This section can help if you’d like to learn more about keeping your bones healthy. It explains why this is important, what factors affect your bones and has tips to help you maintain healthy bones. It also includes information on drug treatments.
If you are looking for information about cancer in the bones, see our sections on bone cancer that either starts in the bones (primary bone cancer) or has spread to the bones (secondary bone cancer or bone metastases).
The human body is made up of more than 200 bones of different shapes and sizes.
Bones consist of collagen - a type of protein - and minerals such as calcium and phosphate. These make bones strong and rigid. Bones are filled with a soft spongy material called bone marrow, which makes blood cells.
The bones have several important functions:
they provide support for our bodies, and the joints act as levers so that we can move around
they protect various parts of our bodies from injury - for example, the ribs protect the heart and lungs
they store important minerals, such as calcium, that are used by our bodies.
Our bones are constantly being broken down and replaced with new bone, which helps maintain their strength and shape. There are two main types of cells that break down and replace bone: osteoclasts break down and remove old bone while osteoblasts make new bone.
Why bone health is important
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Bone health is important throughout your life, but it’s even more important as you get older. This is because bone loss gradually increases as part of the natural ageing process, meaning bones get weaker.
Some people may develop conditions such as osteopenia and osteoporosis:
Osteopenia occurs when the bones become slightly less dense. It can eventually develop into osteoporosis.
Osteoporosis occurs when bones lose their density and become weaker as they lose minerals like calcium.Weak bones are prone to breaks (fractures).
Fractures are more common in people who have osteoporosis. Osteoporosis itself isn’t painful and doesn’t cause any symptoms until a weakened bone fractures. Fractures occur more commonly in the wrists, hips and spine, but they can occur elsewhere in the body too. If a fracture does occur, it can make movement painful and difficult.
About 1 in 2 women (50%) and 1 in 5 men (20%) over 50 will have a fracture at some point. Fractures can occur in younger people too. People who have cancer treatments, such as some types of hormonal therapy, are more likely to develop osteoporosis and fractures.
A lot can be done to prevent bone loss and osteoporosis, and treatments that lower the risk of fractures are now available.
It’s possible to measure bone mineral density, which helps assess the strength of bones, using a DXA (dual energy x-ray absorptiometry) scan. DXA scans can help doctors decide if somebody needs drug treatment for weakened bones.
Factors affecting your bones
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A number of factors affect bone health. These include:
Age and gender
All women have an increased risk of bone loss after the menopause. This is because the level of the hormone oestrogen, which helps keep bones healthy, falls at the menopause.
Physical activity makes our bones stronger. Regular daily exercise is one of the best ways to improve and maintain bone strength. Weight bearing exercises, such as walking, climbing stairs or dancing, are particularly effective.
makes our bones stronger. Regular daily exercise is one of the best ways to improve and maintain bone strength. Weight bearing exercises, such as walking, climbing stairs or dancing, are particularly effective.
Eating a balanced diet helps maintain healthy bones. Having enough calcium in your diet is especially important, as calcium helps build bones and keep them strong.
Family history of osteoporosis
If you have a family history of osteoporosis, you’re more at risk of developing it yourself.
People who have fragility fractures after the age of 50 are more likely to have weakened bones due to osteoporosis. Fragility fractures occur after a fall from standing height or lower. People who have healthy bones are less likely to break a bone from a fall at this height.
Being underweight can increase the risk of fracture and bone loss, so it’s important to maintain a healthy body weight. You might find our information about weight management after cancer treatment helpful.
There are a number of illnesses that can reduce your bone health. These include rheumatoid arthritis, inflammatory bowel disease, coeliac disease, diseases of the lung and liver, and eating disorders such as anorexia and bulimia.
Some drugs, if taken for a long time, may increase your risk of developing osteoporosis. They include:
anticonvulsants, which are used to prevent fits
corticosteroids, which are used to treat a number of illnesses such as rheumatoid arthritis and asthma.
Smoking and alcohol
Several studies have shown that smoking may affect bone health by reducing bone density and causing weakened bones. A high alcohol intake has a toxic effect on bones. It also increases the risk of fractures, as a person may be more prone to falls when under the influence of alcohol. People who drink a lot of alcohol also tend to have a poor diet, which often means their calcium intake is reduced, and this can lead to weaker bones and bone loss. Bone loss is also associated with liver disease, which is common in people who drink a lot of alcohol.
Cancer treatments and bone health
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Some cancer treatments can increase the risk of bone loss and osteoporosis.
Drugs known as aromatase inhibitors - eg anastrazole (Arimidex®), exemestane (Aromasin®) and letrozole (Femara®) - are commonly used to treat breast cancer in women who have been through the menopause. They can cause bone loss insome women and may increase the risk of fractures.
Another drug called goserelin (Zoladex®) may be used for premenopausal women with breast cancer. It stops the production of a hormone called luteinising hormone, which is produced by the pituitary gland (the gland that produces hormones that control other glands in the body). This in turn causes a reduction in oestrogen levels, which can lead to bone loss.
Men with prostate cancer may also have treatment with drugs that stop the production of luteinising hormone from the pituitary gland, increasing the risk of bone loss. These drugs include Zoladex, leuprorelin (Prostap®) and triptorelin (Decapeptyl®).
Some chemotherapy drugs stop the ovaries or testes from working so they no longer produce normal levels of the hormones oestrogen or testosterone. This effect can be temporary or permanent. Your healthcare team will tell you how your chemotherapy drugs are likely to affect your hormone levels. Changes to hormone levels can result in bone loss in both younger women and men. Women may also experience an early menopause.
Other chemotherapy drugs, such as methotrexate and ifosfamide, may have a direct effect on weakening bones. Your doctor or nurse will talk to you about this if you’re going to have these drugs.
Other cancer treatments
Other drugs used in cancer treatments may be associated with changes in bone density. These include imatinib (Glivec®), which is used to treat chronic myeloid leukaemia (CML), advanced multiple myeloma and some gastrointestinal tumours.
Some people with certain types of leukaemia or lymphoma may have steroids as part of their treatment. Long-term use of steroids (eg prednisolone or dexamethasone) can affect bone health by causing bone loss and increasing the risk of fractures.
An operation to remove the ovaries in premenopausal women or the testes in men reduces hormone levels and can increase bone loss.
Looking after your bones
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There are many changes you can make to your lifestyle to improve your bone health. These changes are helpful for everyone, so your family and friends can benefit too.
Eating a balanced diet and making sure you get enough calcium will help you maintain strong and healthy bones. The Food Standards Agency (FSA) advises that a balanced diet should include:
equal amounts of fruit, vegetables and starchy foodssuch as rice, bread, pasta, potatoes and whole grains
some protein-rich foods such as meat, fish and eggs,and pulses such as beans and lentils
milk and dairy foods
a small amount of foods that are high in fat, salt and sugar.
Large amounts of some foods and drinks can upset the calcium balance in the body, so it’s important to have them in moderation. These include caffeine, red meat, salt and fizzy drinks that contain phosphates, such as cola.
It’s also important to eat foods that are rich in calcium such as:
dairy products - for example, milk, yoghurt and cheese
leafy green vegetables - for example, broccoli and curly kale
soy beans, kidney beans and baked beans
dried fruit - for example, apricots and raisins
fish - for example, sardines tinned in oil and tinned salmon.
If you have a dairy-free diet, make sure it includes other non-dairy foods that contain calcium.
Vitamin D helps your body absorb calcium, so it’s important to get enough vitamin D. We mainly get this through exposure to sunlight, which the body converts into vitamin D. This is then stored in our fat. People with naturally dark skin need more sunlight to make vitamin D because of the pigment in their skin. Most people get enough vitamin D for the whole year just by being out in the sunshine for 15–20 minutes every day in the summer. If you don’t go out enough, or if you cover up when you’re out in the sun, try to eat foods that contain vitamin D, such as cooked salmon and mackerel, tuna fish tinned in oil or cod liver oil.
A balanced diet and enough sunshine will usually give you enough calcium and vitamin D to keep your bones healthy. However, taking supplements may be helpful, particularly if you’re having cancer treatments that are known to increase the risk of osteoporosis, or if you’re unlikely to get enough sunshine. Your GP or hospital doctor will tell you if you need to take supplements.
Cut down on smoking and drinking alcohol
If you smoke, try to cut down or stop altogether. You might find our section about stopping smoking helpful. If you drink alcohol, stick to recommended guidelines.
Current sensible drinking guidelines recommend that:
men drink no more than three units of alcohol a day or 21 units a week
women drink no more than two units of alcohol a day or 14 units a week.
One drink isn’t the same as one unit of alcohol. As a guide:
half a pint of standard strength (3-4%) beer, lager or cider contains one unit
a half pint of stronger (5%) beer, lager or cider contains one and a half units
a standard glass of wine (175ml- this is a small glass in pubs and bars) contains two units
a large glass of wine contains three units
a single measure (25ml) of spirits contains one unit.
Drinking large quantities of alcohol in one session - often called binge drinking - is thought to be worse for your health than drinking a small amount each day. It’s also recommended that people have one or two alcohol-free days each week.
Get physically active
Bone responds to physical activity by becoming stronger. Exercise can also improve your coordination and balance. Together, these may reduce your chance of falling and having to deal with any related complications, such as a fracture. How much exercise you do depends on your cancer, its treatment, how fit you are and what you want to achieve.
Remember to get advice from your doctor before you start any exercise regime.
There are lots of different ways to exercise. It’s best to try to find an activity that you enjoy so you’ll carry on with it and not get bored.
Exercise that forces you to work against gravity (weightbearing exercise) is best for your bones. This includes walking, climbing stairs, dancing, hiking and gentle weightlifting. Swimming isn’t a weightbearing exercise, but is a good way to get fit. High-impact exercises, such as excessive running, should be avoided as they may lead to stress fractures and can weaken bones further.
If you haven’t exercised much before, you’ll need to start slowly. Try to set goals that can be achieved at your own pace. As a guide, regular exercise is usually defined as 30 minutes of moderate activity 3-5 times a week. But remember, just doing an activity for 10 minutes can help. Listen to your body and be careful not to overdo it.
We have more information and advice about building up your physical activity.
Checking your bone density
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If you’re at risk of weakened bones or if you’re having cancer treatment that is likely to affect your bone health, talk to your GP or hospital doctors about checking your bone density.
If you have early invasive breast cancer, the National Institute for Health and Clinical Excellence (NICE) recommends that you have a bone mineral density scan if:
you’re due to start treatment with an aromatase inhibitor (eg anastrozole, letrozole or exemestane)
you have an early menopause due to cancer treatment
you’re going to have treatment to stop your ovaries working.
If you need a bone mineral density scan, your GP or hospital doctor will arrange this for you. A bone mineral density scan is also known as a DXA (dual energy x-ray absorptiometry) scan. During the scan, you’ll be asked to lie on your back on a couch while a scanner moves above your body. Special detectors in the scanner are able to measure how much radiation passes through the bones, usually in your spine and hips. This information is sent to a computer that records your bone density.
The scan only takes a few minutes and is completely painless. You may be asked to put on a gown for the scan. You’ll also need to make sure that any metal fastenings such as zips are not in the area of your body that’s being scanned.
Some people worry that the amount of radiation from a DXA scan may be harmful, but the amount used is very low. The results of the DXA scan will show whether you are at low, medium or high risk of developing a fracture. If your risk is medium or high, your GP may advise you to take calcium and vitamin D supplements and you may be prescribed a bisphosphonate drug (see below). These will help reduce the risk of further bone loss and fractures. You will also be encouraged to have a healthy balanced diet, get enough sunshine and keep physically active.
This group of drugs is used to prevent fractures due to osteoporosis. They may also be used to prevent bone loss caused by cancer treatments, such as some types of hormonal therapy, or to prevent or treat secondary cancer in the bone (bone metastases).
Bisphosphonates work by reducing the activity of the osteoclasts, which slows bone loss. Although bisphosphonates don’t help replace lost bone, they can prevent further bone loss and this helps strengthen existing bone.
Bisphosphonates may be prescribed alongside hormonal cancer treatments to protect your bones.
There are a number of different bisphosphonates including:
alendronic acid (Fosamax®)
ibandronic acid (Bonviva®, Bondronat®)
sodium clodronate (Bonefos®, Loron 520®)
risedronate sodium (Actonel®)
disodium pamidronate (Aredia®)
zoledronic acid (Zometa®, Aclasta®)
disodium etidronate (Didronel®).
Bisphosphonates are usually given as a tablet or capsule to treat bone loss and osteoporosis, but they may also be given by injection into a vein (intravenously) or as an infusion.
Tablets or capsules should be taken on an empty stomach with a glass of water, usually first thing in the morning. You will be given instructions for taking them, which will include staying upright for 30 minutes after taking the tablet or capsule. This helps the drug move quickly into the stomach and reduces the risk of the drug staying in the throat or gullet where it can cause irritation.
Side effects of bisphosphonates may include:
a sore throat or inflamed gullet
pains in the muscles and joints
flu-like symptoms, which usually settle after the first dose.
Osteonecrosis of the jaw is a very rare side effect of bisphosphonate treatment. It affects up to five people out of every one hundred (1-5%). If this does happen, healthy bone tissue in the jaw becomes damaged and dies. It happens more commonly in people who have teeth removed or other dental procedures while taking bisphosphonates. It’s also more common when bisphosphonates are given by injection rather than as tablets or capsules. It can result in poor healing of the gums or loosening of the teeth.
If possible, dental treatment should be avoided while taking bisphosphonates. Before taking them, you should have a dental check-up if you’ve not seen a dentist for six months or if you have dentures that don’t fit well. It’s important to let your dentist know you’re taking bisphosphonates. You should also let your doctor know if you need any dental treatment while taking them.
Calcium and vitamin D supplements
If you’re having cancer treatments that are known to increase your risk of osteoporosis, such as hormonal treatments, you may need to take calcium and vitamin D supplements. Your GP will usually organise for you to have a bone mineral density scan before deciding whether you need to take supplements.
Calcium tablets may be prescribed by your GP to be taken alongside bisphosphonate treatment. You can also buy bothcalcium and vitamin D supplements without a prescription from many chemists, but you should always check what dose to take with your GP.
Less commonly used drug treatments
Calcitonin is a naturally occurring hormone that can help reduce the risk of fractures in the spine (but not the hip) in postmenopausal women who have osteoporosis. It’s available as a nasal spray that’s inhaled once a day or as an injection.
Raloxifene is licensed for the prevention and treatment of osteoporosis in postmenopausal women. This drug mimics some of the helpful effects of oestrogen, reducing the breakdown of bone and the risk of fractures in the spine. Women with hormone-sensitive breast cancer being treated with tamoxifen shouldn’t take raloxifene, because it may interfere with the tamoxifen. Raloxifene is taken daily as a tablet.
Denosumab is a new drug. It reduces the breakdown of bone in postmenopausal women who are at an increased risk of fractures due to osteoporosis. It’s normally only used in specific circumstances. For example, when bisphosphonate drugs such as risedronate sodium or disodium etidronate can’t be tolerated or are likely to cause too many side effects.
Parathyroid hormone (PTH)
Parathyroid hormone occurs naturally and is produced by the parathyroid glands (these are attached to the thyroid gland in the front of the neck). It stimulates bone formation and increases the absorption of calcium in the body. A synthetic preparation of PTH called teriparatide (Forsteo®) is available as a subcutaneous injection that’s given daily for a maximum of 24 months. It’s more likely to be used by people who have broken bones due to severe osteoporosis.
Hormone Replacement Therapy (HRT)
Oestrogen has a protective effect on bones. But some cancer treatments may lower the levels of oestrogen in the body. Young premenopausal women may benefit from the protective effect of HRT on bone health if:
they have an early menopause due to cancer treatment
they have a cancer other than breast cancer
they don’t already have risk factors for breast cancer, such as a family history.
HRT may be given until a woman reaches the normal age of menopause (usually about 50) and sometimes for a few years afterwards. HRT is not recommended for elderly postmenopausal women because the risks of developing other health problems (such as heart problems, stroke and breast cancer) outweigh any benefits.
If a man under 60 has a low testosterone level due to cancer treatment, testosterone replacement therapy can be given to get the testosterone level back to normal. This helps increase bone density, which may be reduced in men with low testosterone levels. In older men (over the age of 60), giving testosterone has little effect on bone density even if testosterone levels are low.
There are a number of different types of hormone replacement therapies for both men and women. They can be given as tablets, injections, gels or patches applied to the skin.
If your GP or hospital doctor feels you need specialist advice for the treatment or management of your osteoporosis, they may refer you to a hospital team that specialises in it. These teams
include doctors, nurses and physiotherapists who work closely with occupational therapists and pain specialists.
This section has been compiled using information from:
Bone Health and Osteoporosis: The 2004 Surgeon General’s Report. 2004 US Department of Health and Human Services.
Drug treatments for osteoporosis. November 2009. National Osteoporosis Society.
Breast cancer treatments. June 2008. National Osteoporosis Society.
Osteoporosis and breast cancer. May 2008. Breast Cancer Care.
Twiss J, et al. An exercise intervention for breast cancer survivors with bone loss. Journal of Nursing Scholarship. 2009. 41(1): 20–27.
Reid D, et al. Guidance for the management of breast cancer treatment-induced bone loss: A consensus position statement from a UK Expert Group. Cancer Treatment Reviews. 2008. 34: S3–S18.
Rosen H. Drugs that affect bone metabolism. www.uptodate.com (accessed January 2010).
Medicines and Healthcare Products Regulatory Agency. www.mhra.gov.uk (accessed January 2010).
The electronic Medicines Compendium (eMC). www.medicines.org.uk/emc (accessed January 2010).
Quick reference guide: Early and locally advanced breast cancer. February 2009. National Institute for Health and Clinical Excellence (NICE).
Garlow J, et al. NCCN Task Force Report: Bone Health in Cancer Care. JNCCN supplement. June 2009. 7(3).
Anderson G, et al. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: The Women’s Health Initiative randomized control trials. 2004. JAMA: 291(14): 1701–1712.
Brown C. A Guide to Oncology Symptom Management. 1st edition. 2010. Oncology Nursing Society.
Snyder P. Testosterone treatment of male hypogonadism. www.uptodate.com (accessed March 2010).
Bhasin S, et al. Testosterone therapy in adult men with androgen deficiency syndromes: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology and Metabolism. 2010. 9(6): 1995–2010.
Guidance for the Management of Breast Cancer Treatment-Induced Bone Loss. July 2008. A consensus position statement from a UK Expert Group.
Khosla S, et al. Osteoporosis in Men. Endocrine Reviews. 2008. 29(4): 441–464.
Food Standards Agency Health Diet. ww.eatwell.gov.uk/healthydiet/eatwellplate (accessed March 2010).
For further references, please see the general bibliography.