Osteoporosis: Risk Factors and Prevention
Guest: Dr. Kathie Hermayer - Medicine/Endocrinology, Diabetes & Medical Genetics
Host: Marcy Bolster - Rheumatology & Immunology
Marcy Bolster: My name is Marcy Bolster. I’m a professor of Medicine at the Medical University of South Carolina. I specialize in rheumatology, and I’m Medical Director for the MUSC Center for Osteoporosis and Bone Health. I’ll be talking, today, with Dr. Kathie Hermayer. She is a professor of Medicine at the Medical University of South Carolina. Her specialty is endocrinology. Good morning, Dr. Hermayer. Welcome.
Dr. Kathie Hermayer: Thank you, Dr. Bolster.
Marcy Bolster: Dr. Hermayer, today, let’s talk about the risk factors and prevention for osteoporosis. What kinds of things can you advise patients to do to help prevent osteoporosis?
Dr. Kathie Hermayer: Generally, what I tell my female patients is that after about the age of 30, their bone mineral density starts falling. So, I highly encourage my young, premenopausal women to start taking adequate calcium and vitamin D supplements around the age of 30, particularly women who may be breastfeeding or at risk for loss of bone, because the breast milk actually gives the calcium to the baby. So, women who are breastfeeding need to take special precautions as well. We do endorse weight-bearing exercise, such as walking daily. We recommend at least about thirty minutes, three times a week for patients to have adequate prevention for osteoporosis. And, certainly, ask your family members if you have family members that have been at risk for osteoporosis or have had fractures. Then, you may know that you’re at risk and need to take special precautions. We do endorse asking your family doctors about this and having a conversation with them as to what your risk factors may be and what you can do to prevent them.
Marcy Bolster: Can you tell me what the risk factors a patient should consider in determining that they may be at high risk for developing osteoporosis?
Dr. Kathie Hermayer: Sure. Generally, we’ll look at family history to see if a patient’s family members have had osteoporosis or a fracture in their past. Osteoporosis hasn’t been screened as readily in the past, so a lot of times patients don’t know what their family history is. But, if they notice that Mom, or your aunt, started getting shorter, and had a humped back, they probably did have osteoporosis. Sometimes people know if there’s been a fracture in the family. Cigarette smoking is a risk factor. Any type of alcohol, excess intake, may be a risk factor. Early menopause is a risk factor for a female. And then we can get into certain ethnicities that may be more at risk than others. However, all ethnicities are at risk.
And then there are secondary risk factors: hyperthyroidism, type 1 diabetes, chronic steroid use; usually more than three months of therapy, certain rheumatologic conditions, such as rheumatoid arthritis, systemic lupuserythematosus, chronic renal failure, liver disease, any type of transplant organs in the past, so, many contributing factors for osteoporosis risk.
Dr. Marcy Bolster: So, does a person’s body weight have anything to do with their risk for osteoporosis?
Dr. Kathie Hermayer: It’s really kind of an interesting phenomenon that body weight and risk for osteoporosis are inversely related. So, the thinner a person is, the more at risk they are for osteoporosis. So, actually, an increased body mass index, otherwise known as BMI, is somewhat protective against osteoporosis. The thinking there is that there’s actually a peripheral conversion of testosterone to estrogen, so, heightened estrogen from the adiposity protects people. However, that is not an excuse for people to gain weight, because we do have medications and therapies to help protect people for osteoporosis.
Dr. Marcy Bolster: Why do women have an increased incidence of osteoporosis? Why do they get this problem after menopause?
Dr. Kathie Hermayer: Right. It’s that, premenopausally, women have their estrogen and that seems to protect them from loss of bone. Once women go through menopause, their estrogen levels fall. Consequently, within the first five years of menopause, about 20 percent of bone loss occurs. And then, if a woman has no further protection for her bones after that time, such as bone therapy, calcium, vitamin D, she will continue to lose about one to two percent of her bone mass per year, ultimately leading to a very heightened risk for bone fractures.
Dr. Marcy Bolster: We’ve talked a lot about bone health and osteoporosis in women, do men get osteoporosis?
Dr. Kathie Hermayer: Absolutely. The risk of osteoporosis for a man over the age of 50 is about 1 in 7. It’s a lower risk than for a female, but men are also at risk and, probably, have been under-diagnosed throughout the years because there hasn’t been as much emphasis on men as there has been on women. Although it seems to be, now, in the current population screening, men are getting more attention than they have in the past.
Dr. Marcy Bolster: Are there specific risk factors for men that should make a man concerned that he might be at a higher risk for developing osteoporosis?
Dr. Kathie Hermayer: I think many of the risks that apply to women, such as smoking, family history, history of steroid use, apply to men as well. Obviously, men don’t get pregnant, don’t have babies, don’t go through menopause. However, men are actually thought to go through something called andropause. In andropause, the testosterone level of a man may fall. Testosterone is also protective to the bone for a man, as estrogen is protective to the bone for a female. So, testosterone can actually be used as a therapy to treat osteoporosis in men. So, I think it is important, even though men are less at risk for osteoporosis than women, that men also have this conversation with their primary care providers, as well as their subspecialists, and get screened for osteoporosis if there are significant risk factors.
There is something called the FRAX score that came out about two years ago, whereby you can use an online calculator tool, with or without a bone mineral density study, and estimate your 10-year probability risk of a major osteoporotic-related or hip fracture. This can be used for both men and women of all ethnicities.
Dr. Marcy Bolster: At what age would you say men would need to be more concerned about the loss testosterone in regards to their bone health?
Dr. Kathie Hermayer: Probably, most men should be screened for osteoporosis by the age of 70. However, if there are one or two risk factors prior to the age of 70, it may be indicated to get a bone mineral density study at that time.
Dr. Marcy Bolster: How often should a patient undergo screening for osteoporosis?
Dr. Kathie Hermayer: Currently, with our Medicare guidelines, it’s recommended that a Medicare patient have a bone mineral density, probably, every two years. Anything that’s done above and beyond two years of therapy may not be covered by insurance, and bone density studies are not inexpensive, so I think it’s important to discuss, with your primary care provider, if you’re eligible to get a bone density at the time you’re requesting it. Once the study is done, you want to make sure insurance will cover it because it is a rather costly test. Sometimes you can have screening studies done, such as a heel DXA, or heel ultrasound study, which may be a good snapshot as to whether or not you seem to be at risk for osteoporosis at that time. But, generally, we recommend, for retesting for osteoporosis, no sooner than every two years.
Dr. Marcy: Should a decision to treat a patient be based on the results of a screening heel ultrasound test?
Dr. Kathie Hermayer: We usually recommend that a screening peripheral density test not be used as the ultimate diagnosis for osteoporosis. The way I look at is, osteoporosis is a diagnosis you carry for life, therefore you want to be absolutely certain you have osteoporosis, and not osteopenia, and make sure there aren’t any false readings associated with it. So, the recommendation would be to have a full-body DXA scan if there are any concerns based on a peripheral reading.
Dr. Marcy Bolster: Dr. Hermayer, this has been an informative discussion. I appreciate your time very much.
Dr. Kathie Hermayer: Thank you for inviting me, Dr. Bolster.
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