Osteoporosis is characterized by decreased bone mass and increased bone fragility, which leads to increased risk of fracture. The World Health Organization (WHO) defines osteoporosis as a bone mineral density (BMD) of 2.5 standard deviations or lower from the young adult mean (a T score of -2.5 or lower), calculated for particular sites of the body, such as lumbar spine, hip, or femoral neck. Osteoporosis can lead to a decrease in the quality of life, as fractures are associated with chronic pain, physical disability, and decreased social function. Hip fractures, especially, are associated with major morbidity and mortality. The estimated annual incidence of hip fracture is 250,000 in the United States, with an estimated direct cost of $17 billion. These figures are projected to rise as the population increases and ages, representing a public health problem in the near future.
Because osteoporosis is a major public health concern and a leading cause of morbidity and mortality in aging populations, prevention is a significant public health priority. Several preventive strategies, particularly those addressing nutrition and diet, obesity, and physical activity, greatly influence bone mass and risk of osteoporotic fracture. In this article, we discuss the physiology and epidemiology of osteoporosis and its main clinical recommendation-based guidelines for preventive strategies, primarily for women. Clearly, many challenges remain in the discipline of osteoporosis prevention, including assessment of precursor disease states and their relationship with risk of fractures, particularly in younger age groups.
Definition and Causes
Osteoporosis occurs most commonly in postmenopausal women; the risk for women increases greatly after menopause because the ovaries produce much less estrogen, the hormone that helps protect bone. There are two types of osteoporosis, primary and secondary. In primary osteoporosis, there is bone loss related to aging. In postmenopausal women, the disease can be a result of low estrogen levels, a decrease in bone formation, or an increase in bone breakdown. Women over 65 are the most likely to experience primary osteoporosis.
Osteoporosis is often referred to as the “silent disease” because it is usually not diagnosed until a bone is broken. The disease causes a thinning of the bones, leading to an increased risk of fractures (broken bones). The most common fractures are in the hip, spine, and wrist. Fractures, particularly hip fractures, can severely limit an osteoporotic patient’s ability to carry out everyday activities and can cause significant disability and decreased quality of life. In a 1997 study, the National Osteoporosis Foundation reported that 80% of women who suffered hip fractures were unable to return to at least one of their previous activities. The foundation also stated that approximately 20% of hip fracture sufferers die within a year of sustaining the fracture, and that those who suffer a hip fracture have an 86% risk of dying within seven years compared to a 68% risk for women of the same age who did not fracture a hip.
Prevalence in Women
Because the fracture rate is disproportionately high in women who have a much smaller amount of bone mass, the challenge to stop the disease is to start it in girls. Moderate physical activity, with compliance of an adequate amount of calcium throughout her life, can help that goal.
Women historically have been expected to have extremely light physical chores, to be very concerned about body weight, and usually have increased bone mass during the late teens and early twenties. Most women are also likely to get pregnant when the requirement for several minerals and vitamins increase even more.
If osteoporosis in women is not amended, the most likely result will be a continuous increase in suffering, costs of health care to individuals, government, and private industry, and human loss of independence, mobility, and self-esteem. Women are uniquely susceptible to the several adverse consequences of inadequate dietary intake throughout life.
Although women statistically are more likely to develop the disease, men are not immune; approximately 2 million American men already have osteoporosis and perhaps 1 in 4 men aged 50 years or older are at risk. Osteoporosis is now recognized as a pediatric disease with geriatric consequences.
Osteoporosis can occur in any skeletal site but is most common in the hip, spine, and wrist. In women, one out of every two has an appropriate for the detection of osteoporosis, is the hip. Over two-thirds of fractures occur in women over the age of 65, when 80% of all fractures are known to occur in women and are therefore to a large degree predictable.
Osteoporosis is a major public health problem. In the United States, an estimated 10 million individuals are believed to have the condition and nearly 34 million more are believed to have low bone mass, placing them at an increased risk for the disease. It has been predicted that hopefully 14 million individuals could have hip bone density measurement by the year 2010.
Bone Health and Osteoporosis Risk Factors
Bone mass and strength are gained mainly during childhood and adolescence and peak at about age 30 in women (and about age 40 in men). At menopause, the rate of bone loss increases, resulting in decreased bone mass and strength. In research studies, low bone mass is commonly measured by the density of bone at the hip and spine with tests called bone mineral density (BMD) tests. What effects do your bones have on you? Breaks from osteoporosis in the spine can lead to chronic back pain, loss of height, and deformation of the spine. Hip and other breaks can result in disability, and as many as 20% of people who break a hip die within 1 year from complications. Even if you have a break from osteoporosis, your bone health can improve by eating balanced meals and increasing your intake of calcium, vitamin D, and other nutrients, and by getting regular physical activity. Your bone health will likely change frequently as your bones change. Your doctor or healthcare provider can measure your bone health and suggest ways to improve it.
Osteoporosis and low bone mass are conditions that weaken bones and make them more fragile and susceptible to fracture. Loss of estrogen, as occurs in menopause, is a major cause of low bone mass and osteoporosis in women. Osteoporosis is often considered a woman’s disease because 80% – 90% of women over 65 have osteoporosis or low bone mass. Men can develop osteoporosis, but in general, men maintain higher bone mass than women throughout life.
Importance of Bone Health
The possibility of a broken bone means that women may be scared to do certain things, such as driving or engaging in community events they were involved in. It behaves somewhat like a broken bone in effect. This fear and subsequent inactivity usually contribute to poor overall health. Bone fractures in women often translate into costly health care expenses. According to the National Osteoporosis Foundation, the healthcare system spends millions of dollars a year on bone fractures.
Their bone fractures cause women a great deal of pain, and may even require surgery. Improper post-surgery rehabilitation can lead to postural issues, lung conditions, and even pneumonia. In serious cases, it can contribute to death. Not all fractures are directly caused by weak bones. Studies have shown that fractures also increase shyness and sometimes resulting in isolation.
In the future, you may be at an increased risk of breaking a bone. At least 1.5 million fractures in the body occur every year in the United States due to osteoporosis. It includes and is not limited to fractures; however, wrist, arm, hip, shoulder, and spine fractures. Such fractures are often associated with reduced quality of life.
Building and maintaining strong bones is important for overall health. Osteoporosis affects more than 2 million men in the United States, but it is a large public health issue for women. There are an estimated 6.5 million women in the United States currently dealing with osteoporosis. The lack of adequate calcium, magnesium, and other important nutrients in the diet can affect bone mass in women across racial and ethnic groups.
Modifiable and Non-Modifiable Risk Factors
Modifiable risk factors significantly associated with osteoporosis in women include advanced age, low calcium intake, low physical activity, and considerable smoking and alcohol consumption. Independent risk factors included low body mass index (BMI), use of steroids, low vitamin D intake, early menopause, anxiety, depression, and consumption of cola beverages. Non-modifiable risk factors include sex, a history of parental hip fracture, and race. The link between non-modifiable risk factors suggests that inherent bone fragility plays a major role in the development of age-related osteoporosis and that such measures may be implemented to ameliorate that risk. This essay qualifies the myriad of modifiable risk factors for osteoporosis, both by treatment type and by intervention. Preventing osteoporosis is the best approach to the financial distress potentially facing some women as they age.
Osteoporosis, a disease characterized by low bone mass and structural deterioration of bone tissue leading to bone fragility and an increased chance of fracture, is a major public health problem. Recent studies have shown that modifiable and non-modifiable risk factors contribute to women’s health-related risks of the clinical implications of osteoporosis. This reality makes modifiable and non-modifiable risk factors a good place to begin addressing prevention strategies.
Nutrition and Diet for Bone Health
Since diet cannot supply sufficient vitamin D, the body’s best source of vitamin D is through exposure to sunlight. In the presence of natural light, the body can produce large amounts of vitamin D, so in general, this is an underestimated aspect of the diet which affects bone health. Foods are optional sources of vitamin D but, except for a few foods like oily fish and cod-liver oil which are good sources, natural foods do not provide significant sources of vitamin D. Furthermore, the amount of vitamin D that is bio-available from fish and other foods is difficult to estimate. Finally, vitamin D added to fortified foods and supplements often comes from animal sources because this is bio-available. Vegan women could be at increased risk, therefore, of becoming vitamin D deficient. Other than fish and eggs, naturally occurring vegetarian foods lack significant levels of this essential nutrient.
In general, nutrition plays only a partial role in the development of osteoporosis. However, there are certain well-established essential nutrients that have a major role in guaranteeing good bone health and maintaining bone strength. Calcium is the most important nutrient because it is the principal structural element of the bone. Adults with low calcium intakes have been shown to have a higher risk of bone fractures. Insufficient calcium intake interferes with bone development, is an important cause of rickets in childhood, and decreases bone mass and increases bone loss in adults. It follows that calcium intake and maintaining an adequate calcium balance is important through all stages of the life cycle to reduce the risk of fractures and prevent osteoporosis. Vitamin D helps to absorb calcium from the gut and plays a vital role in bone health. Nutritional experts all agree that vitamin D is essential for healthy bones.
Calcium and Vitamin D Requirements
Calcium and vitamin D supplements can help women reach their daily needs, particularly when they are unable to obtain sufficient amounts from food alone. Calcium supplements often deliver an absorbable organic compound. Some calcium supplements consist of calcium carbonate, calcium citrate, calcium lactate, and calcium gluconate. Vitamin D supplements come in various forms, with vitamin D2 and D3 being the two forms that are available for the general public. Vitamin D3 is the endogenous form of vitamin D made by the skin and directly influences serum concentrations of the nutrient. Most vitamin D supplements contain more vitamin D3 than vitamin D2. Since the effect of vitamin D supplements on serum 25-hydroxyvitamin D levels is equivalent to that of vitamin D-rich foods, selecting a specific type of supplement for a specific individual should be done with caution to prevent harmful effects.
Calcium and vitamin D are nutrients essential to bone health and reducing the risk of developing osteoporosis. The Institute of Medicine (IOM) has established guidelines for calcium and vitamin D that are advised for all women to consume every day. The calcium and vitamin D recommendations developed by the IOM are based on age, life stage, and gender. Some groups of people may need more or less calcium and vitamin D than others, requiring adjustments to these guidelines. Adequate calcium and vitamin D intake can support bone health when combined with a balanced diet, a nutrient-rich diet, and regular physical activity. Adequate calcium and vitamin D levels are important for maintaining the function and structure of growing and mature bones. Therefore, ensuring people have the nutrients needed for promoting bone health without reaching harmful levels is necessary.
Other Nutrients Impacting Bone Health
Other Trace Elements and Elements: Several other trace elements and elements, such as boron, silicon and strontium, impact bone health. These elements are found in certain foods and are currently under investigation for their role in preventing osteoporosis in women. While these elements are essential and must be included in women’s diets, only certain elements have been identified as potentially beneficial for preventing osteoporosis at this time. Citrus fruits, nuts and legumes are rich in boron. Removal of protective hulls and milling of such foods to remove the bran and germ layers diminishes their boron content. Beer and high-fiber foods may increase the excretion of boron from the body. Oysters, grain products, and beer are good sources of silicon. The potential bone building properties of these two elements were first observed when areas with soft water or high silica content in their water, such as France, were found to have lower rates of hip fracture. Information concerning whether other trace elements and elements play a role in bone health is currently being collected, and federal nutrition guidelines are likely to adjust recommendations when all pertinent evidence has been properly evaluated.
Iron: Iron, which is necessary for delivering oxygen to cells, is an important mineral for bone health; however, only premenopausal women (and men) with an iron deficiency can benefit from iron supplementation for preventing bone loss and fractures. One hypothesis for why excess body iron may compromise bone health is that it may cause inflammation and oxidative stress, thus increasing bone resorption. Throughout her life, a woman should rely primarily on a diet rich in iron to fulfill her needs, since iron supplementation for the purpose of preventing or treating osteoporosis is only appropriate in cases of documented, specific need.
Magnesium: Magnesium, an essential dietary mineral, helps regulate the activity of osteoblasts, which produce bone, and osteoclasts, which break down bone. An inadequate intake of magnesium may obstruct the secretion of the active form of vitamin D, which is needed to create proper calcium balance for bone health. By monitoring magnesium status and, if necessary, consulting a physician about magnesium supplements, women may ensure that they consume enough of this key bone health nutrient.
Physical Activity and Exercise
There is much confusion concerning what type, mode, intensity, duration, and frequency of physical activity is needed to reduce the possibility of developing osteoporosis. Whether one exercises because of a doctor’s orders or deems it an integral part of life, exercise may help women keep bones strong. Even for women who have been diagnosed with osteoporosis, exercise can help prevent the kind of fatigue and lack of independence that often results from this condition. In short, postmenopausal women might be wise to take care of whom they have always counted on to give them daily strength. While it may be a bit late in the running in later years, low or high-intensity exercise not only increases muscle strength and reduces the loss of bone mass, it also reduces the risk of osteoporosis and, for sure, gives women a better main chance of preventing and hindering the malaise.
Regular physical activity and exercise are important for building and maintaining maximum bone density in young adulthood and can delay bone loss in older age. The concept of a finite peak bone mass in the early 20s can be a very effective reminder as to why children and young adults should make exercise and physical activity part of their everyday lives. The maintenance of physical activity is vital as women advance in years since the average peak bone mass is 16% higher in physically active subjects compared with sedentary individuals and is 12% higher in female athletes compared to their non-athletic counterparts.
Types of Exercise Beneficial for Bone Health
Studies that include measuring ground reaction forces should be very accurate and provide prevalence data in different age groups for lack of data on ground reaction forces at bone-associated fractures age with respect to its functionality and secondarily because of a lack of motivation regarding their general physical health. These factors warrant further research into the added benefits of impact-loading activities for preserving bone health during the early postmenopause and to which type and to what magnitude the functional capacity of postmenopausal women with a varying degree of different age-related co-morbid conditions also benefit from these benefits, especially in the first decade of menopause when BMD is lost at an especially rapid pace.
Weight-bearing exercise primarily works against gravity and is more effective at weight load and bony sites, transmitting a greater amount of vibrational force in bones and generating a more effective bone response than muscle contraction during static loading. Since bones remodel in response to increased load, the beneficial effects of high strain activities are lost once they become routine. High-impact activities, generating impulsive stress, are thought to be the best types of weight-bearing activity concerning the stimulation of bone toward increased bone formation than resorption. Ground reaction forces are particularly important in the applicability of mechanical loading of the skeleton, producing a rapid increase in strain.
Recommended Exercise Guidelines
The optimal exercise prescription for postmenopausal women is unknown, but specific types of exercise that are important should be viewed as part of a comprehensive osteoporosis prevention strategy rather than as a sole intervention. Moderate weight-bearing exercise, including brisk walking, may prevent low bone density, particularly in the absence of hormone therapy or after discontinuation. The evidence for the use of strength training is less clear. Aerobically oriented exercise that includes power and speed training not only has immediate benefits for cardiovascular health but also has been shown to have long-term beneficial effects on our biomechanics, such as postural sway more systematically, and it may prevent falls. In summary, postmenopausal women engaging in regular intense exercise, including weight-bearing and resistance training, to protect bone health by improving strength and balance. Remember that the skeletal, muscular, and balance system adaptations to regular exercise are dependent continuously on the type, dose, and intensity of the exercise.
General exercise guidelines were given previously. A 30-minute daily walk at a moderate pace to vigorous resistance exercises such as weight lifting for 8-10 strength-training upper and lower body exercises that work the major muscle groups has been recommended. Regular exercise, as a growing body of research indicates, that lack of physical activity is a risk factor for the development of osteoporosis. Currently, we do not know the precise reduction in fracture risk that can be expected for an individual if they engage in exercise. Of course, we still have much to learn about what type and dose of exercise are the most effective in preventing fractures. Aerobic conditioning improves cardiovascular risk factors and may reduce the risk of falling by improving stability and strength, in addition to preventing the development of obesity. Activities that improve balance, such as tai chi, can also be useful. For the patients who have not exercised in a while or who have health problems, an exercise consultation with a doctor of physical therapy and supervised exercise sessions may be helpful to develop an individualized exercise program and ensure proper performance of the program.
Lifestyle Changes and Habits
Dairy products must not necessarily come from cows. ‘Imitation’ products such as those made from coconut milk are now available with the calcium of cow milk. Milk, yogurt, soy alternatives, and cheese provide calcium and related nutrients like vitamins D and K. Your body will use the calcium found in these foods best, so get about 65% of your daily calcium from them.
Fats are part of our food and have been blamed for many of our health problems. Butter on bread, cream in the coffee, and margarines on the rolls should be eaten in moderation, but obtaining that avocado and portion keep those bones from collapsing in old age and reverse increase daily dietary calcium.
Meat, fish, and poultry are important sources of protein, which is essential for the bones and muscles.
Fruits and vegetables provide dietary sources of many vitamins, minerals, and phytonutrients as well as additional substances with unknown health benefits. Eat a variety of colorful fruits and vegetables each day to maximize the protection they offer.
Alcohol: Use it in moderation. Women who chronically overuse alcohol are prone to breaking bones due to poor coordination rather than poor strength.
Corticosteroid Medications: If your doctor needs to put you on corticosteroid drugs to control an inflammatory disease, work with him or her to be certain the condition is controlled with the lowest effective dosage for the shortest amount of time.
Sleep: Get enough sleep. Your body builds bone during rest and sleep.
Cola: Skip it! Consuming cola beverages on a regular basis appears to increase the risk of losing precious bone mineral at the hips.
Exercise: Regular, sustained weight-bearing exercise such as walking or resistance exercise (lifting weights) reduces the risk of osteoporosis. But the evidence that it also protects women against fractures later in life is less strong. Studies have yet to show a reduction in fracture risk with weight-bearing exercise.
Smoking: Stop! Smoking was never good for your complexion or your arteries, and it may increase the risk of fractures.
Smoking Cessation
With an eye toward the prevention of osteoporosis, patients should be knowledgeable concerning the detrimental effects of peak bone mass and subsequent bone loss that can develop in women who continue to smoke. While direct evidence may not exist at this time, smoking cessation should be encouraged in women who are identified as being at increased risk of the development of osteoporosis. As there may be other considerations that must be addressed, smoking cessation methods should be tailored to the individual needs of each patient. The negative effects of cigarette smoking have also been established by observational data and in American women who are found to be at increased risk of osteoporosis, the necessity of smoking cessation should be emphasized. Disease disproportionately affects elderly women. Women who are identified as smokers should be counseled concerning the known risk of osteoporosis associated with cigarette use and strategies for prompt cessation should be carefully addressed.
Smoking is known to be a highly significant and modifiable risk factor for the development of osteoporosis and related fractures in postmenopausal women. Although the exact mechanism behind the smoking risk is not fully understood, it is known that cigarette smoking has been linked to an increased risk for hip, wrist, and spinal fractures. Cigarette smoking has been surmised to affect bone loss and the development of osteoporosis through a variety of mechanisms, including a negative effect on osteoblast function and overall bone mineral metabolism. Women should be counseled concerning the known risks of cigarette smoking with regard to the development of osteoporosis, and advised to stop smoking. In women age thirty and older with a smoking pattern of at least a five pack year history, the U.S. Preventive Services Task Force (USPSTF) guidelines recommend that smoking prevention and cessation be addressed at all health related supportive patient contacts.
Limiting Alcohol Intake
The consumption of alcohol may cause increases in parathyroid hormone, which in turn leads to an increase in urinary calcium. Alcohol is also considered to suppress the ability of the body to use the calcium-rich hormones estrogen and progesterone. By drinking excessive alcohol or catching a buzz, a woman can easily reduce her chances of becoming pregnant. If a woman is a heavy drinker, her menstrual cycle is often disturbed. These hormonal changes directly affect the loss of bone mass. The concern and urgency involve the possibility of osteoporosis and the roughly 1.5 million fractures requiring hospitalization in the U.S. each year. Alcoholism is a leading contributing factor in many of these statistics. The combination of smoking and drinking affects young women’s bone mass and development.
For women who choose to drink, moderate alcohol consumption is defined as the intake of no more than one drink per day. Examples of a drink are one 12-ounce beer, one four-ounce glass of wine, 1.5-ounce of 80-proof spirits, or one ounce of 100-proof spirits. Alcohol may also increase the risk of osteoporosis and fractures by causing an increase in calcium excretion. Additionally, alcohol is a recognized risk factor for osteoporosis and fractures, as well as for an unhealthy diet and sedentary lifestyle, largely through its influence on estrogen levels. Given the potential risks, women who are considering drinking or are currently drinking should consider moderation and the potential for osteoporosis, and discuss those factors with their healthcare providers.
Medical Interventions and Treatments
Agents that increase bone mass include the bisphosphonates, calcitonin, the selective estrogen receptor modulators, fluoride, and the parathyroid hormone. These agents may be employed if a woman already taking estrogen therapy develops osteoporosis or cannot tolerate estrogen. Proper osteoporosis treatment necessitates these drug evaluations of utilization of such alternative therapeutic agents and should only be taken under the care of a healthcare provider. New bone-forming treatments with teriparatide (parathyroid hormone) are currently available. In the case of these novel options, for example, the ultimate aims are the prevention of bone loss, the induction of bone formation, and the relief of the demanding risk of osteoporotic fractures. Clearly, higher risks and increased cost for therapy should be considered when employing any of these alternative therapeutic agents. Consequently, following the initiation of therapy, treatment investigations are mandatory to hold information and regulation of these various therapies. Initial hematopoietic regenerative therapy is prescribed because of its higher risk and lower success rate.
Medical management can be effective for slowing or stopping osteoporosis in women with established disease. However, several qualifiers concern the use, risks, and administration of such forms of treatment. The basis for the treatment of osteoporosis is calcium, vitamin D, and regular exercise. This primary effort to institute is often unrealistic; so, medical treatments are required. Drug therapy options available for postmenopausal women encompass: (a) those that reduce bone resorption, (b) those that promote new bone formation, and (c) those that act as anti-fracture agents. All medical interventions have associated risks and benefits, and thus assessment of these aspects of use is necessary prior to embarking upon treatment. These agent actions, utility compared to risk and hazard, efficacy, and method of administration (i.e., oral or parenterally) should be determined. Hormone replacement therapy (HRT) is presently the most effective treatment available for the prevention of osteoporosis among postmenopausal women. However, evidence must be considered carefully with regard to advisement of HRT as the agent of choice for the prevention of osteoporosis in all postmenopausal women.
Medications for Osteoporosis Prevention
It is important when prescribing medications to prevent or treat osteoporosis that specific recommendations be followed, and benefits and potential side effects be discussed with the patient. Precommit BMD testing before therapy is not required; however, for 3 years after chronic glucocorticoid therapy is started continuous monitoring of bone health is strongly recommended. Therapeutic agents with an established role in the prevention of glucocorticoid-induced osteoporosis are prescribed estrogen replacement, alendronate, risedronate, zoledronic acid, teriparatide, and denosumab. The preference for one agent over another depends on the patient’s underlying bone density, tolerance of the patient to specific side effects of the medication, and other identified contributing factors to a given health problem. As possible, discontinuation of corticosteroids or switching to treatments that do not include corticosteroids is the most effective approach to prevent the adverse effects of osteoporosis.
Current medications are available that can be taken for the prevention of osteoporosis. These medications are mostly related to inhibiting osteoclast activity. Drugs in this class include bisphosphonates, selective estrogen receptor modulators (e.g., raloxifene), estrogens, estrogens in combination with hormone replacement therapy, and calcitonin. Some other osteoporotic medications such as teriparatide, the monoclonal antibody denosumab, and strontium ranelate are for the treatment of osteoporosis, rather than for its prevention. However, they could also be of interest for preventing osteoporosis in women with low bone mass or other risk factors of fracture. These medications should be considered when discussing preventive strategies of osteoporosis in peri and postmenopausal women.
Bone Density Testing and Monitoring
Two types of densitometry measurements can identify the risk of fractures: the dual-energy X-ray absorptiometry (DXA) device measures the amount of bone in the spine, hip, or forearm that are usually susceptible to fractures, whereas the quantitative ultrasound (QUS) device measures the density of the bone in the heelbone. The DXA test is more accurate in measuring fractures that can be used to measure bone strength (the technique is used by the US Preventive Services Task Force). The scans frequently recognize a low bone mineral density that increases the risk of fractures. With therapy, the scans also can track an increase in bone density. The National Osteoporosis Foundation, US Preventive Services Task Force, International Society of Clinical Densitometry and the International Osteoporosis Foundation (IOF) support or recommend measurements. No firm agreement about the starting age of periodic osteoporosis screening have relayed by these organizations but it is recommended identifying asymptomatic women at greater risk in the IOF.
Physicians and public health practitioners agree on the importance of bone mineral density measurement in order to diagnose osteoporosis and reduce the burden of fractures. The National Osteoporosis Foundation recommends routine bone density tests for postmenopausal women who are at an increased risk of osteoporosis. These tests are helpful for older men and women who have experienced fractures but are not sure about the underlying causes. Women who are 65 years of age or older should probably be screened for low bone density. At the same time, 15% of patients with fractures have normal bone density. It is recommended that the test be administered to patients with a history of falls and noted fractures, particularly when these fractures are unexpected when explained by the patient’s very low trauma.