Well, howdy, y 'all. Welcome back to another
episode of You're a Mom on Drugs. My name is
Josh, and I am the son. And I'm Jenny, and I'm
the mom. And if you're new to this podcast, we
are a mother and son combo. My name's Josh and
I got a degree in biology and a master's in public
health from the University of Texas at Austin.
And my ostensibly intelligent, wonderful mother.
Was educated in the great state of Virginia,
as well as you also did your, you did your. So
I got a BS in pharmacy in Virginia back when
you got BS's in pharmacy. They don't do that
anymore. BS stands for bachelor's in science.
Bachelor's in science. Not the other BS. And
then I wanted to pursue additional education.
So I came to Texas and got my doctorate pharmacy
degree. So now everybody who comes out of pharmacy
school has a PharmD degree. Oh, really? Oh, I
did not know that. Yeah, there's no BS in pharmacy
anymore. Okay, so you're a rare breed. Yeah,
us older people, yes. And you also studied at
Duke as well, right? I did a residency at Duke.
I did a pharmacy residency at Duke. Can you explain
to folks out there, what is a residency? So back
when you would get a BS, well, before the PharmD
degree was the only degree you got. After you
graduated from pharmacy school, you could go
do what they called a general pharmacy residency.
And so that's what I did. And they were offered
at different places all over the country. And
so Duke was just one of the places since I had
grown up in Virginia, wasn't that far away from
home. So I went to Duke for a year. And what
you do in a residency is you get exposure to
a bunch of different areas of pharmacy practice,
because I think a lot of people don't realize
that pharmacists, similar to physicians, there's
different areas in which they can practice. And
so you got exposed to that as you did this residency.
And you also, because I was already a licensed
pharmacist, we also had to serve as a staff pharmacist
once a week as well, which meant that you were
working in a satellite pharmacy in a hospital
once a week and stuff. But then after that, they
encouraged me to go get my doctor of pharmacy
degree. And so I came to Texas and did that.
Because you're so smart. And then I did another
residency after that, which was a more specialized
residency. Because now you can also do specialized
residencies in pharmacy as well, too. So all
this beautiful information, all the specialization
has led you to this moment to becoming a podcaster
with your son. Only because you asked. I did.
Yeah. Well, you know, I didn't want, you know,
a lot of times people when they retire, their
brains just turn to mush. And so I didn't want
that to happen to you. And luckily the whole
world benefits from that. Oh, brother. But speaking
of other things that you've experienced, we're
going to do an episode that's kind of near and
deep in your bones, as they say. we're going
to be talking about osteoporosis today. So I
don't know if you just kind of want to kick us
off and kind of take us down the path of how
we normally start episodes and kind of doing
overviews, and then we'll get into kind of the
things that you can do to either treat it or
prevent it. So why don't you give us an overview,
Dr. Seltzer? Okay, well, so as Josh mentioned,
we're going to be talking about osteoporosis
today, which is... actually a major non -communicable
disease, which blew my mind. I was like, I never
even knew it was classified like that. And it's
the most common bone disease. And osteoporosis
is defined as a bone disorder that's characterized
by low bone density, impaired bone architecture,
and compromised bone strength. So you are predisposed
then. to an increased fracture risk. So a fracture
being a broken bone. Okay. It's a public health
epidemic and it can affect all ages, genders,
races, and cultures. It's not specific to any
one particular patient group, although it is
more common in older people, specifically older
women. And we'll get to that a little bit later.
It's actually considered a silent disease as
that there are really not a lot of symptoms until
you break a bone. And it is the major cause of
fractures in postmenopausal women and older men.
So you're like, well, are you serious? Really?
It's a major non -communicable disease? Well,
it affects one out of three women and one out
of five men over 50 years of age. And it's guesstimated
that approximately 50 % of people 50 years and
older are expected to develop this disease. Right
now, approximately 10 million people in the United
States have osteoporosis, with a prevalence in
women of 16 .5%. And about 43 million people
in the United States are estimated to have low
bone density, so they're at risk for developing
osteoporosis. And you can actually, interestingly,
it's been broken down into based on race. And
so actually non -Hispanic white women have a
higher risk of developing osteoporosis. And then
I believe that Mexican -Americans are next. No,
that's not true. Asians are higher and then Mexican
-Americans and then African -Americans. So it
can be differentiated both in men and women.
Yeah, as well as by your race. Right. It definitely
increases with age. There is a 7 % incidence
in women 50 to 59%. I'm sorry, I'm really misspeaking
today. There's a 7 % incidence in women 50 to
59 years of age, and it goes up to 35 % in women
80 years of age and older. And then in men, it's
about 3%. between 50 and 59 years of age, and
it goes up to 11 % in men 80 years and older.
And we'll talk about that a little bit more.
Those who are over, I'm sorry, over 80 % of older
adults who suffer fractures are never tested
or treated for osteoporosis. So they can have
a spontaneous fracture and they think of it.
For whatever reason, they don't think of osteoporosis.
It's like, I just have hip pain or my back's
hurting. Or I just broke it because I'm old or
something instead of looking for some other underlying
reason. And over 90 % of patients who fail to
receive a bone density scan or start treatment
a year after a fragility fracture, which means
that a fragility fracture is one that... Your
bones are weaker and you do something just not
that stressful and your bone breaks and stuff.
And then nearly 70 % of people with actual osteoporosis
go undiagnosed. Wow. So, yeah. It's an economic
health burden as well, too, which you can imagine.
It costs the United States $22 to $25 billion
annually, and it's projected to increase to $95
billion by the year 2040. And most of that cost
is due to hip fractures. They account for about
72 % of the cost of osteoporosis because a hip
fracture is no bueno. There's a lot of other
things that happen after you have a hip fracture.
In addition, there's surgery. You may have to
be put in a rehab or a nursing home facility.
And so that all adds to the cost of it as well
too. And the cost of osteoporosis can exceed
the cost that is associated with breast cancer,
heart attacks. So it's a big deal. Yeah, it's
one of the, I remember, so I looked into some
of the more, like one of the greatest predictors
of mortality for folks kind of after heart disease
and cancer is falling. Because I think we just
don't think about it as like. It's crazy. There's
a mortality figure from 2010. If you're a 90
-year -old man and you fall and break your...
And if you have a fracture, either in your hip
or your femur, you have a 40 % mortality rate.
That means that if 10 90 -year -olds fall, four
of those 90 -year -olds are going to be dead
within a year, which is insane. And when you
think about it, it makes a lot of sense for anybody
who's... kind of a bit younger like myself, it's
like, okay, you break a leg or you break something,
you sit on a while and you heal. And we're going
to get into the biology of bones a little bit
later on in this podcast. But like, just think
about all the things that you can't do when you
have a fracture. Like you can't walk. And maybe
if you're 90, you don't have a lot of people
there taking care of you. So like, how do you
go to the bathroom by yourself? Like, how do
you feed yourself? Like, how do you socialize?
And so it's not really the The fall doesn't really
kill you. It's kind of all these other things
that can add up that over time, the mortality
just kind of tends to creep up on you. So your
quality of life just really diminishes. And then
especially if you're older, getting that bone
to actually heal itself might not even be possible.
And so you unfortunately get a lot of people
who pass away from that. A lot of this episode
today is going to be about preventive measures
because like mom said, it's one of those silent
killers, very similar to like a heart attack
or a mitochondrial infarction where you get plaque
built up over time and then all of a sudden you
have a cardiac event. There's not really a lot
of signs before that that you're going to have
it. So we're hopefully going to give you the
tools and things today that can help you be informed
so that you can basically start building bone
early, no matter what age you are. And, or to
delay the degradation of it. But I just thought
that we'll put some of these graphs in our, we
have like Instagram posts so that people can
kind of see some of these mortality figures.
But this should be one of those higher priorities
than probably we give it credit for. The last
thing I'll say in this and we'll move on is like,
if you look at the hazard ratio for falls. And
a hazard ratio is essentially like how dangerous
is this activity in terms of engaging in it?
And so a hazard ratio of one is essentially saying
like, you're fine going either way, basically.
Like if I drink water, my hazard ratio is one.
It's essentially, it's not, hopefully you don't
drown in a glass of water. Too much water, maybe
not, but yes. But if you have a hazard ratio
of two, that means like you're twice as likely
to succumb to mortality than. than the control,
like just drinking water. So smoking has a hazard
ratio of around two. So essentially, you're twice
as likely to die from something from smoking
a cigarette over time than not smoking. Falling
and hip fractures from osteoporosis has a hazard
ratio of 2 .63 in people over 75. So it even
has a higher hazard ratio than smoking. And the
thing about all the messaging that we go to give
towards people don't smoke because it's going
to cause problems down the road. So this one
even has a higher risk as it for older people,
especially as they get older. So just wanted
to kind of set the stage at this. I know it sounds
like breaking bones. You're getting older. What's
the big deal, but it really can be a big deal
late, especially later in life. Yeah. Okay. So
let's just talk a little bit about. kind of the
mechanics or what a bone is. And so why on earth
do they break to begin with? What is a bone?
So the main components of a bone are collagen,
which gives the bone flexibility and energy absorbing
capabilities because our bones have to absorb
a lot of energy for us to walk and move around.
It also then is consists, the bone consists of
minerals, primarily calcium and phosphorus, which
makes up 50 to 70 % of our bone mass. And this
gives our bones stiffness and strength. And so
this collagen and mineral composition of a bone
are created in a correct balance so that the
bone can deal with stress and strain and resist
fractures. And so if you've got imbalance in
these areas with the collagen or with the calcium
and phosphorus, then that increases the risk
for a fracture because you're going to impair
bone quality and bone strength. Yeah, it's kind
of like having a shock absorber, like when you're
riding a bike or a car. It's like, so when you're
hitting that big bump as you're riding your bike,
all of that energy then, the bump doesn't go
directly to you and the bike. It goes into that
shock absorber so it can be dispersed throughout.
That is correct. So there are two different bone
types. The first is cortical bone. And it's found
mainly in your long bones, like your femur, which
is in the long bone at the top of your leg, or
your humerus, which is the top long bone in your
arm. And they make up 80 % of our skeleton, the
cortical bone does. And then we've got trabecular
bone, which is found mainly in our vertebrae.
Our vertebrae are the bones that are in our spinal
column. and the ends of our long bones. So you
know how bone is solid, but that the end of them
looks a little bit different. Well, in that end
of a bone, it's made of trabecular bone and it's,
that bone is more, is more active. It's got a
higher turnover rate and it's got a larger surface
area. So if you spread it out, it would cover
more space and it's got a honeycomb like appearance.
So that's kind of how that bone looks. So bone
strength integrates or it's a composite of bone
mass strength and quality. And bone mass peaks
at ages between the ages of 18 to 25 years of
age. So when you're in that young, you know,
you don't even know that you're reaching your
peak with your bone. You probably don't think
about that a whole lot and stuff. Well, that's
kind of good to know. So anybody who has kids
out there, if you want your kids to reach peak
bone mineral density, it's probably good to give
them calcium and some activity -based things
to load those bones. Because after that, you're
just going to kind of lose over time, correct?
That's right. There are different factors that
can influence bone mass. Genetic factors is certainly
one of them. It's actually a large part of it.
It's 60 to 80 % as far as, you know, what kind
of bone structure and risks associated with your
bone you're going to have. But other things can
also impact your bone mass, and that includes
nutritional intake, exercise, like Josh just
mentioned, adverse lifestyle practices like smoking
is not good for your bones. And then there's
also some diseases and medications that you may
have to take or you have been diagnosed with
that you really can't do anything about that
could also affect your bone strength as well
to your bone mass as well. Okay. So if you're
taking some of those medications. You might have
to find a way to compensate for some of those
side effects. Right. So one of the big medications
that affects bone masses are glucocorticoids
or steroids that a lot of patients with asthma
or maybe, you know, maybe autoimmune diseases
or people have to, you know, you're trying to
suppress inflammation in your body. And glucocorticoids
are really great anti -inflammatory agents, but
they also have a whole slew of adverse effects
and affects on bone is definitely one of them.
Okay. That's good to know. And hormonal status
is also another thing that affects bone mass,
which we'll also talk about in a little bit,
specifically with regard to women. Yeah. So why
on earth does osteoporosis happen? tissue quality
is directly related to the functional activity
of what we call osteoblasts, osteoclasts, and
osteocytes, and a bone matrix, as well as it
also includes a whole slew of other things, cytokines,
growth factors, and hormones. It's actually a
very complicated process as far as how your bone
grows. You think your bone is just one big, long
piece of calcium, but it's a dynamic system.
It's got a whole lot of things going on in it,
and we're not going to focus in the whole...
complicated mechanics of bone stability and bone
growth. But just for the basics to understand
osteoporosis, I wanted to talk about the fact
that all these things are normally imbalanced.
And so then your bone stays strong, your bone
mass stays stable. But when you have an imbalance
in it, that's when you start having problems.
So osteoblasts, B osteoblasts, are the cells
that will allow you to build bone or form bone.
Whereas osteoclasts, with a C, class, will break
down bone. And osteocytes are the cells that
will differentiate into these different cells.
Okay, so they're like the common denominator.
Right, I think they primarily make osteoblasts.
Yeah, they're going to choose who to be. So B.
for building osteoblasts, C for clashing, like
a cat. Chomping. Yeah, chomping. Tearing it down.
So when you have osteoporosis, then your bone
resorption, which is going to be led by your
osteoclast, is greater than your bone formation.
And that makes sense, doesn't it? So you're going
to have more bone breakdown than you are going
to have bone formation. And it will... Um, it'll
happen in greater quantities and bone formation.
And so it will make your, your, this bone remodeling,
you know, is a, because it's not in balance and
then you have, you're going to develop weaker
bones. Um, I think one thing to say here is like
one thing that I thought was really curious is
like, why would you want to tear down your bone
in the first place? You know, like why do osteoclasts
exist in the first place? And I would, do you,
do you have a, the only thing that I read that
I. Correct me if I'm wrong, but I think somehow
if you break down bone, then it stimulates the
additional formation of the osteoblasts and new
bone formation. I think the question is, why
couldn't you just stimulate more osteoblasts
to just grow? Why do you need to tear down to
have osteoblasts? I think one of the things that,
at least the reasoning that makes the most sense
to me is that Bones are not just for structural
integrity. They're actually a really good storage
site for calcium. And if anybody knows anything
about basic biology, calcium is a really good
signaling molecule. So calcium especially is
used in our neurons to essentially stimulate
when a neuron is firing a signal from one area
to the other. If anybody doesn't know anything
about the central nervous system to communicate
between your brain and your foot, for example,
you use these specialized cells called nerve
cells. And they relay messages like, hey, lift
your big pinky toe, for example. Well, little
pinky toe it would be. Well, they only have one
pinky toe. So it's just true. Oh, true. Good
point. So my left one. And because humans came
out of it, we forget that we just evolved in
a time of scarcity. There just wasn't a lot of
stuff around. So a lot of times, a lot of these
ancient measures of like, why do we store fat?
Why do we store? a lot of these things inside
of us when a lot of it, we forget that we came
from a time of scarcity. So calcium just needed
a place to be stored inside of the body because
it eventually would need to be used. And so it
kind of has this dual function. It's like, okay,
not only are we going to give you skeletal stability,
we're also going to give you a way to use some
of that calcium in times where we need signaling
so we can put it in your bloodstream and they
can go to the appropriate spot. And so it's a
great reservoir for calcium. But like mom said,
that works great. Everything's in balance. But
if you're tearing down more often than you're
building, then you lose more calcium. You might
need it for additional signaling, or maybe there's
just something out of whack in that system. And
that's when you can kind of lose some of the
integrity of the bone. And obviously, even if
you shave off a little bit of the building from
your house, right? Like a little bit's great,
but if you're not replacing it over time, then
your house is going to be structurally unstable
and you increase the risk of something, you know,
collapsing and falling. So very similar to our
skeletal architecture as well as general architecture.
A little bit's fine if you're replacing it, but
if you do that over time, you know, 20, 30, 40,
50 years, that stuff adds up. And I think it's
like, yeah, how can we... We know that it's going
to happen based on what mom said is like when
you're 18 or 25, you build basically all of the
bone inside of your body. That's kind of your
max bone density. And about 60 to 80 % is determined
genetically, as you said, right? So a lot of
it is just kind of predetermined by your parents.
So if you've been dealt a good or bad hand, you
kind of have to know what to do with that information.
And so what can you do going forward to basically
stave off the shaving of that bone? As we're
moving forward. Do I have that correct? Yes.
Okay. So, like Josh referred to, how the bone
is made up and whether or not you've got stability
between osteoblast, osteoclast. And how dense
your bone is, it's called bone mineral density.
No kidding. So anyway, and that's something that
we measure, and we'll get into that a little
bit later when we talk about how to actually
assess whether or not you have osteoporosis or
not. One other thing I wanted to talk about as
far as just how osteoporosis develops, it has
to do, because osteoporosis is seen more frequently
in women of postmenopausal age, you're like,
well, why on earth does that happen? And actually,
it has to do with the fact that postmenopausal
women lose a lot of their estrogen. And estrogen
deficiency is associated with a significant amount
of bone density loss, and it compromises the
bone architecture because estrogen, interestingly,
maintains normal bone resorption rates because
it suppresses the... the growth and activity
of osteoclasts, the chompers, you know, that
break down the bone. And so it's going to decrease
their development, and so it's going to help
maintain good bone formation. But after menopause,
as estrogen levels decline, then you don't have
that... guard against the fact that osteoclasts
want to break down your bone. And so then you're
going to see more of that. And so then you end
up having more osteoclast activity, which are
the chompers that are going to break down your
bone and less bone formation by the osteoblasts.
And so you end up with an increased risk of developing
osteoporosis. So interesting. Yeah. Yeah. And
I also. remember reading that estrogen in women
specifically when they're doing like resistance
training or things with weights or just like
body weights, even things like squats and pushups
is also responsible for breaking down bone and
muscle and things like that. So it's also involved
in this osteoclast, osteoblast thing too. So
men obviously have estrogen inside of us as well
because it gets converted into testosterone.
So it's amazing that this little molecule And
obviously men don't lose estrogen because we
don't go through menopause. So we kind of still
have this molecule to help out with this process.
Whereas women obviously lose a large portion
of it when they go through menopause. So it's
really interesting that it's also, it's a nifty
little molecule that does a lot of things inside
of the body. It does a lot more things than you
thought it did. So also too, as you age. So you
also have an increased chance of developing osteoporosis
because when you get to be 60 years of age or
older, then you will have an accelerated bone
turnover rate and you have a reduction in your
osteoblast bone formation. And so then that's
going to also give you a greater tendency to
develop osteoporosis as well too. So again, those
osteoblasts are not working and growing as fast
as you get older. And then one other term I just
like to make people familiar with, and that's
called osteopenia. So osteopenia is the stage
that you get at between having no normal bone
density, bone mineral density and osteoporosis.
And so osteopenia is defined as reduced bone
density and that bones have a lower mineral content
and are weaker and that they're more susceptible
to breakage and that it can progress to osteoporosis.
Gotcha. So you have normal. osteopenia, and then
osteoporosis. Yes. And it's just a gradual decline
into basically more porosity of the bone because
you're losing density. Right. So there's just
more space in between, less compactness. Right.
Okay. So again, remember, our bones are going
to absorb energy and we step down, we run. you
know whatever and so with that being it being
not as strong it does then give us a propensity
to potentially break a bone yeah my mom always
uh especially during the holidays she always
gets up on counters to reach things because she's
basically she's as small as i am And it is freaks
me out now because I know about this literature
and it was like, she's going to fall one day
reaching for some type of cup and, and, and it's
going to be the end. So, uh, yeah, so far, so
far, so good. I've got good balance so far. So,
um, okay. So then people might say, okay, well
then how do you even know if you've got osteoporosis?
Yeah, that's a good question. So, and again,
we talked about the fact that it's considered
the silent disease because there's often no symptoms
present in the early stages of bone loss. And
the most common symptom is unfortunately a bone
fracture or a bone break. And the kicker or the
characteristics of the fall that may trigger
a like. maybe i have osteoporosis is that it's
a small fall or it's just a minor accident that
in in normal it would never have done anything
to you and now you ended up with a bone break
and you're like what you know and so so that's
kind of a bit of a trigger as to like maybe i
should have this assessed yeah and also a reminder
too that fractures come in very different sizes
right like you get a hairline fracture or like
a pure break like i think sometimes i even my
my A needy thought is when you break a bone,
it's like, you know, like breaking a twig, but
you can definitely just get like a hairline fracture.
That's just this really thin line that can cause
pain and instability in somebody. And the areas
in which fractures happen most commonly in osteoporosis
are going to be in your vertebrae, which are
those bones that are in your spine, your hip,
your forearm, and your humerus. Can you cut that
out? You're going to say uterus. Yeah, that was
wrong. You don't want to have a fracture in your
uterus. So remember, it's your hip, your vertebrae.
Your forearm, because you're going to try to
break your fall, and your humerus, which are
the longer bones in your arm. Yeah, so not your
femur. So that's usually not associated with
that. That is not as much. I mean, you can, but
it's primarily hips because of the way you fall.
That makes sense. But if you don't break a bone,
but you could have these kind of nonspecific
symptoms that may make you think, maybe I should
talk to my healthcare provider about this. If
you lose an inch or more of your height, that's
significant. And so that's really something to
be taught. That's why your doctor's measuring
you when you ever go to the doctor every time,
like how high you are. I mean, especially how
tall you are, especially as you get older, how
high you are. That's a different conversation.
Yeah, there you go. Check our episode on CBD.
Oh, brother. If you have changes in your natural
posture. So if you start stooping more or bending
over, you know, and stuff, that's going to be
kind of a red flag. Like maybe there's something
else going on. If you have shortness of breath,
because if some of the discs in your vertebrae
break, it can somehow impact the whole diaphragm
and your lung and your breathing capacity. And
so you can have shortness of breath. Interesting.
And then also if you have some unidentified or
new or just unaware of low back pain, you know,
like you're not sure why you're having this low
back pain. That also could potentially be a signal
for the fact that you might have osteoporosis.
Another little fun fact, or actually two, Josh
has actually kind of already mentioned this.
So hip fractures cause the greatest morbidity
and mortality in patients with osteoporosis.
The mortality rate can be up to 36 % in the year
following a hip fracture because they become
immobile. A lot of times it's older people. They
can have a predisposition to developing pneumonia.
A lot of times they have to be put in a nursing
home because maybe family doesn't live nearby
and they can't care for themselves anymore. So
it's a big, big deal. The other thing too is
that Once you have what we call a low trauma
fracture, so one of those that you're like, I
didn't do anything. Why on earth am I, why did
this break? Once you have one of those, then
the risk for a subsequent fracture increases.
So having a fracture with osteoporosis is something
we really want to try to prevent. Okay. So who
is more prone to developing osteoporosis? We've
kind of given you a little taste of maybe some
of that. But here's kind of a longer list. So
if you're over 50 years of age, you're going
to be more prone to developing osteoporosis.
And if you're female, and especially if you're
postmenopausal, that just goes with the territory.
White and Asian women, we mentioned this already,
are at higher risk. If you have a biological
family history of osteoporosis. If you're naturally
thin or have a smaller frame, that seems counterintuitive
to me, but that's the deal. Somehow, I think
if you're taller and have bigger bones, that
you would be more likely to have osteoporosis.
I actually think the opposite because I think
if you start off with less bone, then you're
going to lose. What you lose is going to be even
more substantial. And that's exactly what happens.
If you smoke or use tobacco products, that increases
your risk of osteoporosis. Just don't do it,
kids. Just don't do it. Or if you have a diet
that's low or deficient in vitamin D or calcium.
Because you need calcium and vitamin D working
together. Yeah, we're going to talk about that
later when we talk about treatments and stuff.
Yeah, the calcium and vitamin D is an interesting
conversation of how much you need and things
like that. And here's another reason why having
a hip fracture can also just be, just increased
morbidity, mortality. If you have low levels
of physical activity or prolonged levels of physical
inactivity, that's not good for your bones and
stuff. And so, and it doesn't help you. It also
doesn't help you get rid of stuff, you know,
cough stuff out of your lungs and stuff like
that. So it's not good. If you are a chronic
drinker of alcohol, that also increases your
risk of developing osteoporosis. And then there's
a number of different drugs, medications that
can cause or increase your risk of osteoporosis.
We talked about glucocorticoids. There are some
hormone therapies for cancer could potentially
do that. Proton pump inhibitors have a relationship
with developing osteoporosis. Things like Prilosec
and Prevacid. Those are for gastrointestinal.
Heartburn, gastroesophageal reflux disease, peptic
ulcers, those types of things are used in those.
Yeah, I think we did an episode on heartburn
and indigestion very early on. So you can check
out those episodes if you're interested or have
a little bit of interest. And then there are
other medical conditions that could also predispose
you to developing osteoporosis. I thought this
was interesting. Bariatric surgery. There's something
about bariatric surgery that causes you to develop
osteoporosis. Anorexia will do that as well.
If you have thyroid disease or diabetes, it predisposes
you. And then some cancer types and HIV and AIDS.
I wonder with the bariatric surgery, if it's
just because, and with anorexia, it's because
you're not eating as much. And because when you're
not eating as much, you're not getting maybe
the calcium and just the daily caloric needs
that you would need to build up bone, right?
And so, I mean, at the end of the day, you need
nutrients and energy to build things up. So that's
kind of my best guess. I don't really have an
idea why. Let me see if I can look that up really
quickly. Oh, it's okay. Okay. We'll add that.
I was just wondering. Yeah, because I did know
and then I forgot. So, yeah. Because I know that
sometimes people who go through weight loss also
go through their bone mineral density decreasing
as well, which makes a lot of sense because weight
is weight. And one of the things that if you're
going to, if you're going to go through weight
loss journey, whether it be just from cutting
calories or if you're going to do bariatric surgery,
or if you're going to do things like GOP ones,
one of the things that you should really supplement
with is especially protein and also strength
training. Like actually, because what you're
trying to tell your body to do is like, even
though I'm losing weight and fat, muscle and
bone. I'm going to tell my body to, if you have
to direct your resources to anywhere, then you
should probably direct it towards building muscle.
So if you're going to go on a weight loss journey,
it is really good to supplement that with exercise
so that you can essentially keep your muscle
mass and your bone mineral density up while you're
going through that. Yes. I can tell mom's on
a mission right now. She really wants to find
this answer. I know, because I'm like, I read
it. Okay. So, but we'll put a pin in that for
now. And so then, so if you are feeling like
maybe you may be predisposed to osteoporosis
or sometimes your healthcare provider will make
an assessment as you become perimenopausal as
a woman and stuff to give kind of a baseline.
bone density scan to figure out where you are.
So that's basically the kind of gold standard
for determining whether or not - Are we going
to go into diagnostic of like how someone - Yes.
How do you know if you have osteopenia or osteoporosis?
Because like you said, it's silent and there's
no biomarkers for it, but we do have diagnostics
that can tell you where you're at. Right. Okay.
So the - The gold standard is called a DEXA scan,
and it stands for dual energy x -ray absorptiometry
scan. So it helps to determine your bone density.
And there are three areas that are routinely
assessed when you get a DEXA scan. Your lumbar
spine. and both femurs, so both of the heads
of your hip bones. Okay, so the trabecular areas
between your hip and your femur. Right. Okay.
And so your results of a bone density scan, you
end up with a population, you compare it with
a population reference standard, and it's presented
as quantitative value of a bone mineral density
and a T -score. And T -scores are used to compare
to this population reference standard in postmenopausal
women, perimenopausal women, and men over 50
years of age. Or we use a Z -score to compare
it in younger people or premenopausal women.
Isn't it the other way around? Isn't T -score
comparing to the younger ideal? No. T -score
is for older. Z -score is for younger. What I
mean is like, if they give you, because you're
67. Yes. So if they give you a Z score, they're
going to compare it to women your age. I don't
get a, I don't get a Z score. Z scores are not
used in people over 50 years of age. So you're
only going to get a T score just because they're
comparing you to the younger ideal. Right. But
I mean, why wouldn't. I'm sorry, I don't, it's
beyond my pay grade. I don't understand. I mean,
I could go back and read more. Because all a
Z -score is, is like, so we should maybe do a
little basic statistics for folks out there.
So like, I think sometimes when we talk about
things like T -scores, Z -scores, we have to
remember that you're comparing, basically you
want to compare yourself to your peers and say,
okay, my. Most of the time with the DEXA, I actually
just got a DEXA scan a month or two ago with
my lovely girlfriend because we wanted to know
what our bone mineral density was. And it also
is really cool because it measures your lean
mass and your adipose tissue because these are
specific x -rays. If you remember your electromagnetic
spectrum, different rays come in. different wavelengths
so like you have visible light right so you can
go from like blue all the way to red and red
has 400 nanometers blue is around or violet is
around 700 nanometers so they're going to represent
a certain color you can do the same thing with
radio stations too like anytime i don't know
if you all still listen to the radio but if you
tune to 940 fm that's a specific wavelength on
the fm radio station which is you know different
than 1200 um You can do that with x -rays too.
And different frequencies or different wavelengths
of x -rays will interact with different portions
of a tissue. And there's one type of x -ray that
is able to basically go and take a look at your
bones. And then there's one that is able to differentiate
between adipose and muscle tissue, what we call
lean mass. So a DEXA, like mom said, it's a dual
x -ray, which basically means it uses these two
wavelengths of x -ray to look at your body. So
I got a bone mineral density score of 1 .34 grams
per meter cubed or centimeter cubed, not cubed,
squared, because they only compare by surface
area, by two dimensions rather than three dimensions,
because they're coming up with a two -dimensional
scan rather than a three -dimensional scan. And
my girlfriend was around 1 .06. And the question
is, is like, okay, we have these numbers. What
does that mean? So is it right for me to compare
myself to my girlfriend and say, well, hey, my
number's bigger. So therefore, my bones are better.
Well, it's not a good comparison because she
and I are in different demographics. She's a
smaller, younger female, and I'm an older, grandpa
-like man. That's really sick. I mean, you're
not that different in age. It was called a joke.
The idea is like, okay, so my understanding is
in statistics, when you're comparing against
a population, which usually if you've ever seen
like a bell curve before, like I'm just going
to think about it in terms of height, right?
So the average height for a man is I think is
around 5 '8 or 5 '9. So most of the men in the
United States are going to basically hover around
the middle. of that distribution, meaning they're
going to be at the top of that bell. If you can
picture basically a bell, the top of the bell
is going to be where most men are, and you're
going to have a lot more men who are 5 '8 and
5 '9. But there are also going to be extremes,
like the tail ends of those, basically the edges
of those bell. They're going to have men like
me, who are 5 '4 or 5 foot or a lot shorter,
to the left of the top of that bell. And then
you have men maybe to the right of that bell
who might be six foot, seven foot. They're going
to be at the tail end of that bell. And basically
by how many deviations away from the middle,
which we call the median or the mean, we call
those standard deviations, meaning like how many
deviations away are you away from that mean?
And usually we usually deviate as one, two, or
three. If you're a standard deviation of one,
that means you're 82 % sorry, you're going to
basically going to be in the top 18 % of people
in that thing that you're being measured. So
if you're in the plus one standard deviation
for height, you're going to be taller than 82
% of men. If you are two standard deviations
away, I think you're around 95 or is it? Yeah,
95. And then three is 97 .5 % taller than most
men. But if you only had seven foot men in a
population, Like if you had 7 .1 to 7 .7, for
example, the median might be 7 .2, right? So
even you could be in the middle of the bell curve
of people who are only seven foot tall, even
though you're really tall, you're comparing to
this population that's only seven foot tall.
So my point about Z scores and T scores is that
my understanding, at least what I read, is that
a Z score is essentially just comparing you within
people in your age group or in your demographics.
So if you're a woman who is 67, what is my bone
mineral density compared to people who are in
my age group? How well am I doing? And then the
T -score, like you said, is saying like, okay,
how far away am I from my ideal? Like how far
away am I from my 30 to 25 -year -old self when
I was at peak bone mineral density? Because that
is going to show you progression over time, right?
And that's going to be what they're going to
be more interested in. I agree. But I'm just
saying is like there are these two metrics. Because
if I'm a 39 -year -old man. You're going to get
a Z score. A T score is not going to be that
interesting to me. But you can still get one.
Because even though a T score might be interesting
from where you've deviated from, how do you compare
to your peers? Right. So like you said, the T
score is. It's used for diagnosis, and it's a
comparison of the patient's bone mineral density
to the mean bone mineral density of a healthy,
young, which is 20 to 29 -year -old, white female
reference population. It's not adjusted for age,
sex, race, or ethnicity. And the T -score is
the number of standard deviations from the mean
of that reference population. The Z -score is
similar, but it compares the patient's bone mineral
density to the mean bone mineral density for
a healthy sex and age -matched population. You
said it much more succinctly than I did. Yes.
And if you've got race and ethnicity for your
Z -score, that should also be included. Okay.
So it's a lot more specific, but... The T -score
is what is used for treatment and to assess a
bone density scan for an older person. So you're
going to see both use it. It just depends on
which age group you fall in. Well, that's true.
And I think sometimes, you know, the perfect
can be the enemy of the good. So yeah, I think
it's like if you're 67, you're never going to
get back to that. But sometimes you're like,
okay. compared to my peers, how well am I doing?
Yeah. And I don't know, I have to go back now.
And now that we've done this, I need to pull
out all my, my lab results and see if they actually
did a Z score and a T score, just a Z score.
Yeah. Just as, so just to make this point more
clear, like I got my bone mineral density and
it was 1 .34. And I think I was in the, I think
I was a standard deviation away. I think maybe
0 .5 standard deviations away. So I was in good
shape compared to most men in my demographic.
But when I looked at other bone mineral density
metrics in the literature comparing with other
men my age, it was around like 1 .1. So like
the metric that was, it really does depend on
the population you're measuring against. So like
if I'm people who go get DEXA scans. It might
be something called a selection bias. So people
who actually voluntarily go get DEXA scans might
be, we call it a healthy user bias. So it's like
people who are more conscious about their health
might be healthier, have higher bone mineral
density or higher lean mass tissue. So you can
actually get a false sense of where you are or
even an undersense of where you are if you're
comparing yourself to a healthy population. So
that's why it's really good to look at a... your
sample is really important of how you're comparing
yourself to. Because I did this for my girlfriend
as well. And compared to the population she was
comparing herself to, she was quite low. I think
she was in the minus two to minus three standard
deviations away from the mean within people who
get DEXA scans. But when I looked at the literature
in places like South Korea and even the general
United States, She was actually above average.
So it really does depend on the population. So
if you get these numbers and you're comparing
T scores and Z scores, depending on if you're
older or younger, it is really important to know
what population you're referencing against. Because
like mom said, knowing how far, especially for
a T score, how far under you are the ideal is
going to really help you figure out like, okay,
how much bone mineral density have I lost over
time? Because if the average bone density for
a woman at 25, or it's just the average. 20 to
29, I think was that standard. And if that number
is like 1 .25 and you're at a one, then you're
pretty low. And that's going to be pretty worrying,
you know, as you're going forward. So brief statistical
lesson. Thank you. So in order to interpret your
results, once you get a DEXA scan, it's based
on these T -scores. And so if you have a T, so
again, remember the T -score shows how much your
bone mass differs from an average healthy young
adult, and it's primarily a female young adult.
And so if you have a T -score of minus one or
higher, that's considered normal. If you have
a T score between minus one and minus 2 .5, and
these are measured as standard deviations. So
it's minus one standard deviation or higher is
normal. So if you have a T score of minus one
standard deviation to minus 2 .5 standard deviations,
this is what's defined as osteopenia, where you
have low bone mass and low bone density. And
if you have a T score of less than... negative
2 .5 standard deviations, then you have osteoporosis.
If you have a Z -score, if you're getting a Z
-score, and remember Z -scores are used in children,
premenopausal women and males under 50, premenopausal
women and males under 50 years of age. And that,
the number that you're looking for is to not
be less than two. Yeah, that makes sense because
I'm thinking about this now is like, yeah, a
Z score when you're probably past menopause is
not going to make sense because your hormone
profile, especially as a woman, is going to be
a lot different. And also. comparing within your
population, assuming maybe a lot of people have
osteopenia and osteoporosis, it's not going to
do a great job of saying like what you should
be. Right. Because that's a great point. Yeah.
It's like, because it's like, uh, it's comparing
two sick people. Yeah. Or it's like if everybody
in the class failed the exam, like you, you wouldn't
say like, well, the person who got the 58 got
an A and the person who got a 28 got an F and
it's like, no, you all got Fs compared to the
standard that I set, which is A is an A grade
is 90 to 100. So that makes a lot of sense that
you would set it against an ideal rather than
just a general population. If by chance you don't
have access to, or you can't, or you choose not
to have a DEXA scan, there is another risk assessment
that's available. It's called FRAX, F -R -A -X.
And it actually calculates an individual's percent
probability of a major osteoporotic. osteoporotic
fracture and hip fracture over a 10 -year time
period. And it uses factors that significantly
increase fracture risk, like age, gender, low
body mass index, a previous fracture, hip fracture,
in a parent, treatment with glucocorticoids,
whether or not you smoke or drink alcohol. And
the other causes of secondary osteoporosis. And
so then you're going to get this assessment and
it will tell you whether or not you are likely
to develop an osteoporotic fracture. And it determines
an overall risk, including your spine, your shoulder,
your forearm, and your hip. The scores are percentages
and they're typically interpreted if you have
a... FRAX assessment of a percentage score of
20 % or greater for a major fracture or greater
than or equal to 3 % for a hip fracture, that's
going to help you be guided as far as treatment
for low bone density. So that's not good. If
you have a greater than overall 20 % risk of
fracture or greater than 3 % risk of hip fracture,
then probably something needs to be done. OK,
so we're going to focus on now prevention. Like
what on earth can we do to keep this from happening
or or at least make it happen far in the future
or maybe not to the degree that. Yeah, if you
if you picture the if you picture kind of bone
mineral density, kind of like a downward slope,
like a ski slope. Right. Like how do you. Make
it go. Basically, how do you keep the slope nice
and shallow rather than nice and deep? Because
the unfortunate thing is that it's going to happen.
Your bone mineral density is going to decrease
over time. So how do you keep that thing shallow?
Yes. Okay. Yes. How do you keep it shallow? So
again, so prevention is really the primary goal
for osteoporosis. And so the way to do that is
what we call a bone healthy lifestyle. And you're
like, what on earth is a bone healthy lifestyle?
And actually this should begin at birth and continue
throughout life. Well, if I'd only known with
my kids. Well, luckily my bone health is pretty
good at the moment. So, but you're right. I'm
already born and I've gone through 39 years of
this life. So what do I do? 39 yet. I'll be,
oh yeah. So anyway, so you start out with a well
-balanced diet. And so you want to make sure
it has enough calcium and vitamin D and protein
in it. And so we've got a lot, now that we've
got labels that tell us what's in everything,
that finding out what's calcium rich and protein
rich is not as hard as it used to be. Yeah, the
recommended dosage for calcium. um, for minimum
dosage to get what you think is between a thousand
to 1200 milligrams a day. Although I think with
women and postmenopausal women, it's, it's 600
milligrams a day. Um, I, and, um, I think, I
think that you can take more, but taking an actual
supplement because you get it in another, other
things as well too. And interestingly, um, As
the older you get, higher calcium may potentially
increase like your calcium score in your arteries
and potentially contribute to plat formation.
So it's kind of a balance. So the recommendation
is usually about 600 milligrams a day for a postmenopausal
woman. Okay. So you kind of have to balance the
trade -off with some calcium being deposited
in your arteries as opposed to going to these
osteoblasts that are going to be. When you're
younger, you don't have to think about that quite
as much and stuff. So, yeah. Okay. So, but if
you're going to get, let's say, so between a
thousand and 1200 for a normal person, and then
maybe down to 600 for post -menopausal women.
Great. And then also things like vitamin D, maybe
we should go through that pathway of how, why
vitamin D is important. Okay. Go ahead. So I
think a lot of people hear about vitamin D. It's
one of the, I feel like it's one of those things
that's maybe inappropriately seen as a panacea.
But vitamin D, in terms of this and this context,
it is responsible for essentially taking calcium
out of your gut and delivering it to your bone
so that osteoblasts can use it to build up your
bone. Mom's going to hopefully help correct me
a lot of these things because it's... You can
ingest it by a supplement, but I'm just going
to talk about how it's naturally made first.
It is made by something called your parathyroid,
which is the thyroid is in your neck. If you
kind of look up and you kind of look at a man's
like an Adam's apple. And if you're from Texas,
you can do the hook them sign unless you're an
Aggie. And I apologize. But if you look at one
of those obnoxious people from UT or the rock
on signal. If you look at if you kind of do the
like rock on, dude, if you do that with your
hand, the parathyroids are at your pinky, your
pointer finger and the bottom right and left
of that rock on. So they're a portion of your
thyroid gland. And those things are responsible
for secreting vitamin D2, which then gets converted
into its active form, which we call vitamin D3.
And vitamin D3 is responsible for taking calcium
out of your gut, which is usually you consume
calcium by eating things, things like yogurts
and milks and things like tofu. And then it takes
that calcium and then will deliver it to the
bone. And probably a lot of other complicated
pathways that I'm not aware of that maybe you
can fill in if you want. Yeah, so it's also used
in the heart to make the heart beat pump as well
too. Oh, because of those for the ion channels?
Yeah. Yeah, okay. So calcium is important in
a lot of things. And then it gets deposited there.
And probably people have heard that you can get
vitamin D produced by sunlight. And I think a
lot of times people don't realize like... how
little you need in order to make vitamin D3.
Because the sunlight is actually there to activate
to go from vitamin D2, which is the inactive
form, to vitamin D3, which is the active form.
And based on some of the literature I read, you
only need about 10 to 20 % of your body uncovered.
And that usually means your face, your arms,
maybe a little bit of your legs and your midriff.
If you're a woman who likes a little crop top,
you know, you can show your belly a little bit.
Mom's shaking her head. So modest. And I like
it. And so, but you can only have to really expose
that from midday, 10 a .m. to 4 p .m. when you
get kind of maximum sun exposure. And about 24
minutes will actually, 24 minutes of sunlight
can stimulate the maximal production from D2
to D3 of what you need inside of your body for
the day. So usually vitamin D supplementation
is mainly for people who just don't have a lot
of access to sunlight or they're working a night
shift and they're not just able to be out in
the sun. So really a little goes a long way when
you are getting that vitamin D2 to vitamin D3
synthesis from sunlight. And if you do need a
little bit of supplement, there are ways to do
that. And you can maybe take, you know, what's
the recommendation like? 1 ,000 international
units, or maybe it's like 400 international units.
I think it may be 600, but with postmenopausal
women, it goes up to 2 ,000 a day. But also,
too, the whole sunlight thing with vitamin D
conversion, it's not as... It's not as much,
it's not as concerning as it used to be because
we've got so many foods that are fortified with
vitamin D, our milks, our juices and cereals
and stuff like that. So we're able to get it
even if we don't get out. So even from a standard
diet, a lot of that has been fortified with vitamin
D. Yeah. Okay. Excellent. Yeah. That's wonderful.
And they fortify with the active component, I
imagine. Okay. So again, we've got that well
-balanced diet as the first leg or arm or tentacle
in our bone healthy lifestyle. The second is
to minimize caffeine consumption because caffeine
is associated with an increased calcium excretion.
And so it's going to increase rates of bone loss
and it can modestly increase your fracture risk.
So you want to make sure, I believe it was. Oh,
golly, two cups a day of coffee, you know, kind
of the equivalent and stuff. That is the standard
kind of safe dosage. Then the third part is to
avoid or quit smoking because smoking can reduce
calcium absorption. It lowers vitamin D concentrations
and it can increase bone resorption. So it's
not a good thing. Alcohol, we want to limit as
well, too, because it also increases bone resorption
and decreases bone formation. So we've got, so
far, we've got a well -balanced diet. We want
to minimize caffeine consumption. We want to
avoid or quit smoking. We want to limit alcohol
intake. The fifth one is to do weight -bearing
or resistance exercises. So you're going to increase,
I thought this was really fascinating. You increase
bone strain, especially in your weaker bone,
which then will stimulate osteocytes, which will
then lead to bone resorption. which then increases
stronger bone formation. Gotcha. So by stressing
your bone, you kind of say - You break it down
to build it back up again. Oh, that's really
interesting. Yeah. Yeah, I have this great chart
because I think a lot of times people will be
like, well, what type of exercise is best to
kind of build up muscle? And actually, if you
look at individuals who have the highest T -score
or the highest bone mineral density, um college
football is actually goodness gracious but that
comes with a lot of other risks and a lot of
people aren't playing college football and this
is this was a study done amongst uh athletes
uh athletes who essentially are engaging in things
non -professional okay um so all the way at the
bottom was swimming okay so swimming has the
least modest effect on bone mineral density score
Um, and probably right in the middle, probably
where most people are going to want to, uh, engage
in, um, is something like, uh, uh, distance running
or resistance training, resistance training,
especially in females. So, uh, resistance training
is essentially any like pull -ups, small weights,
squats. And one of the things that you can do
that if you're like, I don't want to do any of
that because I just don't like, you know, vigorous
exercise or going to a gym. There's this new
kind of trend called rucking. It's R -U -C -K
-I -N -G. And it's essentially just wearing a
weighted vest. And by wearing a weighted vest,
you add some, like mom said, you add some resistance
onto your frame. That essentially causes your
muscles to go, Ooh, there's some extra weight
here. Like I'm going to signal this pathway,
these osteocytes to break down and then build
back up a little bit better. So if you like to
go on a morning walk, if you're walking your
dog and you want to just say, I want to just
enjoy my walk in the morning and not kind of
add any additional stress. Rucking is actually
a great way to add some additional weight, especially
if you're going to be up and down hills. Elevation
is huge because that kind of forces your muscles
to like either push more effort as you're going
up the hill. And even going down the hill, you'll
be bracing yourself, which can also help strengthen
your bones and your hips, which a lot of times
fractions can occur. And in your lumbar. And
in your lumbar. So as you're getting older, it's
like, okay, where is the risk going to be the
greatest? And as we've talked about, the lumbar,
the vertebrae, the forearms, the hips. Humerus.
And the humerus, which is the bone in your arm.
Between your shoulder and your forearm. Because
a lot of times that's when you're bracing yourself
for when you fall. Or falling on your shoulder
kind of thing. So this is a great compromise
for anybody who just wants to get a little extra
exercise. And for all you men out there who feel
like my bone mineral density score is fine. It
also helps. raise your heart rate a little bit
more, which is great because then you essentially
are getting into something we call zone two cardio,
which is also associated with decreasing mortality
as you go on. Cause you're causing your heart
to, to work a little bit harder, even with a
basic exercise. Um, this, this, um, remind me
that the term again, rucking, are they, are there
different weight? Um, are there different weights
for the wrecking vest? There are, you can get
from, and it probably, it probably helps. Like,
so you would probably need one lighter than me
because there's like eight pounds, 12 pounds,
16 pounds. So very similar when you're at a gym
and you're like, okay, what do I want to lift?
Do I, do I want to, do I want to lift 35 pound,
uh, barbells or dumbbells, or do I want to do
five pound? It's, it really does depend on what
you're trying to accomplish. But I think the
biggest thing is like, do I feel enough resistance
so that I can walk and talk while not, while
being maybe slightly out of breath, but not completely
out of breath. Got it. And I think that is the
best thing to shoot for when you're exercising,
because that means that you're working your heart
enough to give yourself a little bit of like
metabolic boost, but not enough to like, that
you need to like puff and puff. Yes. So getting
kind of that, that zone two cardio sweet spot.
Okay. That's a great recommendation. Thanks,
Josh. Okay. So again, remember for this bone
healthy lifestyle, we've got a well -balanced
diet. We want to minimize caffeine consumption.
We want to avoid or quit smoking. We want to
limit alcohol intake. We want to do weight bearing
or resistance exercises. And the last one is
fall prevention, which is very important. So
that you're looking, especially as people get
older, you want to look at your environment.
The big thing is like moving rugs, slider rugs
out of the way, slippery type floors, things
that you could trip over. And also... You want
to make sure that medications that are prescribed
don't cause you to get dizzy or lose balance
because that can also increase your fall risk
as well too. Okay. So thankfully, in this day
and age, there are a lot of medications that
can be used to manage osteoporosis. Pardon me.
And all of these agents are used in concert with
taking calcium and vitamin D because we need
that for just our bone health. Usually when you're
treating osteoporosis, you might start with what
we call a bisphosphonate, which is... or alendronate
or Fosamax. And I'm not going to go through all
of the medications as far as all their dosages
and all that. I'm going to give you some little
nuances with each one of them. I did find a meta
-analysis of a lot of these medications that
were done and they gave this nice little, it
wasn't a scatter plot. Forest plot? Yeah. And
so essentially lined up of like, what were the
odds ratios of decreasing? you know, osteoporosis
over time. And they gave them with confidence
intervals as well, which I thought was helpful.
It was a good visual. Because especially for
like a drug that says that, you know, it decreased,
the odds ratio was like 42, but the confidence
interval was like, you know, it's like, okay,
this isn't going to be that significant. Yeah.
So oral bisphosphonates or bisphosphonates, they
work by inhibiting bone resorption. So again,
they're going to help stop the bone from breaking
down. And so they don't have great bioavailability
with the oral ones. There are some injectable
ones as well too, but the oral ones is kind of
where a lot of people will start when they're
going to treat osteoporosis. So one of the kickers
is that when you take it, you have to get up
and you have to take it 30 minutes before you
take anything else with a small sip of water.
And you have to stay upright for 30 minutes because
if you lie down, it has some irritant properties
in your gastrointestinal and your gastrointestinal
tracts, your esophagus. And so you're going to
avoid that. So that's, I've taken it in the past.
It's not really a big deal. And you can take
it once a week. And so that's a great, so you're
not taking it every day, but once a week. And
when you take, what the data have shown with
bisphosphonates is that you can reduce your vertebral
and hip fractures and your non -vertebral fractures
by, you know, a variety of percentages you know
from 40 from 20 to 50 percent and with your vertebral
fracture it can decrease it by 70 percent wow
so and you can have some changes in your bone
mineral density anywhere from your spine up to
six percent to your hip up to four percent you
said increase it increase wow that's nice agents
are are you know they're they've definitely you
know found found some efficacy but If it stops
working or you can't tolerate it for whatever
reasons, and so there are other agents as well
too. One of the ones that we've probably seen
in the past commercials for is denosumab, which
is also known as Prolia. It's an injectable.
It's a subcutaneous injection that you get twice
a year, and you have to go to get it from a healthcare
provider. And again, it is an agent. It also
slows bone breakdown. So it's going to decrease
bone resorption. So it's going to work on those
osteoclasts to keep them from acting. Does it
have a different mechanism of action than the
bisphosphonines? It does. And again, it's because
of that whole complicated... Yeah, we will have
to get into it. It's called a wrinkle inhibitor.
So yeah, so it works on another pathway in the
bone to help build it up. So again, it's pretty
effective as well too. It will decrease vertebral
fractures by 68%, non -vertebrals by 20, hip
fractures by 40, and it can increase spine bone
mineral density by 9%. hip bone mineral density
by six. So it's a little bit better than a bisphosphonate.
Then there are a variety of other things that
can be used as well too. Let's see, what else
can I pull out? One is called a tissue selective
estrogen complex. It's a conjugated estrogen
combined with something called basodoxivine.
And so interestingly, this agent is primarily
used In postmenopausal women, it's FDA approved
for postmenopausal women that also have vasomotor
symptoms associated with menopause, that estrogen
part. So the estrogen is definitely going to
help with the bone part, but we don't prescribe
that as much as a single agent anymore to treat
with osteoporosis. And we'll get to that in just
a second. But this combination agent has been
shown to be effective in managing osteoporosis.
Okay, wonderful. Seems like we got a lot of pharmacological
tools. Another one is called a parathyroid. This
one is interesting. The parathyroid hormone analogs.
There are two of them. There's a baloparotide,
which is Tymlus, and teraparotide, which is Forteo.
They actually work to increase bone formation.
And it's the only one I believe that's affiliated
with bone formation. But the interesting thing
is that you can only use it for a maximum of
two years because that effect will decrease over
time. And there's also been some bone sarcomas
shown in rats. So they cap the duration of this
medication for two years because of that. Is
a sarcoma the cancer of the bone? It is. Okay.
And just to remind people of parathyroid, what
we talked a little bit about earlier. Parathyroid
is responsible for releasing hormones that stimulate
vitamin D release and conversion from D2 to D3
in the body, which then builds up bone. So it's
probably acting upon that pathway. Yeah. These
agents don't have as much impact on hip fractures
as they do vertebral fractures. So that's another
factor as well too. So yeah. So maybe if you're
suffering from vertebral fractures rather than
the others. Well, I guess. I guess how would
you, I mean, you're essentially just trying to
do prevention, right? Right. Because you wouldn't
get it after you got a fracture. You may have
had a DEXA scan already, you know? Yeah. Or maybe
you're trying to prevent another one in the future.
It's like, okay, how do I stop a vertebral fracture?
In the osteopenia range and you see that your
hip T -score is worse than your, I mean, I'm
sorry, your vertebral hip score is worse than
your hip score. Yeah, so how can I get my vertebrae
similar to my hip? That makes sense. One agent
that is newer is called Romasozumab, or it's
known as Avenity. It's called a sclerostin inhibitor.
And so what it does is... It is both an anti
-resorptive agent, so it's going to stop the
bone breakdown, but it also causes some buildup
of bone formation as well too. Okay. That's nice.
Double action. Yes. And it has to be, and again,
this is something that if you have never gotten
a DEXA scan and then you get it and you've got
a really bad T -score, this might be something
that your physician might go for first. first
line because they're trying to keep you from
having a bone fracture. Like I said, it inhibits
both bone resorption and it stimulates bone formation.
It's given as a monthly subcutaneous injection.
So monthly subcutaneous injection, but you have
to go to get it by a healthcare provider. And
it's only 12 doses. So you only get it for a
year. And then after that, you've got to then
have continual therapy either with something
like a bisphosphonate like a lindernate or like
something like prolia okay so you get you take
it for a year and then it's not like you're one
and done you need to keep kick starts the system
and then you got to maintain it absolutely so
um the only other thing that i want to mention
as far as treatment is concerned is estrogen
replacement therapy and so in some women that
might be used but it's not first -line therapy
So estrogen, remember, it promotes the activity
of osteoblasts. So it's going to help build your
bone back up and it helps to make it stronger.
And so, and it's going to help reduce bone loss.
But there have been some risks associated with
estrogen therapy, especially if you don't take
it with a progesterone. So you can increase your
risk of endometrial hyperplasias or cancers in
your uterus. There has been an associated with
breast cancer, heart attacks, blood clots and
strokes. But I think just recently they have
modified the... package labeling for estrogens
because I think they've learned how to make the
dosages lower and they still work so that in
a particular circumstance, your physician might
be able to give you one, especially too, if you're
having menopausal symptoms as well. Also that
the study that information came from was called
the Women's Health Initiative, which was, I believe,
done back in the 2000s or the 90s. I think it's
about 25 years old, yes. It was interpreted incredibly
cautiously, meaning that if you looked at the
control arm versus the experimental arm where
the women got hormone replacement therapy, the
number of cancers that the experimental arm got
was four. Women who got a cancer diagnosis and
died from cancer, the control arm was three.
Wow. They reported a 25 % increase, which is
true, but it's literally just one more person.
And just to show you that if you want to be overly
cautious with certain data, you can definitely
make a claim. It's like, well, 25 % more women
got cancer, but it's such a low sample that I
think it got overly interpreted and a lot more
harm. It was caused by women not getting hormone
replacement therapy after menopause. And so I
think we're seeing a reversal from this FDA to
basically say there might be a better road if
women are able to more easily get hormone replacement
therapy. If you've been having menopausal symptoms
for... you know, a decade or more, then sometimes
the estrogen replacement therapy doesn't work
as well as when you first started menopause.
So that has to be factored in as well. Yeah,
there does seem to be a window. It may help with
some of the symptoms, but not all of them. Yeah,
it's going to be an interesting road to see this
become more popular and just to see, yeah, like
maybe some of these conditions like will bone
mineral density get better on women who have
hormone replacement therapy? Yeah, we'll have
to look at that in a couple of decades, right?
Yeah. You're definitely going to be around. Yeah.
I would love that. We can do more episodes. There
you go. There you go. Yeah, me, my 80 -year -old
self. I think, so it seems like one of the easiest
things that you can do, no matter how old you
are, is to go get something like a DEXA scan
or a bone mineral density scan. And I got one
the other day for $60. These are, there are obviously
machines that are better than others. Like if
you really, from what I've read, you can get
a more specialized bone mineral density scan.
that will actually analyze your bone mineral
density depending on the region of your body.
So it'll separate between vertebral, femur, hip,
et cetera. But if you just get, the one that
I got was just a whole body and it just kind
of gave you an overall bone mineral density scan.
I think that's fine, especially if you're young,
but if you're someone who is of like, if you're
65 or older, especially if you're a woman who's
passed menopause, it might be a good idea to
get one of those more expensive bone mineral.
bone mineral density scans so that you kind of
know what you're working with. I think more data
is better so that when you go to your primary
health, primary care doctor, that you can essentially
say, hey, these are my numbers. How would you
go about treating this? And in order to get a
bone mineral, a DEXA scan, you need orders. You
need a prescription. So you can't just walk into
a imaging center and just request a DEXA scan.
That's not true. I didn't need an order. Oh,
I always have to have an order. Oh, no. You can
just go in and get a DEXA scan. Oh, well, that's
news to me. Well, thank you for enlightening
me. Do you want to go after this episode? No,
I really don't. I've had enough. No, they're
all over the place. So the one my girlfriend
and I use is BodySpec. Okay. I went to an imaging
center. Well, you could do that, but there are
places that just offer DEXA scans. Okay. I'm
going to do one every six months now because
it's one where you essentially can kind of see
your progress. I would not do it every six months
personally. Well, it's not just for bone minerals.
I'm talking about for lean mass and body fat
percentage. You can also measure that. But we
digress. We do. But the point is that this is
a very affordable, very accessible technology.
If you do not need a prescription. to get these
scans. And they are a great tool to have, even
just from your personal health. And even there
are certain AI tools coming online now, like
ChatGBT even has a health portion of their chat
that is HIPAA compliant. There's also something
called Open Evidence, which is also HIPAA compliant,
that you can use these scans and type in and
say, hey, this is my DEXA scan. What would you
advise based on this scan? And it can give you
some really good information that you can also
use to take to your primary healthcare doctor
as well. I just Googled, I'm so sorry. I just
Googled whether or not you need a prescription
for a DEXA scan and you do. You don't. I went
and got a DEXA scan. But are you sure you got
a DEXA scan? Yes. Okay. All right. Well, all
right. That's fine. Okay. I don't know. I don't
know what you're looking up. I said, do you need
a prescription for a DEXA scan? And you just
trust the first. It's AI. But it's like, no,
I'm just, I guess my, I guess I'm, I guess, yeah,
these body spec places, I don't know. They don't
require a prescription. Correct. So, and I don't
know if it's the same thing or not. This is good.
This is healthy skepticism. Yes, it is. Right
at the end of the podcast. Because it says, okay,
oh, you know what it is? I know what the difference
is. Tell me. You're getting, so I think we're
both right. Okay. Yours is just like a informational
wellness scan, but mine is a diagnostic scan.
And so a diagnostic scan does require a prescription.
So it's just how it's classified. Yes. Yeah.
So I'm just getting information. Your DEXA scan
is just saying this is an actual diagnostic.
Right. Okay. Yes. And it's probably your, your
machine is probably better. Like it's probably
going to be more specific. Mine's probably not
the, the waves being used are probably just very
general. So I totally agree with that. So I think
just if you're just basically curious, yeah,
do the body spec one or something that is just
commercially available. But yeah, I, even if
you're doing something commercially available,
you don't have to interpret it on your own. I
think that the whole point is to say. I got these
numbers. I got it from this place. Your physician
or whoever you deal with is going to know how
to interpret those numbers. Right. So let's talk
a little bit about this. This will kind of help
us review and summarize kind of what we've talked
about over the last hour or so. So what are some
common misunderstandings or myths related to
osteoporosis? The first one is, and we've...
pretty much dealt with this, that osteoporosis
only affects elderly women and is not found in
men. Well, this is not true. It actually can
be found in all ages and genders, even though
it is more common in older women. Men definitely
develop osteoporosis at lower rates than women
do. Women are four times more likely to develop
osteoporosis because of the whole estrogen deficiency
issue that happens. And it can happen in younger
individuals, especially if they've got some underlying
medical conditions that will contribute to that.
About 54 million Americans have osteoporosis
and low bone mass. And it is suggested that one
in two women and up to one in four men 50 years
and older will break a bone due to osteoporosis.
So it's not something to just kind of brush off.
The second myth is osteoporosis is inevitable
as people age. It's not an inevitable consequence
of aging, but there are some factors like we've
talked about that can contribute to a greater
risk of developing it. But if you do adopt a
healthy lifestyle that we talked about, remember
the good diet, exercise, avoiding smoking and
alcohol, preventing falls, that will help reduce
your chance or help. slow that angle that Josh
talked about as far as bone loss is concerned
and help prolong the time before you might have
some issues with osteoporosis. This might be
kind of redundant, but only frail individuals
develop osteoporosis, and that's not true. You
can have a, I mean... I was not frail when I
was diagnosed with osteoporosis and stuff. So
it's like it just can happen. Again, remember,
we've got all those factors that can contribute
to it. How old were you when you got diagnosed?
I was in my late 40s when I was diagnosed with
osteopenia, and then it just kept getting worse.
Had you gone through menopause? I was perimenopausal
at that time. Okay. Yeah. The fourth myth is
osteoporosis doesn't cause symptoms until a fracture
occurs. And while that's generally true, remember
there's some things that might be happening in
your body if you're starting to have some more
severe osteoporosis. Remember we talked about
you could have lower back pain or you could lose
height or you can have a curvature of your spine.
So those could be things that you're like. Why
am I hunched over all of a sudden, you know,
and stuff? So, yeah, so that's just something
to be considered. The fifth myth, the fifth myth,
drinking milk alone is sufficient for preventing
osteoporosis. And as we've kind of talked about,
that's not true because you don't just need calcium
to prevent osteoporosis, but you need vitamin
D as well as protein and then also resistance
training and some other things to help prevent
osteoporosis. Yeah, because, I mean, calcium
also needs to be absorbed from the gut. And also
it goes to a lot of other places as well. I know
that magnesium is also important. Right, that
magnesium is another one, phosphorus, vitamin
K. Yeah, so a lot of these can be really important
for, because mom says this, like bone is not
this simple just repository. For calcium, it's
this whole matrix composed of a lot of things.
It's actually a living kind of organism kind
of thing. I mean, obviously it's inside of us,
but it's quite fascinating. Yeah, it really is.
Especially those trabecular areas where it's
kind of the more where your joints are. And that
is kind of the area, especially as women go through
menopause, that is the area of bone mineral density
that really falls off. There's this great graph
where it's like men and women in the cortical
areas, like the long shaft of your bone, fall
about the same rate. But the trabecular areas
where women, especially peri and post menopause,
really fall off. So it is really important. For
that area, because that's usually where those
hip joints and the vertebral joints are where
a lot of those fractures can occur. Right. Because
if you fall, you may fall right on that area.
Correct. Okay. The sixth myth. Osteoporosis is
untreatable once it's diagnosed. And although
it can't be cured, we've just identified there's
a variety of things to do to treat osteoporosis.
We've got so many things available now that we
didn't have. even 10 years ago. So there's a
lot of things that your healthcare provider can
use to help you manage your osteoporosis. Next,
osteoporosis risk. So I don't have any osteoporosis
risk factors, so I don't need to be screened.
And so you can think like that, but you might
have some other underlying things that are happening
or you remember you can't see what's going on.
So I didn't think I had any other than drinking
a lot of Diet Coke, which probably did contribute
to it. But you think, oh, that's no big deal
and stuff. And so then you end up with some issues
and stuff. So it's not a bad thing to get screened,
especially as you get older, especially as a
woman, to just see where you stand and where
your baseline is. I think you're referring to
the caffeine and the Diet Coke, correct? Yes,
I am. Yes, okay. Yeah, because a lot of people
are scared of Diet Coke for other reasons that
are unfounded. No, it's the caffeine. Yeah. Yeah.
Okay. Here's a myth that's completely not true.
Osteoporosis is a cancer of the bones. Absolutely
not. It is a bone disease, but it is not a cancer.
Again, it causes your bones, remember, to become
thinner and weaker because of the whole osteoblast
effects with getting less osteoblast building
activity and greater osteoclast or breaking down
activity. So here's the next myth. Screening
for osteoporosis isn't easy, and there are high
risks of exposure to radiation. This is not true.
It's a really easy test. It takes about 20 minutes,
maybe 30, depending on just what they're looking
at. It's painless. It's performed on this thing
called a bone densitometer machine, and it's
very similar to having an x -ray. And you lie
down while it's being done. And most of the time,
you don't have to change into a gown. They just
do it through your regular street clothes. So
that's even an extra step. Radiation is involved
in it, but it's typically less than the amount
of radiation you get when you have a regular
mammogram. So I think it's a safe way to assess
osteoporosis. Correct. Yeah, and the dose makes
the poison. You probably wouldn't want to get
one every day, but compared to, like mom said,
a mammogram or even just a regular x -ray that
you're getting, it's very low. And as far as
frequency of DEXA scans are concerned, we didn't
talk about that, but typically I think that there's
a variety of recommendations. Some healthcare
providers may not give you another DEXA scan
while you're taking a medication for it. My health
care provider usually repeats my DEXA scan every
two to three years just to make sure that I'm
stable. If you are discontinued off of an agent
for treating osteoporosis, usually they'll repeat
it maybe in two to three years to see that you're
stable. And if not, then you may need additional
treatment as well, too. So if you have a negative
scan, though, this is another myth, then you
don't really need another one in the future.
Well, we know that's not true because we keep
changing and our bones do keep changing and maybe
not for the better. They typically change for
kind of a little bit for the worse, depending
on, even though we're maybe doing good bone health
and bone healthy lifestyle because of just aging
and things like that. So it's a good idea every
several years to get an update on it. And usually
your healthcare provider will recommend that.
And finally, the last one, but breaking a bone
is not detrimental as it happens to everyone.
And this is really not the case. And hopefully
we've driven this point home, that breaking bones
is really serious. They're physically painful.
When you break a bone, it hurts, but it also
can result in emotional and mental health challenges.
And you can also have loss of mobility and independence.
And like I said, sometimes it can cause an older
person to have to be placed in a nursing home
facility, which is not a great thing. And so
recovery can sometimes take months. It can require
surgery, weeks of therapy, and you have to change
your whole lifestyle. So it's a huge deal, especially
if you break a hip or you have a fracture in
your lumbar area. So you want to try to minimize
that. Osteoporosis fractures, remember, they
don't have to be caused by trauma, but can happen
simply. This is kind of the scary thing, especially
if you don't know what your T -score is. They
can happen simply by bumping into something.
You could bend or lift something and just do
it the wrong way and it can fracture something.
Or you can have a minor fall or even coughing.
So depending on how fragile your bones are. So
bone fractures are a big deal. Or one of those
big sneezes that you feel like are just going
to destroy your life. Yeah, that's not good.
So just to draw everything to a close, we want
to remind you that osteoporosis affects primarily
older women, but it can be seen in all ages and
genders, races as well too. We want to encourage
older people with a fragility fracture or anyone
with osteoporosis symptoms to be screened for
osteoporosis via either a DEXA scan or a FRAX
assessment to just make sure where you are, to
make sure that what's going on with you as far
as these fractures are concerned, that there's
not this underlying condition known as osteoporosis.
Many medications are available that lower osteoporosis
-associated hip, nonvertebral, and vertebral
fractures, and we're really thankful for those.
And finally, osteoporosis prevention begins at
birth and continues throughout our life by practicing
a bone healthy lifestyle. That's right. So refer
back to our bone healthy lifestyle, which is
have a good diet of calcium, vitamin D, magnesium.
You should be exercising, especially in terms
of things like resistance training, rucking,
and sometimes even distance running. And avoid,
minimize caffeine consumption, stop smoking and
limit alcohol and, and fall prevention. Okay.
Well, with that being said, I feel good all the
way down to my bones, you know? Yeah. Yeah. I'm
glad you do too. Well, we so hope that you learned
a lot on this episode today. I know I did just
like, I'm just be very grateful. I mean, one
of the things that I, that I learned from my
DEXA scan, is that when I looked at my skeleton
and just all the meat that was around, I'm like,
I'm so thankful for my bones. They really don't
weigh a lot. And to look at your skeleton and
how they carry your entire body is really wonderful.
And not only that, but they also supply you with
B cells and T cells from your bone marrow. And
they're just wonderful little organs. You know,
next time that you feel a pain in your bones,
maybe cut them a little bit of slack because
they've been carrying you around for a real long
time. There you go. And I just looked up too,
our average human skeleton weighs 22 to 26 pounds.
Wow. So the rest of it is all the other stuff.
So 24 pounds of my skeleton potentially is carrying
the rest of the 140 pounds that's associated
with me. That's amazing. There you go. Well,
sweet. Well, until next time. We're going to
talk about something else, but we hope that you
learned a lot and we'll see you next time on
another episode of Your Mom on Drugs. My name's
Josh. And I'm Jenny. See ya. See ya.