The Osteoporosis Scare: Separating Fact from Fiction

It may not be the disease women fear most, but that’s not for lack of publicity.

In the past decade, a multibillion-dollar industry has sprung up devoted to preventing, diagnosing and treating osteoporosis--thin, brittle bones that tend to fracture easily. That’s remarkable for a condition most people had never heard of 15 years ago.

These days it’s hard to open a magazine or turn on the television without seeing ads for prescription drugs, pitched by actresses of a certain age, aimed at combating fragile, porous bones. There are stories about the threat osteoporosis poses to aging women, next to ads that are part of the ubiquitous milk-mustache campaign. Bookstore shelves are laden with such self-help books as “The Super Calcium Counter” and “Strong Women Stay Young.” Supermarkets and drugstores bulge with an expanding array of calcium-enriched foods--chewy candy supplements, breakfast cereals, bread, pancake mixes and juices, as well as over-the-counter “natural” remedies that trumpet “bone health.”

The message is unequivocal: Women (and some men) need to take action to avoid developing the insidious, crippling disease that has struck an estimated 10 million Americans and can result in a hip fracture, a dowager’s hump, an aching back, loss of height and death in a nursing home.

Actress Rita Moreno, 68, is the newest spokeswoman for the “Stay Strong! Test Your Bone Strength” campaign underwritten by Merck, maker of Fosamax, the world’s leading osteoporosis drug. Moreno recently told Florida’s Orlando Sentinel that failure to take a bone-density test is “absolutely criminal,” because the noninvasive test takes only 10 minutes and can, she says, avert a dreaded disease.

“I’m all for scaring women when it comes to health,” Moreno recently told the Chicago Tribune.

Just how big a threat does osteoporosis really pose to the tens of millions of female baby boomers approaching or just beyond 50, the average age of menopause, and their older sisters?

Does the difference between a vigorous, independent old age and shuffling, hunchbacked dependence in a nursing home really lie in getting a bone-density test and starting a drug as early as your late 40s in the hope of averting a broken bone 20, 30 or 40 years later?

Interviews with women’s health advocates and osteoporosis experts suggest that the answers to these questions are considerably more complicated, and less clear-cut, than some public-service campaigns, calcium-supplement pitches and drug ads suggest. These skeptics acknowledge that osteoporosis is a serious and potentially devastating medical problem--one that is likely to increase in incidence and importance as more Americans live longer. But they say it has also been the subject of considerable hype and confusion fueled by drug companies and other firms pushing products and by some advocates seeking to raise awareness of their cause.

“I think even people who agree that osteoporosis is a serious public health problem can still say it’s being hyped. It is hyped,” said Mark Helfand, director of the Evidence-Based Practice Center at Oregon Health Sciences University in Portland. “Most of what you could do to prevent osteoporosis later in life has nothing to do with getting a test or taking a drug,” added Helfand, a member of a National Institutes of Health consensus panel that spent three days in March conferring about the prevention, diagnosis and treatment of osteoporosis.

“What’s troublesome about all this publicity is that osteoporosis is getting visibility out of proportion” to its significance, said Deborah Briceland-Betts, executive director of the Older Womens League, a Washington-based advocacy organization active in health education. As a result, she said, other common and equally serious health problems such as heart disease and obesity have received short shrift.

“There’s a whole group of people who don’t need intervention, other than advice about eliminating risk factors, which everyone should get,” agreed Robert Lindsay, a New York internist and one of the founders of the National Osteoporosis Foundation.

Wyeth-Ayerst spokeswoman Audrey Ashby said the company’s promotion of Prempro using pre-menopausal women is appropriate. “It’s an ad that encourages women to talk to their health-care provider about estrogen loss at menopause.”

Sandra C. Raymond, who was instrumental in transforming the National Osteoporosis Foundation from a small interest group that she helped launch in 1986 into a powerful advocacy organization with an annual budget of about $10 million (about 25% of it from drug companies, she said), said that osteoporosis for years suffered from a dearth of attention.

“I don’t think this has been hyped any more than breast cancer has been hyped,” Raymond said. “It’s a very common disease, and women are at very high risk. We’re not trying to scare women, but we’re trying to tell them there are things you need to look at, steps you can take to prevent it. I think if you’ve got a preventable disease, you can’t hype it too much.

What follows is an attempt, based on interviews with two dozen osteoporosis experts and women’s health advocates, to separate the hype from the hard evidence, to put the statistics about risk in context and to debunk some of the most common myths surrounding this increasingly high-profile medical problem.

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“The more calcium, the better.”

It’s easy to see how this one got started, because innumerable studies have shown that American diets are woefully deficient in calcium, the main building block of bone. Calcium is essential at all stages of life, for building bone mass early in life and for reducing bone loss thereafter. Only 10% of girls between the ages of 9 and 17 get enough calcium, according to the recent NIH panel, because many are shunning dairy products in favor of soda.

People who never achieve maximum bone growth in their youth have fewer reserves and may drop to perilously low levels of bone density earlier than those who have developed thicker bones. That’s why adequate calcium is critical for children and teenagers.

But what’s lost in the consume-more-calcium campaigns are two important messages: that calcium alone does not appear to prevent fractures in most women, and that too much calcium may be harmful.

Recently the National Academy of Sciences, concerned that too many people were getting too much calcium from fortified foods and supplements, set an upper limit on intake at 2,500 milligrams per day. Some prominent scientists, including Walter Willett, a veteran nutrition researcher at the Harvard School of Public Health, contend that calcium consumption may not be so desirable and that promoting it “has become like a religious crusade.”

One study of 70,000 American nurses, co-authored by Willett, found that women with the highest calcium consumption from dairy products actually had more fractures than those who drank less milk. Some researchers believe that it’s not a surfeit of milk or other dairy products that’s the culprit, but diets high in animal fat, which can leach vital nutrients from bones.

None of this negates the importance of calcium, both in building bone mass early in life and in minimizing bone loss after menopause. Women lose bone mass more rapidly after menopause because of declining levels of estrogen.

And some experts add that the calcium mania may obscure an even more important non-drug treatment: exercise.

The NIH panel noted that “there is strong evidence that physical activity early in life contributes to higher peak bone mass.” In addition, the panel found, “clinical trials have shown that exercise reduces the risk of falls by approximately 25%”

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“Getting a baseline bone-density test at menopause is essential.”

Not according to most experts, despite claims by some physicians and drug companies.

The National Osteoporosis Foundation recommends universal screening for women without risk factors or fractures at age 65 --when the noninvasive test, which measures bone density at a particular site such as the hip, spine or heel--is covered by Medicare.

The recent NIH panel and the U.S. Preventive Health Services Task Force, an influential independent panel of primary-care physicians, have decided against endorsing mass bone-density screening for any age group. The groups cited variations in the tests themselves, questions about their accuracy and a lack of evidence that expensive testing is justified in patients without significant risk factors or those who have not already broken a bone.

“It’s very hard to tease apart what’s normal bone loss associated with aging and when it escalates to a disease,” said Pamela Boggs, director of education for the North American Menopause Society, a group of physicians and educators. As Boggs noted, there is no agreement about what constitutes “normal” bone density in older women.

Confusion about bone-density tests abounds among physicians, noted Helfand, because the results are imprecise and hard to interpret.

In addition, studies have failed to prove that bone density at age 50 predicts fractures later in life, observed Amy Allina, policy director for the National Women’s Health Network, a Washington-based advocacy group.

That’s because osteoporosis and fractures, while related, are not synonymous. Some women with high bone density have fractures, while others with low bone density never do. Bone density is only one factor--admittedly an important one--that influences the risk of fractures. The other important determinants are bone quality--the internal architecture of bones, which cannot be measured--and the rate of bone loss, which is difficult to gauge.

Even so, a growing number of women are getting bone-density tests in their 40s and 50s, often at the suggestion of their physicians. Last year, according to Allina, Merck officials reported that 3.5 million bone-density tests had been performed in 1999, compared with about 100,000 tests in 1995.

Many women are understandably upset when they are told that the test shows they have “osteopenia”--bone mass that is low, but not low enough to be considered osteoporotic.

“This real scary word gets attached to something that may not be bone loss at all,” said endocrinologist Bruce Ettinger, director of research for Kaiser Permanente’s Medical Care Program in San Francisco.

Take-home message: For most women, a bone-density test at menopause is not useful because the majority of women younger than 65 have an insignificant risk of fracture. There is insufficient evidence that current bone-density tests are a sufficiently reliable way to predict bone loss decades later.

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“Half of white women older than 50 will have a fracture in their lifetime.”

This frightening statistic is a virtual mantra among osteoporosis advocates, but it doesn’t mean what many people think: that one woman in two in their 50s or 60s will break a bone because of osteoporosis.

The truth is that if you live long enough, you may break a bone because of osteoporosis. That’s because the risks of osteoporosis and fractures increase with age. Most fractures are concentrated in women older than 70.

The lifetime risk of having a hip, spine or wrist fracture for a white woman is 39%, according to Mayo Clinic epidemiologist L. Joseph Melton, while the remaining 11% are fractures in other places such as the ankle. That’s based on a life expectancy of 79 years. Black and Latina women are at much-lower risk for all fractures for unknown reasons; most studies have been conducted only with white women.

But lifetime fracture risk, some experts contend, is widely misunderstood and needlessly alarming.

Take-home message: Lifetime risk numbers can be misleading because the risk of osteoporosis rises with age. For most women the chance of breaking a bone at 55 is remote, while the chance of a fracture at 85 is significant. Don’t let misleading lifetime risk numbers steer you into unnecessary treatment.

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“Hip fracture equals nursing home equals death.”

There’s no question that people with hip fractures often wind up in nursing homes. Much of the coverage of osteoporosis in newspapers and magazines includes a statistic commonly cited by the National Osteoporosis Foundation: 20% of women who break a hip and end up in a nursing home are dead within a year.

“When we say that 20% are dead within a year, that’s true,” said Melton, “but at least half of them would have been dead within a year anyway. It’s fair to say that osteoporosis played a part in their deaths, but it didn’t cause it.”

That’s because many of these women are in poor health, suffering from dementia, poor eyesight and other serious medical problems: among this group, the use of powerful, long-acting tranquilizers or antipsychotics that can trigger falls is common. And falls can be an indicator of declining health, overmedication or both.

Breaking a hip, in other words, is often a marker for generally frail health. It tips what has been a precarious balance.

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“Menopause is the most important cause of osteoporosis.”

That’s the implication of some drug ads and a major reason women begin taking hormone replacement therapy at menopause.

In fact, one of the most important causes of osteoporosis is aging.

Everyone loses bone mass as they age. It’s not unlike needing reading glasses: Virtually everyone needs them in middle age because the eye loses its ability to focus.

The association of estrogen and menopause with osteoporosis may stem from the fact that many bone studies have been done on women whose ovaries were removed, not those who underwent normal menopause, said Dr. Susan M. Love, a women’s health activist, noting that surgical menopause seems to accelerate bone loss.

Women do lose estrogen at menopause, which is important in maintaining bone density, she added, but the rate of loss varies.

And results of the definitive study of whether estrogen replacement therapy prevents hip fractures won’t be available for several more years.

In the meantime, some osteoporosis experts advise that for most women without significant risk factors, it’s probably useless and potentially dangerous to start taking a drug at menopause in the hope of preventing fractures decades later. As Love put it, “You could be trading a wrist fracture for breast cancer.”

Take-home message: Menopause contributes to osteoporosis but is not the chief cause. For most women in their 40s and 50s, drugs taken largely to prevent osteoporosis may carry more risks than benefits.