The HMO’s have run with this directive from the International Society of Bone Densitometry ISCD). I read a newspaper headline the other day, “Bone density testing Not Necessary until the age of 65.” I have talked with patients whose doctors are telling them they do not need the test without doing a complete history to see if there is a need. In the photo on the right the woman hunched over on the far right is 65 years of age. The actual directive from the ISCD regarding bone density testing is the following:
Indications for Bone Mineral Density (BMD) Testing
Women aged 65 and older
Postmenopausal women under age 65 with risk factors for fracture.
Women during the menopausal transition with clinical risk factors for fracture, such as low body weight, prior fracture, or high-risk medication use.
Men aged 70 and older.
Men under age 70 with clinical risk factors for fracture.
Adults with a fragility fracture.
Adults with a disease or condition associated with low bone mass or bone loss.
Adults taking medications associated with low bone mass or bone loss.
Anyone being considered for pharmacologic therapy.
Anyone being treated, to monitor treatment effect.
Anyone not receiving therapy in whom evidence of bone loss would lead to treatment.
Women discontinuing estrogen should be considered for bone density testing according to the indications listed above.
There are many reasons to consider bone density testing. Keep in mind that the bulk of our bone mass (about 80%) is laid down by the time we are 18 years of age. So the first question is, did you lay down a good bank account of bone? In my case, I did not lay down a good bank account of bone, which led to borderline osteoporosis before menopause. As a teenager I smoked cigarettes and I did not eat a healthy diet. Add to that, I have small bones and I am thin. This background is enough to request a bone density test before menopause.
After the age of 35, bone loss, especially for women with small frames is .5 to 1% per year. During the menopausal transition it can increase to 1-3% per year. This incremental bone loss adds up. To avoid loss it is critical to resolve gastrointestinal problems and to nurture healthy bones through nutrition and exercise.
Potential Benefits of early testing
Cases of osteoporosis will be caught early through early testing. Knowing you have low bone mass or osteoporosis can be a serious wake up call to resolve digestive issues, eat a healthy bone building diet and maintain an exercise program. Also, if someone has serious low bone mass, proper lab tests can be ordered to determine whether or not bone loss is occurring presently. This is important. Active bone loss is a concern. You can have osteoporosis that is stable, meaning bone loss may have occurred earlier in life or a good bank account of bone was not developed in the first place. A good example is someone who has a history of anorexia or high soda or coffee intake for a period of years. They may not engage in these activities today but such a history, especially in formative years may indicate that the bone did not reach it’s full peak bone mass. This type of history is enough for me to check bone density.
There is a long list of concerns that would make me order a bone density exam based on the patient’s history. The most important time for a woman to consider a bone density exam is before menopause, if she has additional risk factors. Why? Bone loss can be considerable during the years leading up to menopause and up to 10 years after. Age related bone loss (which can be prevented in some people) is .5 to 1% a year and during the menopause transition it can be 1-2% each year or 20% in some women. That is a lot of bone to lose.
Unfortunately, with the headlines reading, “No need for a bone density test until age 65” those who need it most may be over looked. The question you need to ask yourself is whether or not you have risk factors that caused you not to build a good bank account of bone or if you have health issues presently that may be causing the leaching of bone. Osteoporosis is a disease that often is not discovered until a fragility fracture occurs (low trauma fracture). Here is a list of risk factors to consider. If you have any of these risk factors you may have osteoporosis and not know it.
Caucasian or Asian ethnicity
Thin women or small bones
History of fractures
History of dieting
Anorexia or bulimia
Digestive problems (malabsorption)
Relatives with osteoporosis
Parent who sustained non-traumatic fractures
Pregnancy – multiple
Lactation – extended
No menses for extended time
Ovary removal (both)
Smoking particularly in formative years
Heavy alcohol past or present
Heavy caffeine intake
Junk food diet - high sugar, processed carbohydrates, high salt
High or low protein intake
Vitamin D deficiency
Low calcium, magnesium intake & other bone nutrients
Chronic antacid use – we need acid to aid in calcium absorption and protein breakdown
Medications: Proton pump inhibitors, aromatase inhibitors, corticosteroids, antacids, thyroid medications, Dilantin, SSRIs for treatment of depression
Men’s bone can be depleted from the same conditions above that do not apply to women only. In addition men can also have an increased risk if they are smaller in stature or have hypogonadism with a low testosterone output.
Bone density is part of bone quality but bone quality extends way beyond density alone. That is why some people with osteoporosis fracture easily while other people do not. Example: Stacy has borderline osteoporosis and she has a malabsorption problem that has robbed her of nutrients needed to build and maintain healthy bone. She fractured her hip at age 65 with minimal trauma. What is minimal trauma? Falling from a standing height and breaking a bone or breaking a bone with minimal trauma. Most people with healthy bones would not sustain a fracture from minimal trauma. If you have had a fracture, ask yourself if the fracture seemed reasonable given the forces placed upon the bone.
Can you have osteoporosis and have a normal bone density test? YES!
Bone density is not everything and osteoporosis experts are trying to get doctors to think about the disease in many ways. Fractures trump bone density. So, if someone has had fragility regardless of the bone density there is a major bone problem. So, you can have normal bone density and fracture. This means that the bone quality is not good and that the bone is brittle for some reason. To be clear most people who sustain an osteoporosis related fracture also have low bone density.
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