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  Osteoporosis Prevention & Treatment in 2012 Versus 2002

 Written in January 2013

January is a good time to assess one’s achievements and set goals for the future. Ten years ago, I started doing research on osteoporosis prevention and treatment. I’ve noticed both positive and negative changes in the prevention of bone loss and fractures over the past decade. I’ve listed them below, and I conclude with some of my own suggestions for improving osteoporosis prevention and care. I’ve published them here and sent them to several people and associations in the field as part of my bone loss prevention advocacy and as a way of helping support osteoporosis professionals who believe that change is needed. Here are twelve general differences I’ve noted:

1. Thanks to osteoporosis foundations such as the NOF and the rise of social networking, there are more opportunities for patients to learn from one another using online discussion groups now about bone health related issues. Patients can offer helpful insights. However, patients should not give out confidential information or expect to get an online diagnosis.

2. In 2002, medical professionals were concerned about a patient’s risk of fracture throughout their life. Today, doctors are often taught to only consider the patient’s 10-year probability of fracture. Will this help patients remain fracture-free during their entire life?

3. Ten years ago, few doctors recommended Vitamin D. Thanks to significant achievements in Vitamin D research, a much higher percentage of doctors are advising patients to take Vitamin D, and the recommended amounts have increased. As a result, more people are now getting an adequate amount of Vitamin D.

4. In 2002, doctors relied on their knowledge and experience along with the patient’s risk factors, preferences and bone mineral density (BMD) T-scores to determine treatment and preventive options for individuals. That protocol worked well. Today, doctors are taught to use a FRAX tool calculator to determine a patient’s 10-year probability of fracture in order to make drug treatment decisions. Osteoporosis researchers, however, are divided as to the value of the FRAX method of calculating fracture risk. This difference of opinion was highlighted, during a debate at the 2012 annual meeting of the ASBMR (American Society for Bone & Mineral Research) on whether or not FRAX is more useful than individual risk factors for identifying patients who will experience larger reductions in fracture risk with treatment. Dr. Dennis Black, the supporter of individual risk factors, won the debate, based on a digital audience vote. Unfortunately, the FRAX calculator has occasionally been used to deny or discourage bone density testing or to suggest to patients that they needn’t be concerned about breaking a bone.

       A case in point: 12 years ago, the FRAX calculator would have indicated that I "only" had a 9% chance of a major hip fracture in the next 10 years and a 0.6% chance of hip fracture. Based on those percentages, I would have been told not to get a bone density test and not to be concerned about a fracture but to just take calcium and Vitamin D. If a primary care physician told me to exercise, most likely I would not have been given advice about the type and amount of exercise required to maintain bone. Fortunately, FRAX was not used then. About twelve years ago, the doctor at my mother's bone density test center told me that I should be concerned about getting osteoporosis because of my mother's early hip fracture and osteoporosis as well as my thin build. He advised me to get a bone density test in my home town and to take action to prevent bone loss. I followed his advice, got tested and learned a lot from my reports, which prompted me to take many steps to help maintain bone loss and strengthen my back. This helped me minimize bone loss and increase muscle strength. Therefore I am in favor of using the patient's risk factors, BMD T-scores and preferences to make bone health decisions rather than simply using a numerical FRAX score.

5. It used to be relatively easy to find a bone density test center in America. Because of decreased reimbursements for DXA tests by doctors, many doctor-operated DXA centers have closed, although hospital imaging centers continue to offer DXA testing. Unlike the doctor-operated centers, whose technologists often discussed the results with patients and gave them preventive advice, hospital imaging centers typically refer questions about the test results to the patient’s doctor, even though patients seldom have an opportunity to discuss the results face to face with their doctor afterwards. What’s better for patients? --- To get information about their bone health only from their doctor or to get it from both their doctor and test center?

6. In 2002, hardly any hospitals had established fracture prevention programs for patients with fractures. Since then, the International Osteoporosis Foundation has established a “Capture the Fracturecampaign in order to break the fragility fracture cycle; the American Orthopedic Association has established “Own the Bone” to encourage hospitals to take steps to help prevent repeat fractures. Even though more hospitals have secondary fracture prevention programs now, most still don’t have them, but they should.

7. Ten years ago, hardly any doctors recommended back strengthening exercise or physical therapy for patients with compression fractures. Even though physical therapy and back strengthening exercise is a first line of treatment for disc problems and back pain and has also been found be effective in preventing spinal fractures, back-strengthening exercise is still seldom mentioned to patients with compression fractures even though it could be very helpful.

8. In 2002, many women were told at menopause to take steps to prevent bone loss, such as hormone therapy. Getting a prescription for a bone density test at menopause was easier than it is today. A January 2013 Journal of Bone & Mineral Research (JBMR) print article confirmed that bone loss increases significantly during the transmenopause phase and that it begins before menopause SWAN study article entitled “Bone Mineral Density Loss in Relation to the Final Menstrual Period . . .” (pp 111-129)

     Therefore, when a middle-aged woman’s periods start becoming very irregular, this is a good time for a doctor to warn women about the need to do more muscle strengthening resistance exercise to offset the estrogen loss and to take stock of their lifestyle and eating habits as well as their calcium and vitamin D intake. Now that hormone replacement therapy is less prevalent, it seems that discussions about peri- and postmenopausal bone loss are less frequent. Shouldn’t hormone-related bone loss prevention be stressed more now?

9. Ten years ago, bone health recommendations for “safe exercise” focused on exercise that was safe for osteoporotic patients with little concern for the prevention of osteoarthritis and back and neck injuries in all people. Today post-menopausal women are still being told by some osteoporosis professionals to jump rope and hop on hard surfaces to increase their bone density, thereby gradually damaging their joints. In addition, patients with potential back and neck problems are being told to take yoga and Pilates classes at gyms without being given any instruction on which exercises to avoid in these classes. The concept of “safe exercise” among osteoporosis professionals still needs to be expanded to include the prevention of osteoarthritis and back and neck problems even when patients don’t have osteoporosis.

10. The medical establishment used to focus on having a high intake of milk products and calcium as a non-drug means of preventing osteoporosis. Even though they have always advocated having a well-balanced diet, medical professionals are now emphasizing more the importance of other nutrients besides calcium such as Vitamin D and the need to include lots of fruits and vegetables for optimal bone health. They’re also recommending that patients get most of their calcium from dietary sources instead of supplements.

     Many alternative practitioners, on the other hand, advised against consuming dairy products saying that milk is for cows — not humans —- and citing studies showing that Asians, who consumed less milk, often had fewer fractures. (However, Asian food is typically more nutritious than western fast-food meals, and exercise and the vitamin D levels of the participants were not factored into the studies.) Today some alternative practitioners still discourage people from consuming dairy products even though dairy is a good source of dietary calcium and contains essential bone nutrients such as Vitamin B12, which is not available from plants.

11. In 2002, if a patient had a slumped posture, it was unlikely that a doctor would mention this and recommend posture and back strengthening exercise during a physical. Today it is still unlikely that a doctor will offer posture advice during a physical. In fact, posture and back-strengthening exercise is not even mentioned in the Jan 2013 JBMR article entitled “Factors Associated with Kyphosis Progression in Older Women” (pp179-187). However, the article does state: “Hyperkyphosis, or an increased thoracic curvature, is commonly observed in older persons affecting up to 40% of older women . . . Although the development of age-related kyphosis is often attributed to underlying spinal osteoporosis, only 36% to 38% of those with the most abnormal kyphosis have underlying fractures.”

       Fortunately patients can go to their local gym, where some teachers or trainers will point out their stooped posture, telling them it is caused by being slumped for hours in their chairs at work and at home. The teachers will then give them practical advice on improving their posture, something that was absent from the JBMR article; gym participants will be told to pull their shoulders back and down, tuck the tummy, pull the butt in and do the exercises with proper form and posture. It’s amazing how the posture of the entire class can immediately improve with this simple advice. It’s good that researchers are making us more aware of the need to address the topic of kyphosis.

12. Ten years ago, osteoporosis-related conferences usually relegated exercise information to a pre-conference session and/or a concurrent session alongside sessions with non-exercise topics. This year the NOF has devoted an entire plenary session to exercise options so that all participants learn how to use exercise to help patients. This is welcome news.

       For more than twenty years, we’ve had specific information about the types of exercise required to prevent bone loss. Dr. Sydney Lou Bonnick, whose bone densitometry books are standard ISCD (International Society for Clinical Densitometry) texts, also wrote The Osteoporosis Handbook (1994), which outlined the types of exercise required for maintaining and building bone. She backed up her advice with research. Yet, there are still doctors telling patients that all they need to do to maintain bone is to go out and walk a few times a week; this is because the doctors haven’t received adequate exercise training in medical school or at conferences.

       On page 74 of The Osteoporosis Handbook, Bonnick highlights the paragraph “Exercise is site specific. If you want a strong spine, you must exercise the spine. If you want strong legs, you must exercise the legs.” Even though this is common sense, many doctors don’t understand the need for site specific exercise for maintaining bone and are surprised when significant variations of BMD T-scores occur in different areas of the skeleton. Additional exercise information is available at www.avoidboneloss.com/exercise.htm.   

       A September 2012 JBMR article (pp1896-1906) stated “astronauts who have access to sufficient resistance exercise, coupled with adequate energy intake and vitamin D status can return from spaceflight missions of 4 to 6 months with measured bone mass and BMD’s seemingly no different from baseline measures—for most skeletal regions” (p 1900). The article was entitled: “Benefits for Bone From Resistance Exercise and Nutrition in Long-Duration Spaceflight: Evidence from Biochemistry and Densitometry.” Even though the exercise prescribed for earlier flights was inadequate for preventing bone loss, this did not discourage space officials from experimenting with other exercise regimens to find a more effective means of preventing loss. They kept experimenting until they found something that worked. We should take the same approach to finding non-drug methods of preventing hormone- and age-related bone loss.

Suggestions for the Next Decade

The above text already indicates some changes in osteoporosis prevention and treatment that could be beneficial for patients. However, I have a few more suggestions. When doing calcium studies, indicate the type of calcium used, if possible. It would be helpful, for example, to know what percentage of the study participants are taking calcium carbonate versus calcium citrate. Citrate is said to be a potent inhibitor of calcium oxalate and calcium phosphate stone formation (Canadian Medical Association Journal, Aug. 1, 1989). Perhaps the kidney stone formation associated with some calcium supplements could be prevented by taking calcium citrate instead of calcium carbonate. Then doctors might be able to definitively know which type of calcium is preferable.

In the calcium studies that show an increased incidence of kidney stones, try to find out if magnesium was taken together with the calcium supplements. Many nutritionists say that magnesium is necessary for bone health and should be taken with calcium in order to maintain a proper calcium/magnesium balance. This, in turn, can help alleviate side effects from excess calcium such as aortic calcification, kidney stones, muscle cramps, brittle bones and dementia. An article in the Annals of the New York Academy of Sciences (Vol. 747) entitled “The Calcium Rationale in Ageing and Alzheimers disease”, from the Institute for Neurosciences at Northwestern University Medical School also suggests that a proper balance of magnesium and calcium could be important for preventing negative side effects from calcium supplements.

Consider including information on how to interpret medical reports in high-school biology and health courses. Then students could better understand the effects of their lifestyle on their health when they examine their blood results and other medical tests. If proper nutrition is not part of the biology or health curriculum, that should also be included.

Include instruction on how to use free weights and weight machines in physical education classes. I had to pay a trainer to learn this, but many people can’t afford a trainer. Strength training is not only helpful for maintaining bone, it is especially effective for preventing sarcopenia (muscle loss).

Eliminate the requirement for the DXA bone density test for self-pay patients. I know three people who wanted to pay for a bone density test but had to switch doctors in order to get the test done. A colleague of mine, whose mother had osteoporosis, was told by her doctor to just take calcium and walk fifteen minutes a day three times a week and to accept the fact that we all have our genes and we can’t fight with them.

       There is an easy solution to the dilemma doctors face of either being accused of ordering unnecessary tests or else alienating a patient by refusing to write a DXA prescription—eliminate the requirement for a doctor’s order for self-pay patients. No other screening test in America requires a prescription if the patient is willing to pay for the test. Federal law prohibits requiring a prescription for a screening mammogram even though it has about 20 times more radiation than a DXA scan. You can get almost any type of blood test through the Internet without a prescription. Lifeline Screening makes a lot of money by offering carotid and aortic ultrasound screenings, and no prescription is required. Screening CT scans of the heart, lungs, colon and full body are available without a doctor’s order and so are MRIs. It’s hard to understand why the DXA community would want to limit their income by requiring that self-pay patients get a doctor’s order for a DXA screening of their hips and lumbar spine.

       Some medical associations are telling doctors that bone density tests are not cost-effective before the age of 65 unless the person has had a fracture, cancer or is on corticosteroids. It’s true that if the test results are not discussed with the patient, as is so often the case, the test is not worthwhile. In addition, if it is only used to prescribe drugs, then the full benefits of the test are not obtained. NASA and the army have used DXA testing to help develop non-drug methods of maintaining bone, and so can individuals. DXA computer images can also provide a lot of helpful information about the skeleton and can indicate the onset of osteoarthritis and disc problems. One radiologist told me that DXA scans have even been used for the early diagnosis of cancer, allowing patients to get treatment before more serious problems developed.  Hopefully, in the next decade, DXA professionals will take steps to ensure that all self-pay patients who want information about their bone density status are able to get a DXA scan, regardless of their age or risk factors.

Summary of My Recommendations

Many osteoporosis professionals are frustrated with the lackadaisical attitude in the medical field towards the prevention of fractures and osteoporosis. Positive change has occurred in the past decade, but more can occur if we actively lobby for change. Below is a summary of some of my suggestions for improving lifetime bone health:

Care more about the lifetime risk of fracture instead of only the ten-year probability. Why wait until the age of 65 to address issues such as postmenopausal bone loss? Bone and muscle loss prevention should start early in life..

Encourage more hospitals to develop fracture prevention programs. Orthopedic departments should consider establishing on-site or off-site exercise programs as cardiology departments have done. Primary care physicians should have a list of places where they can refer patients for affordable exercise guidance.

Expand the concept of “safe exercise” in the osteoporosis community to include the prevention of osteoarthritis and back and neck injuries for all patients.

Include physical therapy and/or back strengthening exercise as part of the treatment protocol for compression fractures instead of limiting it to drugs and/or surgery.

Take action at perimenopause to help women avoid hormone-related bone loss. Perimenopause is a good time for women to get a baseline bone density test, measure their muscle strength, and establish a program to help maintain their level of bone density and muscle strength, which in turn affects bone strength. In some cases, drug therapy is warranted. One positive example is the Danish study "Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women": in the October, 9, 2012 British Medical Journal.

Include posture advice during physicals when needed. Recommend back-strengthening exercise. Strong back muscles, posture exercise and an awareness of one’s tendency to slump can help prevent kyphosis, which in turn may create back pain and heart, breathing and digestive problems.

Include courses on nutrition and exercise as part of the required medical curriculum for doctors. Also offer this information at medical conferences.

Eliminate the DXA imaging center protocol of refusing to discuss test results with patients. Patients need more information than what they typically get from their primary care physician in order for the test to be useful. At the very least, online information should be available. I’ve been told that Kaiser patients can get all of their medical reports online or via e-mail, and sometimes they get their results the same day of the test. The report is identical to that which the doctor receives. It’s not a watered down version saying, for example, “your results are in the normal range.”

Help DXA centers stay in business by allowing self-pay patients to get a DXA bone density test without a doctor’s order. It should be just as easy for patients to get a bone density test as it is a mammogram, if they pay for the DXA test themselves.

Provide high-school students with the opportunity to learn about nutrition, resistance exercise and the meaning of their medical test reports. Some students are unable to get good nutrition or health advice at home.

The above steps could go a long way in helping prevent fractures and improving the overall health of patients.

Copyright 2013 by Renee Newman             Click here to go to top of web page