Transcription:
Osteoporosis Awareness and Prevention

Melanie Cole (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features, conversations about trending health topics and medical breakthroughs from our team of world renowned physicians at Weill Cornell Medicine. Today's special episode is part of our Women's Health Wednesday series, which features in-depth conversations with Weill Cornell Medicine's top physicians on issues surrounding women's health throughout the life course. Listen here for the information and insight that will help you make the most informed and best healthcare choices for.

I'm Melanie Cole. Joining me today is Dr. Pangiota Andreapoulou. She's a physician in the division of endocrinology at New York Presbyterian Weill Cornell Medical Center and an assistant professor of clinical medicine at the Weill Cornell Medical College Cornell University. Doctor, thank you so much for joining us today. So we're talking about osteoporosis. This is something that's pretty prevalent and I'd like you to start by telling us how common this is and kind of why it happens?What happens to women's bones as we age?

Dr Panagiota Andreopoulou: Hello, everyone. Thank you for the invitation. it's my pleasure to be part of this. So osteoporosis, is a skeletal disorder that's characterized by compromised bone strength and that compromised bone strength predisposes to a higher risk of fractures of broken bones. Bone strength reflects the integration of two main features, our bone density, which is the amount of bone mass. We have the quantity, how much bone and bone quality, like how is a bone distributed?

What is the construct of the bone? How common is osteoporosis? Osteoporosis is actually a very common condition. one in two women over the age of 50 will go on and fracture in her life and have a major fragility fracture, and one in about five men. The importance of fragility fractures is that they can not only affect the quality of life, but they can also shorten the lifespan. 25% of people that suffer a hip fracture, they end up not being alive a year after the fracture, due to various complications.

And 50% of people after a hip fracture, they actually end up needing an assistive device to be able to function such as a Walker or a cane, so they're not able to go back to their pre functional capabilities. So it is a very common and a very important health problem for our aging society.

Melanie Cole (Host): Well, as a 58 year old postmenopausal women, I'm right there with you doc. So I know that this is an issue. It's a problem, but what joints and bones does it typically affect when we talk about fractures and the risk of that and our bones getting less dense? Where are we talking about in our bodies?

Dr Panagiota Andreopoulou: So we are talking mainly about, long bones in our body and about the vertebrae in our spine. The most common fractures, starting around the late fifties, actually, Melanie, in women are fractures of smaller bones like wrist fractures, fore arm fractures, maybe lower leg close to our ankle. And then moving on in the sixties, we start seeing a higher prevalence of vertebral compression fractures, which are fractures of the bones of our spinal column. And then moving on into later ages, like in the seventies and older, we start seeing a higher prevalence of hip fractures, which are fractures of the proximal femur. That's closer to our hip joints.

Melanie Cole (Host): So let's talk about risk factors. And is this more common? You mentioned this a little bit in women than in men. And why do we know why it's more common in women? Is it our hormones? What is it?

Dr Panagiota Andreopoulou: The major risk factor for, osteoporosis is aging and that's in both women and men. However osteoporosis is seen in women, more commonly and in earlier years, about 10 years earlier than we actually see it in men. And the main reason is this dramatic hormonal change that women undergo during menopause. During menopause, the amount of estrogen production from the ovaries starts decreasing. It actually decreases a few years before menopause in a time called perimenopause.

That is about usually, over age 45, when women start experiencing hot flashes and other menopausal symptoms, those reflect the decreasing production of estrogen levels. Therefore, at menopause, the ovarian function completely ceases and due to lack of estrogen, the cells in the bones and the skeleton that cause the bone breakdown, something called bone resorption become active because they are no longer controlled by the inadequate amounts of circulating estrogens.

That dramatic hormonal change leads to pretty fast rapid bone loss, especially during the early years of menopause, like the first eight to 10 years. And then this loss levels off, but continues until the end of our life. So this is why menopause is more common, more prevalent in women and happens at an earlier age. Of course, there's many, many other risk factors that affect risk of fractures and cause osteoporosis. And you'd be surprised, but they do start from earlier years. One major risk factor is genetics.

We inherit both the potential for bone mass accrual, how much bone mass we're gonna have, but also our bone quality to a large degree. So there is a family history of osteoporosis, especially a fragility fractures, and especially of hip fractures then that is a big red flag with major significance. Many individuals, therefore, and that's actually about one in three individuals do not even manage to get to the peak bone mass in their earlier years in their adolescence and young adulthood.

So then they start off with a lower baseline bone mass, when they get into menopause, for example, or the older years, for. So genetic is a major risk factor, very important. Then there's other conditions that can affect, bone, during the growth phase. For example, certain diseases or medications, improper nutrition, malnutrition, young adolescents or young adults who may have limited, diets, restricted diets with low protein, or low calcium or who exercise excessively, but don't really have the necessary energy coming in to replace the energy they're losing.

Eating disorders like anorexia Nervoza. So these are several conditions that can lead to low boner cruel, so low bone mass from the very beginning. and then limited exercise. Also starting from a young age limited physical activity is a major risk factor. So then moving on a lot of conditions and medications can also affect, the bone mass after it has peaked in older adults. And of course in older ages. Other risk factors are bad habits. For example, smoking.

Major risk factor for bone loss and poor bone quality and increased risk of fractures, excess alcohol use again, poor nutrition, low end protein, low end calcium, deficiencies, for example, in vitamin D. And again, certain medications and diseases. It's a very long list of conditions. It could be hormonal disorders like diabetes, very common condition can lead to increased bone fragility due to poor bone quality, hypogonadism, low testosterone in men. Low estrogen women from premature menopause, high cortisol, overactive thyroid, overactive parathyroids, Celia disease, liver diseases, kidney diseases.

Rheumatoid arthritis, inflammatory bowel disease. Multiple medications, psychotropic anticonvulsants steroids, medications, hormonal treatments for prostate cancer or breast cancer, very commonly used. It's just a long list of risk factors that every one of us as physicians has to thoroughly evaluate when we see a patient to assess if they're at risk for fracture.

Melanie Cole (Host): What a comprehensive list that was doctor. And so once you have taken that clinical history, that medical history, and it's so thorough, what are you looking for when deciding on screening and diagnosis, I'd like you to speak about screening and why, and when that's done? I had it recently. It's a piece of cake.

Dr Panagiota Andreopoulou: So, the decision to screen an individual, actually depends on that assessment of their risk for having osteoporosis. Pretty much all professional societies agree that women over the age of 65 should be screened for osteoporosis. There is not as much consensus about men unfortunately, but the International Society for Clinical Densitometry recommends screening over age of 70. In addition, younger women and younger men, of course, if they have risk factors that I mentioned, if they're taking certain medications or have certain medical conditions, of course should be screened earlier, than age 65.

And that's why, taking the medical history is very important on making a decision of who, will be screened. Now, how do we screen for osteoporosis? Well, we basically use as a gold standard, a very, easy to do, cost effective, test imaging modality that is called bone Dexometry, by DXA machine. It is a low dose, two dimensional x-ray, a low dose two dimensional measure of the bone density. It is based in the office. it measures cous amount of bone mass at the lower back, which is our Lubar spine at the proximal femur, the hip. Sometimes at the distal radius, which is our wrist, there are certain features that some facilities offer.

For example, at Cornell, we include assessment of the trabecular bone score, which reflects the porosity of the bone, the bone quality of the bone, another independent risk factor for assessing risk of fracture. It's very helpful. We can also measure at the spinal column, the, dimensions of the vertebrae and do something called the vertebral fracture assessment that screens for already present compression fractures in the spine that could potentially be silent and not previously recognized. Also it can assess for the dimensions of the hip, how thin the neck of the femur is.

Certain measurements that affect as well, the propensity for a fracture. So it's a very, very helpful test, very easy to be done. Very quick. Limited radiation, very, very low. and it's done every one or two years, depending on the patient is taking treatment or not, what part of the skeleton are we closely monitoring? Because some, parts have faster, bone loss, for example, the spine compared to the hip. But generally we assess bone density every one to two years.

Melanie Cole (Host): Well, thank you for that. So tell us about first line of defense. If you determine that a woman's got osteopenia, the softening or pre osteoporosis, in a way of looking at it, what do we do first for them? Tell us about what you would advise first, whether it's exercise and lifestyle changes. You mentioned diet and exercise before. Whether it's medication or estrogen or supplements, vitamin D any of these things, I'd like you to summarize what the treatment modalities look like once you determine that somebody is headed in that direction?

Dr Panagiota Andreopoulou: So, first of all, important measures that have to be taken way before considering treatment. And even in earlier years are related to our lifestyle. Really it's lifestyle measures and those include proper nutrition, proper use of supplements and physical activity. And by physical activity, we basically mean exercise that challenges are bone exercise that has a resistance and weight bearing element. And that could be any type of exercise that we enjoy.

It can start with brisk walking that involves of course, gravity up to like running and jogging, exercise in machines we can use at the gym with the element again of resistance. Classes, Irubics classes, Zumba, ballroom, dancing, anything we really like doing. And also exercises that involve, an element of balance. and strengthening. And for example, yoga and Tai Chi are ideal exercises for that. So anything that we really find joy in can be helpful for our bones in trying to challenge our bone forming cells, to keep making new bone, very important.

There's two types of exercise that are not really challenging our bones. They're not harmful, but we should not just rely on those. And that is swimming and bicycling, great types of exercise, not enough, for preventing bone loss or for, improving our strength.

Melanie Cole (Host): Because they're not really weight bearing, right. Because we're not putting that pressure on our bones?

Dr Panagiota Andreopoulou: Exactly. Exactly but everything else is great. And even if we can do weight bearing exercise twice a week, for an hour that's, more than enough. Of course, exercise is important for all, for our health in general. Especially the one that has the aerobic element. So the second part is making sure that we don't put ourself in danger. For example, someone who has osteoporosis should live and work in a safe and move in a safe environment. So it's important to assess our home for certain hazards, that could lead to a potential fall and a fall can lead to a fracture.

A fragility fracture in fact, is a low impact fracture. A fall from happens from fall from a standing height most of the time. So a safe environment is very important, or using an assisting device if necessary like a cane or a Walker in order to prevent falling. We have to assess nutrition, is that individual eating properly? Do they have a diet that is rich in elements that are important for bone health and what are those? First of all calcium, foods that are rich in calcium are very important because calcium is the main mineral, in our bones. And its what maintains our bone structure and keeps our bones hard enough.

So they don't break as easily. We do lose calcium every day in our life, in our urine. So we somehow have to replace that without replacing it from the calcium that's in our bones in order to maintain a normal blood calcium level. That's why calcium is very important. So foods like dairy products. Have calcium dark leafy vegetables are richen calcium, nuts, eggs have calcium. So there's a lot of different sources, and even most of the, non dairy, types of milk that are very common nowadays, there tend to be enriched with calcium.

So that's very important. The second thing is natural antioxidants. They do help the bone and that's in fruit and vegetables of all colors, very important to have. It's been shown that up to five servings, a day of fruit and vegetables they actually are associated with less hip fractures. These people are healthier when they have this type of diet and of course, protein and interestingly animal protein is actually superior to plant protein, for maintaining bone health. So very restrictive diets, unfortunately even, many are quite healthy, are associated with lower bone mass and bone quality.

But that doesn't mean that excessive consumption of protein is good either. So we have to avoid overeating like too much red meat, too much, animal muscle is not a good thing in our diet because it's actually associated with more bone loss, but having some balance in our diet, having some lean red meat here and there, poultry fish, which is an excellent source of protein, egg, dairy. So these are important things. It's good to include as much as we can, all food groups, but in a balanced way.

Another important aspect is to avoid harmful things. For example, access caffeine and access alcohol, they're really associated with, higher bone fragility and fractures. Supplements are very important and there's a lot of confusion about them. Calcium and vitamin D are really the important supplements for maintaining bone health. Not everybody needs to be taking supplements. This is very important to know. And a lot of the articles in the lay press about them that discourage people for taking supplements.

They actually talk about the general population, but individuals with osteoporosis or osteopenia compromised, bone health must be very diligent about ensuring they're taking just the right amount of calcium and vitamin D. Not too little, not too much the calcium again, because it's important to replace the losses and maintain the balance, in our blood bones, the vitamin D because it's very important in absorbing calcium. So it's highly important to assess those needs in every individual and then make proper recommendations.

As far medications are concerned for treatment of osteoporosis, their goal is really to reduce the risk of fracture by increasing bone mass and maintaining bone quality. There's two main types of medications that we utilize. The main, most commonly used group is medications that decrease the rate of bone loss. And there is another group that just stimulates bone formation. And we do have a combination medication that does both. Those medications have been tested diligently. They've been shown to reduce risk of fracture.

They're not long term treatments they're given for a short time. And they are very safe and effective if prescribed properly. I do get all sorts of questions about them. There's a large degree of apprehension about side effects of these medications, but again, when prescribed properly, they're very safe. For example, the most commonly used the bisphosphate like, Alendrenate, for example, or alendronate, they accumulate in the bone over time. So they can be used up to a certain number of years in order to prevent side effects from long-term accumulations.

Such as very, very low risk of atypical fractures in the femur stress fractures observed with treatments that are reaching like 10 years of continuous treatment, which we really do not do anymore. Also, they might decrease, the rate of healing after extensive bone procedures. And we, recommend to maybe complete invasive dental procedures prior to starting these medications. The most common side effect of oral medications is really increased risk of reflux, which however we can avoid by taking it properly, standing upright, do not lay down after taking the medication for a few hours.

All of these medications across the board may be associated with some types of aches and pains at the start of treatment like fluish kind of, myalgia or arthralgia is which tend to dissipate. And again are more common in people who are low in vitamin D and calcium, less so in people that are well supplemented. That may happen in less than 10% of patients. So really not common. So overall the benefit we get from these medications for their short treatments, compared to their risk profile is very, very favorable.

Melanie Cole (Host): This is such a great, informative interview doctor, as we wrap up, I'd like you to just give us your best advice in summary of prevention, lifestyle, and what you want women to know about osteoporosis and how we can help our bones and be our own best health advocate?

Dr Panagiota Andreopoulou: My best advice is take care of your skeleton. It's really, what keeps your body together no matter how beautiful you look on the outside as far as your skin and your hair, and everything else. If your skeleton is not healthy, then you cannot really, maintain this beauty in the long term. So go out exercise, be active, do the things you love, eat properly, eat healthy, make sure you're on top of your vitamin D and calcium.

And then when in doubt, ask your doctor, should I be screened for osteoporosis? Am I at this age yet? Do I have those risk factors? What should I do? And once you screened, if you get a recommendation for treatment, please do take that treatment. It will really make your life longer, make your life healthier and give you more years to enjoy it.

Melanie Cole (Host): Doctor that was so informative. Thank you so much for joining us and sharing your expertise today. And Weill Cornell continues to see our patients in person, as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Back to Health. We'd like to invite our audience to download subscribe, rate, and review Back to Health on Apple podcast, Spotify and Google podcast. And for more health tips, go to weillcornell.org and search podcasts. And parents don't forget to check out our Kids' HealthCast. I'm Melanie Cole.

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