Overtreatment and undertreatment of osteopenia and osteoporosis are common
By David Dunaief, M.D.
As we get older, bone fractures can have potentially life-altering or life-ending consequences. Osteoporosis is a silent disease where there is bone loss, weakening of the bones and small deleterious changes in the architecture of the bone over time that may result in fractures with serious consequences (1). It affects millions of patients, most commonly postmenopausal women.
One way to measure osteoporosis is with a dual-energy X-ray absorptiometry (DXA) scan for bone mineral density. Osteopenia is a slightly milder form that may be a precursor to osteoporosis. However, we should not rely on the DXA scan alone; risk factors are important, such as a family or personal history of fractures as we age. The Fracture Risk Assessment Tool (FRAX) is more thorough for determining the 10-year fracture risk. Those who have a risk of fracture that is 3 percent or more should consider treatment with medications. A link to the FRAX tool can be found at www.shef.ac.uk/FRAX.
Most of us have been prompted all our lives to consume calcium for strong bones. In fact, the National Osteoporosis Foundation recommends that we get 1,000 to 1,200 mg per day of calcium from diet and supplements if we are over age 50, although recommendations vary by sex and age (2). However, research suggests that calcium for osteoporosis prevention may not be as helpful as we thought.
The current treatment paradox
Depending on the population, we could be overtreating or undertreating osteoporosis. In the elderly population that has been diagnosed with osteoporosis, there is undertreatment. One study showed that only 28 percent of patients who are candidates for osteoporosis drugs are taking the medication within the first year of diagnosis (3). The reason most were reluctant was that they had experienced a recent gastrointestinal event and did not want to induce another with osteoporosis medications, such as bisphosphonates. The data were taken from Medicare records of patients who were at least age 66.
On the other hand, as many as 66 percent of the women receiving osteoporosis medications may not have needed it, according to a retrospective study (4). This is the overtreatment population, with half these patients younger, between the ages of 40 and 64, and without any risk factors to indicate the need for a DXA scan. This younger population included many who had osteopenia, not osteoporosis.
Do we all need calcium?
Calcium has always been the forefront of prevention and treatment of osteoporosis. However, two studies would have us question this approach. Results of one meta-analysis of 59 randomized controlled trials showed that dietary calcium and calcium supplements with or without vitamin D did increase the bone density significantly in most places in the body, including the femoral neck, spine and hip (5). Yet the changes were so small that they would not have much clinical benefit in terms of fracture prevention.
Another meta-analysis of 44 observational dietary trials and 26 randomized controlled trials did not show a benefit with dietary or supplemental calcium with or without vitamin D (6). There was a slight reduction in nonsignificant vertebral fractures, but not in other places, such as the hip and forearm. Dietary calcium and supplements disappointed in these two trials.
Does this mean calcium is not useful? Not so fast!
In some individual studies that were part of the meta-analyses, the researchers mentioned that dairy, specifically milk, was the dietary source on record, and we know milk is not necessarily good for bones. But in many of the studies, the researcher did not differentiate between the sources of dietary calcium. This is a very important nuance. Calcium from animal products may increase inflammation and the acidity of the body and may actually leach calcium from the bone, while calcium from vegetable-rich, nutrient-dense sources may be better absorbed, providing more of an alkaline and anti-inflammatory approach.
What can be done to improve the situation?
Yoga has become more prevalent and part of mainstream exercise. This is a good trend since this type of exercise may have a big impact on prevention and treatment of osteoporosis. In a small pilot study of 18 participants, the results showed that those who practiced yoga had an increase in their spine and hip bone density compared to those who did not (7).
The researchers were encouraged by these results, so they performed another study. The results showed that 12 minutes of yoga daily or every other day significantly increased the bone density from the start of the study in both the spine and femur, the thigh bone (8). There was also an increase in hip bone density, but this was not significant. The strength of the study includes its 10-year duration; however, this trial did not include a control group. Also, while 741 participants started the trial, only 227 finished. Of those, 202 were women.
Significantly, prior to the study there were 109 fractures in the participants, most of whom had osteoporosis or osteopenia, but none had yoga-related fractures by the end of the trial. The “side effects” of yoga included improved mobility, posture, strength and a reduction in anxiety. The researchers provided a road map of specific beneficial poses. Before starting any exercise program, consult your physician.
The moral of the story is that exercise is beneficial. Yoga may be another simple addition to this exercise regimen. Calcium may be good or bad, depending on its dietary source. Be cautious with supplemental calcium; it does have side effects, including kidney stones, cardiovascular events and gastrointestinal symptoms, and consult with your doctor to assess whether you might be in an overtreatment or undertreatment group when it comes to medication.
(1) uptodate.com. (2) nof.org. (3) Clin Interv Aging. 2015;10:1813-1824. (4) JAMA Intern Med. online Jan. 4, 2016. (5) BMJ 2015; 351:h4183. (6) BMJ 2015; 351:h4580. (7) Top Geriatr Rehabil. 2009; 25(3); 244-250. (8) Top Geriatr Rehabil. 2016; 32(2); 81-87.
Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.