Stopping Osteoporosis Before it Starts -- Saralyn Mark, MD -- 05/24/02

Last Editorial Review: 10/23/2003

By Saralyn Mark
WebMD Live Events Transcript

The opinions expressed in this transcript are those of the health professional and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician.

In recognition of National Osteoporosis Month, WebMD wants you to know it's never to early to prevent bone loss. Find out how you -- and your children -- can benefit tomorrow from thinking about osteoporosis

today. Saralyn Mark, MD, was our guest on WebMD Live.

Moderator: Hello, members, and welcome to WebMD Live. Our guest is Saralyn Mark, MD, who has joined us to discuss osteoporosis prevention.

Member: Why is youth the important time to build strong bones?

Mark: Bone is continually being repaired during our lifetime. However, we have certain periods of life while building our bone bank. We accrue 90% of our bone mass while 20 years old; half of that occurs during adolescence. We continually build bone until in our 30s, but the bulk of bone mass accrual occurs in our younger years. And it's that bone mass that we will turn to as we age.

Moderator: Dr. Mark, as the parent of a 6-year-old girl, I hope I represent a lot of parents when I ask you how I can start preventing osteoporosis now, so she'll have good bones when she's my age and older.

Mark: That's a wonderful question. The office on Women's Health within the U.S. Department of Health and Human Services in partnership with the Centers for Disease Control and Prevention and the National Osteoporosis Foundation have developed the National Bone Health Campaign entitled "Powerful Bones. Powerful Girls." This campaign is initially targeting girls aged 9 through 12 with outreach to their parents, to educate them on simple steps to achieve good bone health. We focus on calcium intake, which should occur through diet and physical activity. These basic behaviors need to start in childhood so they will last a lifetime. You can access more information about the National Bone Health Campaign through our web site,

Moderator: These "very basic behaviors" you mention, diet and physical activity, are easier said than done these days, it seems. Do you think the decline in physical activity in kids and increase in obesity over the last few years will mean an increase in osteoporosis down the road?

Mark: Yes, I do. Physical activity is so important in helping us maintain health. It prevents not only osteoporosis but diabetes and heart disease as well. Obesity is a significant problem for all Americans, and the surgeon general recently released a report on this growing epidemic in the United States. It's important for young people to be aware that physical activity needs to be a part of their daily lives. In order to maintain good bone health, a young person should get about 60 minutes of weight bearing activity most days of the week. This does not have to come all at once, and examples of weight bearing activity include walking, taking the stairs, dance, sports (except for swimming and bicycle riding - these don't make you go as much against the force of gravity). If we move our bodies throughout the day, we can achieve the goals we need to protect our bones. We don't have to go to a gym or buy expensive equipment.

Moderator: Why the focus on girls? Are they much more likely to have bone problems later than males? Why is that?

Mark: Osteoporosis affects 42 million Americans in this country; 80% of which are women. Women often have less bone mineral density than men.

Muscle strength and coordination differ, and this may put a woman at risk for falling and fracturing her bones. Furthermore, studies have shown that boys consume more calcium and get more physical activity than their peers. Thus we have created the National Bone Health Campaign, "Powerful Bones. Powerful Girls" to level the playing field for girls. The message we are implying to young girls is also important for young boys.

Member: My friend has two sons, and osteoporosis runs in her family. Should the same preventive measures be taken for boys as for girls?

Mark: Yes. The National Bone Health Campaign did extensive research on what young girls know about their bones and how to reach them with age appropriate messages. However, the behaviors that we emphasize for bone health are important to the health of young boys' bones as well.

Member: My daughter has to stay away from milk and milk products. What else can she eat/drink to get the calcium she needs?

Mark: People may have allergies to dairy products or may be lactose intolerant, lacking the enzyme to digest the sugars in milk products. The body can slowly produce this enzyme when dairy products are slowly introduced into the body. Additionally, there are agents you can buy at the store to put in the dairy products to get the enzyme, which will help you digest the dairy products and may help minimize discomfort with consumption of dairy products. However, if someone is not able to consume dairy products, there are other foods that contain calcium, such as vegetables (bok choy and broccoli), nuts, and seafood. And in today's market, there are many foods fortified with calcium, such as orange juice. Our web site for the National Bone Health Campaign lists many food items that contain calcium and creative ways to get them into your diet. Keep in mind that one can take calcium supplements, but it's not just the calcium that's important but also the nutrients and minerals that are important for bone health.

Member: How do you get kids off of soda and drinking milk again? Soda is available everywhere, and milk is limited, as is bottled water. Would you be more concerned about the sugar consumption in the flavored milks -- coffee flavored, etc.?

Mark: There are studies looking at children's consumption of soda products. Sometimes they are called liquid candy because they have no nutritional value. Many schools have soft drink vending machines since the schools get funding from these companies. The government is working with schools to make sure milk is available and there are efforts to look at children's consumption of milk products. There is almost the same amount of calcium in a flavored milk product than in a non-flavored milk product. So if this encourages kids to drink more milk, this may be helpful. Milk has many vitamins and minerals needed for good bone health and it has a satiety factor, which may tell the brain the body is full and may discourage overeating.

Member: My teen-aged daughter eats several meals per week at school and out with her friends, usually at the mall. She loves junk food. How can I make sure she gets enough calcium?

Mark: Well, by ensuring she enjoys the foods she does eat, and there are many products with calcium in them. Our web site lists many ways to make foods fun and appetizing for young people. It's also been found that children mimic behaviors of their parents. For example, they follow their mothers in regards to what they eat and will follow their fathers in regards to physical activity. So establishing a partnership with your child where you both have healthy habits may be productive for everyone. Our National Bone Health Campaign was developed for young girls by young girls and hopefully provides messages that resonate with their lifestyle. Please visit our web site.

Moderator: Is there anything the pediatrician or family doc can do to monitor bone growth and make sure kids are developing the strongest bones possible?

Mark: Doctors will monitor the linear growth of children to assess them on how they are growing in comparison to peers, and sometimes obtain blood tests to ensure that kidney function and calcium levels are normal. If a child has fractures, a doctor may be concerned that there is a problem with bone development, and a further workup may be necessary. We are learning that fractures in childhood may be a harbinger of things to come, especially if the fractures occur with mild trauma. We are not routinely screening young children with bone density tests at this time.

Member: How much calcium is too much, and what are the effects of excess calcium in the diet?

Mark: Generally, the body can tolerate well over 2 grams of calcium per day. The body will excrete through the urine calcium it does not need. And if the body cannot excrete it through the urine, calcium can deposit in joints and soft tissue. This is generally not a problem for most Americans. If someone has problems excreting calcium through the urine, they can develop painful kidney stones. And there is a syndrome called the milk-alkali syndrome in which an individual may be drinking a lot of milk and taking antacids. This can impair kidney function and can create problems. Fortunately, we don't see this problem too often and the concern in the United States is most people don't get enough calcium in their diet. Only 10% of young girls get the required calcium of 1,300 mg per day. This is a problem.

Member: Some foods like spinach are high in oxalic acid and may hinder the absorption of calcium. How can you balance eating healthy foods like spinach without hindering the calcium your body needs?

Mark: Foods that contain oxalic acids can impair the absorption of calcium from our diet, but you can offset it by taking in more calcium while at the same time taking in more foods which do not contain oxalic acid. It's important to have a healthy diet throughout the day. The body is more concerned with what you have done by the end of the day instead of at one point during the day.

Member: I've heard the body can only absorb 600 mg calcium at one time. True? If so, how do you space calcium intake to optimize dietary intake and supplements?

Mark: Everybody is different, but we recommend that if someone is to take a calcium supplement they take them in divided doses, which is 500 mg each meal, depending on age group requirements. This may be due more to the fact that excessive calcium can cause constipation. Keep in mind that if you are having a balanced diet, with say a glass of milk (300 mg) of calcium, you can still digest and absorb calcium from other food groups. We are more concerned about calcium supplementation when we talk about divided doses.

Member: Does heredity play a role in developing osteoporosis?

Mark: Heredity does play a role in the development of osteoporosis. The genetic contribution may be as much as 70%, so it's important to know the family history on both your mother's and father's side. At this point in time, we can't alter our genetic code but can mitigate the effects by ensuring more calcium in our diets, get more weight-bearing activity in our lives, and avoid smoking and alcohol abuse, which may affect the bone.

Member: What is osteopenia?

Mark: Osteopenia is a state characterized by lower bone mass. The amount that is not as high as what you see in osteoporosis. The World Health Organization developed standards to characterize osteoporosis and osteopenia. One has osteoporosis when their bone mineral density is greater than 2 1/2 times peak bone mass. In osteopenia it's characterized by 1 1/2 times peak bone mass. If one has osteopenia by bone mineral density and a fracture, they are then characterized as having osteoporosis. Physicians are still concerned about patients with osteopenia because they are at risk of developing fractures as well.

Member: Are arthritis and osteoporosis linked in any way?

Mark: A patient can have osteoporosis and osteoarthritis at the same time. Osteoporosis is a disease of the bone. Osteoarthritis is a disease of the joint space. Osteoarthritis, otherwise known as degenerative joint disease, can be caused by excessive wear and tear and can be quite painful. The patient who has osteoporosis and who has not had a fracture may not know they have the disease and it may not be painful. It's important to remember these are 2 separate diseases.

Member: From 18-26, I was underweight (at times being borderline anorexic) and amenorrheic, and I exercised intensely. At 24 a doctor finally prescribed birth control pills, which satisfactorily ended my amenorrhea. Now, at 30, I am a healthy weight, still take birth control pills and still exercise intensely, and two years ago I added weight training to my routine. Yet I am concerned about my years of restricted eating and how that affected my bones. I have no symptoms of bone density loss, but because my estrogen level for several years was at a menopausal level (based on blood work), I wonder if I should have a bone density test?

Mark: Your question is very important and affects many women in this country. You describe a pattern of disordered eating that affected your periods and your body's ability to produce estrogen, which protects bones from excessive loss of calcium. Additionally, a state of disordered eating can put one's body in a stressful state, and other stress hormones such as cortisol can be released. These can affect your body's ability to absorb calcium, thus your bones are at risk for the development of osteoporosis. The drugs that have been approved to prevent and treat osteoporosis have been approved for postmenopausal women. We also don't know how long one can stay on these drugs or need to be on these drugs. There is a new drug in development involving parathyroid hormone, which may help build back bone that we have lost, and it will probably be described for those with significant osteoporosis.

At this time, however, you are doing what you can do to protect your bones through your healthier habits, and a bone mineral density test may not change that. You know you are at risk for the development of osteoporosis, and it will be very important through your behavior (ensuring adequate calcium intake, weight bearing activity, and continuation of birth control pills) that you can protect your bones. This is a decision you need to make with your physician. As with any test, you need to think about what you will do with that information and how it may affect your decision.

Member: Are there any osteoporosis prevention campaigns within HHS focusing on older women?

Mark: The Department of Health and Human Services has a focus on prevention since we believe this is the first step to achieving good public health. There are many materials available that provide information to older Americans, both men and women. A wonderful resource for you is the National Women's Health Information Center. You can access that through (800) 994-WOMAN. Or through our web site, This resource center has links to agencies and organizations that focus on women's health issues, including osteoporosis.

Member: I am 32 years old and have no risk factors other than being a white female. A few years ago, I thought it would be fun to take a bone density test at a health fair and was diagnosed with osteopenia. I followed up with my primary doctor and a bone density test and the results were confirmed. I began taking about 1,000 mg of calcium/day and eating calcium rich/fortified foods, I also exercise quite a bit. Two years later my results in my hips are worse. I am being sent to an endocrinologist to check absorption. Any suggestions on what I should be doing or what to expect at the new doctor?

Mark: It is important to understand why you are losing bone. Your endocrinologist will run a series of blood tests and urine studies. This will probably include an evaluation of vitamin D levels, thyroid levels, and parathyroid levels. A thorough physical exam and medical history will be taken. Please access our web site, the National Women's Health Information Center, for more information.

Member: How often do you need a bone density test?

Mark: Generally it's recommended one not have one more than every two years. The precision of the test may not detect changes in that short of a period of time. If there have been significant changes in health during that time, you may want to establish a new base line on that test. It's important to talk with your physician about what will work best for you.

Moderator: We are almost out of time. Before we wrap up for today, do you have any final comments for us, Dr. Mark?

Mark: Thanks for inviting me to spend the hour with you. It's never too late to protect your bones. Without strong bones you can't have the quality of life we all want. Fortunately, much of what we do to our bones is under our control, and it's important to read, ask questions, and to be aware that your bones are living tissue and need to be protected and nurtured. And this web site is a wonderful first step toward achieving good bone health. Thank you for chatting with me today.

Moderator: Unfortunately, we are out of time. Thanks for joining us, members, and thanks to Saralyn Mark, MD, for being our guest. Be well and goodbye!

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