I’ve broken just one bone in my 61 years – my fibula, the smaller of the two that connect your knee to your ankle. I was skiing, I caught my left foot on some ice and the rest of my body just rotated around it until something snapped. Yeah, ouch. I made a full recovery, but I’d rather not break anything else. I definitely don’t want to become so frail that just sneezing or coughing might fracture a rib, or gravity alone could crack my spine.
Like broken hips and wrists, these are all possibilities with the bone disease osteoporosis. In Britain alone, an estimated 3.5 million people live with porous and fragile bones – and one in two women and one in five men over 50 will have a fracture as a result, according to the Royal Osteoporosis Society (ROS). The older you are, the more likely you are to be affected.
Queen Camilla, the ROS’s president since 2001, lost her mother and her grandmother to osteoporosis. “My family and I watched in horror as my mother quite literally shrank in front of our eyes,” she said in 2011. “She lost about eight inches in height and became so bent that she was unable to digest her food properly, leaving her with no appetite at all … I believe that the quality of her life became so dismal, and her suffering so unbearable, that she just gave up the fight.”
As with dementia, it’s easy to feel powerless in the face of osteoporosis. The risks are higher if you’re a woman (much higher, in fact, mostly because of hormonal changes during menopause), if you have a low BMI, if you suffer from certain diseases, such as rheumatoid arthritis, or if there’s a family history of osteoporosis. Smoking and heavy drinking also increase the danger, and it’s naive to think that most people can stop those at the drop of a hat. But simpler lifestyle changes can do a lot to improve your chances of escaping or surviving the disease.
Diet is a good start, though the advice is mostly what you get in any other context. “Calcium and vitamin D are two nutrients well known to be important for bones,” says the ROS. “But there are many other vitamins, minerals and nutrients that are vital to help your bones stay healthy and strong. Try not to become too concerned with getting all these in your diet. If you enjoy a healthy, balanced diet, you’re probably getting everything you need.” That said, in Britain the weak winter sun means that from the end of September to the beginning of April you should consider taking a vitamin D supplement.
Exercise is vital, and not just any exercise. Although older people are often encouraged to avoid weight-bearing exercises, presumably to avoid wear and tear on their joints, bones actually benefit from them. That’s especially true if they involve some kind of impact – anything from the gentle shocks of walking or climbing stairs, through running, skipping or racket sports, to jumping in basketball or volleyball. Personally, I’m going to give skipping another go, though I have two left feet and usually end up with the rope wrapped around both of them.
Most of these are safe even if you have osteoporosis. The ROS advises sticking to low-impact exercise if you’ve had spinal fractures or many broken bones. In general, though: “The higher the impact, the better for your bones.”
“The basics – strength training, impact-based movement and proper nutrition – apply to men and women,” adds Tara LaFerrara, a Texas-based personal trainer and creator of the Broads fitness app. “But women, especially post-menopause, face a higher risk of osteoporosis due to hormonal changes that accelerate bone loss. That means it’s even more important for women to prioritise lifting heavy, eating enough protein and calcium, and getting vitamin D to maintain bone strength and prevent fractures later in life.” Why protein? “To maintain muscle mass, support bone health, boost metabolism, balance blood sugar and improve mood.”
Muscle, of course, will cushion your bones in the event of a fall. But since the best way to survive a fall is to not have one, you should do as much as you can to improve your balance. The ROS recommends tai chi, dance, yoga and pilates, and has a brief guide to exercises on its website. The NHS has how-tos for sideways walking, simple grapevines, heel-to-toe walks and step-ups. Lunges – forward and reverse – are also good, but challenging. Once you’ve nailed the basics, you can make things harder with a Bosu ball or a wobble cushion.
None of this, however, is guaranteed to spare you from osteoporosis. To detect this, your doctor may send you for a Dexa scan, which uses low-level X-rays to measure the density of your bones. But the first step is usually to complete a Frax questionnaire, a “fracture risk assessment tool” developed by the University of Sheffield. (The ROS website has a similar “risk checker”.)
The questionnaire neatly sums up 11 of the main risk factors for osteoporotic fractures: age; sex; weight and height; whether one or both of your parents has ever broken a hip; whether you smoke; whether you drink three or more units of alcohol a day; whether you have a disorder that is strongly associated with osteoporosis, such as type 1 diabetes; whether you have rheumatoid arthritis; whether you have taken the type of steroids known as glucocorticoids, such as cortisol; and whether you’ve already had a “low-trauma” fracture as an adult. That’s a break that didn’t involve a lot of force, or even had no obvious cause.
Most of us could answer those questions without too much trouble. This will be enough to give an initial estimate of your likelihood of getting a fracture in the next 10 years. If that’s high enough, you’ll probably be referred for a Dexa scan, to measure a 12th risk factor – your bone mineral density.
The NHS won’t give you a scan just because you ask for one. Even if you go to a private clinic, it will need to be signed off by a qualified medical practitioner. “You have to have a clinical risk factor or two before you can have a scan,” says Prof David Reid, an osteoporosis specialist and fundraising ambassador for the ROS.
I’d certainly be unlikely to get one in the normal scheme of things. Reid takes me through the Frax questionnaire, decides my skiing accident does not count as low-trauma, and declares: “Your risk in the next 10 years of having a major osteoporotic fracture is 4% – which is obviously very tiny – and for a hip fracture half a per cent.” He could consult the National Osteoporosis Guideline Group recommendations, he says – “but I don’t need to because I know what it would say, which is to give lifestyle advice alone. And it doesn’t tell you to measure bone density.”
What would tip me into Dexa territory? A low-trauma fracture, for a start. If I’d broken my fibula in less dramatic circumstances, that would raise my overall risk to 9.9% and my chance of a hip fracture to 2%.
Even without that, I manage to wangle a Dexa scan so I can report what it’s like. And it’s like being a sheet of A4 in a flatbed scanner: I just lie down in an ugly hospital gown while the scanner head moves slowly over me, building up pictures of my hips and spine that can be viewed almost immediately, alongside figures for how I compare with other men of a similar vintage.
I’m not claustrophobic – I’m perfectly happy inside an MRI machine, for example – but even if I was, I don’t think there’d be anything in the experience to trigger me. It’s completely painless, and Wendy Best, the radiographer who carries out the scan at 25 Harley Street, reassures me I’m getting much less radiation than I would from a standard X-ray. The same technology can be used for a body composition scan, which will reveal how much of you is muscle and fat, as well as bone. If you’re a bit self-obsessed, as I am, this is fascinating stuff.
There is no doubt osteoporosis can be gruelling. Camilla paints a bleak picture of her mother’s last years, back in the 1990s: “When we tried to speak to the doctors about my mother, they just didn’t want to know. Their attitude was: ‘It’s just another old woman – just take another paracetamol.’” But if you do have the condition, there are a number of medicines that can help, either by slowing down the cells that break down bone or by stimulating the cells that build it – or both. The most commonly used drugs, bisphosphonates, belong to the first group, known as antiresorptives. For women, hormone replacement therapy (HRT) can strengthen bones by increasing oestrogen levels. “There haven’t been many studies comparing HRT with other osteoporosis drug treatments,” says the ROS. “But it’s thought that HRT probably reduces the risk of breaking a bone by a similar amount.” Doctors may additionally prescribe calcium and vitamin D.
To what extent can exercise reverse bone loss? When I asked for people’s stories on social media, one woman told me she had been on bisphosphonates for eight years, and running for two and a half. Her last scan, a year ago, showed a “significant improvement”, which she felt was “definitely down to the running”. She’s now starting weight training. Another woman, 66, was diagnosed as “borderline osteoporotic” and is now in year eight of fighting “this nasty bone disease” with weights and other resistance work. “My osteoporosis has completely reversed itself,” she says.
Then I spoke to Karen Hancock, 69, diagnosed with osteopenia – a less severe and even more widespread version of osteoporosis – at 52 after she got pneumonia and cracked a rib coughing. She had previously broken a wrist while hill-walking. At the time of her diagnosis, Hancock had been a keen runner for more than 40 years, with a best marathon time of just over three hours, and was on HRT because of early menopause.
Hancock still runs, still takes HRT, and has been weight-training for more than a decade. Her bones don’t seem to be getting any worse, she says, and she’s never been diagnosed with full-blown osteoporosis. But although she seems to be doing everything right, nor has she reversed the osteopenia. “If I fall – which I tend to do running because I’m a bit clumsy – I do break things,” she says. “I fell walking in 2023 and broke my elbow and had to have metalwork put in. So I suppose I am at risk of the classic old lady thing of a fractured hip. It’s a bit of a puzzle, because I’m not the classic person who never does any exercise.”
Sarah Leyland, an osteoporosis nurse and the ROS’s clinical adviser, advises against placing too much faith in exercise as a cure. “There does seem to be some new evidence coming out that you may get some improvements. You might actually see bone density improving; you might actually be able to reduce fracture risk with the right kind of exercise. But it’s quite early research, and we just don’t have the studies to show that it makes enough difference in someone who’s already in a higher-risk group. So we talk about it as complementary. We speak to people with very low bone density or people who’ve had fractures, and I think there’s a lack of evidence to say you can do exercise instead of taking medication.”
As for my own scan results, no, I don’t have osteoporosis or osteopenia. On a chart that’s colour-coded green for normal bone mass, yellow for low, and red for osteoporosis, I appear as a little black dot near the top of the green zone. “Bone density is above the upper limit of normal for age at all sites,” the report states. Disappointingly, Reid tells me this doesn’t mean I have Superman-strength bones.
Thanks to the Frax questionnaire, I was pretty relaxed about what the scan might throw up, and it turns out I was right to be. All the same, seeing that little dot in the green makes me determined to keep it there.
