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Scott Webb: Welcome to Right Beside You, a Reid Health podcast. I'm Scott Webb. And today, I invite you to listen as we explore osteoporosis. And joining me today is Dr. Erica Kretchman. She's an endocrinologist with Reid Health. Doctor, thanks so much for your time today. We're talking about osteoporosis, so let's just get a baseline here. What is osteoporosis? And do we know what causes it?

Dr. Erica Kretchman: So osteoporosis is actually a silent skeletal disorder. And we characterize it by a compromised bone strength that is leading to an increased risk of fracture. So it is really characterized by two things, which is bone density and bone quality. So bone density is maybe something that people feel very familiar with because it's the screening test that we use to diagnose osteoporosis. But some people can actually be diagnosed with osteoporosis before they would even reach that typical age threshold to get a bone density by having what we would call a fragility fracture.

Scott Webb: Yeah, we're going to talk more about the bone density test in a bit. But first I wanted to ask you, is osteoporosis more common in women than men? And if so, why are women more likely to get osteoporosis than men?

Dr. Erica Kretchman: Yeah. So that is a very great question because, you know, in general, a part of why I wanted to talk about osteoporosis with you today is that this is something that is really under-recognized in both populations, women and men. And it is really a major health problem. There's about 10.2 million Americans with osteoporosis and then almost over 40 million that have that precondition to osteoporosis, which is called low bone mass or osteopenia.

You are correct in knowing that this is a more common disease in women. But it is something that is often under-recognized or underdiagnosed in men. And really the thing with osteoporosis is that we have a lot of people that are finding out that they have osteoporosis by fracture, and there's about 2 million osteoporosis fractures annually in the United States. And in this, answering this woman versus men problem, 70% actually occur in women. And that is kind of the goal for me as an endocrinologist or a clinician practicing with the treatment of osteoporosis, is to prevent these fractures. Because when we do see so many fractures, the cost of caring for this exceeds the cost of breast cancer, heart attacks or strokes in women age 55 or older.

The other part of your question was what is the risk factors for osteoporosis? Unfortunately, one thing that is a risk factor for osteoporosis that we can't prevent is getting older. So as we have more birthdays, our bones tend to age with us, which means that they typically lose some of that bone quality.

There are a lot of other things that we do in our life that also can affect our bone health. And sometimes these are things that we have long past, like our peak bone density and our youth. But other things that we do day in and day out like smoking, the amount of alcohol we take in, caffeine and other medicines that we take may increase our risk of having poor bone quality or increase risk of osteoporosis or fractures.

Scott Webb: Yeah. So it sounds like it's, you know, as you say, we can't get away from our age, right?

Dr. Erica Kretchman: Yes. Correct.

Scott Webb: Some things are modifiable, some things are genetic. And as you say, you know, osteoporosis is silent. And so therefore a lot of times it's not being diagnosed until someone has a fracture, right?

Dr. Erica Kretchman: Correct.

Scott Webb: Yeah. And that's problematic, of course, for all of us, because when you don't know you have something until you've injured yourself, and as you say, it's just a big burden on the entire system and patients and insurance and all of that. So then diagnosis would be key. So how is it diagnosed? What is a bone mineral density test? And who's a good candidate for that test?

Dr. Erica Kretchman: So a bone mineral test is probably our good general screening tests that we use in the population to diagnose osteoporosis. This is a test that is done at a lot of our hospital institutions. Some offices still have the ability to do their bone mineral density in office. It is a quick procedure in which you are getting a low exposure x-ray of different parts of the skeleton.

So typically it is the lumbar spine, which is the lower part of your spine, right above your sacrum and below your thoracic spine, your pelvis, so to be able to look at the hips. And usually, we're looking at both the right and the left hip. And then sometimes we'll include an image of your forearm. So these are the areas that we're able to see the density of the bone, which helps us predict the risk of fracture by looking at that BMD and getting a test of your T score and your Z score.

A T score is something that is determined in post-menopausal women or men above the age of 50, that is looking at their score as compared to a young healthy population. So that is allowing us to see how thin their bones are and how much of a risk of fracture do they have? The lower this T score is, the more that they have a risk of fracture. And the definition of osteoporosis is with a T score less than 2.5.

There's another condition called low bone mass or osteopenia in which the T scores fall between a -1 and -2.5. So these people may have a higher risk of a fracture than a normal population. And in some sense, even though they are not yet diagnosed with osteoporosis, these are the individuals that we may consider treating to prevent that risk of fracture. So to kind of look in that general screening population, that's how we use a bone density or a DEXA.

There are two other ways that we can diagnose osteoporosis. And one is in that earlier class or people who have the low bone mass or osteopenia, we look at something called the FRAX calculation. So this is taking into consideration what the bone mineral density of their femoral neck was on the bone density. And it looks at their age, sex, weight, whether they have a personal history of fracture or family history of a hip fracture, and then other risk factors like steroid therapy if they have rheumatoid arthritis, smoking, alcohol or other secondary medical conditions that can lead to an increased risk of fracture or osteoporosis.

And this is a very large list of other medical conditions or medications, but to highlight a few, things like hyperparathyroidism; hypogonadism, which really means men with low testosterone or women who may have gone through menopause early; things like malnutrition or liver disease or malabsorptive disorders, and then high-risk medication.

So these are some things that people need to help manage other medical conditions like steroids. Steroids is a big medicine that we're often concerned about if people need to use higher doses for a longer period of time, like three months. And then some other medicines that they may use for routine things like what we call our PPI's or medicines that we use for acid reflux. These are also things that could put them at increased risk of fracture.

So if we find someone who is in that pre-condition of osteoporosis or low bone mass or osteopenia, that has a lot of risk through this FRAX calculation, we're looking to see what is their risk of fracturing in the next 10 years. And if they have over 20% risk of any osteoporotic fracture and over 3% risk of a hip fracture, we really want to treat those individuals.

Then the final way that osteoporosis is diagnosed is a fragility fracture. And unfortunately, this is someone who has had a fracture from a low-energy injury, which we typically define as a fall from standing height and it's of the spots in the body like the vertebra, the hip, the proximal humerus, the pelvis or the distal forearm.

So if we see someone who has had a fracture, it doesn't matter really what their bone density is if it is a fragility fracture. They are formally diagnosed with osteoporosis. And once this fragility fracture has occurred, these are the individuals who have the highest risk of having another fracture from another osteoporosis site. And some of these fractures can occur even without injury.

So we have seen vertebral fractures happen just through parts of daily living. So people walking. I've had patients when they're here, I had a man who came and just walked down a step and kind of heard a crunch and he had a vertebral fracture. So oftentimes you may not have had the fall to recognize the fact that you've had a fracture. So we often assess height loss. So if we see that individuals have lost more than one and a half inches of height, this is a risk for them to may have a undiagnosed vertebral fracture.

Scott Webb: Yeah. You mentioned the height loss. And I was just thinking about, you know, over the years, my grandparents and so on, you know, people just sort of so easily kind of dismiss that. "Oh, well, you know, grandpa's shrunk a little bit. Grandma's shrunk a little bit." You know, my wife's mom used to be, she claims, 5'1" and now she's like 4"11.' so, you know, grandma's shrunk. What are you going to do, right?

Dr. Erica Kretchman: Sure. And this is a really important vital sign for our patients at risk or with osteoporosis. And it's very important that when you come into your clinician's office, that when you're getting a height, that your shoes are off, you're standing straight up and that they are doing their best to get a very accurate height. And I always make sure that we're comparing our heights from each time that we do it because we really work hard to standardize that measurement to make sure that we can see in our osteoporosis patients, that they are actively losing height.

Scott Webb: Yeah. So key, as you mentioned here. And doctor, is there a link between osteoporosis and menopause?

Dr. Erica Kretchman: Yes, absolutely. So we see that, when women go through menopause, they are at the most rapid state of bone loss in those first two years. Estrogen is very important for bone strength and bone health, so this is why the majority of people who do have osteoporosis are post-menopausal women.

Scott Webb: Got it. And, when we talk about treatments, so we've gone through diagnosis today especially, and the different tests and options. And it seems like there are many. Tell us about the medications that are available to increase bone density. And do they have any concerning side effects?

Dr. Erica Kretchman: I'm so glad to talk to you about medical therapy when it comes to osteoporosis, because this is something that I think, as I talk to my other endocrinology colleagues or other people who are passionate about the treatment of osteoporosis, that we often find difficult to express to our patients why they need a treatment and what this treatment will do for them.

And I do definitely want to talk about lifestyle things too because calcium and vitamin D are very important in this space. But when we look at our prescription treatment options for osteoporosis, we really put them in two broad categories. So we have what is an antiresorptive category and then the anabolic category.

What the antiresorptive category means is that these are medicines that are going to stop the bone loss. So they're going to try to help maintain your bones as they are. They really work to turn off these cells that are called the osteoclasts and osteoclasts are something that kind of breakdown your bone so they can help maintain what you have.

The great thing about these medicines is a lot of them have been around since the '90s. So we have a lot of really good data on how we should use them and why we use them and the importance of why we use these to prevent fracture. So when we have people on the right antiresorptive therapy, we typically find that this can help reduce fracture by 50%.

So it has a significant impact on their ability to prevent something like a fracture that would lead them into a high risk of mortality or morbidity in the upcoming years after fracture. So we find that a lot of people will really lose quality of life, some end up in nursing care long-term and there actually is a really high risk of death in that first couple of years after fracture. So we really want to look at preventing that fracture and 50% reduction is very impressive.

In fact, I talked to patients a lot about when we look at these medicines, why we're doing that is that this is the same reduction that we see for people wearing seatbelts in cars. So if you were to be driving and you did not have the seatbelt on, a police officer would pull you over because of the fact that it is a law, click it or ticket. And the reason is because wearing a seatbelt, if you were to get into a motor vehicle accident, would reduce your risk of a severe injury or mortality or death by 50%. And it's a law because it is such an effective thing.

And I often say that it should be a law when it comes to our osteoporosis therapies because it has the ability to reduce that risk of fracture by 50%. But oftentimes people are very nervous about taking these medicines because of some of these rare conditions that have been reported. And there are two things with our antiresorptive classes, which is called osteonecrosis of the jaw and then there's something called an atypical femur fracture.

Now, these conditions are incredibly rare. And if we look at the incidence of somebody getting an osteonecrosis of the jaw. And just to define, this usually happens after a dentist will remove a tooth and the jaw underneath it just gets exposed and doesn't have the chance to heal. In a patient on traditional osteoporosis medicine, this is very low risk. As often as somebody would get struck by lightning in New Mexico. So very rare as compared to the risk of them having a fracture.

So if we looked at if you were untreated, you have about a 25% risk of having a fracture in 10 years versus, if you were treated, a 0.01% risk of osteonecrosis of the jaw or a 0.01% incidence of an atypical femur fracture. So the risks of these conditions that often seem scary or frightening for individuals are very small as compared to the risk of them having something like a hip fracture that takes away their quality of life and even can lead to death in the first couple of years. So I often try to give this information to patients so they know that I'm not treating something they don't have symptoms from just because I feel like I have to click a box, but I'm doing it because this is the most effective way for them to have health and care and reduce their risk of fracture over the next 10 years.

The other side of the osteoporosis therapies are anabolic therapies and these actually will rebuild the bone. So it actually helps make those bones stronger. So oftentimes these are the therapies that we will look to when somebody has gone through a fracture or has a severe risk of fracture, that they have multiple risk factors. They are smokers, they are on steroids, something that really has a very high risk of them fracturing the next 10 years. We will use us to help rebuild the bones and then move over to those antiresorptive that I first talked about that actually will help maintain the bones that they really did rebuild.

Just to also add into this, a lot of patients are often asking about calcium and vitamin D. It is very important that when we have osteoporosis, that we do everything we can in their lifestyle to try to optimize their bone health. And I can give them a prescription for either one of their medicines, but if they are not having the adequate intake of calcium or vitamin D, these therapies are not going to be as efficacious as they should be.

So I typically do recommend that our women try to get 1200 milligrams of calcium a day and men get a 1000 milligrams of calcium a day. And ideally, I like the majority of this to come from the diet, because this is probably the healthiest source for their body. But not everybody can do the full 1200 or 1000 through diet. So we often will bring in calcium supplements like calcium carbonate or calcium citrate and vitamin D, especially in the Midwest where I practice people are often very low on vitamin D because we just don't get enough sun. That's something that we need to look at, kind of getting the supplement typically a 1000 to 2000 IUs a day, but really aiming for that vitamin D to be between 30 and 50 on their blood work.

Physical activity is also very important to help prevent falls because that's typically the most common reason we see fracture. And of course, then other lifestyle things like smoking cessation, avoiding excessive alcohol and caffeine intake are very important to try to keep your bones as strong as possible.

Scott Webb: Yeah, and that is the goal. And doctor, you are such a wealth of information. You really know your stuff, so it was really a pleasure being on with you today and you stay well.

Dr. Erica Kretchman: Okay. Thank you so much for your time.

Scott Webb: You can call (765) 935-8810 to schedule your appointment today. And for more information, please visit ReidHealth.org to get connected with one of our providers.

And that concludes this episode of Right Beside You, a Reid Health podcast. Please remember to subscribe, rate and review this podcast and all the other Reid Health podcasts. For updates on the latest medical advancements and breakthroughs, follow us on your social channels. If you found this podcast informative, please share it on your social media and be sure to check out all the other interesting podcasts in our library. I'm Scott Webb. Stay well.