.

Her calcium-rich diet and supplements have paid off.

Subsequent tests indicated an improvement in her bone density. She is now considered to have osteopenia — not quite osteoporosis but still not in the normal range.

White knows she still has a long way to go. And given her other medical conditions, steroid use will continue to be a factor in her life — for better and worse.

“I take medicine to improve my bones,” she said. “But I still have to take medicine that causes bone weakness.”

White, continued from page 1

in the body and is a powerhouse. It helps mus-cles to contract, the heart to beat effectively, and the blood to clot. Almost all of the body’s calcium is stored in bones, but the body cannot absorb calcium without the help of vitamin D. When there is a deficit in vitamin D or dietary calcium, the body literally steals calcium from bones to make it available elsewhere. A normal heartbeat trumps bone strength.

The downside is the cost of weakening bones and the threat of osteoporosis.

Fortunately, calcium is readily available and can be found in a number of dairy and soy products and canned sardines or salmon (as-suming you eat the bones). Though vitamin D comes predominantly from exposure to sunshine, fatty fish and fortified foods can help increase its levels.

But this is easier said than done, espe-cially for blacks. Many African Americans are lactose-intolerant and shun dairy products. And because of darker skin, even exposure to sunshine is no guarantee that blacks will have sufficient levels of vitamin D.

Calcium and vitamin D supplements are recommended for those less tolerant of natural sources for the two.

Lifestyle is very important. Excessive alcohol and smoking are linked to decreased bone density. Lack of exercise is another

problem. “Exercise and good muscle tone are important not only to keep bones strong, but also to reduce the risk of falling,” explained Burnett-Bowie. “If you fall less, you have a lower risk of fractures,” she said.

Weight-bearing exercises are essential. The pressure on bones during walking or run-ning accelerates bone formation. Orthopedic surgeons now use weight-bearing casts for people with certain leg fractures to facilitate bone healing. Muscle strengthening exercises, like weight lifting, build muscle mass while impacting bones. Other exercises, such as bike riding and swimming, are helpful, but they do not exert as much pressure on bones. Balanc-ing exercises — t’ai chi, for example — are helpful to maintain good posture and balance.

Unfortunately, studies have shown that many patients with osteoporosis are not receiv-ing the appropriate advice or treatment. These findings are especially concerning because of the significant impact that sustaining a hip fracture has on one’s ability to function: 50 percent of seniors who break their hip never return to independent living.

That’s why Burnett-Bowie emphasizes the point. Osteoporosis is not a normal part of aging. Older people who fall from low heights should not break a bone, she cautioned.

“Even if you fall hard, that’s a red flag,” she said. “Tripping on the sidewalk should not result in a break.”

Got 10 minutes? Take a simple test that could save your life …

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Above -1

Osteopenia: Between -1 and -2.5

Osteoporosis: Below -2.5

Results

Hip fractures from osteoporosis can be fatal or result in long-term disability. A bone density test of the spine and hip can determine if you have or are at risk for osteoporosis. The DXA test, a non-invasive low dose x-ray, is the most widely used measure of bone density.

3 Steps to improve bone health … at any age

CalciumHow much a day?age Milligrams (mg)Birth to 6 months 2107 to 12 months 2701 to 3 years 5004 to 8 years 8009 to 18 years 1,30019 to 50 years 1,000Over 50 years 1,200

Where do you get it?sources Mg per servingYogurt, 8 ounces 415Sardines (with bones), 3 ounces 324Cheddar cheese, 1½ ounces 306Milk, 8 ounces 285Tofu, ½ cup 204

Vitamin D

Exercise

How much a day?age International units (Iu)*Birth to 70 years 40071 years and older 600*These figures are currently being evaluated. Scientists believe that a daily allowance of at least 1,000 IU or more are required.

Where do you get it?sources IuCod liver oil, one tablespoon 1,360Sockeye salmon, 3 ounces 794Mackerel, 3 ounces 388Milk, 8 ounces 120Fortified orange juice, 8 ounces 100

Source: Office of Dietary Supplements

Don’t get enough from food? Supplements can help.*The sun is the most significant natural source of vitamin D, but the amount pro-duced depends on the season, city, time of day and skin color.

Don’t get enough from food? Supplements can help.

Sherri-Ann M. Burnett-Bowie, M.D., M.P.H.EndocrinologistMassachusetts General Hospital

Comments on Be Healthy? Contact Health Editor Karen Miller at kmiller@bannerpub.com.

Bones, continued from page 1

Should you get tested? You should if you are … • A woman 65 and older • A man 70 and older • Older than 50 and have broken a bone• A postmenopausal woman not taking estrogen• Taking medications that cause bone thinning• A younger person with one or more risk factors

How much each week?children and adolescents Weight-bearing aerobics 60 minutes a dayMuscle strengthening 3 days a week

adults Weight-bearing aerobics 150 minutes a weekMuscle strengthening 2 days a week

BE Healthy • http://behealthy.baystatebanner.com4