Guest: Dr. Ethel Siris
Presenter : Neal Howard
Guest Bio: Dr. Siris is the immediate past president of the National Osteoporosis Foundation and currently serves on the Board of Trustees of both the National Osteoporosis Foundation in the US and the International Osteoporosis Foundation. She is also a member and former vice chair of the Board of Directors of the Paget Foundation for Paget’s Disease of Bone and Related Disorders. She has previously served on the Council of the American Society for Bone and Mineral Research and on the Endocrinologic and Metabolic Drugs Advisory Committee of the US Food and Drug Administration.
Segment overview: Dr. Ethel Siris from Columbia University talks about common myths about osteoporosis, testing, treatment options and advances coming down the pike.
Health Professional Radio – Common myths about osteoporosis
Neal Howard: Hello and welcome to Health Professional Radio, I’m your host Neal Howard, thank you so much for joining us today. Our guest is Dr. Ethel Siris. She’s here today to talk with us about osteoporosis and hopefully clear up some misconceptions. Talk about some of the latest advances and basically give us a deep look into this disease. Welcome to Health Professional Radio, doctor.
Dr. Ethel Siris: Thank you very much, happy to be here.
N: Give our listeners a bit of your background. Have you always been interested in osteoporosis?
S: Right. Well, I’m trained as an endocrinologist and I’ve been working in this field for many years now. Sometime in the mid-1990s, we began to have ways of estimating people’s bone densities which turned up to be a useful way of saying who’s at risk for future fractures which is what osteoporosis is all about. So, for the past 20 plus years, I’ve been involved in some of the things that have happened to help us diagnose the condition and also how to treat it so people who have osteoporosis are less likely to break bones.
N: Now, is this something that affects people who are up in years or can osteoporosis affect the person no matter where they are in life?
S: Generally speaking, when we talk about the 2 million fractures that occur in this country every year related to osteoporosis, we’re talking about fractures that occur after the age of 50. But there are a lots of things that go on in our lives before we get to 50 that impact on the amount of bone we make and on the quality of that bone and then after age 50, what happens to the bone we have that can lead to a weakening of that bone and the lessening of the amounts such that older people who fall down may break something.
N: You mentioned things that we do prior to age 50. What in your opinion is the one thing that we can do prior to age 50, whether it be nutritionally, or exercise, or what have you that can lower our propensity to get osteoporosis later on?
S: Well by the time you’re at 30 or so, you’ve built is much skeletal mass, you’ve built is biggest skeleton as you’re going to get based on genetics. I think before you get to 50, what you want to do is lead a clean life and by a clean life what I mean is, don’t smoke. One of the things that’s bad about cigarettes has to do with bone. Don’t drink in excess and excess is a defined in our field as 3 alcoholic drinks a day or more. And stay physically active. Obviously, a big part of the fractures that occur in the later years of life are consequence of falling on a weakened bone. So one of the big components of not breaking bones later is to be as strong as possible in terms of your muscles, your balance, and your coordination prior to getting older and I think it’s difficult for a 78 year old with osteoporosis to suddenly start exercising. But if you’ve been physically active from your childhood or adolescence and you remain physically active I think that serves you well as you get into your older years. Leading a clean life and getting adequate calcium from food ideally, dairy foods, and making sure that you’re not Vitamin D deficient. Those are the things you want to do prior to getting into your 50s.
N: So are you saying that osteoporosis is preventable if we do certain things?
S: Well, osteoporosis means that you have bones that are weak enough that they may break with minimal trauma. It’s the fractures that we’re really trying to prevent. Some people are going to build a small skeleton because that’s genetically what they’re programmed to build. And in a woman after menopause, she will lose bone. We are at certain cut points for the amount of bone that we call ‘normal low’ or ‘frankly osteoporotic’. We can certainly prevent postmenopausal or age related bone loss, so that people’s bone densities don’t go way, way, way, way down. But most importantly, we want to prevent fractures associated with low bone mass or frank osteoporosis and that’s where it’s a combination of medication if appropriate, finding ways not to fall, and making sure that you’re calcium and Vitamin D sufficient. We’re not telling people to take extra but we want to make sure that people are getting enough and as I said, calcium rich foods are great way to get the calcium. Vitamin D is trickier because when you’re younger, sunshine will give you the Vitamin D that you need. As you get older, you may need to take a supplement of Vitamin D if your level is too low because it’s harder to make it as you get older. So yes, osteoporosis per se, meaning a very low score is preventable if you picked up the fact that somebody is losing and approaching that level of low bone mass. But most importantly, we want to prevent the fractures associated with low bone mass or osteoporosis. Lots of people are going to have low bone density and we want to pick those people up, find out who they are and then work very hard to prevent the fractures that they are at risk for sustaining.
N: When you’re talking about fractures, are we talking about those that resolved from a fall on weakened bone? Or maybe, fractures that aren’t necessarily that visible or cause that much of a problem, say you step wrong on a step or maybe stepped too hard on weakened bone and you got a hairline fracture somewhere in there. Is that something that is going to cause future problems or once you have been diagnosed with osteoporosis, are even the smallest fractures harder to heal or is the healing a factor at all?
S: Generally, healing is not the problem. When we talk about osteoporosis-associated fractures, we’re talking about the major breaks from minor falls. And what we mean by that is the most terrifying fracture for an older person is the hip fracture. That involves being hospitalized usually having surgery, then winding up in rehab, sometimes in a nursing home having a hard time learning to walk again if you’re old enough. We’re also talking about pelvis fractures, shoulder fractures, wrist fractures, pretty much any bone but the big ones are the ones that I just described and of course, a very importantly, spine fractures. Spine fractures can occur lifting something way too heavy. Most of the other fractures occur in the setting of falling from a standing height, I’m not talking about falling off a cliff. I’m talking about standing up, tripping, falling down, you can break bones in your back, you can get spinal fractures from a fall or from lifting something too heavy. But most other fractures are associated with falling. I think that any broken bone can be highly annoying but the fractures that I’m describing are disabling. They are the kind that require a period of management, often by orthopedic surgeon where you have to recover function after the loss of function, even something like a wrist fracture can leave you with a wrist that is not as flexible as it once was can leave you with chronic discomfort in the wrist even after it heals. So, what we’re trying to do is prevent fractures that impact very negatively on quality of life over the short period and sometimes over the longer term. Many of these fractures in older people lead to a terrible fear of falling and people psychologically are uncomfortable going out of the house, they’re terrified of falling. It’s something that can spoil the third of life that is after menopause if you’re a woman. And it can certainly interfere with enjoyment of life in both men and women. So, it’s important to try to prevent the major fractures.
N: Now, when it comes to determining whether or not a person has osteoporosis, what are some of the tests that are involved? And is this something that is done routinely when you walk into the office if you have a certain age or if you’ve of a certain age and have a fracture? Is the test for osteoporosis the norm or is it something that has to be requested specifically?
S: You’re asking a fantastically good question. Medicare has recommended that if you are a 65 year old woman or a 70 year old man and you’ve never had a bone density test and by a bone density test, I’m talking about a non-invasive painless easy test that you can set up through your physician where they scan over your spine, portion of your spine, they scan over the hip area, and in some cases, also the forearm. And this is the standard way, this has been the standard way up until quite recently for making a diagnosis of osteoporosis because when you do a bone density test, which as you said is recommended for everybody. If you’re a woman after 65, if you’re man at 70 or over, this is supposed to happen in everybody and it doesn’t, that’s the first thing. If you’re post-menopausal woman less than 65 or a man between 50 and 70, and you’ve got a major risk factor for future fractures, meaning you have a medical condition that may predispose you to have bone loss and fractures, or if you’re on the one of the number of medications that may lead to fractures, you’re supposed to have the test. The way test work is it’s given a score and the score is called the ‘T-score’. If your T-score is between 0 and -1, your bone density is normal and you’re called normal. If it’s between -1 and -2.49, it’s called ‘low bone mass or osteopenia’. This is not a disease, this is just the low score. If it’s -2.5 or lower and it can get much lower believe me that’s called osteoporosis. And for a long time that was the sole way of making the diagnosis. Recently, a task force that I chaired coming out of the National Bone Health Alliance, expanded or recommended strongly that we expand the diagnosis opportunities to ‘yes’, continue to do bone density if that’s the way it’s diagnose. But, if your bone density and again we’re talking about post-menopausal women and older men, if you’re bone density is low but not frankly osteoporosis, but you’ve already had a fracture of the spine, the shoulder, the pelvis, and in many cases the wrist, your clinical diagnosis is osteoporosis. Similarly, if you break your hip in this age range, we don’t necessarily need a bone density to tell us you have osteoporosis, you have it. And finally, there’s a risk tool that came out of the World Health Organization called, ‘FRAX’ and in the United States, when we do this little calculation which is very easy to do, it combines risk factors which are well validated with your hip density score. If your predictive fracture risk for next 10 years exceeds certain cut point, where going to call that osteoporosis cause you’re at high risk. So we now have multiple ways of making the diagnosis and probably anybody who sustains a fracture after 50, should have the bone density. If the fracture occur during the train crash, it could be the train crash. It could also be that it was the train crash in which a person with terrible bones broke a bunch of them. So, you need the test. If the test to bone density test is terrific in that setting, you don’t get too upset about it, these are great, your bones are not bad but you may find somebody has low bone density and of course. If any of these ways of making the diagnosis suggest that you’re at high risk for fracture, you have osteoporosis and you need to be treated to prevent fractures.
N: What is the one, the biggest misconception in your opinion, in your experience that you want to dispel among our listeners today?
S: Okay, very quickly. The 3 things you have to do to prevent fractures are not be calcium or D deficient, take medication as appropriate and be strong. Exercise so that your bone, your muscles will be strong to prevent falls. The biggest misconception in my opinion is that the medicines that we use carefully for specific blocks of time, somehow rather are dangerous. They are not dangerous. Used correctly, the medicine that are approved by the FDA to prevent fractures or generally, very well tolerated and remarkably safe. There are rare side effects people should know about, but in most cases, if you need one of these drugs the benefits you will get greatly, greatly, greatly outweigh any potential risk from side effects and people should be open-minded and willing to accept medication if it’s going to make a huge difference in their lives in a positive way.
N: Great. And where can our listeners go other than our physician to get just a bit more information about osteoporosis?
S: A wonderful website, www.nof.org. NOF is the National Osteoporosis Foundation. It’s just a terrific website with loads of good information which I strongly recommend.
N: Well it’s been a pleasure talking with you this afternoon doctor.
S: Thank you very much, I appreciate the time. Bye, bye now.
N: You’ve been listening to Health Professional Radio, I’m your host Neal Howard, in studio with Dr. Ethel Siris from Columbia University, a leading expert in osteoporosis, talking about testing, treatment options, and some of the myths and misconceptions surrounding osteoporosis. Transcripts and audio of this program are available at healthprofessionalradio.com.au. You can listen in on SoundCloud and download, you can subscribe to this podcast on iTunes. You can also go to hpr.fm.