As the winter months arrive and temperatures reach the freezing point, there arises an unwelcome chance that a simple stroll outside becomes a treacherous ice capades-esque disaster. Especially for older people, the risk of slipping on ice and breaking a bone is one that everyone should consider.
This discussion with Columbia’s Dr. Ethel Siris explains some of the most important aspects of life-long bone health, including ways of preventing osteoporosis starting at any age and when and how to seek treatment for fragile bones.
**Note this conversation has been lightly edited and adapted for text**
So, Dr. Siris, we're using the idea of slipping on ice as a jumping off point. Is slipping on ice something that is potentially risky for some people?
Slipping on ice is a disaster for lots of people because as we age, in women, it's after the age of menopause, which let's say is roughly around 50, we lose bone. And when you lose bone, two things happen. One is that as you get older and older, you have less and less bone, the bone gets thinner. You can't see this, but if you actually could take a microscope and look at the bone, you'd realize there was less bone there. In addition, the architecture of that bone, the bone is put together, is altered when it's aggressively being lost. And as a consequence, there's less quantity of bone and there's also a poorer quality of bone. What does that do? It makes the bone less strong. So that if you slip on the ice and go down hard, you're much more likely to break the bone than would have been the case 20 or 30 years earlier.
So, it sounds like if you’re above a certain age, it really becomes a problem…
It's interesting that the two groups of people who break bones when they trip and fall are little kids and older people. In little kids it’s because their bones are small because they're small. The amount of force that's exerted with a bad fall on the bone in a little kid may exceed the strength of that bone to resist it and it'll break. The same thing is true in older people whose bones have become somewhat thinner, there's less of it, and it's not as well put together. And if you hit the ground hard enough, when you fall, you may very well break a major bone.
You say “break a major bone” what does that refer to? What kinds of falls are you most worried about?
I'm not really talking about fingers or toes or sometimes people fall on their face and they break their noses, that's not what I'm talking about. I'm talking about an older person who slips and unfortunately falls sideways or slightly backwards. That individual may break a hip, and that's a very serious fracture.
Hip fractures become a big risk on average when you get into your upper 70s and beyond and more and more people today are living to be in their upper 70s and beyond. But if you hit your back hard enough, you may break a bone in your back if you have thinner bone in the spine. Wrist fractures are very common if you slip and fall. Because if you're a little more limber, as you go down, you may be able to get your arm out. And if your entire body weight hits your palm as you go down hard on your arm, you may wind up breaking a wrist. So that's another common fracture associated with the ongoing bone loss, which if bad enough is called osteoporosis, meaning that a bad fall can break a major bone.
I see. Now, is some degree of bone loss normal as a person ages? And how much of this is inevitable versus when does it cross the line into something that needs actual treatment?
That's a really good question. I think in the case of women, every woman after menopause is going to lose bone. Now, if she shows up at menopause with a really big skeleton, like somebody who has a tremendous bank account when they retire, you can afford to have withdrawals occur and still have plenty of bone left. So some people have very good sized skeletons and some people are genetically programmed to lose more slowly. Other people will lose more quickly and lose more bone. So I think that bone loss per se is inevitable. But when it gets to a certain level of loss, then you're in trouble because you've had perhaps a lesser amount to start with, even though it was in good shape. If you lose it a little more quickly, by the time you get into your 60s or 70s, you may already have fairly low bone mass.
How do we know, or measure, whether someone is more at risk?
Luckily for us, since about the mid 1990s, we've had a tool that allows us to figure out which women are in trouble and which women are probably not in trouble. And that's the use of a test called a bone mineral density test, utilizing something called DXA. And that's the abbreviation for dual-energy X-ray absorptiometry, but just call it DXA, it's easier. That's the name of the machine that allows you to measure the bone density.
What about older men? Do they also have to worry about this?
Older men can lose bone also. Older men start out in general with bigger skeletons than older women. Men are bigger than women on average, so they have more bone mass. Men don't have quite the same equivalent change as the female menopause.
In older men, there often is some reduction in testosterone and most men will have a little bit of bone loss, but they may not have quite as much as women. If a man lives to be old enough though, into his 90s, he also may have enough that he may be at risk. So we can measure the bone mineral density in both men and women.
What is the process of the Bone Mineral Density exam?
We make a measurement at the spine and at the hip because those are two vulnerable locations, places where fractures can occur.
At Columbia, we also look at the forearm, not so much the wrist, which is hard to measure well, but the shaft of the arm. People with very low scores in the shaft of the forearm sometimes turn out to be people who've had a lifetime of calcium or vitamin D deficiency. And we can identify people from that. But when you measure the bone density, we get the measurement in the older person and we compare it with an ideal value, which is the average bone density in 30 year olds. So the real question becomes, how much lower is the older individual than that 30 year old?
How do you read the results? What kinds of scores are worrisome?
We calculate something called a T-score. And unfortunately for us, we created negative numbers, which is a horrible way to report things, but we did it and we're stuck. If your negative number is no worse than minus one and you're 60 years, 70 years of age, it's considered normal, your bone density is normal.
If you're between minus one and minus 2.49, we use the term low bone mass, which is sometimes called osteopenia. If you're minus 2.5 or more negative, and the more negative you are, the worse it is.
But if you're minus 2.5 or more negative, it's given the word osteoporosis.
Okay so between zero and minus one is still normal at that age, the middle category is between minus one and 2.5 (that is, low bone mass or osteopenia), and then minus 2.5 or below is osteoporosis.
That's just a way of categorizing people to indicate who's at risk and who's not at risk. If you have a score of minus 2.5 or lower at the spine or the hip, you theoretically have osteoporosis and not just theoretically, you have it by definition. And if you're an older individual, you better do something about it because you're already in trouble and it's only going to get worse.
For some people, having a score that's considered low, let's say minus two, for example, at the hip. If you're 80 years of age, that's not good to have a score of minus two. If you're 51, it's less of a concern. At 51, the concern is what am I going to be when I get to be 80? Because you may be a lot lower. But if you're much older and you have a score in the osteopenia range, the low bone mass range, minus one eight minus two at the hip, that may be enough to categorize you as being at high risk for fracture.
So would you define osteoporosis as the state of a person's bones that increases substantially the risk for fracture?
That is precisely the definition that we use. It is a disease that puts the person who has it at a higher than acceptable risk for a later life fracture. Doesn't mean you're going to fracture, but it means that your risk is clearly elevated and it can be based upon bone density alone if you have a score of minus 2.5 or lower. It can be based upon having had a hip fracture already. If you've had a hip fracture and your bone density only shows osteopenia, we have a consensus group that came together and said, "That's also capable of being called osteoporosis." Because if you broke your hip, you've demonstrated you're capable of breaking your hip, so you have osteoporosis.
Are there other indicators of osteoporosis or is the bone mineral density test the only diagnostic?
There's a third way to diagnose it and that's where we take advantage of the fact that as I mentioned, if you're in your late 70s or 80s or older, your age itself is a risk factor for fracture. And there's an algorithm, a little equation called FRAX. And when we open up the FRAX calculation, we put in, yes, no answers to a series of clinical risk factors like smoking, whether your mother or father broke a hip, whether you personally ever broke a bone after the age of 50, and several others, we put that into the algorithm, we put in your age, we put in your gender. And we put in your hip bone density score and you push a button and it gives you a 10 year risk for various types of fractures. If that risk on FRAX is higher than a certain cut point, which is actually 3% for hip fracture, 20% for other major fractures, that level of risk is considered osteoporosis.
So this can calculate the likelihood of a fracture? Whether it’s high like 50 percent or lower like 2 or 3 percent?
And even though 3 percent doesn't sound like a big risk, it is a significant risk because the outcome is pretty awful. If you break a hip, you have to have surgery and you may have to go to a rehab facility or possibly a nursing home, whatever other medical issues you have may get worse while you're recovering. It's not good. A 3 percent risk is actually high enough that you ought to be treated. So it's a way of diagnosing you. And it's also a tip that you probably ought to be treated.
If you've got osteoporosis like any of those characteristics, there are treatments that are needed to try to strengthen the bone. That's what the treatments do, they make the bones stronger. You get back some of the strength that you lost to make the likelihood of a fracture much less. We cannot eliminate the risk of a fracture, but we can dramatically lower that risk with the treatments that we have.
Well, that makes sense. So if you've got osteoporosis and you slip and fall, you are at high risk of being in trouble. But if you have osteoporosis but you're treated and you slip and fall, you may be in less trouble than the person who never got the treatment.
What I tell my patients is this: if you have osteoporosis by any of our criteria, low bone mass and a prior fracture or risk factors adding up to a risk, there are really three things you have to do.
Number one, you have to make sure that there is nothing else going on in you that might be contributing to your bones. You don't have a medical problem or you're not taking a medication that's bad for bone.
In addition, somehow or other you're getting enough calcium and enough vitamin D. Now, the operative term here is enough, enough is enough. You don't have to take extra; taking more than enough doesn't do any good. You simply don't want to be calcium deficient or vitamin D deficient.
And there are blood tests we can do to verify that a given patient's calcium intake is adequate. I measure the blood calcium and I also measure something called parathyroid hormone.
If the parathyroid hormone level is perfectly normal and the calcium level is perfectly normal, that's a pretty good indication that that individual is getting enough calcium from diet or, if not, a little bit of supplementation of the diet with a small amount of medication, pills of calcium.
In addition, we can measure people's vitamin D levels and if they're normal they're normal and that's great. So that's the first part.
So blood tests are part one of three, what’s part two?
The second part is of course, the treatment with medication and there are a variety of drugs out there, they're used in various ways, and they can be changed. If one isn't the right way to go, it can always switch to something else. But the medications are very, very helpful.
Ok great, so part one is blood tests, part two is treatment…
And the third part of what you have to do is very simple: Don't Fall. Now, what does that mean? “Don't fall,” nobody wants to fall. But there are two elements to “Don't fall.”
The first is that you should be as physically fit as you're able to be. It's pretty clear that exercise has a very specific role in osteoporosis. But it's not what you think, it's not that you're going to build bone with exercise. When you're in your 50s, 60s, 70s, 80s, and 90s, you're not going to build bone with exercise, that's not what it's for. When you're growing or a young adult and your bones are still growing, exercise may help build some bone. But when you're older, you're not building bone with exercise.
What you are doing is making yourself more physically fit so that if you slip, you may be able to right yourself and not go crashing down onto the ground.
If you fall when you have osteoporosis, you might break something. If you don't fall, you probably will never break anything unless you're very, very old and have horrible bone density in the spine, then turning in bed can break something. But almost all osteoporosis fractures follow a fall potentially from a standing height, you don't have to fall out of a third story window, just falling onto the ground can break a bone.
So number one, physical fitness is helpful to keep you stronger in general and make it less likely that the bone will break because you may not fall.
The second element of not falling is more elusive, but it's very important. And that is called paying attention and being mindful.
Don't rush if you're an older individual, you can run out of the house if it's on fire. But other than that, you probably should not be running to do something, you walk and you pay attention to the environment you're walking in.
If you're walking down the street with a friend and you're walking forward, you should be looking forward not sideways at your friend because there are all kinds of pitfalls and traps in front of you that you might accidentally stumble into. An awful lot of my patients who have fallen and broken bones, because we can't eliminate the fractures, trip on a curb because they're in such a rush to cross the street before the light has changed and the curb is crumbling, so they trip and fall.
Or they're out hiking and they're not paying enough attention to the hole in the ground and they get a foot caught in the hole and they go down hard. So you have to be aware of your environment.
Great point, slowing down, and being mindful and alert about where you are walking can prevent months or years of recovery, and it’s not just outdoors, right?
This is true at home, in the house. You should never walk into a pitch dark room without turning on the light. Somebody may have put a suitcase in front of something and you didn't know it was there. I've had people fracture in that setting.
So you want to be careful at home, you want to be very careful near the tub, near the shower, near the toilet because sometimes the floor is a little bit wet. You have to be attentive to your environment. And it's not that hard to do, you just have to pay attention.
When you're traveling and you're in a new place, it's a really good idea to scan the scene and realize that the streets are cobblestone and that shoes with a high heel or a bad idea things like that.
That’s right, high heels might, indeed, be a bad idea…
Proper footwear is important, I wouldn't wear flip flops. If I have a risk of falling, and I have to wear a sandal, it should have a strap on the back. Silly little things like that can make all the difference. And probably the single biggest one is not rushing, focusing on what you're doing and not rushing.
I think that's a fantastic rule of thumb and it cannot be overemphasized.
I do want to ask you about an attitude of hesitation that many patients have about accepting medical treatment for bone health. People accept the idea of treatments for high blood pressure and high cholesterol to prevent serious outcomes like heart attacks or strokes. But, what sort of things have infiltrated attitudes where patients don't always feel the same way about osteoporosis? What has clouded or muddied the waters there do you think?
I think it really all started when the osteoporosis drugs first started to show up. The first one were so-called bisphosphonates. These are pills taken initially every day, but it was changed for most of them to once a week or in some cases once a month. A certain number of people, if they don’t take it exactly by direction, they might get a little indigestion from it. The trouble is that people get indigestion from lots of things. Especially older people will often have a little bit of gastroesophageal reflux. It was very difficult for some people to sort out whether it was the pill or whether it was just their underlying reflux. The pills didn't cause reflux. But if you happen to have reflux anyway and you got symptoms of heartburn, you didn't know if it was from the pill. So that was the first problem.
The second problem was that after these medications, particularly the pills and an intravenous drug, which is similar to what's in the pills but is given once a year for three years by vein, sometimes longer, those pills were associated extremely rarely–and I want to underscore extremely rarely–with two very nasty side effects. One had to do with dental issues. It turned out that primarily among a small minority of people with cancer in bone, who get the same drug as the osteoporosis patients, but they get huge amounts, they get much, much higher doses than we give for osteoporosis. In that population, after a dental extraction, a tooth has to be pulled, and the dentist pulled it. Normally when you pull a tooth, it's all healed up within say six weeks. The jaw bone has to heal, it's been wounded by removing the tooth in a very tiny minority of these folks, it wasn't healing. And there are a lot of bacteria in the saliva so that these people were getting infections in the bones of the jaw. The jaw is a unique bone. So they were getting something called osteonecrosis of the jaw.
Now, in my opinion, while this is a very bad side effect–which eventually heals up, they can usually take care of it–in the beginning nobody knew what it was. So some of the patients really had a mess of trouble with infection and dead bone. It was blown out of proportion in terms of its seriousness. There's no question that you need to take the drugs for finite blocks of time. And in the case of these bisphosphonates, we give holidays, there are other drugs where we don't. But the point is, if they're given correctly, carefully and if the oral surgeon is aware of the benefit risk, in other words, if somebody really needs one of these drugs to avoid a hip fracture, you want to be able to give it without scaring people to death. The dental practitioners have come up with guidelines for ways to minimize the risk. You can't eliminate the risk of this problem, but it is rare.
The second side effect that began to be seen in the mid 2000s was something that was seen in osteoporosis patients on some of the oral agents, the pills. And that was a rare type–and again, the word is rare–a very rare type of thigh bone fracture, where somewhere between the groin and the knee, the individual might have a little bit of discomfort in the outer part of the thigh. Which over several days to weeks might get a little worse and then one day the thigh breaks in half. Horrible, snaps in two, that's called an atypical femur fracture. Now, these are rare and they have a particularly striking characteristic when you look at the x-ray. They're not confused with anything else.
But for people who have bad osteoporosis, the risk of a broken hip is so much higher than the risk of one of these rare thigh bone fractures. And you can lower that hip fracture risk dramatically. You can also lower the very small risk of a thigh bone fracture by giving a holiday from the bisphosphate, which is what we do, which is what we've always done. Because with the bisphosphate treatments, you can give it for a finite block of time, three to five years, usually three years for the IV, sometimes a little longer, five years for the oral. And then we learned a long time ago that if you stop it and you stop taking it, what's already in the system keeps working for another year or two, but it allows everything to refresh itself and it cuts the risk of this so-called thigh bone fracture. So there are ways to minimize the risk of the super rare side effects and maximize the benefits of preventing the common fractures.
But I think the combination of the initial concerns about indigestion and all of that and then the later concerns about these two rare but nasty side effects, which in my opinion have been overblown a little bit in terms of how common they might be, they're not that common. I think that that has gotten in the way of being able to use these drugs. So again, I'm talking primarily about bisphosphates. There's another one which is an injection given every six months, which has a different way of working, but has rarely been associated at higher doses, the cancer doses, with jaw necrosis and very rarely with these bisphosphate bone fractures, I think maybe less common even than with the bisphosphonates. But those are the most commonly used drugs. We have other drugs that stimulate bone formation of bone, but they require frequent injections and they're rather expensive. And while they're wonderful for some patients, the average osteoporosis patient will probably either get a bisphosphate or this other drug that's the twice-a-year shot in the arm, which takes a second to give.
That's very helpful. So unfortunately I think when they say “bad news travels faster than good news,” the bad news got out there very quickly like wildfire, but didn't really give enough emphasis to the fact that millions of people have had millions of fractures be prevented by effective treatment of osteoporosis.
One of the research studies I got to participate in a number of years ago, other people had traced the fact that in the era of both awareness about osteoporosis and also the availability of the drugs, the rates of hip fracture were going down. Even though more and more people were living to be older and older, the rate of hip fracture was definitely declining. If you then came to the period in the 2000s, the mid 2000s when these side effects showed up and when people stopped taking these drugs, we were able to show that between 2007 and about 2015, the rate of hip fractures leveled off, having been on the decline, it leveled off, and it looked like it was coming back up again. Because people were not being treated.
It sounds like a lot of people who could benefit from treatment are missing the opportunity, without knowing there is help.
It's a concern. And I think that if people are treated by a physician who has some knowledge and experience on how to use these drugs, they are remarkably benign. They don't interfere with other drugs, they're really pretty effective and they don't have a lot of problems. And if they're taken correctly, and if one isn't for you there's another one coming along, the oral bisphosphonates are now very inexpensive because they're all generic.
I think most people, if they're willing to give it a try, find a drug that'll work for them and potentially be very helpful. We can't eliminate the fractures, but we can cut the risk anywhere from 40% to 70%, and that's pretty good.
Now, let's talk about prevention for a minute. Is there something an average person can do to keep their bones healthy or prevent worsening osteoporosis? Can they exercise? You've already mentioned this, but some people say, "I'm not going to take the medicines, I think I'll just exercise a little bit more." Is that a reasonable strategy?
Well, I think if you're already postmenopausal, the exercise is a nice idea. But it is not going to prevent you from losing bone if you're genetically programmed to lose bone once your estrogen levels wean tremendously because of menopause. So you're absolutely right, that exercise alone isn't going to do it.
Calcium and vitamin D by themselves are not going to do it, absolutely not, it's not enough. You want to take it because you want to make sure you're getting adequate amounts of calcium and D to avoid changes in your body's configuration that might make you lose more bone. In other words, menopause is the issue in a woman. If she's also calcium- or D- deficient, it's just going to make it all worse. But it's not going to prevent you from having whatever bone loss you're programmed to have.
So I think that what we've always emphasized is that it's a great idea to lead a healthy lifestyle. From the time you're a little kid, you should participate in physical activity so that you can hopefully build as big a skeleton as you're genetically able to build.
If you're a couch potato who does nothing but look at a computer all day long, looks at toys and computers and things, you want to get out there and run around. So you want to allow your skeleton to grow the way it's intended to grow.
So bone health is really a lifelong pursuit that starts young. What about things to avoid?
Smoking is bad for bone, alcohol in excess is bad for bone. Some people unfortunately have to take medications that are not good for bone. Corticosteroids are bad for bone. If you have to take them, you have to take them, but you ought to perhaps check your bone density and see if there's anything else that needs to be done to try to protect you if you have to take prolonged oral or other forms of corticosteroids. So I think leading a healthy lifestyle is very important.
Teenage girls who develop conditions like anorexia nervosa are more likely to have bone loss. Not only because they lose their estrogen production, but because their nutrition is impaired. So good nutrition is very valuable. So it's the usual: eat well in a healthy manner, don't drink to excess–excess is three drinks or more a day–don't smoke for lots of reasons, including bone, and be as physically active as you can possibly be so that you can build the best skeleton that your body is going to be willing to let you build.
These are really important habits, and I imagine especially because you don’t necessarily know if or when or how much your genes may later cause your bones to deteriorate.
Osteoporosis is often called the silent disease because the first symptom is the pain from a broken bone. In other words, it doesn't hurt. If you come to your doctor and say "My hip is bothering me, I'm having this discomfort in my hip." That's probably arthritis, it's probably not osteoporosis.
Having thin bones doesn't hurt until it breaks and then it hurts like crazy. So it is not going to give you symptoms.
Wow, and because you won’t know until it’s too late, or you break a bone, at what age is it recommended to get screened, and determine whether you need treatment?
The guidelines say you should take a bone density test at age 65 if you haven't yet had one and you're a woman. Most men might think about doing it at 70.
And if you're recently post-menopausal and you have other risk factors, you've been on prednisone or you have a medical condition that may predispose to osteoporosis, and there's a long list of them, have a bone density test sooner and see where you are.
Wherever you are, there's something that can be done to try to keep you from progressing and getting worse. And if you're already fairly far along, there's a lot that can be done to make that fracture risk go way, way down.
That's very helpful. There are probably also some medical conditions people should be aware of that might require an earlier than 65 or 70 bone density assessment. Can you comment on some of those? Like thyroid?
Hyperthyroidism. With people who are hyperthyroid, everything gets revved up including bone removal. So hyperthyroidism, once it declares itself, certainly can be addressed and dealt with.
There is a condition called primary hyperparathyroidism where you have four little glands in your neck that are responsible for regulating calcium. And if you have significant abnormalities of the parathyroid glands, that can lead to having lower bone density as well.
But there's a whole host of them. If you have a condition like celiac disease, you may have difficulty absorbing calcium and vitamin D.
People who are seriously overweight often have bigger skeletons. But if they undergo bariatric surgery, they may lose bone in the setting of that surgery because they have trouble absorbing calcium and vitamin D.
Certain chemotherapies are bad for bone. Often chemotherapy for cancer will cause a premature early menopause. Or having an earlier than expected menopause is not good for bone. There are a variety of neurological disorders which can make people more frail, which makes them more susceptible to falling. But if they affect nutrition and muscle strength, that also can impact on the risk of having more bone loss.
There's a whole wide range of things that are in this category. And if somebody were to Google “osteoporosis,” they would be able to look at the long list of medical conditions. I think most physicians are quite aware of which conditions are which. Any disease that requires steroids is going to be trouble. People who've had transplants, they may have some bone loss. And if you're aware of this going into it, there are things you can do to address it.
Thank you for that. That's very, very helpful and so clear. So I guess just to wrap up, is there one takeaway that you would want everyone out there to know? Just the one point, as we enter into these cold winter months and rushing around, that you'd like to put out there.
Well, I'm going to do it in one long sentence: “If you're older, find out if you're at risk, get your calcium and vitamin D in adequate (not extra( amounts, and don't fall.
And not falling is a function of, really in the wintertime, using good judgment, paying attention. Don't slip on the ice. What are you doing on the ice in the first place? Stay away. Those are the kinds of things that I think we all need to do.
And it's not just the winter, by the way, we did a study a number of years ago that showed a lot of hip fractures in the spring. And we said, "Wait a minute, there's no ice in the spring, why is this happening?"
And we thought maybe it had to do with the fact that during the winter, a lot of these osteoporosis patients were being super careful. They weren't outside, they weren't walking, they were losing some strength in their muscles. And then when spring came along, they were out there loving it and tripping and falling because they were deconditioned.
So during the winter, don't slip on the ice, but if you live in an apartment building, walk the corridor and, if you live in the suburbs, walk on your street, just be careful and don't do it when it's raining or snowing.
Advice from an expert for all ages. Thank you so much.