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Scott Webb: Bone loss in and of itself isn't really a problem. But bone loss due to osteoporosis, for example, can lead to falls and fractures and other health complications. And joining me today to go over the signs, symptoms and treatment options for bone loss is Dr. Lee Day. He's a rheumatologist with Prisma Health.

This is Flourish, a podcast brought to you by Prisma Health. I'm Scott Webb. And Dr. Day, thanks so much for your time. As we get rolling here, what causes bone loss and why is it so harmful?

Dr. Lee Day: I think to understand bone loss and the harms of it, it's important to just take a look at bone development briefly. So when we're born, we kind of have this genetically determined peak bone mass. And so, a large amount of how much bone we will eventually develop is kind of genetically predetermined and we have, of course, no say over that. When anybody gets to about 18 to 20 years old, they've reached about 90% of their peak bone mass. And then before age 30, you kind of reach what we would consider your peak bone mass or the period of time where your bone is as strong as it's going to be. And it's built up by more bone building than bone breakdown. But after you crest 30 and really into the 40s and 50s, you end up with more bone breakdown than bone buildup. And so there's a gradual decline in bone mass for the rest of anyone's life.

For women, interestingly, menopause represents the sharpest decline. So for roughly the first 10 years after menopause, there's a steep amount of bone loss. In terms of the cause of that, it really is genetics we think for the most part. There are some additional factors in life and certainly some things you have no control over, but a lot of the development of osteoporosis or low bone mass is really out of your hands interestingly.

Scott Webb: So doctor, if I'm hearing you correctly, it's pretty much all downhill after the age of 30.

Dr. Lee Day: We knew that already, right?

Scott Webb: Yeah, we sure did. You know, doctor, I'm wondering when it comes to bone loss, is it really of any significance or consequence to us ultimately? Or is it because of the bone loss and the fact that that may lead to fractures and things like that? Is that really why we should be concerned about bone loss? And also really is bone loss reversible in any way?

Dr. Lee Day: The loss of bone mass by itself, I would say doesn't really mean a whole lot in the scheme of things. It's the risk of fractures as you mentioned that's the outcome that we care about. And when you have low bone mass, the risk is that you can have fractures that occur from like normal parts of life. So a fall from standing height could result in a fracture of your hip or your spine, which can be really severe. And every year, we estimate about 2 million people in the United States have fractures related to osteoporosis.

There are some things we can't control, with the genetics. There are things we can, so smoking, alcohol use, an inactive lifestyle, dietary habits, primarily with calcium and vitamin D. And, you know, you mentioned the idea of reversibility and, if reversability means at any point in your life get back to peak bone mass, that's unlikely to happen. Even with some of our strongest medicines, we can't really get people back to that spot. But the way that I think of it is if you look at these various things that increase anyone's risk of osteoporosis, it sort of bends that curve to a more steep decline when you smoke, when you drink more, certain medications, certain medical problems can do it, you know. So it's important to identify those things and address them. That way, you know, as you have the gradual decline in bone mass that many people have, that decline is less steep. That's how to really approach it, rather than the idea of reversibility, how to sort of optimize yourself so that you're not losing bone at a higher rate than you need to.

Scott Webb: And doctor, when it comes to signs and symptoms, you mentioned, you know, injuries, fractures, you know, if we're walking down the hallway and we bump our arm into the wall, we really shouldn't break our arms. So maybe that's one of the signs or symptoms of bone loss, but are there other things? Do we lose height? Do we just maybe generally feel weaker?

Dr. Lee Day: Osteoporosis is really considered a silent disease for the most part without any true symptoms. You know, something like osteoarthritis, a lot of times pain is the primary symptom that someone might notice. But with osteoporosis, you often don't until things get pretty bad, which is when, you know, a fracture develops.

But some things that might clue you in to that are some of the things you mentioned. So height loss could indicate that you're having some fractures in your spine. And so with those fractures, you would potentially lose height. Sometimes with fractures again in the spine, people can have more of a bent forward position to their spine. You may have pain, certainly if a fracture develops. I would say that's the time when I worry about pain.

A lot of times patients think that losing bone is a painful thing, but really it's not. The pain from bone loss, it's pain from a fracture. Even saying that, a lot of spine fractures don't even cause pain. And so it's important for clinicians to know what's going on with their patient and look for signs of things that might suggest that there are spine fractures. There are some guidelines that sort of indicate a time in one's life where screening for those fractures in the spine actually is helpful, again because they can sometimes be painless as well.

Scott Webb: Yeah, doctor, and my kids like to tease me that I'm losing some height and they're probably not wrong. Maybe I just can't stand up straight as I used to. But I feel like I, you know, was at 6'4" at one time. And now, I'm more like 6'2-1/2," So they like to tease me. And it seems to me that like with my grandparents or great grandparents, we used to sort of joke that, "Oh, well, you know, grandma and grandpa are just getting smaller. They're shrinking." It does seem like we just sort of accept that, that, you know, you get older and you start to shrink, but maybe we don't have to, right, doctor?

Dr. Lee Day: I think that's exactly right. People do tend to lose some height as they go, but, you know, a major loss should certainly clue you into something else going on. I think that's just actually a really interesting point overall, the idea of what we expect aging to be like. And I think sometimes people will ignore a lot of things going on because it's like, "Well, I'm supposed to hurt because I'm getting older," "I'm supposed to be really stiff" or "I'm supposed to lose height" or those kinds of things. And I think for the clinicians and people who know you well, your family doctor, for example, who you've been seeing for a long time, just sort of know when things are changing or you'd at least have a good enough relationship to bring those kinds of things up with them, so they know what to look for.

Scott Webb: And doctor, we established that things start to go downhill at 30 unfortunately. And 50 sounds like maybe the marker, if you will, like once you get to 50, that's when maybe some red flags or concerns. But generally speaking, you know, at what age do you begin to see bone loss? And is it generally more women than men?

Dr. Lee Day: It is generally more women than men. If you look to the overall rates of osteoporosis in the United States and actually if you include low bone mass to that, which is kind of like a precursor as you're developing it, you end up with about 54 million Americans overall. For women, the risk is higher than men of getting osteoporosis. And interestingly in women, the risk of having osteoporosis is higher than the risk of having a heart attack or a stroke or even breast cancer. And in men, the risk of having osteoporosis is higher than having prostate cancer. And I think sometimes that is not appreciated how common osteoporosis is compared to a lot of other medical conditions.

The age is really an interesting, and I don't want to say controversial point, because there've been some good studies to look at, you know, if this is a condition where there are really no symptoms, when should you screen someone that ends up being, you know, not only cost-effective, but if you initiate treatment, your chances of preventing a fracture are highest? And what has come out of that is a pretty universal recommendation for women to start screening with a bone density scan at age 65. For men, starting at age 70. There are times where screening could come earlier though. So if there were other medical conditions or medications, you know, things like that. But that should be up to patient's physicians or specialist physicians who have expertise in those conditions to know that that's sort of an exception to the standard screening timeline.

Scott Webb: Well, doctor, I'm somebody in my early 50's, so it's been downhill for quite a while for me. But I'm beginning to sort of feel those aches and pains, those things you said, really around 50 is when they start to kick in. So as we wrap up here, what are some of the best ways that we can prevent bone loss? And can we prevent bone loss with changes in diets or maybe just exercising more?

Dr. Lee Day: For osteoporosis, what kind of remains in the diet is, you know, certainly eating a healthy diet, but one that contains enough calcium and enough vitamin D. And that's an important dietary point because our bodies rely on calcium and vitamin D in order to maintain a healthy skeleton. And if you don't have those things, you're not able to maintain that as well. And so there are recommendations based on someone's age for how much calcium they should get in their diet and the same for vitamin D. Fortunately, with vitamin D you can also get that from being outside and having some sun exposure. Calcium in the diet though can be kind of hard to come by, especially if somebody for some reason they don't want to or they can't have dairy products, it can be a little bit tough, but supplements can help with that as well.

And then, the other end is physical activity. It's well established that being too sedentary can increase your risk of bone loss. And so having enough activity and really the activity should include resistance training. I think a lot of patients are very interested to talk to their physicians about exercise and I'm not sure that everyone gets as clear of advice on this as they would like. For example, walking is really popular to do, especially in older age for cardiovascular benefits and just staying active. But by itself from a bone health perspective or bone preserving perspective, walking doesn't have much of an effect.

And so, you really need to think about weight-bearing exercise in whatever way that comes in, resistance bands or kettlebells or if people want to lift weights, you know, those sorts of things can be used. And I think it's a good idea for us to promote these things to patients at an earlier age though, so it becomes a normal thing that they do, and it's not somebody who, you know, is already at an advanced age with significant medical problems who also has a bunch of fractures and then you're trying to talk about weight-bearing exercise. That can be really tough.

We also have help from our physical therapy colleagues. And so here in Columbia, there's a physical therapist that I specifically refer my patients to who has expertise in osteoporosis and helps patients with targeting muscle strength and posture and balance to overall reduce the risk of falls, which is a big risk factor for fracture as you would expect.

Scott Webb: Doctor, this has been really eyeopening today. I've learned that I'm more likely to get osteoporosis than prostate cancer, which I'm not sure if I'm winning in that scenario or not, but I really do appreciate the education as I'm sure listeners do. So thanks so much, and you stay well

Dr. Lee Day: Oh, you're welcome. Thank you. It was a pleasure.

Scott Webb: For more information and other podcasts just like this one, head on over to prismahealth.org.

This has been Flourish, a podcast brought to you by Prisma Health. I'm Scott Webb. Stay well.