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A 77-year-old woman from Plainview, N.Y., wrote that after a recent bone density test, she was told she had osteopenia.

Although she is very active, takes 1,500 milligrams of calcium and 400 international units of vitamin D every day and uses a vaginal estrogen cream, her internist and gynecologist recommend that she take medication to rebuild lost bone and prevent further loss.

Hesitant about taking "any kind of medication" and wondering if she really needed a bone-building drug like Fosamax, she went to the library and looked up osteopenia on the Internet. "I am very glad I did," she wrote, adding that she learned that "one, osteopenia is not osteoporosis; two, medication is not recommended for people my age; and three, good calcium intake plus activity and estrogen are better than medication" to keep bones strong.

As more people middle-aged and older take highly recommended bone density tests, the diagnosis of osteopenia has become common. It is, by definition, a stage between the healthy bones of the average 35- year-old and the fragile bones of someone with osteoporosis.

The diagnosis is based entirely on a person's bone density, most accurately measured by dual-energy X-ray absorptiometry, or DXA. Technically, osteopenia is a bone mineral density that is 1 to 2.5 standard deviations below the young adult peak bone density. Osteoporosis is defined as more than 2.5 standard deviations below peak bone mass.

Osteopenia is a warning, not unlike a diagnosis of prediabetes or cervical dysplasia. It is a warning that a person is at increased risk of developing full-blown osteoporosis and fractures. Unfortunately, many physicians are not well-versed in the difference between osteopenia and osteoporosis and how best to treat each of these conditions.

Not everyone with osteopenia develops osteoporosis, because bone loss may stop or slow enough to prevent it from becoming severe. Many factors, from genetics to living habits, influence the risk of progression, and changing the factors under one's control is the preferred way to keep osteoporosis at bay in someone who has suffered some bone loss.

Ins and Outs of Bone

Bones are continually being remodeled; they are resorbed under the influence of cells called osteoclasts and then rebuilt by osteoblasts. When bone resorption exceeds bone formation for a long time, osteopenia — net bone loss — is the result. If this process continues unchecked, the fragile bones of osteoporosis are the likely result.

In adolescence, most people accumulate bone mass, with bones reaching maximum growth by the mid-20's. (Exceptions may include teenagers with anorexia or girls who are very thin and so active that they fail to menstruate.) After the mid-20's, bone resorption gradually exceeds rebuilding, and bone is slowly lost, particularly the bones of the vertebrae, wrists and part of the thigh known as trabecular and cancellous bone.

In women at menopause who do not replace estrogen, bone loss accelerates drastically for five to seven years, rendering older women far more likely than men to develop osteoporosis. Without estrogen replacement (or a drug like raloxifene that mimics the action of estrogen on bones), about 5 percent to 10 percent of trabecular bone is lost in the first two years after menopause.

But men are not immune to this disorder. Especially at risk are men whose testosterone levels drop significantly in their later years and those who have androgen-blocking treatment for prostate cancer.

Maintaining strong bones into middle age and beyond requires at least two lifelong factors: a good intake of calcium and vitamin D (which can also come from exposure to sunlight) and mechanical stress on the bones, achieved through weight-bearing and strength-building activities. Unfortunately, many young people are entering adulthood without a full complement of bone — especially young girls trying to maintain stick- thin figures, those who have abandoned milk for soft drinks (and consume no compensatory calcium) and those who spend nearly all their waking hours on their fannies.

Once net bone loss starts in early adulthood, they are at risk of developing osteopenia even before midlife and osteoporosis thereafter, with a greatly increased chance of suffering a debilitating fracture.

Certain diseases and medications can increase a person's risk of excessive bone loss. People with hidden celiac sprue (an inability to digest gluten, a protein in grains) commonly develop low bone density, which improves once the problem is diagnosed and they are placed on gluten-free diets. Cancer patients under treatment are often at risk because of poor appetite, fatigue that limits activity and treatments with radiation and certain chemotherapeutic drugs.

People with autoimmune diseases like rheumatoid arthritis who have to take prednisone for long periods also usually experience excessive bone loss. And premature infants risk osteopenia later because 80 percent of bone mineralization normally occurs in the last third of fetal life, when acquisition of bone minerals is much higher than after birth.

Controlling Osteopenia

Several influences — family history, ethnic background, age and sex — are out of a person's control, but many things can be done to prevent osteopenia from developing into osteoporosis.

First and foremost, be sure to consume adequate amounts of calcium and vitamin D. The usual recommendation is to take about 500 to 600 milligrams of calcium twice a day to supplement dietary sources. Dietary calcium need not come only from dairy products or a few vegetables. Citrus juices and some breakfast cereals, as well as milk, are sold with added calcium. As for vitamin D, needed for the body to process calcium, studies at the Tufts University School of Medicine strongly indicate that older people need more vitamin D daily than is commonly recommended — 800 international units, rather than 400 units.

Regular physical activity that puts stress on the bones is also important. This can include walking, jogging, dancing, cycling and swimming, lifting small weights and working out on muscle-strengthening equipment. University of Wisconsin researchers showed that women in their 80's who worked out by holding onto to the back of a chair and stomping their feet were able to increase bone mass in their hips and thighs.

Estrogen replacement starting in perimenopause is an excellent way for women to avoid rapid postmenopausal bone loss. Whenever estrogen is stopped, however, bone loss is likely to accelerate unless some other estrogenlike drug is taken in its place. Women who have had an estrogen-sensitive breast cancer can instead take tamoxifen or raloxifene, which have estrogenic effects on bone but not on breast tissue. Raloxifene (sold as Evista) may be ideal for menopausal women with osteopenia who cannot or will not take estrogen.

Quitting smoking is another important strategy, for many reasons beyond bone protection. And alcohol consumption should be limited to one drink a day for women and two drinks a day for men.

People who must take medications like prednisone that increase bone loss may require treatment with a bone-building drug like Fosamax to prevent osteoporosis.

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