Osteoporosis in African American Women

In osteoporosis [ah-stee-oh-pore-OH-sis] the volume of bone is low and the bone structure is deteriorating. Bones become so fragile that the hips and the spine are unable to support the body in an upright position. People with osteoporosis can easily experience a broken spine, hips, ankles, wrists, other bones, and even lose their teeth, along with gum disease. In the past, when African Americans had extensive exposure to the sun and did heavy weight-lifting jobs, osteoporosis and low bone volume were rare in that group of people. But today in the United States, osteoporosis is an epidemic that occurs in children, teens, adults, and the elderly in all cultural groups. It is the most common and costly bone disease. More than 44 million Americans have the disease and it costs the health system more than $19 billion every year, excluding dental care. Yet the number of people with osteoporosis and dollars spent per year on this problem are probably higher because so many people go undiagnosed.

A high number of African Americans are not diagnosed or treated for osteoporosis because of the false belief that African Americans do not get osteoporosis. Since three out of four people with osteoporosis and low bone volume are women, the failure to diagnose and treat osteoporosis in African Americans is largely a failure to recognize, diagnose and treat African American women. Although the data are not complete, it is estimated that more than 40% of African American women have osteoporosis, low bone volume, and are at risk for fractures.

More American women die each year from hip fractures than from heart disease, stroke, breast cancer, uterine cancer, or ovarian cancer. After having a hip fracture due to osteoporosis, African American women remain sicker longer and die earlier than any other cultural group. The reasons for this remain unclear. Studies show that African American women and white women have some of the same risk factors for osteoporosis. These include older age, ostmenopausal [post-men-oh-PAW-zuhl] status, prior history of broken bones and osteoporosis in immediate relatives. Risk factors common in whites include small bone size, cigarette smoking, and use of glucocorticoids [gloo-ko-KOR-tih-koids] (medicines used to treat asthma and inflammatory diseases). White women have smaller bone size than African American women; however, African American women also lose bone mass after age 30. This loss is accelerated after menopause.

Doctors can figure out a patient’s chance of having a hip fracture within 10 years with two tests. A bone density (BMD) scan is combined with a “Frax score,” which the doctor obtains from a simple questionnaire. African American women are not offered BMD scans and this questionnaire as often as white women. And often they are not even diagnosed with osteoporosis after being treated for broken bones! Also, for people without health insurance, the local emergency care center is often where treatment is obtained. Doctors have little time and/or not enough staff to educate the patient about their disease. For many women, lack of regular health care adds to delays and lack of attention for diagnosing osteoporosis. This lack of care may add to the reasons why the African American woman has more chance of complications and medical problems in recovering from a hip fracture.

To build bones and keep them strong, a person needs enough calcium, vitamin D and weight-bearing exercise throughout life. From childhood to the mid thirties, when bones are being built, women need at least 1000 IU of vitamin D and 1000-1200 mg of calcium daily (more during pregnancy). There are several reasons why African American women may not get these. African American women and children have low levels of vitamin D and low rates of calcium intake. Although vitamin D can be made in the skin when humans are exposed to sunlight, African Americans have dark pigment, which lessens the body’s ability to produce vitamin D in the skin. Also, the high rate of obesity in African American women may play a role in keeping vitamin D levels low and enhancing osteoporosis. That’s because obesity reduces the body’s ability to use vitamin D and limits a person’s ability to do weight-bearing exercise. Calcium intake may also be limited because the diet may have low calcium content. Starting in childhood, many African Americans have a milk product intolerance. So, during the years when they should be building their peak bone mass, they avoid milk products, which are usually the foods that are highest in calcium.

Current preferred first-line treatments for osteoporosis are bisphosphonates [bis-FOS-fuh-nates], drugs that prevent the bones from being thinned. However, in the United States, these drugs are not prescribed as often for African American women and, if prescribed, they may not be affordable.

In summary, osteoporosis can be prevented. In the African American woman, osteoporosis is a dangerous disease. When fractures do occur, African American women can have more medical complications and even higher risk of death, during recovery. If you are an African American woman, make sure to take charge of your health, learn what foods contain the calcium you need and learn what supplements you should take to meet calcium and vitamin D daily intake goals. Ask your doctor about what exercise is best to keep your bones as healthy as they could be and whether your bone density should be checked and how best to do that. If you have had a fracture, discuss with your doctor where you could get your bone density checked. If prescription medication is needed and your health insurance coverage is limited, ask about generic options and patient assistance options. Take your medication consistently! Dr. Juanita A. Archer is an Emeritus Associate Professor of Endocrinology in the Division of Endocrinology, Department of Internal Medicine at Howard University College of Medicine. Dr. Theresa Fynn is a Fellow in the Division of Endocrinology, Department of Internal Medicine at Howard University College of Medicine.

Dr. Juanita A. Archer is an Emeritus Associate Professor of Endocrinology in the Division of Endocrinology, Department of Internal Medicine at Howard University College of Medicine.

Dr. Theresa Fynn is a Fellow in the Division of Endocrinology, Department of Internal Medicine at Howard University College of Medicine.