"Indeed, it was a W.H.O. panel financed by the pharmaceutical industry that in 1994 defined normal bone mass as that of an average 30-year-old woman. Because bone naturally deteriorates with age, anyone much older than 30 is likely to qualify for a diagnosis of osteopenia; using similar logic, a middle-aged woman might be said to have a skin disorder because she had more wrinkles than her 30-year-old daughter."
-Kate Murphy, "Splits Form Over How to Address Bone Loss" New York Times, Sept. 8, 2009
Should We Hold Off On the Bone Drugs Until We Get Osteoporosis?
"...some researchers argue that it makes more sense for a woman to delay taking medications until she crosses the line from osteopenia to osteoporosis. 'The less time a woman's on drug therapy, the less chance for adverse events,' says Bess Dawson-Hughes, M.D., director of the Bone Metabolism Laboratory at Tufts University and chair of the committee that updated the National Osteoporosis Foundation guidelines."
-Nissa Simon, "Are Women Being Overtreated for Bone Loss? Many Drugs Have Serious Side Effects" AARP Bulletin Today, March 27 2009-
Are Drug Companies Pushing Drugs to Treat Osteopenia?
"The drug industry has already begun marketing its osteoporosis drugs to the large group of women defined as having osteopenia: potentially half of the world's postmenopausal women. Notwithstanding the geniune value of these drugs in reducing fracture risk for some women, we need to ask whether the coming wave of marketing targeting those women with pre-osteoporosis will result in the sound effective prevention of fractures or the unnecessary and wasteful treatment of millions more healthy women."
-Pablo Alonso-Coello, MD & colleagues, "Drugs for Pre-Osteoporosis: Prevention or Disease Mongering", BMJ 336:126-29, Jan. 19, 2008
What Is Osteopenia?
Note that the baseline for normal is for an average 30-year old woman.
What your T-score means:
- A T-score between +1 and -1 is normal bone density. Examples are 0.8, 0.2 and -0.5.
- A T-score between -1 and -2.5 indicates low bone density or osteopenia. Examples are T-scores of -1.2, -1.6 and -2.1.
- A T-score of -2.5 or lower is a diagnosis of osteoporosis. Examples are T-scores of -2.8, -3.3 and -3.9.
The WHO classification of osteoporosis (notice that 80% of women over 50 have either osteopenia or osteoporosis)
*Below the young adult mean.
**In white women older than 50 years
from BMJ 336:126-29, Jan. 19, 2009
Why is Osteopenia Now on My Radar Screen?
On Tuesday morning I read the New York Times piece, "Splits Form Over How to Address Bone Loss" , which highlights the controversies on whether or not to treat osteopenia (aka pre-osteoporosis) with bone-strengthening drugs.
There are also some docs who question the use of the new World Health Organization online tool, FRAX (click here for the tool), which is intended to help women and their doctors figure out what their risks are for future fractures. It's a decision tool--to help you sort out whether or not you need to start on Fosamax, Boniva, Reclast, Actonel, or Evista.
What Are the Concerns About FRAX?
1. The FRAX tool doesn't take into account factors like: vitamin D deficiency, physical activity, and the use of drugs that can erode bone, like epilepsy drugs and antidepressants, or how long or how much someone has been smoking or drinking. Good point. I'll buy that!
I noticed that it only takes into account a parent with a fractured hip--not one with spinal or wrist fractures or diagnosed osteoporosis--as in my case. Isn't a parent with osteoporosis an important risk factor?
2. Some physicians think the tool causes women undue worry (please!!) and may encourage them to start bone-strengthening drugs sooner than necessary. But wait-check this out: One of the physicians who expressed this concern for FRAX in the NYT article is Dr. Nelson Watts of Cincinnati. He thinks it should be abolished. Look what I found from my H.H.L.L. March 2008 post about FRAX:
Rosemarie Moenster, a 65-year old Cincinnati teacher, was being treated with 2 medicines, Actonel to rebuild bone, and Evista, to prevent bone loss. When she started to experience complications her doctor advised stopping the Actonel. She was terrified of worsening osteoporosis, but when her doctor, Nelson Watts ran the new FRAX risk tool, the news was good. Her risk of hip fracture was less than 1%, and the risk of major breaks was 12%. She could safely stop the Actonel, and is continuing the Evista.
The NOF recommends treatment when the 10 year hip fracture risk is 3% or higher, or if the risk of other major fractures in the spine, shoulder or arms is 20% or more. According to FRAX, it looks like Ms. Moenster might not need the Evista either--but then I don't have all the facts.
As for me--I don't understand the concern about FRAX. My T-score is a not-so-great -2.1 (not so far from the -2.5 osteoporosis diagnosis). I'm almost 60 (can't believe it!), have a strong family history of osteoporosis, a small frame and guess what? There's no need for me to use drugs.
According to FRAX my long-term risk of a hip fracture is 1.3% and my major fracture risk is 9.3%--which improved from my last BMD scan. (Remember: It's a 3%/20% To Treat Guideline) So...the FRAX didn't cause "undue worry"--it allayed my worries--thank you very much!
What Are the Concerns of Medically Treating Osteopenia?
2. Exaggerated benefits. Some experts believe that testing and subsequent drug prescriptions for women over 50 may be a waste of time and money. There are concerns that the drug companies are strongly marketing drug treatment for osteopenia. Be sure to read Pablo Alonso-Coello's article: "Drugs for Pre-Osteoporosis: Prevention or Disease Mongering", BMJ 336:126-29, Jan. 19, 2008.
He has serious concerns about the drug company sponsorship of articles that have "reanalyzed" data for patients with osteopenia. There is a huge potential market out there--50% of women over 50 have osteopenia--and Alonso-Coello and many other physicians believe the benefits of drug therapy do not warrant treating millions of women.
The National Osteoporosis Foundation recommends screening women without risk factor at age 65--and men at 70. For a list of the NOF Guidelines, click here.
3. Playing down side effects. Do we really want to subject women with normal bone loss--at low risk of fracture--to drugs with potential side effects? Consider the rare osteonecrosis of the jaw from Fosamax, the more common and sometimes serious gastrointestinal side effects, and the increased risk of stroke and venous thromboembolism from Evista.
4. "The drugs work if you have osteoporosis. But some studies suggest there is little benefit, if any benefit at all, if you take these drugs when you have osteopenia," according to Dr. Steven Cummings, Professor of Medicine and Epidemiology at the University of California at San Francisco.
A study published in the Mayo Clinic Proceedings 80(3):343-49, Mar. 2005, found that Fosamax quickly becomes effective in women with osteopenia or osteoporosis, but the authors conclude:
"The absolute risk of vertebral fracture is low in osteopenic women without a previous fracture; thus, the number of fractures that would be prevented with Fosamax therapy is small. For women who already have a vertebral fracture the risk of a new fracture is 5 times higher."
My comment: If drugs like Fosamax work so well & so quickly--why not just "watch & wait"--with regular BMD scans--and start treatment when bone loss increases?
My Experience with a Diagnosis of Osteopenia
Rather than prescribe drugs, my doctor ordered tests--lots of tests. She wanted to figure out if there was an underlying cause for my bone loss, besides my age. Here's what she checked for:
1. Vitamin D. I had my vitamin D level checked. It was a too-low 29, and she immediately advised me to add 1000 IUs of vitamin D3, in addition to the maybe 800 IUs I was already getting from Citracal & a multi-vitamin. A 3 month follow-up showed improvement up to the barely acceptable level of 33.
She has since advised me to take 2000 IUs. It's been a few years since I've had this tested, but I'm anxious to see where I am now. According to Dr. Michael Holick, the vitamin D maven, a score closer to 50 (but under 100) would be better; and Dr. Heike A. Bischoff-Ferrari concluded that the optimal level of vitamin D to prevent hip and nonvertebral fractures in older adults should be at 75 nmol/l. ("Optimal serum 25-hydroxyvitamin D levels for multiple health outcomes" in Sunlight, Vitamin D and Skin Cancer, edited by Jorg Reichrath, 2008)
2. Celiac Disease Blood Test. This under-diagnosed condition can be a cause for low bone mineral density. This checked out just fine for me.
3. Parathyroid Hormone Test (PTH). Was my parathyroid in working order or was it causing calcium to be removed from my bones? Again--no problem here.
4. Calcium-Phosphate Urine Test. With this test you collect all your urine for 24 hours. It's done to see if you're losing too much calcium or phosphorus--which the body needs to build & repair bones & teeth. And no, you can't venture far from home when you're collecting a 24-hour urine sample. This was loads of fun, especially carrying a big plastic jug filled with pee to work. I passed this test too!
5. Turns out I have run-of-the-mill old-age osteopenia.
My Bone Strengthening Plan:
1. Vitamin D3--close to 2400 IUs a day (note: as of 2011 this is up to 4000 IUs) + sensible sun-exposure in the Spring & Summer when I can--which isn't often. The recommendation from Dr. Michael Holick for my fair skin type & location: around 2-3 days of sun exposure of arms & legs for about 10-15 minutes between the hours of 10 am-3 pm. Sunscreen on the face.
Note: The NOF recommends adults 50 and over need 800-1,000 IUs of vitamin D daily. And although previous research showed D3 to be superior to D2, recent research has showed both types are equally effective.
2. Magnesium--200 mg in the morning & 200 mg before bed with Citracal.
3. 1200 mg of calcium a day--some in supplement form--some in food. (note: as of 2010 this has changed)
4. I take a low (1/4 dose) of Estrasorb--a transdermal estradiol--which has been shown to maintain bone density--along with a 100 mg of Prometrium (progesterone) 12 days a week.
5. Weight-bearing and muscle strengthening exercise. I lift weights and practice yoga to improve my balance--and prevent falls.
6. I keep alcohol consumption down to less than 2 glasses of wine a week.
7. I load up daily on bioavailble-calcium-rich greens like kale in my green smoothies.
8. I follow the research-backed advice of Dr. Bess Dawson-Hughes, the director of the Bone Metabolism Laboratory at Tufts University, and one of the developers of the U.S. FRAX guidelines. I eat lots of vegetables and fruit, plant protein, and ease up on the cereal grains.
"Diets high in protein (especially animal protein) and cereal grains produce an excess of acid in the body which may increase calcium excretion and weaken bones, according to a new study accepted for publication in The Endocrine Society's Journal of Clinical Endocrinology & Metabolism (JCEM)"
When older adults eat diets high in protein & grain, acid is produced, and as we age our bodies are less able to excrete this acid.
"One way the body may counteract the acid from our diets is through bone resorption, a process by which bones are broken down to release minerals such as calcium, phosphates, and alkaline (basic) salts into the blood. Unfortunately, increased bone resorption leads to declines in bone mass and increases in fracture risk."
For a link to my post about Dr. Dawson-Hughes' study, "Osteoporosis Prevention. A Diet High in Fruits and Vegetables and Low in Animal Protein and Grain" click here.
9. Are these interventions working? Yes! My 2 year follow-up BMD shows that I'm maintaining my bone density.
Note: I recently picked up a provocative book at my local library, Building Bone Vitality. A Revolutionary Diet Plan to Prevent Bone Loss and Reverse Osteoporosis by nutrition professor Dr. Amy Lanou and health writer Michael Castleman. It just came out in May 2009.
The authors looked at over 1200 studies and present an argument that turns the idea of drinking milk and eating dairy for bone health on its head. They recommend that the most effective way to prevent bone loss is a combination of daily walking and eating more of the low-acid foods like fruit, vegetables, legumes, and soy--with little, if any, meat, dairy, and fish and a modest amount of breads, cereals, and pastas. Dr. Dean Ornish has written their foreword. I'll let you know what I think of it when I have a chance to look at it more carefully. UPDATE: I reviewed the book & included a synopsis here
Be sure to read:
From HHLL: "Osteoporosis Prevention. A Diet High in Fruits and Vegetables and Low in Animal Protein and Grain" click here.
Take the FRAX Test here.