Melanie Cole (Host): Welcome to Bryan Health Podcast. I'm Melanie Cole. And joining me today is Megan Simpson. She's an ortho trauma advanced practice provider at Bryan Health, and she's here to tell us about osteoporosis today. Megan, thank you so much for being with us. As we get into this topic, which is so important as we age, can you tell us a little bit about what happens to our bones as we age? What is osteoporosis?

Megan Simpson: So, osteoporosis is a loss of density or mass within our bones. Once we reach the age of about in our late 20s, early 30s, we hit our peak bone mass. And then all of us, men and women, start to lose some amount of bone density throughout our lifetime. So, osteoporosis is this loss in density that then causes an abnormal structure and a weakening of our bones, making an increased chance of us to have a fracture. Simply said, if you picture your bone as a honeycomb for a healthy bone and then you put osteoporotic bone next to it, that bone of the osteoporosis would have much larger holes than your healthy bone does.

Melanie Cole (Host): So, when we think of this bone mineral density loss, what bones does it typically affect? Are we talking about spine, hips, knees, kind of all of them? Where do we see it most often?

Megan Simpson: So, it really does affect all of your bones, but the ones that we see having the most effect of that increase in fractures is typically in your spine, your wrist, proximal humerus, hip fractures. So, here at Bryan, we do a fracture liaison service. When somebody comes onto our service with a fragility fracture, which is a fracture that is sustained by a low energy mechanism like a ground-level fall, the patient gets treated by our orthopedic surgeons and then, in followup, meets with one of the advanced practice providers here in our clinic to discuss osteoporosis and start the workup for this.

Melanie Cole (Host): Let's talk about risk factors for a minute. You mentioned as we age at the very beginning, and that's obviously the main risk factor. But there are some risk factors that we can control and tell us a little bit if it's more common in men or women, but speak about this risk factor situation, genetics, whatever it is, lifestyle. Is there anything we can do to slow down this bone density loss?

Megan Simpson: So, it is more common in women. One in about two women over the age of 50 will end up with a fracture due to osteoporosis and about one in four men over the age of 50 end up with an osteoporotic fracture Some of the other risk fractures are being post-menopausal, being Caucasian, and then also having like a low body weight.

Some of the risk factors that we can modify are making sure that we're drinking alcohol in moderation. Alcohol does affect your nutrition level, which then does boil down to your bone getting the nutrition that they need to stay strong. Avoiding smoking. And then, making sure that we get the right amount of vitamin D and calcium intake, as well as staying active. It's really been shown that weight-bearing exercises as well as weight strengthening exercises, so if you think of lifting weights or resistance band type exercises at least three to four times a week, do help us to kind of slow our bone loss down.

There are a few other risk factors that are also sometimes not avoidable, depending on people's comorbidities. So people that are being treated for cancer with chemotherapy or some of the medications that are used to treat diabetes or seizure disorders. Even some of the medications that cause immunosuppression also put people at higher risk for having osteoporosis.

Melanie Cole (Host): So I want to hit one more risk factor for a second, Megan, which is menopause. Because I even told you off the air that I am a postmenopausal woman, and so this risk of losing some of our bone density after menopause because of our hormones and now everything's changing. So what do you tell women of a certain age that they can be doing to try and strengthen their bones? You mentioned vitamin D lifestyles, alcohol, smoking, exercise. Is there anything related to menopause that we should be doing or that's recommended that we do?

Megan Simpson: There is with screening that we can do, and that women after menopause, some people do have hormone replacement therapy, which does sometimes help kind of hold off osteoporosis, but screening and just kind of discussing with your doctor those risk factors. There is a FRAX score, which is a list of kind of questions and risk factors that your doctor can go through with you. And then, it really does give kind of a chance of having a fracture within the next 10 years. And then, also making sure that we get our DEXA scans. Typically, that started at 65 years of age, unless that FRAX score, which should really be done at the age of menopause, is higher than we would recommend getting that DEXA scan done sooner and then repeated usually every couple of years depending on the result.

Melanie Cole (Host): I'd love you to tell the listeners what that DEXA scan is. So, what does that involve? What does it entail? What does it show us?

Megan Simpson: That DEXA scan gives us the quantity or the amount of bone. It's a bone mineral density test, so it's noninvasive, similar to going in for an x-ray. And they look at your bone density at your lumbar spine and then, usually, typically at a hip or at your wrist or forearm. And that can give us a range of normal bone density, which would mean that you don't have osteoporosis. And then, in between osteoporosis and normal bone density is osteopenia, which is that in between phase where we don't necessarily need to start people on pharmacotherapy or prescription medication to treat osteoporosis yet, but there are definitely interventions that we can do to help slow the bone loss, so we can hold off the progression of osteoporosis.

Melanie Cole (Host): Well, I think that's really important because we do hear so many ads on TV and in the media about these medications for osteopenia and osteoporosis. So besides doing this weight-bearing exercise, which is just vital and making sure that we get our calcium and our vitamin D and those lifestyles that you mentioned, Megan. Tell us a little bit about the medication situation and whether or not these are recommended once the course starts, if we are headed in that direction. Or are they used prophylactically, preventively? Tell us a little bit about the medications on the market. And what should we be asking our doctors about those?

Megan Simpson: Typically, these medications are not started, until you have osteoporosis. That being said, if you do have osteopenia and then you end up with a fragility fracture, sometimes these medications are started before your DEXA scan truly shows osteoporosis. So that fragility fracture is one of the things that leads us to start medication sooner, because it's been shown that once you have that initial fragility fracture, you are at an 86% increased risk of having a subsequent fracture if you are not treated for osteoporosis. So that's a warning sign. Some of the medications can be oral medications, so some of those are bisphosphonates. The most common ones that are prescribed in that category are like Fosamax, Boniva. These medications really help decrease the osteoclast, which are the cells that break bone down. There are some stomach side effects with these and it can cause people to have some heartburn, reflux, so they also have to be taken before meals. You have to wait for 30 minutes prior to eating anything, and you do need to sit up afterwards. And that helps to reduce some of those side effects, that sometimes can make that a little difficult for people to take. There are other bisphosphates that are given IV for treatment and they're sometimes a little bit easier for patients to comply with.

And then, there are different medications, Prolia being one of them, that works to help prevent osteoclast formation. And that is also given as an injection taken every six months. And then, there's also different hormone therapies that people can be put on that work with your hormones to help slow bone loss, just depending on your cause of osteoporosis.

A common side effect of all of these medications is osteonecrosis of the jaw, which is one thing that a lot of patients are very scared about. This is like a death of your jaw bone. It is very, very rare and typically seen when these medications are used in higher doses, not just in the doses that people are on for osteoporosis, or when these medications are used for a long period of time without being paused. that being said, your oral bisphosphonates, things like Fosamax, your Boniva, those medications, you do need a drug holiday from those, typically after three to five years just to help your body be able to not develop thick but brittle bone. When these medications are not paused for a period of time after you've been on them for three to five years, some people can be at risk for what we call an atypical femur fracture, which is when you get a fracture of your femur, which is your thighbone, typically because your bones are thick but brittle. and that can be seen with people that are on bisphosphonate therapy for many years without ever taking like a holiday from that medication.

Melanie Cole (Host): What a comprehensive answer. So well-explained because, boy, it could be confusing with all the information that we're getting. As we wrap up. Megan, what would you like to tell the listeners about osteoporosis, osteopenia, the softening of the bones, brittle bones, fractures, possible fractures, which is something that we know that if you break a hip, it increases your mortality. So as we get older and we're losing some of the strength of our bones, what would you like to tell the listeners about screening and lifestyle and your best advice for hopefully preventing it?

Megan Simpson: So, it's just really important to make sure that we have that well-balanced healthy diet, making sure that you're getting enough protein intake, enough calcium and vitamin D intake. We get a lot of the vitamin D from the sun. So, in the fall and winter months, sometimes we do need a little bit of a supplement for that vitamin D benefit. It is possible to get too much of these vitamins, so it is important to talk to your healthcare provider just to make sure that you're on the correct amount. Staying active, exercising, walking, and just making sure that we're taking care of our bodies helps not only to slow our bone loss down, but also helps us to prevent falls. It keeps our balance up and our coordination and so that way hopefully you don't have that fall that causes the fragility fracture. And then, just doing things around your home to help prevent those falls. So things like moving rugs that might cause easy tripping, moving cords that are in the way, making sure things are well lit. If you walk with a walker or a cane, just making sure that that is available for you so that you don't have those accidental trips or falls.

Melanie Cole (Host): Great information. Really important too, Megan. Thank you so much for joining us today. And thanks to our Bryan Foundation partner, Davis Design.

Please visit our website at bryanhealth.org for more information on DEXA screening and osteoporosis. That concludes this episode of Bryan Health Podcast. Please remember to subscribe, rate and review this podcast and all the other Bryan Health Podcasts. I'm Melanie Cole.