Getting older may be a risk factor to developing bone problems such as osteoporosis and broken bones. But these conditions are not an inevitable part of ageing.

“Good nutrition and plenty of exercise, as part of a healthy lifestyle, is important to ensure your bones stay strong as you age. This will help to reduce the risk of osteoporosis and the broken bones it causes,” says Sarah Leyland, clinical advisor at the Royal Osteoporosis Society.

Practitioners caring for older people can play a crucial role in helping patients to boost their bone health by offering life style advice, and directing them to additional support, as well as raising awareness about bone conditions, the risks, the treatments and steps to prevention.

A common bone problem for older people to be aware of is osteoporosis - a condition that causes bones to lose strength and break more easily. According to the Royal Osteoporosis Society (ROS), 3.5 million people in the UK are estimated to have this condition.

However, as osteoporosis is not ‘visible’, people may be unaware they have the condition until there’s a problem. “It’s a silent disease,” says Dawn Skelton, professor of ageing and health at Glasgow Caledonian University, and chair of the Royal Osteoporosis Society Expert Statement on Exercise and Osteoporosis. “It doesn’t give us any warning – people don’t know they have osteoporosis until they fall and have a fracture.”

Osteoporosis in numbers

  • 5 million people in the UK are estimated to have osteoporosis.
  • Half of women and 20% of men over 50 will break a bone because of osteoporosis 1.
  • Osteoporosis causes 500,000 broken bones every year in the UK, costing over £4.5 billion 2.
  • Someone suffers from a broken bone every minute due to osteoporosis 3.
  • It is estimated that 137 million women and 21 million men have high osteoporotic fracture risk globally, with this prevalence expected to double in the next 40 years 4.

Osteopenia

Patients may also be unaware they have osteopenia – which means their bone density is lower than the average adult, but not low enough to be diagnosed as osteoporosis. “This does not mean that a person will develop osteoporosis, or be more likely to break any bones. Having lower bone density is just one of the risk factors for breaking a bone, says Ms Leyland.

Risk factors

There are a number of risk factors, highlighted by ROS which increase an individual’s chance of their bones losing strength. Aside from ageing, some factors that may increase a person’s risk of low bone density include a close family history of osteoporosis - particularly a hip fracture in a parent, early menopause, and certain medical conditions, such as inflammatory conditions, hormone-related conditions, or malabsorption problems. Other risk factors include taking high-dose steroids for more than three months, long-term use of certain medicines that can affect bone strength or hormone levels (such as anti-oestrogen tablets that many women take after breast cancer) and having a low body mass index (BMI). Heavy drinking and smoking can hinder the absorption of calcium and can interfere with the function of the bone building cells, and a lack of vitamin D could also increase people’s risk of osteoporosis and broken bones.

While there are many risk factors associated with low bone density there are also numerous ways to boost bone health. Practitioners caring for older people can be a valuable source of advice and support – sharing information, signposting to further resources, and encouraging steps that patients can take to help prevent bone conditions like osteoporosis (see resources box).

Diet

As bones need many different nutrients including minerals and vitamins, “it’s all about eating a healthy, balanced diet”, says Ms Leyland. ROS recommends including foods from the four main food groups: fruit and vegetables, carbohydrates (like bread and pasta), dairy or plant-based alternatives, and proteins, like beans, eggs, and meat.

“It’s important to have calcium in your diet, or consider taking a supplement,” said Dr Lis Boulton, health and care policy manager, Age UK. She advises that individuals from the age 50 onwards need around 1200mg per day. Sources include dairy, fish, green leafy vegetables, plant-based drinks with added calcium, and nuts.

Vitamins

“You should supplement the calcium with Vitamin D to aid absorption,” says Dr Boulton. She advises that people need 10mcg per day. “It’s difficult to get this in the autumn and winter, so it’s a good idea to take a daily vitamin D supplement. In the spring and summer, short periods of sun exposure without sunscreen will help us make vitamin D from sunlight, but it’s important not to burn,” she says.

Patients can also be advised – and supported - to make lifestyle changes, such as giving up smoking and reducing their alcohol consumption, says Ms Nazarko.

Exercise

“Maintaining regular weight-bearing and muscle-strengthening exercise is great for bone health at any age,” says Ms Leyland. “Bones stay strong if you give them work to do. So, practitioners should encourage those with osteoporosis to exercise regularly to maintain their bone health, improve balance and reduce their risk of fractures.”

For exercise to be most effective at keeping bones strong, she advises patients combine weight-bearing exercise with impact, such as jogging or stamping, and muscle strengthening exercise.

In May this year, a new consensus statement drawn up by an expert panel and endorsed by ROS, on how best to maximise bone health, reduce fracture risk, and improve posture in those with osteoporosis was published in the British Journal of Sports Medicine.

Key recommendations from the consensus statement, called: ‘Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis’, included:

  • Resistance training which ideally uses resistance machines or weights, building up gradually to heavy loads - the maximum that can be lifted eight to 12 times. If this isn’t an option, circuit training, rowing, Pilates or yoga, stair climbing, sit to stands, heavy housework, gardening or DIY may all be good muscle-strengthening alternatives.
  • Regular impact exercise, for example, running, jumping, aerobics, Scottish dancing/Zumba, and many ball games.

Any practitioner contact with a patient aged over 50 should include some reference to finding out how active they are, and whether they do any exercise, says Ms Skelton. “Having that conversation raises the prominence of exercise. It’s so important to ask that open question: ‘How active are you?’ and make patients aware that more activity reduces the chances of many health problems,” she says. And whatever exercise patients choose, she says “it should be something they like, as they’re more likely to stick to doing that exercise regularly”.

Exercises, or activities that challenge balance “are vitally important for good bone health”, and can be integrated into people’s daily routines, says Dr Boulton. For example, patients could try standing on one leg while cleaning their teeth, or waiting for the kettle to boil - making sure there’s something to hold onto if they start to fall. “We need to narrow our base of support, to challenge our balance and wobble a little. No wobble, no progress!” she says.

The Chief Medical Officer’s Guidelines for Physical Activity outline exercises to improve strength and balance. These include lifting weights, yoga, Tai Chi, bowls and dancing. Local Age UKs run tailored exercise classes or programmes for older people across the UK and most gyms will too (see resources box).

50 plus women, bone health and the menopause

During the perimenopause and menopause, the drop in oestrogen affects bone density. Oestrogen is important for keeping bone density and bone strength stable. Dr Boulton explains that in the first five years after menopause, women lose up to 10% of their bone density, on average. Women over 50 have the greatest risk of developing osteoporosis, being four times more likely than men to develop it, she says.

Dr Boulton advises that Hormone Replacement Therapy (HRT) is “generally safe and effective for women going through perimenopause and menopause”. It can provide the same levels of oestrogen that the body has been used to and can also be used as an osteoporosis treatment for menopausal women under 50, and as an option for women aged 50-60, she says.

Ms Skelton says that research on post-menopausal women taking HRT has found “huge improvements” in their bone density, and can postpone osteoporosis and osteopenia”.

Advice about falls prevention

“Looking after your bone health and strengthening your muscles is the best thing you can do to prevent a fall,” advises Dr Boulton. She says research evidence shows that strength and balance exercises can prevent falls, “as long as they are the right kind of exercises”. “As well as aiming to be physically active for at least 150 minutes a week - so you get slightly warm and out of breath - we should all be doing exercise to increase our strength and improve our balance twice a week,” she says.

Making practical adjustments to everyday activities and surroundings “can help people feel confident and steadier on their feet”, says Ms Leyland. “A combination of good balance, coordination and reflexes goes a long way to reduce risks of a slip, trip or fall.”

NHS services such as physiotherapy, occupational therapy and home modifications can also reduce risk of falls and injury in frail older people, advises Ms Nazarko.

“Ideally adults will build strong bones in youth and maintain the best possible bone density in middle and later life,” she says. “Unfortunately people are less active than other generations and may have to make a conscious effort to develop and maintain bone health.

A key message for patients is that it’s never too late to make that effort. “We need to look after bones throughout our life, and it’s always possible to do something to help reduce the risk of fractures – there are positive steps you can take,” says Ms Leyland.

She points out that there are also “effective medications that can reduce the risk of breaking bones”. So rather than practitioners thinking about “just falls prevention, or just medication” for patients, she says they need to consider “both sides of the picture”.

Dr Boulton says that concentrating on forms of exercise that challenge strength and balance, can help people rebuild and maintain their bone density, and carry on living their lives as they wish to - independently.

For Ms Skelton: “It’s important to raise awareness about the value of physical activity, to reduce falls, and reduce the risk of osteoporosis. And we also need to make people aware that along with physical activity, good posture and good diet will make a difference to our comfort and health in our later years.”

References

  1. van Staa TP, Dennison EM, Leufkens HG, Cooper C (2001). Epidemiology of fractures in England and Wales. Bone. 29(6)517-22
  2. Svedbom A, Hernlund E, Ivergård M, Compston J, Cooper C, Stenmark J, McCloskey EV, Jönsson B, Kanis JA, EU Review Panel of IOF. (2013). Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporosis. 8(1-2):137.
  3. International Osteoporosis Foundation, Broken Bones, Broken Lives: A roadmap to solve the fragility fracture crisis in the United Kingdom
  4. Odén A, McCloskey EV, Kanis JA, et al. Burden of high fracture probability worldwide: secular increases 2010-2040. Osteoporosis Int 2015;26:2243–8.

 

Useful resources/contacts

From the Royal Osteoporosis Society (ROS):

From Age UK: 

From the NHS:

 


To find out more about bone health, please attend our annual conference - Health and ageing in a post-Covid NHS - on 18th October 2022 at Hallam Conference Centre, London.

Dr Madhavi Vindlacheruvu will be talking about how fracture and osteoporosis services can be rebuilt and reset following the Covid-19 crisis.


 

A quick guide to physical activity and exercise for osteoporosis by the Royal Osteoporosis Society