Osteoporosis is a disease in which bones become porous and weak. As they lose strength, they are more likely to break. Bones in the spine, hip, wrist, pelvis, and upper arm are particularly at risk of fracture in people with osteoporosis.
Azar Khosravi, MD, an Endocrinologist with City of Hope, is here to talk about the causes and the treatments of osteoporosis, and some lifestyle approaches for preventing bone loss.
Selected Podcast
Osteoporosis: Thinning of the Bones
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Learn more about Dr. Azar Khosravi
Azar Khosravi, MD
Dr. Azar Khosravi graduated from medical school from the Shahid-Behesthi University in Tehran, Iran. She moved to the United States in 2000, and first worked as a Research Assistant at San Francisco General Hospital, in the Department of Family Medicine. Dr. Khosravi went on to complete a residency in Internal Medicine at Saint Vincent Hospital in Worcester Massachusetts, followed by a Fellowship in endocrinology at the National Institutes of Health in Bethesda, MD, from 2004 through 2007. She then served as an instructor in Endocrinology and the Associate Director of the Osteogenesis Imperfecta Department within the Kennedy Krieger Institute at Johns Hopkins, where her research focus was on bone and mineral metabolism. She also served as a Clinical Associate, in the Skeletal Clinical Studies Unit, Craniofacial and Skeletal Disease Branch at NIDCR, NIH. She is board certified in Internal Medicine, and in Endocrinology and Metabolism. Her research focuses on metabolic bone diseases.Learn more about Dr. Azar Khosravi
Transcription:
Osteoporosis: Thinning of the Bones
Melanie Cole (Host): Osteoporosis is a condition in which bones have weakened and are more likely to break. Fractures from osteoporosis can result in pain and disability and you need to be thinking about prevention no matter what your age or medical history. My guest today is Dr. Ozar Khosrav. She’s an endocrinologist at City of Hope. Welcome to the show, Dr. Khosrav. Tell us about osteoporosis. First of all, what is it?
Dr. Ozar Khosrav (Guest): Thank you very much. Osteoporosis is part of metabolic bone diseases and a condition that weakens the bone, the structure of the bone changes such that with less trauma and sometimes a simple fall from the level ground, fracture happens. There are certain parts of the skeleton that are prone to such fractures, such as spine or the hip, which are the more important sites of your concern in terms of consequences.
Melanie: Who’s at risk for osteoporosis? We tend to think of it more in women but men can get it, too, yes?
Dr. Khosrav: Correct. The truth is still 80% of these fractures happen in women but you’re absolutely right. Men are the group in which it’s usually neglected. It’s less discussed and less treated. Men tend to have the condition about a decade later than usually women get it. So, for women they are at higher risk post-menopausally after age 50, in general. For men, it usually happens 10 years later.
Melanie: How does cancer treatment, and you’re an endocrinologist at City of Hope, how does cancer treatment affect bone loss?
Dr. Khosrav: Hugely. Usually, we tend to say if the condition of older people, depending on what kind of cancer and what kind of treatments they go through, it causes bone loss. What happens is, normally people accrue bone until age about 25, or even 30, especially in men. Whatever happens before that age doesn’t allow the bone mass that needs to be put on the skeleton to be there. So, they tend to lose it earlier. There are certain cancers, especially the blood cancers, say, leukemia, lymphoma, and multiple myeloma, cancers that happen in the bone marrow effect the bone much more than other types of cancers. It could be a child with leukemia and sometimes the presenting symptom is actually vertebral fractures. If it is the kind of cancer that affects sex hormones or affects puberty, that also has a huge effect. Actually, the highest risk for bone loss happens in premature menopause. That means if a woman goes to menopause as a result of chemotherapy before age 40, it causes 7% bone loss in one year, which is about 15 times higher than that women at that age would have gone through just normally. The other treatments that affect hormones, say, treatments for prostate cancer also have huge effects on the bone. A lot of chemotherapy, radiation therapy [inaudible 04:42] uses part of chemotherapy transplant also triples the risk of bone loss, especially immediately after transplant. A lot of cancer therapies cause bone loss but also changes in the lifestyle. They have a lot of days of bed rest. Their diet changes during those treatments, their physical activities--and all these culminate in a lot of bone loss.
Melanie: Dr. Khosrav, if testosterone in men, say, with prostate cancer-- if the goal of that treatment is to lower that level of testosterone which can grow prostate cancer, where is that fine line of worrying that it’s now diminishing bone density like Lupron or one of these while you’re treating them for cancer?
Dr. Khosrav: Right. Prostate cancer, specifically, has a tendency to go to bone. That’s where it metastasizes. That’s one huge risk for fracture right there. These are usually older men. They already are at risk of bone loss even without prostate cancer. Then, you add the low testosterone to the treatment and a lot of them do get radiation therapy. So, all of these cause a lot of bone loss and, again, in men even with prostate cancer, even if they’re going through what we call “androgen deprivation” therapy which one of them is Lupron, as you mentioned. They are at a high risk. Still, they are usually a group of cancer patients that get the least attention in terms of osteoporosis. In addition, I have to say, a lot of these treatments that we offer for osteoporosis also lower the risk of metastasis to bones or even reoccurrence of cancer. So, it has some positive effects on the cancer itself. For that reason, we have lower thresholds to start patients on treatments for osteoporosis when they have cancer.
Melanie: That’s very cool what you just said about the fact that it can help actually reduce the amount of metastasis into bone. What are these treatments that you’re talking about? Are they lifestyle, are they medication--a combination?
Dr. Khosrav: Yes, a combination. We always, always start with lifestyle. That’s our golden opportunity to reach patients, to have them change gears to a healthier lifestyle. The foods that are rich in calcium, especially vegetables and dark, leafy green vegetables like chard, kale and turnip greens – those kind of vegetables and broccoli have a good amount of calcium. Dairy, especially yogurt, has a lot of concentrated calcium. In terms of Vitamin D, there are some food sources, say, fatty fish that are rich in both calcium and Vitamin D. Egg yolk has some Vitamin D but apart from that if the food is not fortified, the food source of Vitamin D are rare. Sunshine is one way of getting Vitamin D. Some patients end up needing Vitamin D supplementation but with calcium, I have to say a vast majority should be able to get from diet unless they are on a special diet that doesn’t allow them. There are some treatments like steroids that don’t allow the calcium and Vitamin D to be assimilated into the body, so they usually need higher calcium and Vitamin D supplementation or more from the food. Exercise is a huge part of lifestyle and, depending on a patient’s age and physical fitness, they can be starting from walking, any kind of weight bearing exercises or even better, if they are able to do impact exercises. Any exercise that puts them in anti-gravity mode, say, jumping, jump rope and trampoline is really good for balance. Even if patients are older, they usually are able to do one leg hopping. Hop on one leg and then the other side. If they are doing it in a protected and safe area in their home, they should be able to do that. There are a lot of other weight bearing exercises a patient can do. Weight lifting is a really good exercise. There are other non-impact exercises, say, tai chi that has been shown, especially in older populations, to improve their balance and lower the risk of falls which can result in fractures. Yoga has been shown to what we call strengthen the core and reduce the risk of falls. It also strengthens their muscles. They have been shown to improve bone density or at least maintain it. There are, however, some exercises that are not weight bearing and are not useful specifically for the bone. They are really good for other purposes but not for the bones. Swimming or even biking are not particularly helpful for bone.
Melanie: Do you recommend if a person is going through cancer treatment, a man with prostate cancer or a woman with breast cancer, or something, do you recommend supplementation like magnesium which instructs that calcium in the body so that they can absorb calcium more readily and use it? Do you recommend adding a supplement – a multi-vitamin, extra calcium-magnesium, Vitamin D--any of these things?
Dr. Khosrav: Usually not unless I feel that they are not able to get it from food. Again, for magnesium, if they are eating quite healthy, say, a good amount of magnesium. They should be able to get them from food. For calcium, there’s some evidence but controversial that calcium supplementation, especially in men, might even be harmful. Although not all studies have shown that. I really try when it comes to calcium to convince them to get it from food. Magnesium supplementation, as far as we know, doesn’t pose any harm. So, if that’s needed, it can be done. A multi-vitamin, again, if patients are eating healthy, honestly they shouldn’t be needing it if they don’t have any absorption issues.
Melanie: Give us some of your best advice about postural related issues with osteoporosis in the last few minutes here and, really, what you want people going through cancer treatments to know or the general population about osteoporosis.
Dr. Khosrav: We are trying to prevent fractures. So, it’s a preventive measure and patients since they might not have any symptoms, might not realize how important it is. We just talked about the lifestyle modifications but there are treatments that, yes, they do have side effects but they also cut the risk of fractures by 50%, which is pretty good. The diagnostic modalities that we have including, DEXA scan, is widely available. It’s generally not expensive and covered by insurance. It has very, very low radiation. We have good diagnostic measures, good treatment and I know that there’s a lot of concern about risks of the treatment but you always have to balance that with the risk of fractures and falls and consequences of osteoporosis in addition to the benefits that these medications have in terms of lowering the risk of cancer. I urge people to ask their doctors once they reach, even the general population, once they reach 65 for women and 75 for men, everybody deserves to go through screening for osteoporosis and if patients have cancer, usually after the treatment is over or even before treatment has started, that’s the time to get a DEXA scan, even if the patient is very young just to have a bassline and see where they are so that we can plan the appropriate treatment so that they don’t lose more bone as they go through the treatments.
Melanie: What great information from City of Hope. Thank you so much, Dr. Khosrav, for being with us today. You’re listening to City of Hope Radio. For more information you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Osteoporosis: Thinning of the Bones
Melanie Cole (Host): Osteoporosis is a condition in which bones have weakened and are more likely to break. Fractures from osteoporosis can result in pain and disability and you need to be thinking about prevention no matter what your age or medical history. My guest today is Dr. Ozar Khosrav. She’s an endocrinologist at City of Hope. Welcome to the show, Dr. Khosrav. Tell us about osteoporosis. First of all, what is it?
Dr. Ozar Khosrav (Guest): Thank you very much. Osteoporosis is part of metabolic bone diseases and a condition that weakens the bone, the structure of the bone changes such that with less trauma and sometimes a simple fall from the level ground, fracture happens. There are certain parts of the skeleton that are prone to such fractures, such as spine or the hip, which are the more important sites of your concern in terms of consequences.
Melanie: Who’s at risk for osteoporosis? We tend to think of it more in women but men can get it, too, yes?
Dr. Khosrav: Correct. The truth is still 80% of these fractures happen in women but you’re absolutely right. Men are the group in which it’s usually neglected. It’s less discussed and less treated. Men tend to have the condition about a decade later than usually women get it. So, for women they are at higher risk post-menopausally after age 50, in general. For men, it usually happens 10 years later.
Melanie: How does cancer treatment, and you’re an endocrinologist at City of Hope, how does cancer treatment affect bone loss?
Dr. Khosrav: Hugely. Usually, we tend to say if the condition of older people, depending on what kind of cancer and what kind of treatments they go through, it causes bone loss. What happens is, normally people accrue bone until age about 25, or even 30, especially in men. Whatever happens before that age doesn’t allow the bone mass that needs to be put on the skeleton to be there. So, they tend to lose it earlier. There are certain cancers, especially the blood cancers, say, leukemia, lymphoma, and multiple myeloma, cancers that happen in the bone marrow effect the bone much more than other types of cancers. It could be a child with leukemia and sometimes the presenting symptom is actually vertebral fractures. If it is the kind of cancer that affects sex hormones or affects puberty, that also has a huge effect. Actually, the highest risk for bone loss happens in premature menopause. That means if a woman goes to menopause as a result of chemotherapy before age 40, it causes 7% bone loss in one year, which is about 15 times higher than that women at that age would have gone through just normally. The other treatments that affect hormones, say, treatments for prostate cancer also have huge effects on the bone. A lot of chemotherapy, radiation therapy [inaudible 04:42] uses part of chemotherapy transplant also triples the risk of bone loss, especially immediately after transplant. A lot of cancer therapies cause bone loss but also changes in the lifestyle. They have a lot of days of bed rest. Their diet changes during those treatments, their physical activities--and all these culminate in a lot of bone loss.
Melanie: Dr. Khosrav, if testosterone in men, say, with prostate cancer-- if the goal of that treatment is to lower that level of testosterone which can grow prostate cancer, where is that fine line of worrying that it’s now diminishing bone density like Lupron or one of these while you’re treating them for cancer?
Dr. Khosrav: Right. Prostate cancer, specifically, has a tendency to go to bone. That’s where it metastasizes. That’s one huge risk for fracture right there. These are usually older men. They already are at risk of bone loss even without prostate cancer. Then, you add the low testosterone to the treatment and a lot of them do get radiation therapy. So, all of these cause a lot of bone loss and, again, in men even with prostate cancer, even if they’re going through what we call “androgen deprivation” therapy which one of them is Lupron, as you mentioned. They are at a high risk. Still, they are usually a group of cancer patients that get the least attention in terms of osteoporosis. In addition, I have to say, a lot of these treatments that we offer for osteoporosis also lower the risk of metastasis to bones or even reoccurrence of cancer. So, it has some positive effects on the cancer itself. For that reason, we have lower thresholds to start patients on treatments for osteoporosis when they have cancer.
Melanie: That’s very cool what you just said about the fact that it can help actually reduce the amount of metastasis into bone. What are these treatments that you’re talking about? Are they lifestyle, are they medication--a combination?
Dr. Khosrav: Yes, a combination. We always, always start with lifestyle. That’s our golden opportunity to reach patients, to have them change gears to a healthier lifestyle. The foods that are rich in calcium, especially vegetables and dark, leafy green vegetables like chard, kale and turnip greens – those kind of vegetables and broccoli have a good amount of calcium. Dairy, especially yogurt, has a lot of concentrated calcium. In terms of Vitamin D, there are some food sources, say, fatty fish that are rich in both calcium and Vitamin D. Egg yolk has some Vitamin D but apart from that if the food is not fortified, the food source of Vitamin D are rare. Sunshine is one way of getting Vitamin D. Some patients end up needing Vitamin D supplementation but with calcium, I have to say a vast majority should be able to get from diet unless they are on a special diet that doesn’t allow them. There are some treatments like steroids that don’t allow the calcium and Vitamin D to be assimilated into the body, so they usually need higher calcium and Vitamin D supplementation or more from the food. Exercise is a huge part of lifestyle and, depending on a patient’s age and physical fitness, they can be starting from walking, any kind of weight bearing exercises or even better, if they are able to do impact exercises. Any exercise that puts them in anti-gravity mode, say, jumping, jump rope and trampoline is really good for balance. Even if patients are older, they usually are able to do one leg hopping. Hop on one leg and then the other side. If they are doing it in a protected and safe area in their home, they should be able to do that. There are a lot of other weight bearing exercises a patient can do. Weight lifting is a really good exercise. There are other non-impact exercises, say, tai chi that has been shown, especially in older populations, to improve their balance and lower the risk of falls which can result in fractures. Yoga has been shown to what we call strengthen the core and reduce the risk of falls. It also strengthens their muscles. They have been shown to improve bone density or at least maintain it. There are, however, some exercises that are not weight bearing and are not useful specifically for the bone. They are really good for other purposes but not for the bones. Swimming or even biking are not particularly helpful for bone.
Melanie: Do you recommend if a person is going through cancer treatment, a man with prostate cancer or a woman with breast cancer, or something, do you recommend supplementation like magnesium which instructs that calcium in the body so that they can absorb calcium more readily and use it? Do you recommend adding a supplement – a multi-vitamin, extra calcium-magnesium, Vitamin D--any of these things?
Dr. Khosrav: Usually not unless I feel that they are not able to get it from food. Again, for magnesium, if they are eating quite healthy, say, a good amount of magnesium. They should be able to get them from food. For calcium, there’s some evidence but controversial that calcium supplementation, especially in men, might even be harmful. Although not all studies have shown that. I really try when it comes to calcium to convince them to get it from food. Magnesium supplementation, as far as we know, doesn’t pose any harm. So, if that’s needed, it can be done. A multi-vitamin, again, if patients are eating healthy, honestly they shouldn’t be needing it if they don’t have any absorption issues.
Melanie: Give us some of your best advice about postural related issues with osteoporosis in the last few minutes here and, really, what you want people going through cancer treatments to know or the general population about osteoporosis.
Dr. Khosrav: We are trying to prevent fractures. So, it’s a preventive measure and patients since they might not have any symptoms, might not realize how important it is. We just talked about the lifestyle modifications but there are treatments that, yes, they do have side effects but they also cut the risk of fractures by 50%, which is pretty good. The diagnostic modalities that we have including, DEXA scan, is widely available. It’s generally not expensive and covered by insurance. It has very, very low radiation. We have good diagnostic measures, good treatment and I know that there’s a lot of concern about risks of the treatment but you always have to balance that with the risk of fractures and falls and consequences of osteoporosis in addition to the benefits that these medications have in terms of lowering the risk of cancer. I urge people to ask their doctors once they reach, even the general population, once they reach 65 for women and 75 for men, everybody deserves to go through screening for osteoporosis and if patients have cancer, usually after the treatment is over or even before treatment has started, that’s the time to get a DEXA scan, even if the patient is very young just to have a bassline and see where they are so that we can plan the appropriate treatment so that they don’t lose more bone as they go through the treatments.
Melanie: What great information from City of Hope. Thank you so much, Dr. Khosrav, for being with us today. You’re listening to City of Hope Radio. For more information you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.