Bone strength is rarely paid attention to in dieting and exercise, but is a critical feature of health in an aging human body. Bone strength is determined by four things: bone mass, mineral content, microarchitecture and macroarchitecture.
As physicians, we are primarily concerned with bone mineral density (BMD), a measure of bone mass and mineral content. Peak bone mass is developed by the time we reach our early 20s. Childhood health, genetic conditions and current lifestyle factors can influence bone mass. Medications, such as steroids, can lead to a loss of bone mass over time, especially when used chronically. So, in the setting of so many factors out of our control, how do we recognize and reduce our risk for osteoporosis?
Osteoporosis is a medical condition characterized by a reduction in BMD, which increases the risk of developing fractures. This is a silent condition that develops over decades. Our bones are constantly remodeling, with old bone being replaced by the formation of new bone. In osteoporosis, destruction outpaces formation. In the hospital, we discover these in female patients who present to the emergency room with a femoral neck fracture (hip) or vertebral fracture (spine). However, in the doctor’s office, your physician will approach you for screening depending on certain risk factors and age.
The United States Preventive Services Task Force recommends that physicians screen all women aged 65 years or older with a dual-energy X-ray absorptiometry (DEXA) scan. The task force also advocates for screening in postmenopausal women younger than 65 years who are vulnerable, as estimated by a clinical risk assessment. We usually do not screen premenopausal women or men aged 50 and younger without risk factors. Patients receiving long-term steroids in excess of 2.5 mg a day for at least three months should have a baseline assessment. Once a BMD is measured, a normal score means no further maintenance screening is needed.
The DEXA scan provides two scores: the T-score and the Z-score. The T-score reflects BMD compared with the average BMD of a young, healthy adult of the same sex. The Z-score reflects the BMD with the average BMD of the age group of the individual involved, taking sex and body mass index into account.
Independent reporting for Pine Bluff & Jefferson County since 1879.
When the T-score is between -1 and -2.5, the diagnosis of osteopenia is given. At this juncture, medicines may be initiated to help reduce the risk or postpone the development of osteoporosis. A T-score of -2.5 or less for the femur neck, total hip or composite (two or more diagnostic vertebrae) lumbar spine diagnoses osteoporosis. If the hip or spine cannot be accurately measured by BMD, DEXA of the distal third of the radius can be used. Fragility fractures (those occurring with the equivalent of a fall from a standing height or less) after age 50 automatically diagnose osteoporosis. Once osteoporosis is diagnosed, treatment is offered. The goal of treatment is to decelerate further bone loss. In some cases, new bone growth was also detected.
There are additional testing tools available to diagnose low osteoporosis, such as quantitative calcaneal ultrasonography, peripheral DEXA, and quantitative CT, which can be used to complement central DEXA. However, the mainstay of diagnosis rests on the gold standard, the DEXA machine.
WHY ARE WOMEN AT HIGHER RISK?
Women are at higher risk for developing osteoporosis for several reasons: hormonal changes, lower peak bone mass, smaller and thinner bones, to name a few. As we age, we lose a precious hormone, estrogen, which, among its many functions, helps rebuild bone. Starting in perimenopause but more noticeably in menopause, estrogen levels drop, leading to an increase in bone loss.
Women generally have a lower peak bone mass compared to men. Peak bone mass is the most significant amount of bone an individual builds during their lifespan, typically by the early to mid-20s. Because women start with less bone mass, they have less “reserve” to draw upon as they age, making them more susceptible to significant bone loss. Women’s bones are often smaller and thinner compared to men’s bones, which means they are inherently less dense and more prone to osteoporosis-related fractures.
Other risk factors include a family history of osteoporosis, calcium and vitamin D deficiency, sedentary lifestyle, smoking, excessive alcohol consumption and low body weight. Certain medical conditions, such as rheumatoid arthritis or prolonged use of corticosteroids, can cause bone weakening.
Osteoporosis is a severe condition, but you can take action today to reduce your risk. Lifestyle changes cannot be emphasized enough. Quit smoking! Monitor alcohol use; if you are uncertain as to whether your alcohol use is excessive, consider discussing whether or not you have alcohol use disorder with the physician. Other measures include pursuing a calcium-rich diet. Get your vitamin D levels checked. Although the task force does not direct physicians to screen for vitamin D, it is a simple blood test that can be performed in your doctor’s office. Vitamin D is available over-the-counter and can be easily obtained. Use caution before starting vitamin D supplementation in individuals with already normal levels, as toxicity can lead to adverse effects. Finally, engage in weight-bearing exercises consistently. Early detection and management are key to minimizing the impact of osteoporosis and maintaining a high quality of life.
Sources: 1. US Preventive Services Task Force. Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement. JAMA. 2025;333(6):498–508. doi:10.1001/jama.2024.27154; 2. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/osteoporosis-screening; 3. https://www.osteoporosis.foundation/health-professionals/fragility-fractures.
Dr. Naznin Jamal is a Jefferson Regional Medical Center hospitalist.