On Point submissions are individual member viewpoints and not North Carolina Medical Society policy.
Dr. Andrew Bush, MD, FAAOS, FACS, CWSP
Rates of osteoporosis and fractures associated with poor bone quality, which are known as fragility fractures, are at epidemic levels. It is estimated that osteoporosis affects approximately 200 million people world-wide. Currently, it is also estimated that 10 million individuals over age 50 in the United States have osteoporosis. Each year an approximately 2 million individuals suffer a fracture due to osteoporosis. The risk of a fracture increases with age and is greatest in women. Approximately 1 in 2 women and 1 in 5 men age 50 or older will experience a hip, spine, or wrist fracture sometime during their lives. Approximately 40% of individuals are unable to return to their homes following a fragility fracture and require relocation to a nursing facility. As many as 20% of individuals will die within 6 – 12 months of a fragility fracture. Also, an additional 33.6 million individuals over age 50 have low bone density or “osteopenia” and thus are at risk of osteoporosis and fragility fracture. Estimated costs of providing care for osteoporotic fractures among Medicare beneficiaries was approximately $14 billion in 2018. The cost is expected to increase to over $23 billion in 2025.
To stem the exponential rise in osteoporosis and fragility fractures and the associated human suffering and financial burden on society, it is important that our healthcare policy makers develop and implement public-wide screening and testing programs, and education programs to increase awareness of the public on the importance of bone health. Also, our leadership needs to show that it is serious in this endeavor by allocating sufficient resources to the front-line healthcare providers to appropriately address this crisis in their patient base. However, until that policy-shift happens, there are things that can be done on an individual basis to maximize bone health and to minimize the risk of fracture.
Bone health is not too different from heart health or gut health – we have to realize that all of our body systems work together in unison and often it is when that synergy gets interrupted and things are out-of-synch that we get sick. The basics of good health are pretty consistent – nutritious and balanced diet, active lifestyle, minimizing stress, appropriate exercise and plenty of rest. Also avoiding unhealthy lifestyle habits such as smoking and excessive alcohol consumption and eating low-nutrition and overly processed foods. These recommendations are pretty universal. However, there are some bone-specific recommendations.
Proper nutrition is extremely important for healthy bones throughout life but in particular during the years that bone is forming – up to approximately 30 years old. After that, the amount of bone that we have in our bodies will decrease as we get older. This bone loss happens in both men and women but it happens at much more rapidly and to a higher degree in women. There are some estimates that women may lose approximately 20-30% of their entire bone mass in the 10-15 years surrounding menopause. That is why the majority of fragility fractures happen in women. Now it is not inevitable that all that bone loss has to happen and things can be done to prevent or slow down bone loss. Although the main goal of a Bone Health program is to stop bone loss, it is just as important to address bone health early – early implementation of health nutritional habits twill help maximize the bone-building process and will optimize the amount of bone that we have throughout our lives.
An additional factor that is very important in both forming and maintaining healthy bone is activity and exercise. Bone development and remodeling is driven by the applied forces that the bone “feels”. Impact (light to medium) stimulates the bone cells called osteocytes that live in the bone matrix to send out signals to the bone building cells – the osteoblasts to start responding to those forces by building more bone. Also, bone health is maintained when muscles are strong so that the bone “feels” the pull of those muscles. Strong muscles come from living an active lifestyle and doing regular exercises. There is a theory that optimal bone building comes from additional exercises – the phrase “osteogenic loading” specifically refers to exercises where bone feel additional applied forces that stimulate bone to maintain its optimal composition. It is also known, that maintaining muscle strength helps maintain a good sense of balance – and when you have good sense of balance falls and therefore breaks are less likely!
Monitoring of the bone health is the foundation of fracture prevention in the way monitoring blood pressure is to stroke prevention and mammograms are to breast cancer prevention. The early detection of any of these conditions, allows for early treatment to be institutes to prevent the long-term consequences of the disease. Bone health assessment is looking for osteoporosis. Although, some may still consider developing osteoporosis an unfortunate part of growing older, it is now understood that fracturing due to idiopathic age-related bone loss is not an inevitable part of aging but a potentially preventable disease process. Nutrition and exercise fight against osteoporosis – monitoring makes sure that they are working.
The term for bone monitoring is known as bone densitometry – the measurement of bone density. Determining bone mineral density (BMD) has been the traditional method of diagnosing osteoporosis and predicting fracture risk. The most common way to measure BMD is by using Dual Energy X-ray Absorptiometry (DXA). DXA has been around for over 30 years and has been the backbone of Bone Healthcare. It is a method of measuring BMD by using low-energy x-ray and has been considered reasonably reliable for measuring BMD and diagnosing and treating osteoporosis.
There is another method of bone densitometry that not only determines BMD but also give a measure of the Bone Quality. Radiofrequency Echographic Multi Spectrometry (REMS) is a newer method of performing monitoring bone health that was developed and has been used in Europe for almost ten years and has replaced DXA as the official method of bone densitometry in Italy. REMS uses ultrasound to measure BMD. However, the ultrasound is also capable of measuring Bone Quality and therefore when REMS is used to assess bone, more information is obtained and there is a better way to predict fracture risk. REMS is still very new in the United States but its popularity is growing as more and more people are finding out about it.
If levels of nutrition and exercise were not enough to maintain a healthy skeleton, or other medical conditions are affecting bone quality, then there are specific medications that can help to prevent bone loss or even to reinvigorate the bone to build back a little. The decision to use any of these medications should be made in consultation with your bone healthcare provider. And if you are started on any of these medications you must be compliant with the directions of use and monitoring the effectiveness of the medications is also essential.
In conclusion, it is important to remember that your bones need to be monitored and cared for like any other part of you and although we focused on bone health as a women’s health issue, poor bone health can affect anyone. So, bone healthcare is an issue for everyone and something that we all need to be aware of. Everyone has a skeleton and we need to pay attention to and take care of our skeletons because …
If you ignore your bones, they will go away!
Dr. Bush is with Central Carolina Orthopedic Associates.
Does Insurance pay for the REMS test? If not how much is it? How long does it take to get in to have one done?