Q: What is osteoporosis?
Dr. Miller: Osteoporosis is the disease of bone, it is a disease of aging. it is a condition in which there is a progressive increased fragility of bone, decrease of bone mass and bone strength and it is quantifiable by the modern test.
Q: I think when people think of osteoporosis, they think of their hunched over grandmother. But it's not just a disease of women, correct?
Dr. Miller: It is a disease of aging, per se that we are all subject to it. We are all exponentially going to be more at risk for it as we age. And women are predominantly affected likely because of the rather sudden drop in estrogen that occurs at menopause. About 80% of the total patients with osteoporosis are female, but 20% are male. And they have not been given equal opportunity.
Q: Women get a scheduled bone density test around menopause. But what about the guys? How would you know if you're at risk?
Dr. Miller: Gynecologists are tuned to and astutely aware and have been on a campaign to make certain that at menopause women obtain their first screening bone density. Men do not have that advantage. They don't get a screening bone density and therefore many go neglected until late stages when osteoporosis already ... at full force.
Q: Can you stop osteoporosis from getting worse? Can you take someone with brittle bones and make the bones stronger? What is the goal?
Dr. Miller: The goal really is prevention. Because it is very difficult to reverse bone loss once it occurs. So ... we're really at the guidance of the pediatricians and family practitioners and internists to try to do all the good things to prevent osteoporosis in later age.
Q: To prevent osteoporosis, how early should we start taking steps?
Dr. Miller: Pediatricians are geared toward adequate calcium intake at each age level right through early childhood. And our maximum bone mass is reached by age 20. So during the first 20 years is critically important.
Q: Equally for boys and girls?
Dr. Miller: Correct.
Q: Are you concerned about the children growing up now? There's lots of juice and soda out there ... and maybe children have less milk intake than in the past.
Dr. Miller: Yeah. This is true. And the other problem is there's much more of this activity (making moves of video games) than active sports and weight-bearing exercise is crucial for maximum bone development and maximum bone mass.
Q: Women have hormonal shift at menopause. What happens with guys? Is there a hormonal change, a testosterone drop?
Dr. Miller: Women unfortunately go through a rapid estrogen decline and deficiency averaging at age 50, with a range 45 - 55. Men have a very gradual hormonal decline over decades of time and they don't have a sudden drop in the male hormone level. So their bone loss occurs similarly, much more gradually. And most of the time men are not diagnosed until they have a fracture or they have an incident that brings them to attention. For example, routine x-rays do not show significant bone loss until about 50% of bone mineral is already lost. So routine x-rays are not very helpful until it's at a late stage.
Q: In a perfect world, would there be bone density tests for men at a given age?
Dr. Miller: Yes. Men now can qualify for bone density testing at age 70. This is being changed as we are seeing men at higher risk really deserve a bone density by age 50. And it is the role of the physician to advocate for men to have screening at an earlier age. If they wait until age 60, the chances of a man with osteoporosis developing a fracture in the rest of their lifetime is 25%. So certainly we like to see men screened especially they're in any of the high-risk categories.
Q: And for an older person to have a bone fracture, that can be life-threatening sometimes.
Dr. Miller: Yes, in fact men after hip fracture do worse than women in their recovery and have a 10-20% mortality rate over the following five years. One of the other issues that's not being addressed adequately for men and women is if and when a fracture occurs, no matter what their bone density is they deserve anti-bone resorption therapy. And it's probably the role of the orthopedist and the internist and often the endocrinologist to initiate aggressive treatment after any fracture.
Q: There aren't a lot of bone-building treatments available … so the goal really is to save what you have left, correct?
Dr. Miller: Bone that is treated with the dysphosphenates, which are the most widely and longest used, usually get stronger even at a given bone density, so there's advantages to having people at high risk and certainly after fractures to be on this therapy.
Q: If I'm a guy in my early 40s, drank milk and exercised as a child, should I worry about bone loss? Should I keep drinking milk?
Dr. Miller: Well, you know, there's always the um .. availability of calcium in the diet. Milk and milk products - dairy - provide a lot of calcium. Most of the green vegetables also provide significant amount of calcium. So in addition, the young healthy man in their forties can usually supplement with Vitamin D as well, which will enhance the absorption of calcium in the diet.
Q: So don't give up on calcium in the diet just because you're a grown-up?
Dr. Miller: Correct.
Q: It does provide some advantage?
Dr. Miller: Correct. Especially with dietary sources. There's been a recent article this past year which indicated that post-menopausal women taking the usual 500-600 milligrams of calcium twice a day compared to women who didn't take calcium supplement at all, had higher amounts of calcium depositing in their coronary artery wall. So then there's been a lot of controversy now about is it good or not good to take calcium in pill form.
Q: So how significant is the problem of men/osteoporosis in your view?
Dr. Miller: Well, about 20% of osteoporosis patients are male and their risks are very similar to female. Their fracture risks are identical and their recovery from a fracture is perhaps even worse than women's recovery. So it is very dangerous, equally dangerous for men at high risk to go unnoticed and undiagnosed. What it means to me is that men at age 50 and over - especially if they have any of the risk factors for osteoporosis - should go ahead and advocate and their physician should advocate for a bone density screening.
Q: The risk factors are … ?
Dr. Miller: There are several. And if any one of these are present, it would merit a screening of bone mineral density at age 50 or over. That would be primarily and most importantly fracture, age per se, and um ... bone density readings that are low. So those are the three things that are thought to increase risk. But in terms of modifiable factors, smoking, alcohol intake, inactivity, weight-bearing exercises are very important to maintain bone strength. So someone who is inactive or immobilized is at higher risk. Family history is a risk if there are other family members with osteoporosis.
Q: How do you make sure it's covered by insurance?
Dr. Miller: Screening can be done if any of the modifiable risk factors are present, so if someone was a smoker, someone had poor calcium intake, if someone was a significant alcohol user - usually more than three drinks a day - ... many reasons why a healthy male at age 50 would qualify.
Q: If I tell you I'm a heavy drinker, should I ask you to have a bone density test?
Dr. Miller: To some degree, yes. You know, women get a front row seat and menopause is their entry ticket. Men get a back row seat and they have to prove there are specific reasons why they should have a bone density.
Q: You said in a perfect world, age 50 would be perfect time to start getting them?
Dr. Miller: Yes, age 50 and onward for women. And men with any potential risk factors. Now there are several hormonal risk factors. And so if anyone has any of the endocrine disorders, um, particularly overactive thyroid, overactive parathyroid which leads to excess leaching of calcium. If steroids are administered for any given medical condition, that significantly accelerates bone loss as well.
Q: That's for men and women?
Dr. Miller: Correct.
Q: So if you're a man who smokes, drinks, has a lack of good calcium intake ... you could be in trouble?
Dr. Miller: Low calcium intake ... prior fracture ...family history.
Q: Those are all things that would help you qualify for insurance to help pay for a bone density test?
Dr. Miller: Yes.
Q: Are drugs getting better for osteoporosis?
Dr. Miller: Although there is pharmacologic therapy and choices that can be made now, none of them are highly successful or immediately successful. So the bone turnover rates and bone remodeling and bone formation is a slow process, so it's frustrating to everyone if they see a year or two years of therapy and the bones got one to two percent better.
Q: So it's better to work with your kids, get them to drink milk and eat their veggies now. But then if you see something at age 50, better to catch it then and stop it than see it at 70 and see bones breaking?
Dr. Miller: Correct. Now along that line, to further assess which people should get aggressive therapy, because all the drugs have side effects, there has been developed a scorecard called a 'Frax' score. And what it is a fracture risk assessment of which bone density is only one of several factors that are added / intimated into a total 10 year risk probability. And so almost everybody who has a bone density where there is some degree of bone loss but not yet osteoporosis, is given the additional data of this Frax score which if showing a high enough probability of fracture becomes another indicator for aggressive treatment.
Q: With osteoporosis, the biggest concern are hip and vertebrae breaks vs. legs/arms?
Dr. Miller: Correct, although forearm fractures are almost as common as hip fractures and all the three sites are major problems with a fall. So at times, the radius bones in the, in the non-dominant arm are measured.
Q: If you have osteoporosis and you break hip ... is repairing it harder?
Dr. Miller: Repair after a fracture does occur at any age range and it is healed with stronger bone if they are on a medication to offset bone loss. so many people are now routinely put on a bone strengthener after any fracture.
Q: Does bone degrade over time ... or does it stop at a certain point?
Dr. Miller: No, it does progress and it's very hard to regress. So it's like many other aging phenomenon where you lose muscle mass as we get older. We lose brain mass. And we lose bone mass. And it's very hard to offset the natural course of aging, still. But treatments are available and it is not a guarantee that you're going to have a fracture even in the moderate osteoporosis range. In that regard pharmacologic treatment is only one component of what people can do to minimize their risk. The British are known to have initiated publicity about fall prevention, things to do also to minimize injury if people do have a fall , even practical things like having a foam pad around the hip areas in people that are at very high risk. Advice to not have throw rugs or highly glossed wax floors. And be careful where the dog is sleeping and toys that the kids leave around so that you don't have falls.
Q: Can men in 30s or 40s have osteoporosis or is that a rarity?
Dr. Miller: It's rare to see osteoporosis before age 50 and I've had two patients that had it at age early 40s and one was really resistive to drugs and did not want to take treatment and asked to take another bone density two years later. He was in the osteopenia range, which is degree of bone loss not so severe to qualify for osteoporosis. And low and behold, two years later his bone density was identical to his last one. And he has not yet had a fracture.
Q: If a mother has osteoporosis, is her son predisposed to the condition?
Dr. Miller: It's not yet known the full genetic basis for osteoporosis. So that right as of now any family history of osteoporosis may be at increased risk for descendants to have osteoporosis as well.
Q: If you're older than age 20 and if you're drinking milk every day, are you building bone or maintaining your level?
Dr. Miller: Yes ... after age 20 the bone mass is just maintained constant. And there's a whole series of internal in part hormonal signals that regulate this.
Q: So unless you're on medication, you're not building bone?
Dr. Miller: Well you do continuously break down and build bone. Bone is not innate cement block. It is a live organ. So there's always this process of bone formation and bone resorption and the two balance each other out. And many things can influence that: weight-bearing exercise is definitely a promoter of bone formation and they've even done studies comparing elite marathon runners compared to an elite bicyclist. And the marathon runners had slightly better and stronger bones than the bicyclist. The assumption is it's more fully weight-bearing and some people think the pounding effect may stimulate stronger bones.
Q: So if I'm 25 lifting weights and drinking milk, what is that doing for me?
Dr. Miller: I think it should be lifting weights, having good dietary calcium intake and lastly, good exercise.
Q: Is that going beyond where I am at age 20 or just keeping the levels where they need to be?
Dr. Miller: After age 20, we stay on a plateau. And that's usually very adequate to maintain a low fracture rate.
Q: What about steroid use?
Dr. Miller: Anybody that's taking steroids for any medical reason - that is Prednisone, Cortisone ... steroids that are very effective as parts of treatment for any number of medical conditions - whenever anybody's on steroids, they should be on a bone strengthener, even if it's for a month or two. Because that offsets the rapid bone loss that is induced by steroids.
Q: Even children on steroids?
Dr. Miller: No, I think this would be for adults only. it would be particularly for those at higher risk. But people with rheumatoid arthritis, for example, have much higher risk and age does not become the dominant determinant for them.
Q: How much radiation is there in a bone density test?
Dr. Miller: It's about 1/10th of a single routine chest x-ray.
Further helpful information can be found at the National Osteoporosis Foundation Website here.
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