Bone Loss: avoid the hard sell
We don’t all need DEXA to assess our risk of FRAX-ure

Coralee Thompson, MD

It seems like everyone is getting bone scans to check the levels of bone loss. Most of these people are told they have bone loss, but they’re not told that it’s quite normal. The recent push for bone mineral density studies – such as the DEXA scan – represents another example of excessive medical testing that leads to over treatment, potentially doing more harm than good. Not everyone should be tested, nor should all women be tested. Medications to treat osteoporosis do cause unwanted and dangerous side effects. For those with excessive bone loss – those at the highest risk for osteoporotic fractures – avoiding testing and treatment can be problematic, potentially causing reduced quality of life and even increased risk of death. Both scenarios are costly to society. The key is balance.

Recommendations
The World Health Organization created an online simple questionnaire to calculate your risk of fracture. It’s called the FRAX. This can help you determine the need for testing and possible treatment. This can be found on their website: http://www.shef.ac.uk/FRAX (go to the “calculation tool” drop down menu).

Recent recommends include bone mineral density testing for women older than 50 years – but only if they are at risk for fracture. These risks include a previous fracture after age 50, medical conditions (such as rheumatoid arthritis) and medications (such as cortisone) that cause bone loss.

Bone loss
The most significantly period of bone loss in women occurs in early menopause (primarily due to low estrogen levels) and continues for only about five years when it stabilizes. The average woman loses about 2-3% of bone mass each year during this time, but healthy women have slower rates of decline. Studies show that women who take hormone replacement therapy (HRT) do have less bone loss, but as soon as HRT is stopped, bone loss is rapid ultimately resulting in the same level of bone loss. There is no long term benefit of HRT, yet there are plenty of known risks. Men can also develop osteoporosis as well, usually from reduced levels of the hormone testosterone.

Vitamin D
Another period of bone loss commonly occurs in elderly men and women, but this is due to lifestyle problems, making it easily preventable. The two most common causes include vitamin D deficiency (too little sun exposure), and reduced physical activity. Optimum vitamin D levels in the blood should be 30 to 60 ng/ml. Those who are overweight, dark skinned, taking medications and have intestinal problems have the greatest risk for vitamin D deficiency. The biggest problem is insufficient sun exposure – our best source of vitamin D is from the sun. More than 50 percent of so-called healthy adults have vitamin D insufficiency – even in sunny climates. When levels are low (a simple blood test can tell you), supplementation is the first step to correcting the problem. You can’t rely on foods fortified with vitamin D because these levels (and the current recommendations) are simply inadequate. Additional benefits of vitamin D include improving balance (which significantly reduces the risk of falls), improving immunity, maintaining muscle mass and improving calcium utilization.

Calcium
Not everyone needs extra calcium for bone health as vitamin D is much more important. Those who are low in vitamin D may temporarily need supplemental calcium until vitamin D levels are restored. In this case, 800 mg a day is usually sufficient. Even in a dairy-free diet, calcium supplements are normally not needed beyond 500 mg a day. Taking smaller amounts through the day is more effective than one larger dose. Unfortunately, many people don’t have enough stomach acid, making calcium absorption much less efficient. This can occur in those who are highly stressed or are taking medications to reduce stomach acid.

Exercise
While almost all of our bone building occurs during childhood and before skeletal maturity, exercise can significantly prevent bone loss. The greatest benefits of exercise come from the tremendous metabolic activity of muscles, improved cardiovascular health and the prevention of falls. Even an easy 20-minute walk will produce benefits on the first day. In addition, increasing overall activity is very helpful. In the elderly, improving balance and strength, evaluating cognition and vision, reducing unnecessary medications, and safety of the home environment are more critical to fracture prevention than simply adding another drug to treat bone loss.

There are a lot of factors we control regarding bone loss – the most important of which is just being healthy. Consider these simple and effective strategies:
- Eat healthfully everyday.
- Stay physically active, including weight-bearing exercises (walking works well).
- Get adequate sun exposure (but avoid overexposure).
- Have your vitamin D levels checked (especially in early spring when storage levels are lowest).
- Avoid over-the-counter and prescription medications if not absolutely necessary.
- Spend time barefoot everyday (to help strengthen muscles and improve balance).
- Avoid thick, over-supported shoes (which can weaken muscles and create poor balance).


For more information on these issues, read “In Fitness and In Health” by Dr. Phil Maffetone.