The other day, I had an e-mail from a 70-year-old woman who is following the Better Bones Program. She was obviously very frustrated by what she considered a lack of progress. “I’m doing everything I’m supposed to,” she said, noting that she was eating alkaline and testing her pH, exercising daily with weights, meditating, and taking her vitamin supplements religiously. But she’d just had a DEXA scan and was upset because nothing had changed. Her bone density was no different than it had been the last time she’d had her bone density measured 2 years ago, and she couldn’t understand why it hadn’t improved.

At first, this struck me as a little bit funny. She clearly didn’t understand something very important. For a woman after menopause, keeping bone density stable is a big accomplishment! Keep in mind that the average in her 60’s and 70’s loses 1 or 2% of her bone mass every two years. That means that over the course of 3 years, this particular woman had maintained her bone density instead of losing the 1-2% she might normally have expected to lose just from the average wear-and-tear of aging. Compared to a lot of her peers, she’s doing pretty well! In light of the fact that the average women loses as much as 47% bone of her bone mass by her late 80’s, this client’s stability of bone as she ages is a real sign of success.

Then I reconsidered. I thought, "this woman thinks she’s failing at something when she’s succeeding — that’s a problem!" Here she was, beating the odds and keeping her bones stable year after year, yet she felt like she wasn’t doing enough. I did not want her to walk away feeling defeated when she’d just won a wonderful victory. But how to get that point across to her and others like her?

Well, here’s a small analogy for you. Many personal trainers will tell someone they’re helping to lose weight to pay no attention to what the scale says, but instead gauge their weight loss success by how their clothes fit. It’s somewhat the same with bone health. For many of us, “optimal bone health” might mean results not visible to the naked eye or even to a DEXA scan — a strengthening of bone that leaves it more flexible and less prone to fracture, but that doesn’t increase its overall density. Some might also find their bone density stabilizes, as the woman who wrote me did (even if she didn’t recognize this stability for the achievement it is). Some see small gains in bone density, and a few see significant increases in bone density. But for most, the improvement might not really show up on any measurement made by a DEXA scanner.

What you do often get with a natural bone health program is a visible improvement in overall health — stronger nails, more supple skin, healthier teeth and gums, often better digestive health — that signifies that the body is getting what it needs and therefore doesn’t need to tap the bones for resources. Like a pair of suddenly loose pants on a person whose bathroom scale says she hasn’t lost a pound, sometimes the measuring device should be disbelieved if the body itself says that good changes are happening.

It’s also true that one might have such gains but not see them, since (as I’ve commented in earlier blogs) DEXA machines are notorious for having poor accuracy from one scan to another. A DEXA scan must show a change in density of at least 5-6%, according to noted bone researcher Susan Ott, to indicate a definite change in bone density; anything less than that could just be variation in the scanner or operator skill. The woman who e-mailed me, for example, could very well have had an increase in bone density of 1% from year to year, but the variability in DEXA measurements might have masked the increase.

So there are two points I’d like everyone to take away from this. One is that your success might not be measurable or quantifiable in terms of increased bone density—but that doesn’t mean you should discount it. Having stable bone mass as we age is something to celebrate! The other is that the point of a Better Bones Program and the approach I’ve long advocated is not to make sure everyone has bones equivalent in density to a 25-year-old athlete, but to give the bones — and the body, too — the resources they need to obtain optimal health.

Today, I read with dismay The New York Times’ health column about vertebral compression fractures. In my opinion, it presented an inaccurate picture of what’s happening when it comes to spinal fractures. I want to address some of the points that stood out for me because I feel this article spreads a lot of fear where it’s just not necessary — and as I mentioned in a recent post, fear itself is damaging to bone!

First, let’s look at the statement that “by age 80, two in every five women [or 40%] have had one or more vertebral compression fractures.” Similar statistics have been bandied about for years, but when I took the time to look for hard data supporting them a few years ago, I found it very difficult to substantiate such high numbers. The sole large-scale study that looked at long-term risk of vertebral fractures, a review by J.A. Cauley and colleagues that came out in 2007, actually debunks this statement. As I noted in my article on spinal fractures at the time, "The results of this study suggest that earlier estimates of spinal vertebral fracture incidence have overestimated real fracture incidence. Over fifteen years, from age 68 to 84, only 18% of all US Caucasian women experienced a vertebral fracture. Overall, counting those who entered the study with an existing vertebral fracture, a little over 26% of all women had radiological evidence of a spinal fracture by age 84. This figure is significant, yet not as worrisome as the 35‐50% estimate previously reported."

I also take issue with the statement that “vertebral fractures are a telltale sign of bone loss.” They’re not — they’re a sign of bone weakness, and there is a difference between the two! While low bone density does increase the risk of fracture, most fractures occur in persons whose bone mineral density is above the osteoporotic range. The strongest predictors of fracture in the Cauley study were advancing age, having low body weight, and the presence of a prior bone fracture — not low bone mineral density.

Now, I have been arguing for years that bone mineral density alone doesn’t predict fracture risk, and the study on which this article is based seems to agree with that assessment on its surface. The study’s authors note that the presence of vertebral fractures in women whose bone density isn’t osteoporotic means that the true diagnosis should be osteoporosis, not osteopenia — and with that, I’d agree. But the follow up statement shows where all this is truly headed: “Asked if such women should receive bone-preserving medication, Dr. Ensrud said emphatically, ‘Yes!’” This position is in direct contrast to the recommendations of the U.S. Surgeon General — that persons with bone loss should be directed to make changes to their dietary and exercise habits first, then assessed and treated for the cause of the bone loss, and then put on bone medications if the situation warrants. (The implicit assumption of Dr. Ensrud’s response is that bone drugs are always warranted.)

The idea of looking for the causes behind skeletal weakness is not even suggested, and the word “exercise” doesn’t appear in the New York Times’ article until the very last line. Yet numerous studies show low vitamin D levels to be a major cause of bone loss and weakening among most of those who fracture. Exercise, as countless more studies have shown, should be the first line of defense against osteoporosis and fractures — and considering that a Mayo Clinic study has shown a 300% reduction in risk of new vertebral fractures from simple back strengthening exercises (far more than ANY bone drug can claim), it is disturbing that Fosamax is mentioned so much more prominently than exercise.

I could go on (and on), but rather than write a novella, I’ll state my primary issue thus: The overall message is that multitudes of postmenopausal women are destined to fracture in their spine, and that they should immediately be given bone drugs for even a minor, unfelt, spinal deformity defined as a “fracture”. I would hope for a more balanced, public-interest analysis of this important health issue from one of the most important news outlets in the United States, if not the world.

One other note before I stop — I also find it troubling that all of these messages are aimed primarily at women. Studies in the U.S., Canada, and several European countries show that older men often have “silent” vertebral fractures (only seen upon X-ray) just as frequently as women do, yet the article makes no mention of looking for these hidden fractures in men and giving them drugs for these symptom-less vertebral deformities.

But here’s the bottom line: women and men with osteoporosis, even those found to have a “silent” symptom-less vertebral deformity in old age, need not automatically be given bone medications. It has been the position of the U.S. government’s top health official for most of the past decade that medication is the last resort, not the first! And that is a message that I hope all my readers get — and pass along.

References

Brody, J.E. 2011. Along the spine, women buckle at breaking points. New York Times June 27, 2011. URL: http://www.nytimes.com/2011/06/28/health/28brody.html (accessed June 29, 2011).

Cauley, J. A., Hochberg, M. C., Lui, L. Y., et al. 2007. Long‐term risk of incident vertebral fractures. JAMA 298(23):2761‐2767.

O'Neill T. W., Felsenberg D., Varlow J., et al. 1996. The prevalence of vertebral deformity in european men and women: the European Vertebral Osteoporosis Study. J. Bone Miner. Res. 11:1010.

Brown, S. E. 2008. Spinal vertebral fractures among US Caucasian women: New statistics and new insights. URL: http://www.betterbones.com/bonefracture/spinalvertebralfracture.pdf.

Davies K. M., Stegman M. R., Heaney R. P., Recker R. R. 1996. Prevalence and severity of vertebral fracture: the Saunders County Bone Quality Study. Osteoporos. Int. 6:160.

If you’re a woman “of a certain age,” you’ve probably already heard the fairy tale that women’s bones crumble at menopause. I’ve said many times that thin bones don’t have to be weak bones, and women with osteoporosis or osteopenia in midlife won’t necessarily have a high risk of fracture, but it’s still wise to look at your fracture risk factors — including bone loss — and take action. The question is, how would a woman approaching menopause (but not yet past it) find out if she’s losing bone at a rapid pace, which could be a red flag for heightened fracture risk after menopause?

We know from research that the rate of bone breakdown as measured by markers of bone resorption such as the NTx test correlates with rate of bone loss in menopausal women. But are these markers of bone resorption helpful in predicting which perimenopausal women might fracture later in life? A new study from the University of Pittsburgh suggests this might be the case.

Looking at 2,406 premenopausal women over a period of 7.6 years, researcher Dr. Jane Cauley and colleagues found that women who had NTx levels above the median at any of the yearly clinic visits had a statistically significant (55%) increase in fracture risk within the 7.6 years of the study. So a higher-than-average rate of bone breakdown even several years before menopause could well weaken bone. From my work here at the Center for Better Bones, I find it is wise to look at markers of bone resorption well before menopause. As we now know, bone loss begins in the late 20s and early 30s and, given our current lifestyle, accelerated bone breakdown can occur much earlier than commonly recognized.

If you are a woman approaching menopause — or even younger! — and have a family history of osteoporosis or other risk factors, consider taking our Bone Health Profile to determine the basis of your osteoporosis risk. Then, look into getting an NTx test to see whether you have higher than the average bone turnover — and if you do, consider taking steps to alkalize your diet, reduce stress, and get bone-building exercise as a way of addressing the concern before it becomes a real problem. (You can look at my article about stopping bone loss in menopause for more ideas.)

An ounce of prevention is worth a pound of cure!

Reference:
Cauley, J, et al. 2010. Bone resorption and fracture across the menopausal transition: The study of women's health across the nation (SWAN). ASBMR Meeting, Toronto, Abstract 1093.

P.S. There’s a very funny Saturday Night Live spoof ad that skewers the drug companies’ fearmongering around menopausal osteoporosis that I hope everyone will watch!