Scott Webb: Osteoporosis is a disease that weakens our bones, causing them to become fragile, and this can lead to fractures. And though there are no obvious signs and symptoms for osteoporosis, it is relatively easy to diagnose and treat. And joining me today to talk about osteoporosis, how it's diagnosed and treated and how Summa health is working to help folks with osteoporosis is Natalie Hiltbrand.

She's an advanced practice provider with Summa health.

 This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb.

Natalie, thanks so much for your time today. We're going to talk about osteoporosis, signs, symptoms, diagnosis, and so on. So as we get rolling here, what is osteoporosis or what happens to folks who are suffering from it?

Natalie Hiltbrand: So osteoporosis is a disorder of the skeletal system. In osteoporosis, we see a decrease in bone density and changes in the microstructure of bones. So there are two types of bone tissue. There is trabecular or cancellous bone tissue. And that is found in joints, at the ends of long bones and inside vertebrae. And this is more of like a spongy type of bone tissue. And then there's also cortical bone tissue and that is found in long bones. It's the compact hard, outer layer of bones.

Remodeling of bone occurs throughout the lifespan. And in this process, bone is repaired and strengthened. Bone cells called osteoclasts allow for resorption of bone, while osteoblasts form new bone. Now, when bone resorption by osteoclasts outweighs the formation of new bone by osteoblasts, remodeling of bones becomes imbalanced and trabeculae within bone becomes thin, they decrease in number and this affects the microarchitecture of bones. We see cortical thinning and the bone then becomes increasingly porous and more fragile, which leads to an increased fracture risk.

Scott Webb: Yeah, it can. And when we think about who's at the highest risk for developing osteoporosis, is it only women? Is it only, let's say, you know, older women? Who exactly is at risk for osteoporosis?

Natalie Hiltbrand: So we do certainly see people with advancing age getting osteoporosis, but it is not just females. Males can also get osteoporosis. People with a family history of osteoporosis are also at higher risk and that people who are of Caucasian or Asian descent, people with low body mass index are at risk. Other risk factors are malnutrition, smoking, heavy alcohol intake, and then certain medications. So for example, glucocorticoids, if a patient is on long-term prednisone, this can lead to osteoblast and osteocyte apoptosis, and that can cause thinning of the bones and lower bone mineral densities. People who have had significant amounts of weight loss are at higher risk of osteoporosis. People who have had early menopause.

And then there are also certain disorders that can lead to osteoporosis, so endocrine disorders, diabetes. The bone anabolic action by insulin and amylin are inhibited, especially in type 1 diabetes since the body isn't producing insulin like it's supposed to, and that can lead to osteoporosis. And so can hyperparathyroidism, because bone breakdown by chronic excessive parathyroid hormone occurs. And then if someone has untreated hyperthyroidism, thyroid hormone receptor alpha on osteoblasts and osteoclasts is triggered and that leads to bone loss.

Now, there are certain gastrointestinal disorders as well that can lead to osteoporosis. Celiac disease and inflammatory bowel disease. In these diseases we see malabsorption. And also specifically in inflammatory bowel, these patients usually have a low body mass index. Sometimes they are placed on steroids for treatment of flares, and these things can certainly lead to decreased bone mineral density. And then lastly, autoimmune diseases, so lupus and rheumatoid arthritis. In these disorders, we see inflammatory cytokines released and this promotes bone resorption as well.

Scott Webb: Yeah. So it sounds like there's a lot of folks who are at risk for developing osteoporosis. So I think the natural followup is what are the signs and symptoms? Do folks know that they have osteoporosis? Is it just sort of unexpected fractures? You know, someone bumps their arm walking down the hall and they develop a fracture or something like that. How do folks know? And then we're going to get into DEXA scans and so on.

Natalie Hiltbrand: So that is an issue. So with osteoporosis, it's been referred to as a silent disease because there aren't usually too many signs and symptoms that really lead up to it. It usually is that fragility fracture that prompts us to think, "Well, is this caused because we do have low bone density?" And then that would prompt the ordering of a DEXA scan.

Scott Webb: Yeah. And let's go through that then. What exactly is a DEXA scan and who's eligible?

Natalie Hiltbrand: A DEXA scan is a dual-energy x-ray absorptiometry scan. And in DEXA scans, there are low amounts of radiation used to identify bone density and mineral content. So this is used to determine diagnosis of osteopenia and osteoporosis. Bone density is evaluated in DEXA scan by measuring density in the hip and in the spine. And this helps us to assist in predicting a patient's fracture risk.

Now, individuals who are eligible for DEXA scanning would be women 65 and older and men 70 and older. And then people who have had a fracture after the age of 50 can be considered for DEXA scanning. Post-menopausal women, regardless of age, with risk factors for osteoporosis, as well as menopausal women with risk factors should be considered. And then men aged 50 to 69 with risk factors. And then, if there is concern for vertebral fracture in a patient, this is a big clue into possible osteoporosis. So if a patient would present with back pain and an x-ray is performed and a vertebral fracture is identified, a DEXA scan should certainly be ordered in this case.

Other ways to identify possible vertebral fracture would be a loss of height. So if a patient comes in in a year's time, we noticed that they've lost a half an inch of height or a total loss of height which is one and a half inches from their original height, this can indicate vertebral fracture as well.

Scott Webb: Yeah. And I think we've all had that experience with older relatives, grandparents, great grandparents, you know, that used to be sort of the joke. "Well, grandpa's shrunk a little bit" or "Grandma's shrunk a little bit." But the reality is if grandma and grandpa are shrinking a little bit, there's likely a cause as you're saying, right?

Natalie Hiltbrand: Yes, that is correct.

Scott Webb: Yeah. And so if somebody has been diagnosed with osteoporosis or when they've been diagnosed, what are the treatment options?

Natalie Hiltbrand: Treatment options can start with lifestyle modifications. So exercise is huge, not only in treatment of osteoporosis, but prevention as well. So things like walking, jogging, resistance training are very important. These things help to strengthen muscles and bones. And actually exercise is shown to decrease risk of falls because it improves balance. People should be exercising 30 minutes at a time, three times weekly in order to see these positive effects of exercise on bone strength. And then diet is also another thing that plays a big role in treatment and prevention of osteoporosis. So it's important that we have adequate calcium intake and we can get this through the diet with low fat dairy, green vegetables, broccoli, kale, collard greens and fortified foods like certain cereals and fruit juices. Vitamin D is also important because it helps our body to absorb calcium and we can get this through the diet in fatty fish like salmon. Vitamin D is more difficult to get through the diets. Sunlight is something as well that we can get vitamin D from. And, if it's determined that our dietary intake of calcium and vitamin D are too low, there are supplements for calcium and vitamin D available as well.

There are also pharmacologic treatment options for osteoporosis. Now, there are antiresorptive medications that decrease the bone resorption rate and there are anabolic medications that increase bone formation. So the formation of bone in this case is outweighing the resorption of bone. These medications can be administered orally, they can be injected or they can be infused intravenously. There is a nasal spray option. It's less commonly used, but it is an option. And then if hormone therapy with estrogen is indicated, we can discuss use of a transdermal patch.

Scott Webb: Yeah, that's perfect. And lots of options, which is always great for patients about how to prevent something, how to treat it. And as we wrap up here, Natalie, and this has been really educational, I want to have you talk about what you and the folks at Summa Health are doing, you know, to support patients with osteoporosis.

Natalie Hiltbrand: Summa has identified a care gap in patients with low bone density. So initiative was taken by Summa Women's Institute to develop a specialized program to provide multifaceted collaborative care to these patients. So Summa is launching an Osteoporosis Bone Health Clinic, and the goal of this clinic is to narrow the care gap that has been identified within these patients who suffer from low bone density. We'll have three locations. There will be one at the main campus at Akron City, one in Barberton and one in Hudson. I'll be the nurse practitioner there and I will initiate treatment as clinically indicated and work collaboratively with a healthcare team of dieticians, exercise physiologists, physical therapist and other specialists as indicated if the secondary cause of osteoporosis is identified. We hope to start seeing patients at the beginning of February 2022, and we're really hoping to be able to positively impact the community with our efforts in this new program.

Scott Webb: Well, I'm sure you will. And one of the things I love about Summa Health is that they always bring the technology, the medicine, the caregivers. You know, you all bring that to the people, right? It's not just in one central location where everybody has to come to you. You try to bring the medicine and the care, you know, to the communities that you serve, which is just awesome. So, Natalie, thanks so much for your time today and you stay well.

Natalie Hiltbrand: Thank you. You too.

Scott Webb: Call (234) 867-7606 to schedule an appointment to see an osteoporosis specialist. And if you found this podcast to be helpful and informative, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Stay well, and we'll talk again next time.