Osteoporosis is a common disease that reflects a decline in bone mass typically associated with aging in women and men. Because there is a decline in the overall strength of your bones, there is an increase in the likelihood that your bones will break or fracture, therefore, screening, prevention and treatment for osteoporosis is of utmost importance.
- understand the difference between osteoporosis and osteopenia
- know when you need to be screened for osteoporosis
- know the risk factors for osteoporosis
- know behavioral contributions to bone health
- take a careful look at your family history
- assume you can’t fracture if you only have osteopenia
- assume all MDs are up to date on osteoporosis treatment
- believe everything you read about osteoporosis drugs
- neglect to ask that a FRAX assessment be performed
- forget to take you calcium
You may hear the terms osteoporosis and osteopenia quite frequently in discussions about bone density. These terms both reflect some decline in your bone mineral density and reflect the value of a T score measurement on your DEXA, or bone density test. The T score is a measure of your bone density compared to the bone density of a healthy young adult woman (around age 20). If your T score is between -1.0 and -2.5 you have osteopenia. It is not until the T score is less than -2.5 that you qualify as having osteoporosis.
Generally speaking, most women will undergo their first screening DEXA around menopause. If you have an underlying risk factor for osteoporosis, such as chronic steroid use for example, your doctor may recommend screening earlier. Healthy postmenopausal women without osteoporosis needn’t get screened more frequently than every few years.
If you don’t reach peak bone mass as an adolescent, you are at risk for developing osteoporosis later in life. Therefore, adequate nutrition and calcium/vitamin D intake is especially important in the early years of your life. Vitamin D deficiency is one of the most common causes of osteoporosis in this country. High levels of parathyroid hormone, thyroid disease, chronic disease, celiac and underlying malignancy can result in osteoporosis.
It is very important to understand how daily habits can negatively impact your bone health. For example, smoking, inadequate weight bearing exercise, and drinking more than 3 drinks per day can adversely affect your bone density. While likely insufficient alone to drastically improve low bone density, regular weight bearing exercise is still regarded as a very important part of the management regimen.
If you have a strong family history of osteoporosis and/or fracture, you need to be more vigilant about being screened and treated. A parent history of hip fracture is one of the most important pieces of information that goes into your doctor’s decision making regarding treatment.
In fact, the greatest number of hip fractures in this country happen in women who are osteopenic because they outnumber those with frank osteoporosis by a large margin. Having said that, while almost all postmenopausal women with osteoporosis should be offered treatment, if you are osteopenic, you may actually not need to be treated.
With some exceptions, you should be under the care of either a rheumatologist or endocrinologist for the diagnosis and treatment of osteoporosis. These are the medical subspecialists who are trained and educated in the pathophysiology of bone. Up to date treatment and diagnostic recommendations are a part of their everyday practice.
Probably one of the most common concerns has to do with the drug Fosamax and others in its class (for example Actonel, Boniva, Reclast). You may be familiar with the concern regarding atypical fractures associated with long term bisphosphonate use as well as the risk of avascular necrosis of the jaw. Both of these issues have been studied at great length and the recommendations have been adjusted accordingly: although the literature does not suggest a highly likelihood of atypical fractures in long term bisphosphonate users, treatment tends to be of a shorter duration than previously. Similarly, you should be screened for periodontal disease prior to initiating therapy with these drugs, and avoid IV treatment in those at greatest risk for avascular necrosis. Most cases of the latter have occurred in cancer patients receiving much higher chemo doses of these medicines.
The FRAX assessment is just one of the many pieces of information that is used to decide if you need to be treated for osteopenia/porosis. FRAX stands for ‘Fracture Risk Assessment Tool’ and was designed by the World Health Organization. It takes into account your family and personal history of fracture, age, height and weight, DEXA scores and a few other variables to generate a 10 year probability of fracture. Doctors use these FRAX scores in their decision making analysis for treatment.
Calcium and dairy have been getting a lot of heat lately, somewhat unfairly. The most recent recommendations are that if you are a healthy premenopausal woman, taking 1000 mgs of calcium and 400 iu of Vitamin D daily are not necessary to reduce the risk of fracture. This incorrectly sends a message that having calcium and D is not important, which is simply not true. If you are a child or adolescent you need adequate calcium and vitamin D to reach your peak bone mass, and if you are a postmenopausal woman with osteoporosis or vitamin D deficiency, you do need to take your supplements! More recent recommendations, because of the potential risk of heart attack or stroke, is to get at least half of your daily calcium requirement of 1200-1500 mgs daily from diet, for example from leafy green vegetable and low fat dairy. The best source of vitamin D is the sun; fortified milk, orange juice and supplements are also acceptable.
Osteoporosis reflects a decline in bone mineral density (BMD) in men and women associated with aging. There are many secondary causes of low BMD that your doctor needs to assess before initiating therapy. Decision tools include the DEXA scan as well as FRAX measurements. There are many different treatments available in this country as well as legitimate concerns regarding their safety. You should be under the care of a practitioner familiar with the safety profile of the various different medicines available. Adequate weight bearing exercise as well as calcium and vitamin D intake are essential for healthy bones.