Osteoporosis: Does It Start In Childhood, Teens, 20s, 30s Or Later?
Most of us think of osteoporosis as something that happens later in life.
But the foundations of osteoporosis can begin decades before a diagnosis is ever made.
So when does it really start?
In childhood, when we are building our skeleton?
In our teens, when bone formation is occurring rapidly?
In our 20s, as we approach peak bone mass?
Or in our 30s and beyond, when maintaining the bone we have built becomes increasingly important?
Our Osteopaths answer is: all of these stages matter.
Osteoporosis rarely has a single starting point. Instead, our bone health reflects the skeleton we build when we are young, combined with what happens to that skeleton throughout adulthood.
Genetics play a role, but so do nutrition, physical activity, muscle strength, hormones, medical conditions, medications, stress and the forces we place through our bones.
And because bone is living tissue, constantly being broken down and rebuilt, what you do later in life still matters.
The strength of your skeleton at 70 is influenced by what happened at 15, 25, 45 and 65.
That is why understanding osteoporosis should start much earlier than old age.
Your skeleton starts preparing for later life in childhood.
Childhood and adolescence are critical periods for bone development.
During these years, the skeleton is growing rapidly and accumulating bone mineral.
Physical activity, nutrition, hormones and genetics all influence how much bone we build.
Running, jumping, climbing, sport and other weight bearing activities provide mechanical forces that stimulate developing bones.
At the same time, adequate calcium, vitamin D, protein and overall nutrition provide the raw materials needed to build the skeleton.
Most people reach or approach their peak bone mass during their 20s .
You can think of this as your skeletal reserve.
The more bone you accumulate during childhood, adolescence and early adulthood, the more reserve you may have available when bone loss begins to exceed bone formation later in life.
But peak bone mass is only part of the story.
What if we do not build enough bone in the first place?
For a long time, osteoporosis has been thought of predominantly as a condition of older age.
Early onset osteoporosis is still uncommon, and there can be genetic or medical causes. But there are also growing concerns about factors that may prevent young people from reaching their full potential peak bone mass.
These can include: • inadequate nutrition or prolonged low energy intake • eating disorders and restrictive eating • low calcium intake and low vitamin D levels • reduced weight bearing activity • prolonged periods of inactivity • hormonal disruption, including loss of menstrual cycles • gastrointestinal conditions such as coeliac disease • inflammatory or chronic illness • certain medications, particularly prolonged corticosteroid use. This matters because osteoporosis later in life is not only about how quickly we lose bone. It is also about how much bone we had to begin with. Australian physical activity guidelines recommend that children and young people aged 5 to 17 accumulate at least 60 minutes of moderate to vigorous physical activity every day, including activities that strengthen muscle and bone on at least three days each week. That matters for bone because childhood and adolescence are the years when the skeleton is rapidly building mass and strength. If young people are consistently less active, particularly if they are doing little running, jumping, sport or other weight bearing activity, they may receive less of the mechanical stimulus that helps build a strong skeleton. This raises an important concern: some young people may be entering adulthood with a lower skeletal reserve than we would ideally like, before age-related bone loss has even begun. This does not mean that an entire generation is destined to develop osteoporosis. But it reinforces why bone health needs to be considered much earlier than middle age. The goal is not simply to prevent bone loss when we are older. It is also to help children, teenagers and young adults build the strongest skeleton they reasonably can in the first place. Reaching your 30s does not mean the opportunity has passed. It is easy to hear that peak bone mass is reached in our 20s and assume that by our. 30s the opportunity to influence bone health is over. It isn’t. Bone continues to undergo remodelling throughout life. During healthy young adulthood these processes are relatively well balanced. As we age, that balance can gradually shift towards losing more bone than we replace. The rate at which this happens is influenced by many things, including: • hormones • muscle mass and mechanical loading • nutrition • vitamin D status • physical activity • medications • medical conditions • smoking and alcohol • chronic stress and sleep • prolonged inactivity. So while we cannot go back and change the skeleton we built as teenagers, we can continue to influence how well that skeleton is maintained. Bone strength is about more than bone density When osteoporosis is discussed, most of the focus tends to be on bone mineral density. Bone density is important, but it is not the entire picture. Bone strength is also influenced by: • bone size and geometry • cortical thickness • the internal trabecular structure of bone • mineralisation • collagen and the underlying bone matrix • the way bone responds to mechanical force. This is why fracture risk cannot be predicted by a single number alone. Two people with the same bone density do not necessarily have exactly the same fracture risk. Age, previous fractures, falls risk, medications, health conditions, muscle strength and other factors all matter. Osteoporosis is usually silent One of the biggest problems with osteoporosis is that you generally cannot feel it developing. There may be no pain, no stiffness, no obvious symptoms and no warning that bone strength is declining. For many people, the first indication is a fracture following relatively minor trauma, such as a fall from standing height. This is why osteoporosis is often described as a silent condition Around two thirds of Australians over the age of 50 are estimated to have either osteoporosis or osteopenia, also known as low bone density. That means low bone density is not unusual. It is extremely common. Osteopenia and osteoporosis are not the same thing When you have a DEXA scan, your bone density is compared with the bone density expected in a healthy young adult at peak bone mass. This comparison is reported as a T score. For postmenopausal women and men aged 50 and over, the commonly used ranges are: T score Classification Above minus 1.0 Normal bone density Minus 1.0 to minus 2.5 Osteopenia, or low bone density Minus 2.5 or lower Osteoporosis Osteopenia simply describes the range between normal bone density and osteoporosis. It tells us that bone density has reduced, but not to the level used to define osteoporosis. These categories are not completely separate states where fracture risk suddenly appears once the T score reaches minus 2.5. Fracture risk exists on a continuum. People with osteopenia can still sustain fragility fractures, particularly when other risk factors are present. In fact, approximately half of fractures in Australians over 50 occur in people whose bone density is in the osteopenic range. So osteopenia should not necessarily be dismissed as “almost normal”, particularly when it occurs alongside a previous fracture or other risk factors. How common are osteoporosis and osteopenia in women and men? Australian modelling suggests that low bone density is far more common than the number of people who have actually been diagnosed. Among Australian women aged 50 and over, modelling estimates approximately: 24% have osteoporosis and 48% have osteopenia. Among men aged 50 and over, approximately: 6.5% have osteoporosis and 56% have osteopenia. So while osteoporosis itself is considerably more common in women, reduced bone density is also very common in men. Many people simply do not know they have it until they are investigated for another reason or experience a fracture. A normal calcium blood test does not mean you have strong bones. Around 99% of the body’s calcium is stored in bones and teeth. Only a very small amount circulates in the bloodstream. Your body keeps blood calcium within a tightly controlled range because calcium is essential for nerve signalling, muscle contraction, heart function, blood clotting and many other processes. If calcium availability falls, the body can draw calcium from bone to help maintain normal blood calcium. So it is entirely possible to have normal blood calcium and low bone mineral density at the same time. A routine blood calcium test is therefore not a test for osteoporosis. Blood tests can still be useful when investigating possible causes of bone loss, but bone density itself is assessed using a DEXA or DXA scan. What is a DEXA scan? DEXA stands for dual energy X-ray absorptiometry. (link https://www.healthdirect.gov.au/procedures/diagnostic-tests-and-scans/bone-density-scan) It is a low radiation scan most commonly used to measure bone mineral density at the hip and lumbar spine. A DEXA scan can help identify low bone density and osteoporosis, but it is only one part of assessing fracture risk. A complete assessment may also consider: • age • previous fractures • family history • medications • menopause and hormonal history • medical conditions • falls risk • blood tests • sometimes spinal imaging • fracture risk assessment tools. When can you get a Medicare subsidised DEXA scan in Australia? Australians aged 70 years and over can qualify for an initial Medicare subsidised bone density scan. You may also qualify earlier when recognised risk factors or medical conditions are present. These can include: • a fracture following minimal trauma • previously demonstrated low bone density • prolonged corticosteroid or glucocorticoid treatment • conditions causing excess glucocorticoid production • male hypogonadism • significant female hypogonadism or loss of ovarian function at a young age • hyperparathyroidism • chronic liver disease • chronic kidney disease • proven malabsorptive disorders • rheumatoid arthritis • some conditions associated with excess thyroid hormone. The exact Medicare eligibility and repeat interval depend on the clinical indication. A referral from your doctor is required. It is also worth checking whether your imaging provider bulk bills the scan, as
Medicare eligibility does not necessarily mean there will be no out of pocket cost. You can also opt to have a DEXA scan earlier in life, however there will be an out of pocket fee. So when does osteoporosis really start? There is no single answer. For one person, the story may begin with inadequate bone development in adolescence. For another, it may begin with hormonal changes in midlife. For somebody else, medication, illness, nutritional deficiencies or prolonged inactivity may accelerate bone loss later. The important point is that osteoporosis usually develops over years rather than appearing suddenly in old age. And understanding where you are starting from gives you an opportunity to influence where you go next. In the next article, we will look at some of the factors that can accelerate bone loss in adulthood, including the differences between men and women, perimenopause and menopause, chronic stress, medical conditions and the significance of an apparently simple wrist fracture in your 50s. If you would like to discuss your bone health with our Osteopaths, please book an appointment here