Scott Webb (Host): Osteoporosis is often called a silent disease, and my guest today is back again to tell us what that means and explain how we can help folks who are suffering from this common medical condition. And joining me again today is Dr. Ebaad Malick. He's the Director of Osteoporosis with Orthopedic Associates of Central Maryland.

Welcome to A Bone to Fix from Orthopedic Associates of Central Maryland Division. I'm Scott Webb, and I've got A Bone to Fix with you. Doctor, it's nice to have you back on the podcast. We're going to talk today a little bit more about osteoporosis. And you mentioned before when we spoke before that it's often called a silent disease, right? So, what does that mean exactly? And what's happening inside the bones before somebody notices a problem?

Dr. Ebaad Malick: So, osteoporosis is called the silent disease mainly because people walk around not necessarily knowing they have it, until they have a complication such as an osteoporotic fracture. What's happening inside the bones is that the rate of bone resorption or, you know, breaking down the bone is happening faster than the bone can remodel and rebuild itself.

Now, when we're younger, this balance of breaking down bone and building it up again is kind of balanced, and that's why we don't have, you know, a lot of osteoporosis when we're younger unless you have a secondary cause. But as we age, and especially in women after menopause when their estrogen levels drop, the rate of breaking down the bone via osteoclast activity outpaces rebuilding the bone via osteoblast activity. And it is important to know that osteoporosis can affect men as well. And that by the time something is noticed, the disease is unfortunately typically advanced. A useful framing that we use for this is that for every standard deviation drop in bone density below the young adult mean, fracture risk actually doubles or triples.

But the patient, you know, whether they're at a T-score of 0 or a T-score of -3, which is what we use to define, you know, normal density osteopenia and osteoporosis, people at various T-scores might feel exactly the same.

Host: Right. And as you say, it's a silent disease, and folks may suffer fractures when they wouldn't sort of expect to suffer those fractures. So, let's then talk a little bit more about who's most at risk for developing osteoporosis and maybe, I don't know, some risk factors that might surprise people?

Dr. Ebaad Malick: Yeah. So, you know, as we age in general, people in their seventh, eighth decades of life, so on and so forth, they're at increased risk, and then post-menopausal women because of that drop in estrogen. So according to the New England Journal of Medicine, roughly 20% of United States women over 50 and 30% over 65 meet criteria for osteoporosis based on DEXA scans. And another 40% of those patients also have osteopenia, which is not 100% osteoporosis, but it is a lower bone density than "normal."

Some risk factors of developing osteoporosis in addition to age and, you know, being post-menopausal are low vitamin D, chronic steroid use, hypogonadism or low testosterone levels in men, very low body weight, a BMI below 20, smoking, greater than or equal to three alcoholic drinks a day, a hip fracture in one of your parents, and a prior fracture, as well as rheumatoid arthritis.

Host: Right. So we've said, you know, it's a silent disease, but you may have the risk factors. So knowing your risk factors and doing something about it, of course, seeing someone like yourself. And I was doing the math there. You said the number of decades we've been alive, and I'm in my seventh decade somehow. So, maybe I should start thinking a little more seriously. But in general, broadly speaking, when should folks start thinking about their bone health and just osteoporosis screening?

Dr. Ebaad Malick: I always tell my patients you should always be thinking about your bone health as part of your comprehensive health. So even when you're young, you know, you should be making sure you get enough calcium, get enough vitamin D, stay active, adequate sleep, because when you're younger, you build your base, and you reach your peak bone density. And as you get older, that bone density only kind of drops.

Now as you said, you're in your seventh decade of life, you want to, you know, look at your other risk factors if you're a man. And if you think, you know, you have low testosterone, type 2 diabetes, maybe you've had a history of gastric bypass, you want to speak to your physician about individualized DEXA screening. And if you're a post-menopausal woman, 65 or older, you should definitely get a, DEXA scan to see if you have osteopenia or osteoporosis.

Host: Right. Yeah, you mentioned bone density and the DEXA scan. What is that exactly, and how do you then use the results to determine a patient's fracture risk?

Dr. Ebaad Malick: Yeah. So, a bone density test or a DEXA scan is essentially a series of X-rays done at various parts of your body. And from that X-ray, we can obtain something called a T-score. So, a T-score of 2.5 or lower because it goes like negatives, think golf. But in this situation, the more negative you are, it's not a good thing. So, 2.5 or lower, it meets criteria for osteoporosis. Additionally, if you're in that range of osteopenia -1 to -2.5, but have a fracture, then you also meet criteria for osteoporosis. And a DEXA scan, you know, is one of our most valuable tools because it gives us an objective measure of bone strength. It tells us whether a patient has normal bone density, osteopenia, or osteoporosis. And it's something that we can repeat and see your progress.

Host: Right. Yeah, check over time. And makes me wonder then, Doctor, are there things that we can do in terms of maybe pills, supplements, whatever it might be, calcium, vitamin D, nutrition, exercise? Like, what can we do to prevent or at least manage our osteoporosis?

Dr. Ebaad Malick: Yeah. So, you mentioned vitamins and supplements. The first two things that I would recommend and, of course, with oversight of a physician, is calcium and vitamin D supplementation. Calcium provides the building blocks for our bones, and vitamin D helps your body actually absorb the calcium efficiently. So, being deficient in one or the other could lead to lower bone density.

In addition to that, you know, you want to make sure that you're doing what we call resistance training. And the most common form of resistance training that we have now is, you know, people going to the gym and lifting some weights. Now, you don't have to be Arnold Schwarzenegger about this, but finding some way that you can comfortably move but still challenges you in a safe manner a few times a week can help decrease the rate of your bones losing density as you get older.

Host: Yeah, you made the Schwarzenegger reference there. And I think a lot of us, you know, when we think about this, we maybe bite off more than we can chew, and sometimes just simply walking more, a little bit resistance training, a little bit of weight training. Like, we don't have to go all in to maybe put off things or prevent things like osteoporosis, of course. So then, Doctor, let's talk about your role there, maybe the treatments that are available, and how do you decide which option is right for patients.

Dr. Ebaad Malick: Yeah. So, you know, I have a unique background of family medicine, but also now fellowship-trained in interventional and chronic pain. And although I treat chronic pain from head to toe, I also know that, you know, osteoporosis is a silent disease that we encounter in family medicine, but an osteoporotic fracture can also lead to chronic pain.

So at Orthopedic Associates of Central Maryland, I will be seeing pain patients, but also be leading an osteoporosis program where if someone has an osteoporotic fracture, we want to get them in for a follow-up, and make sure that they have appropriate DEXA screening, appropriate vitamin supplementation. And if they need medication, like you had mentioned, we can start them on a few of our medications that we use for osteoporosis.

So, one of the medicines that we use for osteoporosis are in the class of bisphosphonates. These are medications that decrease the rate of your bone density decreasing. And then, another one is a monoclonal antibody, denosumab, that also does this. However, there are somewhat newer medicines that actually can stimulate the body to build new bone. And in that situation, you know, we would probably refer to a rheumatologist, but there are many different options out there for patients.

Host: Yeah. Lots of options and help is available, of course. And as we talked about when we got rolling here today, you know, it's a silent disease. If folks want to learn more, we did another podcast about osteoporotic fractures. They could back and listen to that one. These are sort of companion podcasts, if you will. Just give me a chance here at the end, Doctor, maybe the biggest misconception about osteoporosis that you'd like to clear up, do a little myth-busting for folks?

Dr. Ebaad Malick: Yeah. I think the biggest misconception that I would like to get through to people is that, you know, osteoporosis is not simply an inevitable part of aging. It is true as we get older, we may get weaker or our bones might become a little bit weaker, but osteoporosis is a medical condition that puts you at risk of complications that can really negatively impact your life.

It is preventable, but it's also treatable and manageable, and we have excellent screening tools, effective medications, and lifestyle interventions that can significantly reduce the risk of fractures in patients with either osteopenia or osteoporosis. And one more misconception that I want to get across too is that if you haven't broken a bone, you don't have osteoporosis, so you don't have to worry about that.

You know, I hope no one breaks a bone, but there are plenty of patients that are walking around that have never broken a bone that do have osteoporosis and are putting themselves at risk if they don't get screened.

Host: Right. As you say, it's a medical condition. It is—perhaps for some—preventable manageable, treatable, of course. And the work you're doing there at Orthopedic Associates of Central Maryland. Good to have you on board. Great to have you on these podcasts. Thank you so much.

Dr. Ebaad Malick: Thank you so much for having me.

Host: Find out more about us online at mdbonedocs.com. And please remember to share and subscribe to this podcast. And that's all for today. I'm Scott Webb. And that was a bone that's fixed.