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Gabby Cinnamon (Host): Welcome back to the Well Within Reach podcast, brought to you by Riverside Healthcare. I'm your host, Gabby Cinnamon. And today, I am very excited to be joined by Dr. Ashraf Uddin, an endocrinologist at Riverside, to talk about osteoporosis. Thanks for coming on the podcast today.

Dr. Ashraf Uddin: Glad to be here.

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Host: So before we get into today's episode, can you tell us a little about yourself and your background? It's your first podcast with us.

Dr. Ashraf Uddin: Yeah. I'm an endocrinologist here at Riverside. I have an interest in multiple types of hormone disorders and have so since I've been very young. I have a personal connection to things like diabetes myself and managing that and helping people navigate different sort of hormone problems. I'm also part of a new gender-affirming care program here at Riverside. It should be I think probably the only place you can get that kind of care in an 80-mile radius or so from here. And I also have an interest in osteoporosis, which is what we'll be talking about today.

Host: Yeah. It sounds like you're a perfect person to talk to about this. So first off, can you explain what osteoporosis is and how it affects bone health?

Dr. Ashraf Uddin: Yeah. Osteoporosis is a condition where your bones have become very brittle and thin over time and increases your risk of fracture. The main dangerous thing about osteoporosis is that it's a very silent disease. And for that reason, it requires lots of screening. Many people have osteoporosis and may not know it or may need to be screened for osteoporosis and may not have been done in the past. Anybody who's had fractures of especially the spine or the hip are people that should be screened for osteoporosis. And it's something that I've noticed in the community, is needing a lot more education and knowledge about the awareness of it.

Host: So, you mentioned fractures in the spine or hip. Those will be risk factors. Are there any other risk factors for osteoporosis that people should be aware of?

Dr. Ashraf Uddin: Yeah. There are several. Most commonly the sources from being postmenopause, having less estrogen in your system in general. Any sort of condition that would lead you to have less estrogen or testosterone would cause you to have increased risk of fractures. For example, people who have breast cancer or are on estrogen-blocking therapy or men with low testosterone having to take testosterone injections have increased risk. Also, people who are on long-term glucocorticoids or steroid injections or pills, either that's for COPD, or whether that's for like joint pain, they have a much higher increased risk of developing osteoporosis over time.

Host: How can osteoporosis be diagnosed? You mentioned screening. Can you talk about that?

Dr. Ashraf Uddin: The most common screening test for osteoporosis currently, and is being used widely, is a DEXA scan. And this really just involves like some x-rays, and it's a pretty simple procedure to get done, and it gives us a lot of information about how the bone's mineral density is. And with that, we can determine whether you're osteoporotic, or you're in a precondition called osteopenia, and we combine that with your risk of fracture to determine whether you should be on some treatment or not.

Host: So, with a lot of health things, we talk about how there are factors within your control. And then, unfortunately, sometimes there are things out of your control, like age, gender, and so forth. But are there any lifestyle changes that you can make to help manage or even prevent osteoporosis from happening?

Dr. Ashraf Uddin: Yeah. Lifestyle stuff that can help with osteoporosis are making sure you have adequate amounts of calcium and vitamin D in your diet. Other things would be like making sure you have some good, healthy exercise that's weight-bearing of sort, and that means like skeletal weight. So, typically, these things are adequately accomplished, but sometimes they require like supplementation for like calcium or, you know, vitamin D supplement pills or, you know, some sort of like exercise program that can help kind of increase your amount of skeletal weight-bearing exercise, especially if you have a hard time with mobility and have limitations.

Host: Cool. With the rise of alternative dairy products and those having less calcium, do you think that's an issue? Because, you know, I feel like grandparents and older people, "Oh my gosh, you drink almond milk. There's not calcium in that. That's not good for your bones." is that like actually where people were getting a lot of their calcium from? So, do you think that could lead to more osteoporosis?

Dr. Ashraf Uddin: There is a decent amount of calcium that does come from milk in general, but also almonds themselves also do have a lot of calcium in it.

Host: Oh, interesting.

Dr. Ashraf Uddin: The thing that I do consider in that situation is whether the milk is fortified with vitamin D, which it is voluntarily done so in the United States. So, that would be a consideration in any sort of like alternative milks that you may obtain for other purposes, et cetera, that may not be fortified for that reason. Typically, the dietary things that have high amounts of calcium are going to include nuts and stuff, like we were talking about, milk, cheese, vegetables. There are some fruits and stuff, like oranges and apples that can have adequate amounts of calcium in them. So, there's a lot of different sources, and we ideally want to get most of it from our diet. So, making adjustments where you can, if you have these conditions especially, would be important.

Host: Interesting. I think that's good for people to know, especially people who are actually lactose intolerant, allergic to milk, that kind of thing, that you can still get that calcium from other sources. Are there any specific exercises or physical activities that people can do to improve their bone health?

Dr. Ashraf Uddin: Well, I touched on it a little bit earlier, but mainly trying to have weight-bearing exercises of some sort with your skeletal weight on it. It's interesting that we find that in patients who are much more skinny and actually more light have higher risk of developing osteoporosis over time. So, it's one of those things where being heavier sometimes has actually been protective, so that's an interesting fact. There are obviously some conditions that increase your risk of osteoporosis, even if you are heavier, if you develop diabetes or rare conditions where we have hormonal disorders.

Other things that would be helpful for exercise to know are people who have had like spinal injuries also lose a lot of bone mass over time very rapidly in the first few years, because they're not on their feet anymore and not up and exercising. So, in general, I would just suggest things that have you upright, having your own body weight and strengthen your muscles around your bones to help support you.

Host: Interesting. Good to know. We are going to take a quick break to talk about primary care at Riverside.

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Now, back into this episode. So, what medications and treatments are available for osteoporosis?

Dr. Ashraf Uddin: It's a lot different than what it used to be. So, there's a lot of different options, including pills, like alendronade, which is like a once a weekly pill that can help treat osteoporosis. There are also IV infusions that are given once a year for osteoporosis. More recently, there are also injectable medications that help actually build some of the bones, when the former medications I mentioned hold on to sort of what you have already. So nowadays, we try to come up with a tailored approach with our patients to see what their goals are, kind of what kind of risk factors they have. Are some of those things changeable or not? And how much is there risk in the future of developing a fracture. And we determine our treatment based off of that risk essentially.

Host: What are some symptoms or issues people diagnosed with osteoporosis may experience? I know you mentioned fractures and bone breaks. Is there anything else that people should look out for?

Dr. Ashraf Uddin: That's kind of the danger of it. It's really a silent condition overall. So, it really wouldn't cause many symptoms at all until something bad could potentially happen. So, that's why it's very important to make sure you talk to your doctor about getting screened with a DEXA scan or some form of like bone density measurement, and if needed, seeing a specialist for treatment if you need to.

Other than that, there is some question of whether there is some vague amount of bone pain that can occur with osteoporosis. But usually, that is not the case unless you have very small microfractures, et cetera. Usually, pain is more related to osteoarthritis and joint issues.

Host: So, talking about screenings, can you remind everyone who should be getting screened for osteoporosis?

Dr. Ashraf Uddin: So, this is kind of a controversial thing based off of what society you talk to. But typically, it's driven by medicare and medicaid and what they cover and stuff. And typically, after the age of 65, all women get a bone density scan every two years. There are some organizations that suggest that everyone over the age of 50 should have some sort of screening for osteoporosis. But typically, because of kind of how Medicare and Medicaid kind of guide these things, we typically do it after the age of 65 in postmenopausal women. Earlier, if you've had any sort of fracture, that would be a reason to do a bone density scan, especially one that is considered low trauma, like you should not have broken a bone in that situation. Other things would be all men sort of over the age of 70 should typically be screened for osteoporosis, especially so if they have other conditions like low testosterone or had a prior fracture. People who have chronic kidney disease on dialysis can also develop bone density issues over time and they should also be screened. There's a large amount of population that I'm not sure that we have enough time to cover every single one. But yeah, most people should be at an older age in general.

Host: Yeah, that's very helpful to know. So once someone has been told they have osteoporosis, is there any way to "overcome" it? Or is it kind of one of those things that once you have it, that's it?

Dr. Ashraf Uddin: I would say that it is something that's there once you have it. We have only this sort of one measure that's been sort of standardized for bone density that measures how much mineralization is in your bone. And with that, like usually most of our treatments are trying to improve our bones in one direction and sustain it. But over time, there is some bone density loss regardless with aging. So, really, we're trying to stem that progression overall, and it's not something that just goes away on its own.

Host: So, what can people who have been diagnosed with osteoporosis do to reduce their risk of fractures or other, you know, injuries related to it?

Dr. Ashraf Uddin: Predominantly, it would be like seeking treatment to lower your risk. When we do a bone density scan, we typically calculate something called a FRAX score, which gives you your risk and percentages, so it's more tangible for patients to hear and see how much their percentage risk of hip fracture or any sort of major osteoporotic fracture is. I don't know if I answered that question fully.

Host: No, that was good. It was because I was thinking, I didn't have anything on here about, you know, is it different phases? But I think that kind of makes sense. Is it like, "Okay, just osteoporosis," or can it be like worse in certain cases, you know?

Dr. Ashraf Uddin: Yeah, I mean, we have osteopenia, which is like the pre-condition. Then, we have osteoporosis. And there is like some thought that, you know, you have severe osteoporosis after a certain measurement, but it doesn't make a difference. You should be on treatment already by that point.

Host: Yeah. That makes sense. Before we go, is there anything else you would like to add?

Dr. Ashraf Uddin: I would say that osteoporosis is something that's very often forgotten, and it's like a huge issue in America and everywhere in general. And I would say especially so in our community here. They say that about 80% of people who have an osteoporotic fracture, so we're talking people who've already had complications and problems from osteoporosis have not had any treatment for osteoporosis beforehand that could have prevented that fracture. So, this is a rather serious issue overall.

In your aging years, you should think of hip fractures as something that is just as severe as a heart attack, but it's not really given that same sort of severity or importance. Many people who develop a hip fracture in their older years have a very low life expectancy after that hip fracture and also lose a lot of their mobility and, you know, independence as well, which we aren't just thinking about longevity of life, but also quality of life when we're treating somebody for osteoporosis and preventing fractures.

Host: Yeah, the hip fracture thing is very interesting, because, you know, not to end on a down note, but that it usually does tend to be a downhill spiral, unfortunately, for a lot of elderly people when they experience that hip fracture, especially if they did have independence and everything before that. After that, unfortunately, it's usually a lot harder for them.

Dr. Ashraf Uddin: Yeah. And so, I just didn't want to end on a down note either, but you know, I just wanted to make sure that it's stressed how important this condition is and why I wanted to speak about this topic here today.

Host: Yeah. Well, thank you so much for sharing all this information. It is a very important topic and we're grateful to be able to provide this information to the community. Thanks for coming on the show.

Dr. Ashraf Uddin: I appreciate it. Thank you for your time.

Host: And thank you, listeners, for tuning in to Well Within Reach, brought to you by Riverside Healthcare. For more information about Riverside's team of endocrinology specialists, visit riversidehealthcare.org. Also, make sure to rate and leave a review for our show on Apple, Spotify, or wherever you listen to podcasts.