As we age, our bones become light and hollow like the bones of birds because they lose some of their protein and calcium.

       Osteoporosis is the natural aging of bones, which begins after menopause in women and after testosterone declines in aging men.  Bones should be dense and strong enough to carry our weights and resist breaking if we should fall.  When they become light and hollow, they start to break at the slightest trauma or even without trauma.  Broken hips and spinal vertebrae are the bane of age; they ruin the quality of life and shorten its duration.
      Osteoporosis should be suspected when our bodies become light and frail with age and especially when an older person breaks a bone for any reason.  Heavy bodies resist osteoporosis because bones that carry heavy weights tend to retain their high density.  This is one of the few benefits of being overweight.  Other causes of osteoporosis are smoking, heavy alcohol intake, sedentary life styles, epilepsy medications, serotonin antidepressants, long-term cortisone treatments, low calcium intake, low vitamin D levels, colitis, malabsorption syndromes, Celiac disease, low weight, poor nutrition, etc.
      Osteoporosis can be tested for in two ways: a) by measuring bone density and b) by measuring bone quality.  Bone density x-rays should not be routinely performed on fit menstruating women, fit women on hormone replacement therapy, fit sexually potent older men, and fit but overweight older men and women.  In these populations, the yield of bone density x-rays is quite low.  Bone quality, on the other hand, is measured at no cost and without exposure to radiation by a simple computerised algorithm called FRAX, which is available on the web at  http://www.shef.ac.uk/FRAX/.  It estimates the ten-year risk of major fractures such as hip, arm, and spine.  If the risk of hip fracture is >3% or the risk of the other major fractures >20%, then the National Osteoporosis Foundation recommends considering osteoporosis therapy regardless of the results of the bone density x-rays.  The realization that good bone density does not have to mean good bone quality has deepened our understanding of osteoporosis.
      Unlike FRAX, which can only measures bone quality, bone density x-rays are useful in diagnosing both osteoporosis and the pre-osteoporosis stage known as osteopenia.  And while FRAX may be widely used as a screening test, bone density x-rays should be reserved for those who fit the osteoporosis profile such as women five years after menopause, men who decline sexually after 65, chronically ill or frail or underweight older persons, and persons on medications that promote osteoporosis.  Such persons, if they are found to have osteoporosis, will need to be treated with preventive osteoporosis medications with the aim of preventing future fractures.  However, if they are found to have the pre-osteoporosis stage of osteopenia but without a high fracture risk by FRAX, then they may be adequately managed with calcium and vitamin D tablets plus life style modifications and increased weight bearing exercises.
      The osteoporosis medications are not benign and should be used with caution.  The Bisphosphonates such as Fosamax, Actonel, and Boniva can burn the esophagus and need to be taken upon arising on an empty stomach with strict instructions not to eat or drink or take other medicines or lie down for 30-60 minutes after intake.  They may also cause breakdown of the jawbones after dental procedures or if the dental health is poor.  Other side effects are body aches, upset stomachs, and chest pains.
      The hormones (estrogen for women and testosterone for men) also prevent osteoporosis but are seldom used for that purpose.  They are primarily indicated for the treatment of hormone-deficiency symptoms but the prevention of osteoporosis is one of their side benefits.  There is, however, a female hormone like agent called Evista, which is primarily used for the prevention of osteoporosis.  Unfortunately, all these hormones can increase blood clots, strokes, heart attacks, etc. and should only be used when the benefits clearly outweigh the harms.
      All men and women over 30 should take enough calcium and enough vitamin D.  Enough calcium means 1200 to 2000 mg daily.  The usual calcium tablets contain 500 to 600 mg and most people need to take two to four tablets daily.  Calcium is constipating and is best taken with meals.  Many calcium tablets also contain Magnesium, which prevents constipation.
      The dose of vitamin D3 should be 1000-2000 units daily.  Vitamin D3 tablets are available in 1000 or 2000 units and should supplement the calcium tablets because without vitamin D, the calcium is not absorbed nor made available to bones.  Taking up to 4000 units/day of vitamin D is not harmful, especially for those who do not spend much time in the sun.  Many calcium tablets also contain vitamin D but they don’t contain enough and should not be used as the main source of vitamin D.  They should always be taken with 1000-2000 units of vitamin D3 daily.
      Osteoporosis is, for most people, a preventable disease.  The antidotes for this bone-aging syndrome are proper amamounts of calcium and vitamin D to be started at or before the age of 30.  A healthy life style with no smoking, low alcohol intake, frequent weight-bearing exercises, and good nutrition is as important as the calcium and vitamin D supplements.
      Testing older, chronically ill, and frail men and women for osteoporosis may save them from the horrible consequences of bone fractures.  Since osteoporosis is an asymptomatic disease, the first symptom may indeed be a broken hip or arm or spine and when that happens, the disease may well be too far advanced to reverse.