By Risa Kagan, MD, FACOG, CCD, NCMP (Member, Medical and Scientific Advisory Board)
I have been working in the bone world for many years. I know it’s challenging for consumers to keep up with the emerging science and research, so here is a look at where we came from and where we are now.
Advances in medicine over the past several decades have helped us live longer, and because many women previously didn’t live long past menopause, we didn’t know the impact of the loss of estrogen on bone mass.
In the 1980s, bone density testing machines gave us the ability to identify the quantity of bone mass and monitor changes in the trabecular structure of bone. This is when we started using the terms “osteoporosis” and “osteopenia.” The World Health Organization in 1994 established a definition of osteoporosis based on the statistical concept of a normal distribution. A T-score is a standard deviation from the average 30-year-old, and a consensus of scientists determined that more than 2.5 standard deviations below the mean should be defined as “osteoporosis.” “Osteopenia” became the standard term for a T-score between -1.0 and -2.5. Osteopenia is not a disease, but a term created by the World Health Organization (WHO) to describe low bone mass. Anyone with a T-score greater than -1.0 was considered “normal.”
Not perfect, but a start
One of the main reasons it wasn’t perfect is that because we didn’t do a bone density test on a person when they reached peak bone mass at age 30, we didn’t really know whether a T-score at age 50 was the result of bone loss. Maybe that’s the peak bone mass/ density they ever achieved.
As the science has improved, we have learned that we need to focus on bone quality as well as bone density. The quality of the bone is important in understanding fracture risk. Just like high cholesterol is a risk factor for heart attacks and high blood pressure is a risk factor for stroke, osteoporosis on a bone density test is a risk factor for fracture. We can think of fractures as “bone attacks.” We are now thinking about treatment and prevention strategies to focus on fracture prevention, rather than just bone density. As a result, we realized that not all patients were candidates for osteoporosis medicines, especially women and men who are relatively young, without any risk factors for breaking a bone.
Having a better understanding of bone quality is encouraging us to engage in more conversations with patients about fracture risk. We use calculators to understand patients’ risk profile and their chances of breaking a bone. This helps us focus on a bone health plan that is appropriate for an individual.
As a consumer, you have an important role to play in this discussion. Knowing your risks and taking action with your doctor to prevent bone loss can help you avoid a “bone attack.”
Not all people will have the luxury of prevention strategies alone. Whether it’s a medical condition, a medicine that you take, or a family history of bone loss and fractures, you could be one of the patients who would benefit from a medication to reduce the risk of a “bone attack.”
Patients should not be afraid of the medications that are available. All the medications used for the prevention and treatment of osteoporosis have good safety data, and they reduce the risk of fractures, especially spine and hip fractures. We know that 25% of hip fracture patients die within a year and the majority of the rest are not able to live with mobility without assistance. We know now how to determine who is a good candidate for treatment based on fracture risk and what medicine would be best.
In December 2017, a study that reviewed the Medicare database found that the decline in hip fractures had leveled off. The researchers estimated that 11,464 additional hip fractures (costing $459 million) occurred from 2013-2015 due in part to a decline in screening and treatment and an increase in other chronic conditions, like diabetes. We are now facing a public health crisis in our older population.
Let’s remember that knowing our risk factors and our bone density scores is just the start. Doctors and patients need to work together to take action and prevent bone loss and fractures.
About Dr. Kagan
Dr. Kagan is a board certified obstetrician-gynecologist and Clinical Professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco. She serves on the Medical and Scientific Advisory Board of American Bone Health (FORE) and is the principal investigator on numerous women’s health clinical research studies. Dr. Kagan is well known as a communicator and teacher and is often approached by media and public forums for her expertise and frequently is an invited speaker at national and international scientific meetings.