A Healthy Foundation

How much do you know about your skeleton—the framework that carries you throughout your days? Here, get schooled on how to promote bone health at any age, what to do if a bone breaks and how to identify and treat osteoporosis, a bone loss disease that affects close to 10 million Americans

Written By Lauren B. Johnson
Photographs by Sarah Westmoreland

Our skeletons are physical marvels. Four times as strong as concrete, a one-inch cube of human bone can theoretically bear the weight of five pickup trucks. In fact, ounce for ounce, our bones are stronger than steel.

They use that strength for important work. Every year, our skeletons carry our body weight an average of one to three million steps. Not only do bones act as the body’s structural framework—held together by tendons, ligaments and muscles—they also protect our internal organs, store calcium needed for bodily processes like muscle movement and cardiac function and house marrow that produces new blood cells.

Powerful? Yes. Invincible? Nope. Bone-breaking events can strike even the healthiest of frames. And as we age—especially if we don’t give our bones the care they crave throughout our lives—they can weaken, becoming more susceptible to fractures.

In the following pages and with help from Roper St. Francis Healthcare affiliated gynecologist Elaine Eustis and orthopaedic surgeon Keith Merrill, we’ll explore the science behind bones, learn how to strengthen them at any age and get to know osteoporosis, a disease that impacts the quality of life of millions of Americans.

What’s in Bone?

Bone development, a process called ossification, begins in utero about eight weeks after conception. At birth, babies possess roughly 300 soft bones made mostly of cartilage, which, over time, gets replaced with a harder collagen and calcium phosphate matrix. Our bodies create bone throughout childhood and into early adulthood, at which point our bone mass peaks and stabilizes. “At age 30, our body stops putting calcium into bones,” explains Dr. Merrill. By the time we reach adulthood, we have a framework of 206 bones that make up about 15 percent of our body weight.

Though our bones eventually stop growing longer, new bone is constantly being created thanks to two types of cells fueled by nutrient-rich blood: Osteoclasts dissolve bone tissue and osteoblasts build new bone. Like any remodeling project, the demolition team (osteoclasts) and the construction crew (osteoblasts) must work together to form a strong structure. “Starting around age 40 though, the rate at which we break down bone exceeds the rate at which we build bone,” says Dr. Eustis. As a result, our bones naturally deteriorate, losing density and strength as we age.

Control Your Bone Health

NASA reports that astronauts lose an average bone mass of one to two percent each month while away on long missions. The cause? Zero gravity. According to the International Osteoporosis Foundation, gravitational force acts as a mild weight-bearing exercise, highlighting the link between exercise and bone health. Physical activity, particularly weight-bearing exercise, causes beneficial micro-fractures in our bones. “When stress is put on bones, the body compensates and builds new bone, making our skeletons even stronger,” explains Dr. Eustis.

Other daily choices also impact our skeletal system for better or worse. Bone health gets a boost not only from physical activity but also from adequate intake of calcium, which supports bone structure, and vitamin D, which helps the body absorb calcium. (According to Harvard University researchers, without adequate levels of vitamin D, the body can only absorb 10 to 15 percent of dietary calcium consumed.) While important for people of any age, these nutrients are especially imperative before and during the teen years, when bones are still growing. “You need to put a lot of calcium into storage up to age 30 and then continue with an adequate dietary supply,” says Dr. Merrill.

Several studies, including 2016 research published in the journal Open Heart, have found calcium consumed via food and drink to be more beneficial than calcium supplements. To boost your intake, load up on calcium-rich foods such as beans, nuts and leafy greens. Dairy products like milk and cheese contain high levels of calcium, as well; however, Dr. Eustis cautions against relying solely on dairy for your calcium needs. Recent studies have found that when the body digests animal protein—which is also found in cow’s milk and dairy products—more acids are released into the bloodstream, which the body then neutralizes by taking calcium from bone. “It’s best to get calcium from a range of food sources,” says Dr. Eustis. “And if you don’t get enough from your diet, a supplement is the next best option.”

Though Vitamin D doesn’t occur naturally in many food items, it is plentiful in fish, mushrooms and eggs. We also soak up vitamin D from the sun, but slathering on the recommended sunscreen blocks that absorption. “Almost everyone needs to bolster their intake with fortified foods or a supplement,” says Dr. Eustis, noting that many cereals, oatmeal and orange juice brands are fortified with the vitamin (see sidebar below for recommended daily intake).

At the other end of the spectrum, alcohol, nicotine, caffeine and sodium all work against the body’s calcium supply. We lose 6mg of calcium for every 100mg of caffeine consumed (about what’s in a standard cup of Joe or large Pepsi) and 40mg of calcium for every 2,300mg of sodium (the recommended daily allowance). Chronic heavy drinking also disrupts our calcium balance and vitamin D production while wreaking havoc on the hormones responsible for bone formation, including testosterone, estrogen and cortisol, notes the National Institutes of Health.

“The most important thing to avoid is smoking,” says Dr. Merrill. “It’s horrible for our bones.” Not only does nicotine decrease our absorption of calcium, it also disrupts the hormones in charge of bone remodeling, reduces blood supply to our bones and kills bone-producing osteoblasts. Smokers suffer from severe bone density loss, and those 65 and older are as much as 40 percent more likely to break a hip than non-smokers, reports the American Academy of Orthopaedic Surgeons.

Why Bones Break

There are three common causes of broken, or fractured, bones: trauma (like from a car accident or sports impact injury), overuse (think a stress fracture in a runner’s foot) and medical conditions that weaken bone (the most common of which is osteoporosis). While those lifestyle factors mentioned won’t help protect you from blunt trauma or, in many cases, overuse injuries, they do help prevent osteoporosis.

Dr. Elaine Eustis

Osteoporosis, a word meaning “porous bone” or “bones with holes,” is defined as the loss of bone density, which makes bones weak and more susceptible to fragility fractures. Fragility fractures are bone breaks that result from a movement or fall from standing height or less—for example, a trip results in a hip break, rolling over in bed causes a spine fracture or a coughing fit leads to a cracked rib. “Osteoporosis is painless; you can’t feel your bones getting weaker,” notes Dr. Eustis. “So unfortunately, fragility fractures are often the first sign of the condition.”

According to the National Osteoporosis Foundation, roughly 10 million Americans have osteoporosis, and another 44 million have low bone density levels, putting them at risk for developing the disease. It’s estimated that osteoporosis causes roughly two million broken bones every year. “Not only are these fragility fractures painful, they often require hospitalization and surgery, which can present complications such as wound infections, pneumonia and blood clots,” explains Dr. Merrill. “Spontaneous spine fractures can also lead to height loss and kyphosis, a hunching in the spine.”

“Women are at increased risk for developing osteoporosis because they don’t achieve the same peak bone mass as men during their early years and, after menopause, they lose bone more rapidly because of the loss of estrogen, a hormone that helps build bone,” notes Dr. Eustis. In fact, she says, more women suffer from osteoporosis than heart attack, stroke and breast cancer combined, and one in two women will break a bone in their lifetime due to the disease.

More women suffer from osteoporosis than heart attack, stroke or breast cancer combined. —Dr. Elaine Eustis

Diagnosing—and Treating—Osteoporosis

To catch osteoporosis as early as possible, the National Osteoporosis Foundation recommends bone density screenings for all women starting at age 65 and all men at 70. Those with strong risk factors, like smoking or a previous fracture, should be screened starting at age 50. Doctors measure bone loss by comparing a patient’s bone mass to that of an average 30 year old, calculating a T-score based on the deviation from that standard. A T-score between -1.0 and -2.4 leads to a diagnosis of osteopenia (the precursor to osteoporosis). Osteoporosis is diagnosed when the T-score is -2.5 or lower.

Dr. Keith Merrill

To determine a patient’s T-score, doctors perform a quick, noninvasive bone mineral density exam called a DEXA (dual-energy x-ray absorptiometry) scan, which measures how many grams of calcium are packed into the hip and spine. “The test is easy,” says Dr. Eustis. “You simply lie on a table with a pillow under your knees while the lab tech runs a scanner over you. It’s similar to a CT scan but there is minimal radiation and it is not enclosed.”

Providers may screen early if a patient smokes; drinks alcohol heavily; takes certain medications associated with bone loss; or has other risk factors, including early menopause, a family history of osteoporosis, a personal history of adult bone fracture or certain endocrine and autoimmune disorders (for example, hyperthyroidism, hyperparathyroidism, rheumatoid arthritis or lupus). “The test is repeated every two to five years because, for better or worse, bone density doesn’t change quickly,” says Dr. Eustis.

Unfortunately, osteoporosis cannot be cured. It can, however, be reversed. One way to assess osteopenic patients is with a FRAX (Fracture Risk Assessment Tool) score, which calculates the risk of a broken bone within the next 10 years using data such as age, lifestyle, T-score and medical history. This score helps determine whether treatment should include lifestyle adjustments (like quitting smoking, limiting alcohol and increasing weight-bearing exercise) and/or the use of osteoporosis medications. Postmenopausal women are also frequently prescribed estrogens to promote bone growth, says Dr. Eustis. “With treatment, osteoporosis can improve, reversing back to a level of osteopenia and decreasing the incidence of future fractures,” she says.

Another important step toward reducing your risk of fractures is to rid your home and yard of possible trip hazards, such as throw rugs, cords and uneven flooring. Installing grab bars and ensuring your house and yard are properly lit help, as well.

The docs’ best advice for strong bones? Keep them healthy from the outset. “Most important,” says Dr. Merrill, “is putting plenty of calcium and vitamin D into the bank at an early age and throughout your life. In other words: Start young and plan for retirement well.

“Most important is putting plenty of calcium and vitamin D into the bank at an early age and throughout your life. In other words: Start young and plan for retirement well.” —Dr. Keith Merrill



After falling down a flight of stairs last year, West Ashley resident Krystal Harmon underwent bone reconstruction surgery to repair multiple broken bones in her right ankle. Today, the photographer is healed and back to shooting in her favorite places, including West Ashley’s Mary Adler Park.

Krystal Harmon, 34

In September 2019, West Ashley resident Krystal Harmon slipped and fell down a flight of stairs. “When the injury happened, I knew at the moment that my ankle was broken—I heard the bones crack,” says Krystal, who went straight to the Roper Hospital emergency room. Krystal met with Roper St. Francis Healthcare affiliated orthopaedist Dr. Heather McIntosh and received a temporary cast. Within days, she underwent bone reconstruction surgery. “It required nine screws and a plate,” recounts Krystal, who wore a temporary cast for three weeks after surgery then switched to a boot. She fully recovered from the injury within seven weeks.

Though Betty Bell has always been active (“I ran the bridge run for 25 years!” she says), she has stepped up her exercise game since being diagnosed with osteoporosis in 2015. She and her husband, Frank, walk miles through the Old Village in Mount Pleasant, where they live, nearly everyday. She has also added a calcium supplement to her daily routine.

Betty Bell, 65

At age 60, Mount Pleasant resident Betty Bell underwent her first routine bone density scan, as recommended by her OB/GYN, Dr. Elaine Eustis. When the results came back, she was diagnosed with osteoporosis. “It was a surprise to me,” says Betty, who hadn’t considered her risk for the condition until then. To ward off further bone loss and try to reverse the condition, Betty began receiving biannual injections of Prolia, an osteoporosis medication that inhibits osteoclasts, or the cells that break down bone. A bone density scan she has received since showed that her T-score has improved.
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Don’t Stress about Stress Fractures

To ward off a stress fracture (which are most common in the lower legs and feet), always ease into new fitness routines, especially those that are high impact, says Dr. Merrill. Bones are able to remodel in order to adapt to increased impact levels over time; however, if you apply too much pressure too often too soon, they can fracture. To prevent injury, aim to increase exercise intensity and/or load by less than 10 percent every week, wear properly fitted footwear, cross-train and get adequate intake of calcium and vitamin D.
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When Bones Break

Your 5-year-old falls from a kitchen stool and breaks her wrist. Your 16-year-old fractures his collarbone during a football game. You—an avid distance runner—feel a sharp pain in the ball of your foot every time you hit the pavement. No matter how healthy bones are, blunt force can cause them to bend too far and break, and repetitive, low-grade pressure can sometimes lead to a stress fracture.

Symptoms of a bone fracture—whether that’s a traumatic bone break or a fragility fracture—range from swelling and tenderness that doesn’t resolve after days to bruising to deformity (as in, the bone is visibly broken or out of place). A stress fracture typically causes swelling and sharp pain that worsens over time.

In either case, get to a doctor as quickly as possible. “Bones can mend themselves with proper treatment and support, but seeking help promptly is important as, without it, the condition can worsen or cause complications,” says Dr. Merrill. For a blunt-force trauma or fall, go to urgent care or the ER. For a stress fracture, make an appointment with your primary care doctor or an orthopaedist.

An x-ray or MRI can detect a break (the latter may be needed to spot a hairline fracture), and a plan for recovery will be determined based on the degree and location of the injury. Treatment ranges from prolonged rest to a splint or cast to surgery, in extreme cases. “Typically, a fracture can heal in roughly six to eight weeks,” says Dr. Merrill.
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Feed your Foundation – 10 foods that support bone health

1. Dark leafy greens are rich in calcium, though some, like spinach, are also high in oxalates, which bind to calcium and make some of it unavailable. Kale and collards get the green light!
2. Canned salmon and sardines are loaded with calcium since you eat them bones and all.
3. Fresh and dried figs are ripe with antioxidants, fiber and a good bit of calcium.
4. Soybeans (i.e. edamame and tofu) provide a significant amount of calcium.
5. White beans are chock full of calcium, as well as fiber, micronutrients and protein—adequate intake of the latter of which is known to help fortify bone health as well.
6. Almonds are packed with healthy fats, calcium and protein.
7. Seeds (think poppy, sesame, chia and celery seeds) deliver a one-two punch of calcium and protein.
8. Milk lets you drink in calcium and is often fortified with vitamin D.
9. Yogurt is full of both calcium and protein. Low-fat yogurt has about 33 percent more calcium than Greek yogurt.
10. Cheese has plenty of protein as well as calcium. Just one ounce of Parmesan provides a third of your recommended daily intake of calcium.

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Bone Up

Weight-bearing exercise and resistance workouts increase bone density, balance and strength. The doctors recommend incorporating these forms of physical activity into your daily routine for optimal bone health:

1. Walking or jogging
2. Stair climbing
3. Racket sports (tennis, racquetball or badminton)
4. Jumping rope
5. Dancing
6. Yoga or Pilates
7. Tai chi
8. Golfing
9. Weight lifting
10. Aerobics

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Roper St. Francis Healthcare’s Osteoporosis Program

In 2019, Roper St. Francis Healthcare established Charleston’s only comprehensive osteoporosis program. Aligning orthopaedics, primary care, endocrinology, gynecology and internal medicine, the program aims to streamline treatment and increase access to care.

“Our primary goal is to provide patient education,” explains program director and certified fracture liaison Katy Conner, PA-C, who frequently speaks about bone health at the Lowcountry and Waring Senior Centers. Patients concerned about osteoporosis can call the office directly, but most come by way of their primary care doctor, gynecologist or orthopaedist.

“Any patient with a hip or fragility fracture gets an option to be referred to the program,” says Conner. Last year, the team served more than 700 people. Prior to the appointment, patients undergo a bone density scan and lab tests to assess overall bone health. During their visit, patients meet with Conner, who explains osteoporosis, reviews bone health history and risk factors, discusses test results, assesses balance and gait, recommends nutrition and home safety tips and explains treatment options. From there, Conner follows up regarding medications and future bone density scans while also ensuring the patient connects with a primary care doctor. “We work with the patient as a team to reduce the risk of future fractures,” she explains.

Osteoporosis Office Locations:

61 West Medical Building
1483 Tobias Gadsden Blvd., West Ashley

Roper St. Francis Mount Pleasant Hospital
300 Highway 17N, Mount Pleasant

Roper St. Francis Physician Partners
8950 University Blvd., North Charleston

For more information, call (843) 606-7174.

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Bone Myths: Fact or Fiction?

MYTH: A healed broken bone is stronger thanit was before.
While a protective cuff of extra-strong new bone does form around a fracture as it heals, this “callus” eventually diminishes. In the end, the bone might be as good as new, but no stronger than other bones nearby.
CONCLUSION: FICTION

MYTH: Some people are naturally prone to broken bones.
Research shows that genes control bone mineral density and the production of collagen, a protein needed for bone formation. Because we can inherit genes that affect bone development, osteoporosis does tend to run in families, making family health history an important risk factor for the disease.
CONCLUSION: FACT

MYTH: Calcium supplements cause cardiovascular disease.
Though several recent studies show an association between calcium supplements and increased risk of cardiovascular disease, the research is still unclear on whether or not the two are directly linked. What is clear? Calcium prevents osteoporosis, so you shouldn’t avoid it. Since our bodies better absorb minerals from our diet, it’s best to get calcium from food and drink whenever possible.
CONCLUSION: INCONCLUSIVE

MYTH: Osteoporosis only affects white women.
Research does show that Caucasian and Asian women have the greatest risk for osteoporosis—especially petite women with a small body frame. However, men and women of all ethnicities can develop the disease.
CONCLUSION: FICTION

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Nutrient Number Goals

The Institute of Medicine recommends 1,000mg of calcium and 600 International Units (IU) of vitamin D daily for most children and adults under 50. “You typically won’t get those levels from a multivitamin,” says Dr. Merrill. “I recommend calcium and vitamin D supplements for everyone.” By age 50, the calcium requirement for women jumps up to 1,200mg; for men, that leap occurs at age 70, at which time vitamin D intake for both men and women should also increase to 800IU.
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Bad to the Bone

According to the International Osteoporosis Foundation, of adult patients suffering a hip fracture, an average of …

40% will never walk independently again
33% will require a nursing home within a year
20-24% will die within a year

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