Last week, Sarah and I had a great conversation in our Facebook community (JOIN US HERE) about bone health. It's a topic we've touched on many times before, but it resurfaced recently in different ways for both of us. For those who don’t know, Sarah recently discovered an injury she’s shared about on her Instagram. I'll link her most recent post [HERE] as it will resonate with many, if not everyone, reading this today.
As for me, the discussion came up again after reviewing the results of my last bone mineral density (BMD) test a year ago. It was reported using only one score, though there are two common methods. My provider and I agreed it would be wise to obtain the second report to get a more complete understanding of my unique situation. What I’ve learned through this process is that, yet again, context really does matter. Interpreting BMD scores requires thoughtfulness because, like all health markers, we are each unique. Even organizations like the American College of Sports Medicine and the International Olympic Committee recognize the need for more nuanced BMD reference values, questioning whether they should be sport-specific, dependent on the type of sport, sex, or age.
It’s clear that nuance and specificity are essential, especially for athletes versus non-athletes. But today, we’re not here to dissect how complex it needs to be. We're here to talk about a few key things:
Are You Protecting Your Bones? What You Need to Know About Bone Health Before It’s Too Late
Do you need a bone mineral density test?
Bone health starts earlier than you think, and decline doesn’t wait until post-menopause.
Your hormonal health plays a massive role in your bone health.
Things to start taking seriously now.
WELCOME TO PART 1 !
Are You Protecting Your Bones? What You Need to Know About Bone Health Before It’s Too Late
Okay, so "too late" is dramatic but we did want to grab your attention. 'Too late' is in the eye of the beholder.
When was the last time you thought about your bone health? It’s okay if your first thought was about an aging family member or a personal injury. For most of us, when we break a bone in an accident or sports-related incident, the main concern is, "When will it heal?" rather than diving into our overall bone health and how our lifestyle choices might be impacting it. And honestly, that’s totally normal—we’ve all been there.
Unless you’re presented with some urgent news from a healthcare provider or are surrounded by incredibly health-conscious and proactive people, the idea of thinking about your bone health in a deeper, preventative way just doesn’t happen for most of us. Why would it? Without a pressing issue, it’s easy to assume that your bones are just "fine." You don’t feel them weakening, and they’re not something you can visibly check in the mirror. So, unless something forces you to address it—whether it’s an injury, a diagnosis, or the need for a medical test—it’s easy to put bone health on the back burner. Isn’t that just the same story for our health in general, sigh.
But what if I told you that waiting for that major wake-up call is setting you up for future issues? Bone health is a long game, and the habits you establish today could be silently affecting your bone density for years to come.
Let’s talk about the specific tests then dig into the real deal of what you can do! A test is great, but what are you going to do about it is magic!
Have you ever heard of a bone mineral density (BMD) test? And more importantly, do you need one?
If you haven’t had BMD, you're not alone. Most women don't think about their bones until later in life, when the risk of osteoporosis becomes very real. But here’s the catch: osteoporosis doesn’t appear overnight. The health of your bones is the result of years—decades, even—of lifestyle choices, hormonal shifts, and whether or not you've prioritized bone-strengthening activities.
Do you need a BMD test? Let’s find out together—by the end you may have a better idea and if not we are here to help via formal consulting services. Reach out ( HERE )
How is BMD tested?
There are a few different options but the most common as well as most well accepted for the general population and sport is a dual energy x-ray absorptiometry (DXA or DEXA) scan.
Benefits of a DXA is it is incredibly noninvasive and low radiation. You’d get more radiation flying a domestic flight than this scan. I am not suggesting you get this nor any scan/x-ray on a daily basis nor around such devices unless you are wearing protective equipment but merely suggesting the 1x every so couple of years exposure for the sake of your health is incredibly negligible.
There is also:
Quantitative Computed Tomography (QCT)
HERE is a beautiful 7 page paper from 2012 (so about 12 years old and with bias but still a hefty amount of good information long as it can be read neutrally… welcome to how Sarah and I gather information) paper discussing some differences in scoring between the QCT AND DXA. It is important to recognize that they are discussing a normal population scoring, not necessarily athletes. (note: I use ‘normal’ in now was as a dig but a term to of distinguishment)
Biomechanical Computed Tomography (BCT)
Radiofrequency Echographic Multi Spectrometry (REMS)
As well as peripheral tests, it is worth noting “The results from these types of tests are not comparable to central DXA measurement and therefore difficult to interpret for diagnostic purposes and thus additional testing is often required. These types of tests serve mostly as screening tests to help identify people who are likely to benefit from further bone density testing at the hip and/or spine. Screening tests cannot accurately diagnose osteoporosis and should not be used to see how well an osteoporosis medicine is working” https://www.bonehealthandosteoporosis.org/
However, for the sake of inclusion and your knowledge they do exist and may serve an acute purpose:
Tests at Peripheral (Non-spine, non-hip) Sites (ie: arm, leg, wrist, fingers, or heel.)
pDXA (peripheral dual energy x-ray absorptiometry)
pQCT (peripheral quantitative computed tomography)
QUS (quantitative ultrasound)
Pulse-echo ultrasound (P-EU)
What is a Z-score and T-score?
T-scores represent numbers that compare the condition of your bones with those of an average young person with healthy bones. A “average young person with healthy bones” is typically someone in their 30’s. This is typically the same comparison for across women’s hormonal health as well.
Z-scores instead represents numbers that compare the condition of your bones with those of an average person your age. (20 year old compared to a 20 year old, 65 year old compared to a 65 year old)
Where confusion comes into play is that it is that a we understand that it is suggested that a "T-score is “ for “postmenopausal women and men over age 50, and as Z-scores for children, premenopausal women, and men under age 50" but if you go back to the above you can see why that maybe and is TRULY so important! At 65 would you really want to be compared to another 65 year old or would the lighthouse be how far off are we from what is considered 'healthy' and at our 'best' ? (depending on the situation we could actually argue a for both!)
The word “for” can be confusing and in some cases too isolating and even misleading. Many folks believe a T score is only for post-menopausal women and men over the age of 50. We do not want to be word ninja’s and frankly hate when people are as we’d like to say we all do our very best but we also recognize words matter and we don’t mind going the extra lengths to ensure we understand things broadly.
A T-score is important for measuring your bone health compared to an average 30-year-old. “The reason you’re being measured against an average 30-year-old’s score is that this is when your bones are at their peak mass. The measurement is known as SD for standard deviation. If you’re a 65-year-old woman (post menopausal), your T-score will tell you how your bone density test compares to that of a 30-year-old. Your Z score will indicate how your bone density measures against another 65-year-old woman. (reference LINK 1, LINK 2, LINK 3 )
Now, this is where it gets interesting as “the American College of Sports Medicine (and the International Olympic Committee defines normal bone health in athletes from a Z-score ≥ −1.0." (LINK) but as mentioned before they recognize that they may need to get more specific with criteria. We can agree, especially with athletes ranging from 16/17 to 40’s+ and across different sports and vast medical/hormonal profiles.
This also brings up the argument about a female who is an athlete but also had a different history such a POF (premature ovarian failure) or a premature menopause. Would that female benefit from only a Z score being compared to non-athletes or a T score being compared to a ‘healthy’ (still non-athlete) 30 year old with robust hormone profile. You can see how this person may benefit from both a Z score and a T score with a very thoughtful interpretation.
We aren’t here to solve the conundrum but to bring interpretation to light.
The Big Final Question: Do You Need a BMD Test?
Before we dive into the medical criteria, here are some of our thoughts to help you triage your personal need for testing.
Regular alcohol consumption: Yes
Smoker: Yes
History of amenorrhea: Yes (this is proactive)
Conditions that increase the risk of anovulatory cycles: Yes
History of using corticosteroids, bisphosphonates, hormonal birth control, blood thinners (e.g., warfarin, heparin), blood pressure drugs, anti-cancer drugs (including aromatase inhibitors), PPIs (acid reflux medications): Yes (consult your provider—this is not a comprehensive list)
History of eating disorders: Yes
Diagnosed with Premature Ovarian Failure: Yes
Induced premature or surgical menopause (e.g., full hysterectomy, bilateral oophorectomy, bilateral salpingo-oophorectomy): Yes
Multiple injuries and fractures: Yes
Curious and wanting to be proactive: Yes
As functional health coaches, we work closely with our clients. Do we suggest that every client immediately run out and get a BMD test as step one? No, just as we don’t suggest every client get full comprehensive labs, mold tests, or GI maps right away. However, after a thorough review of your health and lifestyle, the recommendation for BMD testing might come much sooner than typical medical guidelines suggest.
Medical Criteria for BMD Testing
BMD testing is not generally recommended for younger men or women (under 50) unless a medical condition predisposes them to osteoporosis or there are unexplained fragility fractures.
All women and men 65 years or older
Postmenopausal women and men 50-64 with fracture risk factors
Younger men or women (under 50) with a disease or condition associated with low bone mass or bone loss
After evaluating your day-to-day habits, it might be time to ask your healthcare provider about a bone mineral density test. This can provide a baseline understanding of your bone health and help track changes over time. However, before you do that…
The Final Word
Every day you wake up is an opportunity to invest in your future health. Many wait until they’re left with no choice, but that doesn’t have to be you. On the flip side, life can throw unexpected challenges, even when you’re doing all the ‘right’ things. Does that mean your efforts were wasted? Absolutely not. You’re better off for it.
You might not see or feel the effects of bone loss right now, but taking action today can safeguard you from the long-term consequences of osteoporosis. By focusing on your hormonal health, incorporating strength training, and staying proactive, you can help keep your bones strong and resilient for years to come.
Ready to get started? If you’re unsure about your next steps or need personalized guidance, consult with us today and let’s map out the best course of action for your bone health.