Osteoporosis Update 2017 – Research On Aging
the Sam Andros Stein Institute for research on Aging is committed to advancing lifelong health and well being through research professional training patient care and community service as a nonprofit organization at the University of California San Diego School of Medicine our research and educational outreach activities are made possible by the generosity of private donors it is our vision that successful aging will be an achievable goal for everyone to learn more please visit our website at aging UCSD edu welcome to the Center for healthy aging public lecture series for those of you I haven’t had a chance to personally meet my name is Julia van zina I’m a program representative for the Center for healthy aging and the Center for healthy aging focuses on health and well being through innovative research training and also community outreach this event is one of our many public outreach purposes that we do in our work including this public lecture series is supported entirely through donations I want to take a moment here and thank each of you who have supported us throughout the years our work wouldn’t have been possible without you we look forward to advancing this exciting work together with you and with more info for more information about our Center and for how to donate please visit aging UCSD edu without further ado I’d like to introduce our speaker for this evening dr. Heather haha flick Heather is a professor of medicine at UC San Diego she provides under canalla G and primary care for adults she has a special interest in osteoporosis thyroid and women’s health issues dr. halleck is consistently named top doc in San Diego magazines physicians of exceptional excellence dr. Hoffler completed her fellowship training at UC Irvine College of Medicine and her residency training at Beth Israel Medical Center she completed her internship at University of Pennsylvania School of Medicine dr. Hoffler earned her medical degree at Philadelphia College of Osteopathic Medicine and her undergraduate degree at Cornell University she is board certified in internal medicine and endocrinology diabetes and metabolism please help me in welcoming dr. Heather Affleck what I’m going to do today is a little different than I’ve done in prior years because I think we have a lot of new information and I want to make sure that everyone absorbs it well I’m going to talk mostly today about we’ll start and describe a stayer process to you I’ll talk about how we diagnose it secondary causes of osteoporosis fracks and we’re going to talk prevention I will talk briefly about the treatments but I think that that is now a talk in itself so I hope to come back and return very soon for osteoporosis part 2 so let’s get started and talk about the definition of osteoporosis so it’s a skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture and bone strength really integrates two features bone density which is something we obviously can measure with a bone density scan but there’s also something we have to take into consideration and that’s are the quality of bone and that’s what we’re doing more and more so you can see here a lot of people get confused when they come to my clinic what’s austere process versus osteoarthritis so osteoporosis as you can see here this is a normal bone matrix in the spine in a vertebra but here is osteoporosis there’s decreased bone density reduced networks increased porosity whereas with osteoarthritis when people ask me this is a normal spine it’s actually just occurring more in the interred in the disk space and in joint spaces in the hip so it’s really a narrow disk but it’s not loss of bone density so that is the big difference for you to know and the main way that we evaluate is through a bone density test but there’s also other characteristics of bone that we can measure and that is the bone remodeling architecture and damage accumulation and we are getting better in that as well so all these together the bone mineral density bust bone quality equals the strength of our bones so I always bring this up I think osteoporosis is an important topic this is a slightly older slide but it’s really important to know that we there’s really a high incidence of osteoporosis compared to other disease states that are very common and so you can see here the rate of osteoporosis is much higher and why is this important while fractures are associated with an increase morbidity and mortality meaning an increased risk of infection death problems associated with a fracture so it’s very important that we identify and treat people at risk and so it’s common about one in three woman over 50 will experience an osteoporotic fracture in their lifetime as well as one in five men and this is really important that we look at this population and figure out how we can identify this another important thing that we’re learning is that a first fracture over the age of 50 is really important a risk fracture is an indication that perhaps as you can see here over the next five to ten years your rate of fracture your risk for having another fracture is very high so it’s important that when you have a fracture you talk to your primary care doctor and you alert them that you had a fracture and hopefully you will get a bone density and get care from that because it’s important that we identify people as risks so the first fracture is very important and should be n is an event where we can help diagnose and treat so why are we worried about fractures we’ll look at the compression fracture of the spine there’s many different types you might hear of these wedge and crush fractures but really what’s happening is this is when height loss occurs and pain fractures are a downward spiral they’re associated with pain height loss problems so we want to prevent these in everyone and that’s why we’re doing bone density scans and assessing risk the other big thing which can be a problem is a hip fracture and as we know hip fractures increase the risk for problems infections and even death so these are there are many different types of hip fractures diagnosed on the area where it occurs but it’s very important that we prevent spine hip and all types of fractures so how do we diagnose it what should you do well most people hopefully have seen this machine in this room this is a bone density machine and basically the bone density we assess the hip and the spine are the two main areas and what it’s measuring is bone mineral content over area as we said before and then there’s the criteria many of you probably have heard of these t scores that your doctor uses to describe how bad are your bones or what state are your bones in or how good so normal is minus one and above a t score so what is a t score it actually compares your bone mineral density with the mean value for young adults and expresses this in a standard deviation it is a tool to help your physician understand where your bone density lies so there is something called low bone mass which we used to call sto pina and actually at UCSD we’re getting very good now at not using the term osteopenia and really referring this to low bone mass and this is if you have a t score a one two 2.5 the diagnosis of osteoporosis is if your t score is less than minus 2.5 so that means minus 2.5 minus 2.8 minus 3 anything lower that is diagnostic of osteoporosis now if you have what’s called a fragility fracture that is a fall that that from a standing height or something that really shouldn’t cause a fracture for instance you twist and you have a fracture you cough and you have a fracture or they pick up a fracture on your x ray that’s a fragility fracture that equals osteoporosis automatically even if your bone density falls in the normal range that is an osteoporotic fracture and it is important that we identify and treat that there is something on the bone density scan that we use in patients less than age 50 that’s called a z score when you’re less than age 50 we compared you to someone of your own age and that is termed a z score but typically we use this T score to kind of put you in range and classify you and I’ll explain more so this is the picture that I look at every day when I’m looking at my patients bone density scan I always look at the picture the spine and the hips and it helps me I look at all these numbers and pictures but I know I am certified and I know how to read these and to see what your values are so this is something that when you have a bone density this is the printout that your physician receives now I just want to alert you and make you more knowledgeable in this area sometimes patients come in and they say wow my hips are low and I have osteoporosis but my spine is really good and normal but and then sometimes people with normal spine are fracturing and the important point is your physician really does need to look at the picture of the spine bone density sometimes as you can see here there’s a lot of white in this area and when you have arthritis as we discussed before which is very common part of Aging it actually falsely elevates that t score on your bone density and so it’s not accurate in many patients so it’s very important that these pictures are looked at so what I do when I see that is I know then I can’t trust as much as I trust the hip bone density but I can still get an estimate but there’s other values sometimes you might be asked to do a distal radius of wrist DEXA if your spine cannot be evaluated so there’s other ways we can look at it but it’s very important that if your your spine values look really good but your hips are not as good that you look at these pictures to see and so that’s what just an important point that comes up often in my clinic a new thing that’s very experimental but actually is now on use I have a few patients who are seen by clinics in New York City that they’re using this now as a standard of care we do have this at UCSD in our research facility this is called a trabecular bone score and hopefully this will be more mainstream for use as well and this helps to get us around the issue of the spine bone density it actually uses a computerized program you take somebody that looks the same you can see here they have the same bone mineral density but they actually look at their Trebek in the bone in the vertebrae and here you can see with their various and see that there’s actually loose porosity whereas in the other one of this bone density they have a higher score so the is becoming more useful to help us with those spine problems it is available in a research center at UCSD but once again hopefully soon we’ll have this as an availability to help us look at the spines that are problematic so just something you may hear about in the future so who should have a bone density scan this is a very difficult question and I’ve been tasked to look at this at UCSD for our quality committee because it’s the guidelines are different and it’s really hard there’s been new guidelines this guideline so and there’s all different societies that disagree and so definitely I will give you my opinion on this but I will tell you that there is one criteria that is definite and the United States Preventive task force the one who really makes the primary care guidelines recommends a bone density in woman aged 65 and older everyone should have a bone density now men it is more difficult there have been mixed studies now let’s remember that men are just as much at risk for fractures as women and men really do have fractures in their 80s and the incidence is very high so I do agree with the National Osteoporosis foundation skyline’s and some other guidelines that men age 70 and older should have a bone density scam and I do get these in my primary patients I see a lot of male osteoporosis and it’s very important that we identify just as women as they turn 50 their estrogen goes down men as they age testosterone declines hormones decline at an older age so 70 seems to be an ideal time that men should be screened obviously with a fracture anybody should be screened a first fracture after age 50 and then if there’s a risk factor you can start screening at an earlier age the Rianne risk factors we’ll talk about in a bit I mean the reason we’re not screening as early we did used to send everyone in their 50s some people might remember going a lot more often in the past and we did that but now we’re treating a lot later and a lot different which I’ll explain later so I really think 65 unless a risk factor 65 is the starting age for females and men age 70 so this comes up this question in my clinic how often should I have a bone density scan and there’s not an easy answer for this as you so first of all it is very important to have your bone density scan on the same machine and the brand and preferably at the same location so for instance at UCSD if you’ve done it at La Jolla you should continue in La Jolla not go to the Hillcrest in the La Jolla because they do a lot of quality testing controls so it’s important to have it on at the same location so we can compare there have been some studies that say well maybe comparison isn’t good and different data but I think it is important that if you are at a clinic to have it at the same place now Medicare has changed their guidelines and they allow us to get a bone density every two years now sometimes we can get one sooner if you’ve started treatment there are very abilities to that but if you’re doing okay every two years now recent studies have said if you are in your 50s and I’m sorry in your early 60s and even if you’ve had one earlier and you have that low bone mass osteopenia perhaps waiting five years is just okay as well and even ten years some studies say so it is very variable an individual so I suggest you discuss with your physician about how often um and you can see here they’ve done out that recent study that’s what I’m saying that if you’re 50 to 64 without even osteoporosis you don’t need a screen if you got it younger until you’re 65 again so that’s showing there was a study on that now there is something else we do not do this regularly at UCSD but some of you at other institutions may get a lateral x ray along with your bone density screen and that’s called a vertebral fracture assessment so some societies to say that if patients have lost greater than height loss greater than an inch and a half that we should make sure that there are none of those spying compression fractures so when I see someone in the clinic so I don’t you know these are the guidelines of one society I don’t screen everyone but anyone that comes to my clinic that has had height loss greater than an inch and a half we’ll get a spine x ray to make sure they don’t have a fracture also anyone that’s on steroids which is a risk factor greater than three months so I this is the biggest one now what else can cause height loss once again that arthritis that asked your arthritis you can lose height from the disk space narrowing and that so there are many reasons people always get worried about the curvature having a lot of compression fractures of the spine can cause it but our itis can cause it to which is something that is of Aging and that we really can’t prevent or treat so at this time so it’s important though if you have lost height to get an x ray of the spine or ask your doctor for a spy’ low spine it’s called a lumbar or thoracic and thoracic x ray so what are so the other thing when patients come into my clinic I want to know why do you have osteoporosis especially in the younger age group I don’t want to just say here’s your treatment goodbye I want to know is there a reason that I can fix so maybe you don’t need the medications and we can turn this around or is there something and is there something underlying so obviously whew there’s a lot of causes that we need to think about so I just put that up to tell you there is just a lot but I ask when I’m doing my history in the exam room I’m asking a lot of questions on my patients and I try to figure out if there’s any reason so there are many causes and I’ll just run through some of the things that you can think about so in men and a woman having an early menopause so in women age less than 45 if you’ve had an early menopause and did not go on a hormone therapy that is a risk factor now most people now if you’ve had a hysterectomy under early menopause we do treat with hormone therapy until age 50 but if you’ve had an early menopause that’s a risk factor and then in men we checked for testosterone because obviously low testosterone is a risk factor for reduce bone mineral density and osteoporosis thyroid actually hyperthyroid the fast I ride not slow hypothyroid that can actually cause bone loss when somebody is in a hyper state so we make sure when that TSH is very low we want to make sure that people are on the correct dose of their thyroid medication a big causes something called primary hyperparathyroidism and that is a calcium and parathyroid hormone does your doctor easily can check for that there’s calcium in the lab work that is done on routine exams so they can see if your calcium is high and that would be a clue to this so it’s very easy to pick up but basically it’s one of your glands and it’s secreting extra hormone that can be deleterious to your bone and cause bone loss vitamin D deficiency we all know is a big one I’m sure everyone hopefully in this room has had that checked we had a mass checking since 2008 and even mine when I got mine checked it was 24 it wasn’t in the insufficiency so but we have to make sure though because if it is truly less than 20 it is a risk factor and we need to make sure that that is checked 20 to 30 and we’ll talk about vitamin D a little more lately is considered an insufficiency and the goal when we do therapy is really above 30 is the main goal we can talk about that when we talk about vitamin D Cushing syndrome or releasing too much cortisol so stress hormone we’re all stressed now we’re on their phones we’re running around we’re so probably secreting a lotta extra but that doesn’t necessarily cause bone loss but there is a syndrome called Cushing’s where you secrete too much cortisol and there are physical features associated with that but a doctor would pick up on and that caused it and diabetes has been associated with bone loss and fractures so it’s very important if you do have diabetes to make sure you’re getting your bone density screens and talking to your physician hypercalcemia is a cause that is where you’re releasing too much calcium into your urine and that usually produces a kidney stone there might be a sign of that but there are things that we check big thing that I see actually in a younger age and older age anyone that’s had bariatric surgery is at a very risk there’s been lots of studies that show the big large amounts of weight loss can cause bone loss and also all the nutrients because of the having the surgery you need to make sure that these pictures are on vitamin D and getting repleted with the proper amounts of calcium and other minerals malabsorption so bowel disease Crohn’s ulcerative colitis celiac disease these are all important things that I look for and talk to my patients about to make sure they don’t have hematologic disorders bone marrow lymphomas cancers can be associated with bone loss medications which we’ll talk about transplant patients they’re on a lot of medication kidney transplants liver transplants so I look at those patients very closely and assess their bone mineral density alcohol directly toxic to the bone more than three glasses a day medium sized is considered a risk factor for bone loss one to two a day they still say it may have a positive effect but once you get over the three glasses there’s a deleterious effect on bone tobacco use very harmful to the bone pregnancy lactation for long periods of time can cause bone loss and kidney and liver disease states can cause bone loss so what are some medications so I always do a very thorough review of the Med list of the patients that come in so make sure that you talk to your physicians you know to make sure you’re not on any medications that may be harming you or cause bone loss so steroids are a big one and that’s long term so it’s not the steroids that you get for a bout of asthma it’s not anything that you take for five or ten days for anything else this is three months worth of steroids so that’s important so short courses are okay steroid injections patients ask we don’t know at this time now inhaled steroids for asthma or COPD there have been Association studies but obviously the benefits do outweigh the risks heparin and coumadin long term there have been associations anticonvulsant there’s been some new literature on gabapentin which is a medicine that we use for pain that there may be some associated risk with fracture there’s a medicine we used to use a lot for seizures phenytoin or dilantin these medicines rev up the metabolism of vitamin D and can lead to vitamin D deficiencies chronic pain meds are very important these do can be directly toxic to the bones and cause bone loss proton pump inhibitors we’ll talk about on the next slide lithium a medication has been associated the big ones that we’re now seeing in a lot of our clinic our aroma taste inhibitors these are medicines that people are now on for breast cancer so there’s been many studies that we now we used to use tamoxifen and this is a whole other talk in itself but these medicines that woman are now on after certain types of breast cancer for five years and then out to ten years now even we’re going longer suppress all the body estrogen and definitely lead to fracture there’s the many studies that show that they have increased fracture risk and there are fractures associated so we do watch women on these medicines very closely and in men similarly prostate cancer and there’s a special type of therapy androgen deprivation therapy that some men may need and that too is associated with osteoporosis bone loss fracture excess thyroid medication as we said there have been some associations with SSRIs which is zoloft prozac celexa but that’s been more associated in very high age with fall risk and things like that and then there is something that we used to use for diabetes that we don’t use anymore tea CDs that is associated with hip fracture so a common question I get asked is about the proton pump inhibitors so this the names you might hear is omeprazole and nexium and all those names as effects so these there was a study in 2006 that showed some association between hip fractures and chronic use and then and this is due to decreased it decreases the your calcium absorption and then they thought oh well it’s associated with hip fractures in tobacco users so what I do in my clinic and what I encourage all of you to do is that definitely if you need these medicines stay on them take your calcium you know if you have conditions but sometimes people don’t and we used to kind of just leave people on it so I find a lot that I can take people off or say maybe use it every other day see how much you need it there’s other types of medicines out there called h2 blockers pepcid zantac see if that works I mean if you need it you need it but we do try to say just because of this implicative data if you don’t need it maybe try some thing else so that is out there as a potential effect so what do I do in my clinic in terms of so I look through the history I’m asking all these questions to try to find and tease out these issues and then there’s some laboratory tests now this has become more controversial I always get I mean if you’re you usually get in your yearly physical a metabolic panel which will tease out a lot of these issues with the calcium liver tests the CBC any kind of cancers different things so you’re a routine blood test that you’re getting really should suffice to figure out some of these underlying causes if I’m worried and somebody’s lost a lot of bone or they’ve had fractures then I proceed with further workup so just you know not everyone needs all these tests but phosphorus and magnesium underlying disorders are rare but every once in a while we can pick those up and I have so I do check those vitamin D of course we want to make sure that’s sufficient and the 24 hour urine for calcium and creatinine I make sure that you don’t have too much you’re not spilling out too much calcium into urine that hypercalcemia this is a test for there’s something called multiple myeloma which is a type of cancer that leads to fracture so if someone has a fracture I’m not sure I may order that in males I do order testosterone and the thyroid test and then parathyroid hormone if the calcium is elevated I may order that and then this this TGG iga is a test for celiac in a select population this test I leave on there the dexamethasone that’s to rule out any excess cortisol syndromes but I don’t do that frequently because that’s something you can pick up on the physical exam so basically these are some things that I do look at sometimes I order different things bone markers but this is a general comprehensive lab to make sure I don’t miss anything that I can treat in the clinic so this is just a case we work really closely at UCSD with our orthopaedic team under dr. Steven Garvin we’ve really whose chief of our orthopedics we’ve really set up a nice fracture program we have 200 chronologiste working embedded in orthopedics clinic I’m up in the La Jolla clinic and my colleague dr.
The human body is programmed to self-destruct as we age. But the speed at which this happens is entirely up to us. Studies have proven this a fact, time and time again. Unfortunately, I can’t make you 19 again but I certainly can show you how to reverse the aging process drastically with this free audiobook.
Mc. Allen is down in Hillcrest and this is a case I presented with one of our surgeons dr. Lee but it was just a nice case showing that he had picked up someone who had all these fractures we went through in order labs and it ended up we found out that she had cirrhosis of her liver and so we saved her life actually because if he hadn’t referred in the past you know fracture goodbye but he referred to the clinic she got treatment and actually she’s she became my primary care patients so she’s doing just great but if we hadn’t he if he hadn’t referred we may have missed some other underlying causes and that’s happened a couple times to me in the clinic to the orthopedic surgeons have referred the fracture patients that I’ve picked up certain kinds of cancers something called master of cytosis I pick up primary hyperparathyroidism so I think it’s really important that we’re thinking about a fracture and wondering why what is going on why is someone having it so the question comes when we do this and we do the bone density scan who do we treat how do we decide these days who needs treatment so if anyone remembers so in 2008 we kind of changed her thinking of this if anyone remembers before 2008 we took your T score and we said your T score is minus 2 or you’re a menopause everyone going Fosamax today does everyone remember that we did that and we left you on it for years right yes so that’s what we used to do and then in 2008 we started to think about risk factors who do we treat how do we treat so we don’t just take a blank number anymore and just put you on the medicine we really think about it and think about you and assess so obviously though if you do have asked your process and your high risk we should treat but we really have to think about this low bone mass category that t score of minus 1 to minus 2 point 5 do we treat what do we do and so as you can see here depending on bone mineral density scores the fracture rate goes up see in the orange as you have osteoporosis but the number of fractures is high in the osteo Pina and some of that might be kind of what explained to you before in the spine even though it looks osteopenia it might truly be lower and people are refractory but this is important that this group we try to figure out should we treat you in that osteopenia or low bone mass group so we know about some major risk factors right age is a enormous risk factor that is the risk factor for osteoporosis so as your age goes up you can see here even at the same T score a minus two point five at seventy you’re much higher risk of fracture 24% fracture risk versus at age fifty T squared minus two point five you have a 12% 10 year risk of fracture so age is very important also a prior fracture as we discussed earlier increases your risk for future fracture so at age sixty a t score a minus one point eight and having a fracture is a much higher risk than a t score of the same at the same age but no prior fracture so once again we know that prior fracture is important so that brings me to the fracks so anyone that is in these osteo pinna cranes should have this frac score calculated by either your primary physician or whoever you’re seeing and also now our radiologists do this for us and it’s fantastic because on your printout if you’re a UCSD patient and I know it Scripps Kaiser and sharp they do this to and any other systems it is already there for you so you can see your risk for fracture and remember this is if you have osteopenia if you have osteoporosis your risk is already high so this is something that we fill out and I still use a slide that I made a long time ago but this is just to show you we if somebody is 70 and their tee score is minus 2 and they have no risk fractures they actually might not need treatment so in the past we always treated these patients but now we know that there’s a lot of factors so we know that weight is a factor having low weight less than 126 pounds is a risk factor for osteoporosis prior fracture parent fracturing their hip is huge I always ask patients about that so any family history of your parent is a risk factor smoking currently not past current steroids rheumatoid arthritis and alcohol as we discussed before now this score if you plan on doing it on your own and assessing your risk online with your scores just note we don’t use the spine for all the reasons that I’ve mentioned before so it can only be your hip score that you put in there so you can’t use your spine and that’s because the hip as I discussed is a more accurate measure so this gives you your and then you punch in the button and you get your 10 year risk of fracture so what does that score mean if your 10 year risk if so view of osteopenia or minus 1 to minus 2 point 5 your 10 year risk of hip fracture if it’s greater than 3% the number that you get then treatment is likely indicated and if your 10 year risk is greater than 20% for any fracture then treatment might be indicated so this is just a guide and you know we use this as a guide to say whether or not treatment is indicated so this really looks gives you a good idea of what we’re doing here so here we were in 1999 to 2008 and we just treated everyone with these scores but look at what we missed we missed these high risk patients above 25% that were in their 80s and we treated all these young patients who might have had even osteoporosis but don’t need treatment so now we’re getting people that are more in their 70s and 80s and we’re treating them and anyone in the lower ages that might meet new treatments so you can see that we’re doing a better job by using this frac score of capturing the right population to prevent fracture further fracture so it’s only indicate indicated you can only use this scoring system for someone aged 50 and older and and technically you’re supposed to use it only if you have not been on treatment for a while because it can falsely change results and remember to use the hip or femoral neck t score and remember it is only a guideline so clinical decision making is still important so what do we do to prevent osteoporosis what are some of the things that we can do so there’s a lot and I will go through it and we can talk about what you can do to help prevent it so calcium so these are the current recommendations 1200 milligrams daily for women older than 50 a thousand for men older than 50 and 1200 for men over 70 and the goal now is we try to obtain our calcium from food sources if we can so that’s changed a lot I bet a lot of people here were put on the 1500 milligrams a day told to take it three times a day breakfast lunch and dinner and for many years so now we’ve changed this we say try and get it through food if you can because what we realized is perhaps there’s an association with all this calcium so some people were taking a lot of calcium plus dietary calcium and perhaps there was a risk of that depositing into the heart and causing coronary artery disease that being said there’s been a lot of conflicting data since that time saying no I think that we’re actually okay and this may not be but for that reason we are taking a step back and saying 1200 max get through the diet and then through food and then supplement if needed so this is something I can give everyone at the end this is on the National Osteoporosis foundation website WWN OS org this is a great website there’s so much information so I encourage you to look at this website and this is on there and I have a handout but this is something that I encourage my patients to go home and do you know and just make sure they’re getting enough so for instance if you look at a container of milk you can see that it’s 30% in an 8 ounce cup so that equals 300 milligrams if you drink that whole cup almond milk there are also fortified foods that are great sources of calcium almond milk breads lots of different things that you can do orange juice so I’m amount for instance has a very high quantity of calcium 500 milligrams and then you automatically get a 250 a day so I always tell my page if you’re drinking one glass of milk at 300 and you add 250 you already have one calcium supplement 500 milligrams and then if you get other food sources cheese yogurt some greens you’re probably getting your 1200 so there are a lot of people I know who avoid dairy and so in that case you should supplement if needed and it’s okay so some people might have a little bit of food sources and need one supplement but I think now we’ve moved away from the two supplements and most people just if they’re having a healthy diet filled with calcium rich food either need none or just one supplement a day so that’s where we are so what type patients often ask me this what type of calcium I go to the food store at CVS there’s millions what do i do Costco I don’t know so actually the goal the thing is we really don’t know there’s no type that is better than the other but there’s some tricks so calcium carbonate needs to be taken with food for best absorption so calcium carbonate is something that’s in Toms or you really have to look at your label and see what you’re taking calcium citrate does not need to be taken with food and can be taken in any type of environment and so we do like that if you are on that proton pump inhibitor we do prefer the calcium citrate that can be taken at any time of day but does one work better than the other no as long as you take it the right way and then as you know it can come in gummy form and in chocolate forum and in tablets and powder now and all kinds of things and that’s fine whatever you like is great as long as you’re getting it but we say so there’s all different types as I said these are the main types and there’s a lot of my patients like there’s bone up and all different kinds online but really just make sure you’re not going overboard and make sure you’re taking the right type so another thing that comes up commonly in my office is patients come in I say please bring your bottles of calcium and sometimes they come in and you can see her it’s so tricky so look at this one two tabs equals 400 milligrams but this one one tab equals 600 even today I had someone coming that was taking 10 tabs just to equal 600 IU’s of vitamin D and she hadn’t read the label and she was vitamin D deficient so I don’t think she so I think you have to look at your labels really closely bring them into your physician if you have any questions but I find this all the time that people are not taking the right doses or sometimes too much so please look at that and it’s very different everything every type of calcium is different so that it is very tricky so please look at your labels so vitamin D another important building block to bones and prevention and I do want to say before I move forward with calcium and vitamin D that there have been some studies in the last few years that have been very conflicting right some say you need this some say that they don’t reduce fracture so my take on everything while there have been a lot of observational studies that show that there’s been some studies that show remember calcium and vitamin D have never been shown they’re not a treatment they haven’t shown to reduce the risk of fracture but they have been shown in some studies to increase bone mineral density although they’re having some studies recently that say maybe maybe not that being said I do think if we’re on a low calcium diet we’re gonna be at risk and we’re gonna probably realize 10 years from now that we probably should be at least taking the minimum so that’s why get it in your diet and then vitamin D I do think is important you do need a supplement to get to the right level which I’ll discuss now sunlight obviously is a good source but then our dermatologists do not like us but and even in San Diego there’s been studies that we are deficient despite son but we wear a lot of sunscreen here right yes so that does inhibit the Rays from being absorbed so I always say to people measure your vitamin D you don’t necessarily need it I have people that do just fine so really the REC I followed the guidelines I know there’s a lot of people out there that thought you know we thought a lot we thought oh wow when it first started it’s gonna cure breast cancer and cure heart disease and this is going to be our end all and I hope it is but right now we don’t know and so I’m also cautious because when I go to my endocrine meetings there are some studies that show was too much a problem there were those studies that showed that perhaps too much vitamin D in older patients led to fractures so there’s been some things so I’m always one to go the moderate road and that is I recommend about 800 to a thousand that’s our recommendations and then max dose that’s truly recommended it’s four thousand now there may be some people who need more malabsorption different things celiac you know this is within the range so what level do i attain well I just like my patients to get over a thirty to thirty two this whole thing about treating to a level of fifty this we don’t know I can’t tell you today that there’s at one level the real studies were done showed that less than twenty was actually when fractures occurred in this twenty to thirty is insufficient see I bet most people out here the average person when I was first checking in 2008 most people were in their 20s to 30s range and you know who we don’t know but we do know that as you approach your 30s it reduces this level of parathyroid hormones so we think that thirty is somewhere where you should be above that so that’s what I aim for and that’s what I like to see in my patients and so I do think it’s important that anyone that has osteopenia or osteoporosis get a vitamin D test and make sure because we do know if you are low it improves bone density and while it never was shown to prevent fracture it is still a building block to bone density exercise very very important part of prevention so we recommend about 30 minutes of weight bearing exercise five to seven days weekly and try to do that exercise that you can do so low impact walking elliptical is actually a weight bearing exercise low impact aerobics Tai Chi for balance and being on your feet those are great I tell my patients get out there and walk that is great obviously the high impact to doing different things so there’s and then there’s been studies on this so there were a lot of studies that show that there is maintenance or improvement on bone density although recently some studies have shown out that they’re not sure whether or not truly doing all this weight bearing exercise helps so hopefully we will have more data out there but we do know that people that are in mobile or not moving do lose bone density so obviously there’s something to getting out there walking moving that is great so I just I love it most of my patients walk or do something like that and it’s great bikers swimmers and I’m gonna add because we’re in San Diego surfers surfers well I do see a lot of those male surfers that are not doing anything but surfing and so bikers they’re not walking in between so if you are a biker please get out there and walk a little bit swimmers walk you need to be on your feet for a little bit because we do see some osteoporosis associated with these activities those are not weight bearing activities muscle strengthening exercises I get a lot of questions about that what does that mean why do we have to do the weights and you know walk so muscle is important and I’m going to address that later we’re actually doing a study at UCSD looking at this it’s called sarcopenia where as you age your muscle mass around the bone actually declines so we want to kind of keep our muscles strong when you fall you want to have padding around your bone it helps with the network’s so muscles are very important do as a little you know little nice weights resistance training at Target buy some light weights do the best that you can or gym so these are good to keep your muscles alive and healthy now physical therapy can be very important another thing that I assess is balance right Falls why do fractures happen 75% of all fractures happen because of Falls we want to prevent that so physical therapy can be very helpful I send a lot of people there’s a woman a physical therapist at UCSD Lauren Hermus who specializes in physical therapy and for us too your process and bone disease so we have someone that does a lot of training with patients here orthotics and they can develop treatment plans to focus on weight bearing exercise so even a visit with a physical therapist if needed may be helpful and of course fall prevention is a huge part that’s what I hear all the time when we hear fractures in the orthopedic clinic I tripped over the vacuum cleaner cord I fell at night out of my bed I walked to the bathroom and didn’t have the light on and sat down and fractures you know lighting mats rails so just it’s very important I hear a lot about tripping and falling and so fall prevention is a good way to prevent fracture so this question comes up a lot what about caffeine so actually thanks to our very own dr. Elizabeth Barrett Connor who I believe many of you know who did the Rancho Bernardo trials the big osteoporosis trials here at UCSD early on showed us that it’s actually okay it’s not caffeine that’s the culprit so coffee is okay as long as you’re getting your adequate calcium and tea there is actually some evidence that that was reported at asked one of our bones societies a year ago that black tea may help then again that was in very high quantities like six six cups a day so more to come on that soda Cola so there was a 2006 tough study that showed that the phosphoric acid specifically this isn’t seltzer water in the colas at three cans eight ounce cans or greater a day did produce bone loss so just some evidence you know I do have people who come in that tell me they’re drinking a liter a day so maybe you want to cut back to one you know these are just some evidence but soda is the culprit it’s not caffeine that we know of today so that’s some good news and then I will end here I really always talk about the treatments but we’ve become so much more complex in our therapies and I know you all probably want me to talk about that and I will I will come back but I have decided that it’s really a two part talk so I’m gonna mention some generalizations just so you understand a little bit about our therapies when you’re going to the physician so most of our therapy is these are your bone cells and osteo class break down your bone and osteoblasts build up your bone and so most of our therapies that we have inhibit the osteoclast they stop bone breakdown and that’s the bisphosphonates and de knots about Prolia most of our therapies this one we now have two therapies we have teriparatide or Forteo and something just came out recently caught a bala pirate eye that’s a new medicine that also works in a pathway of formation but we’ve been using terra. Power type for a long time now it’s been out over ten years it’s a great and it is the only therapy that stimulates new bone building and new breakdown so that is a and all the other ones target the osteo class so I actually didn’t update this but there is that one new one but basically these are all our therapies that we have so we have we don’t really use I Bandra nade anymore or boniva we have alendronate the oral bisphosphonates IV we have something called Dena semadar / Leah and Forte oh and the new one a bala parrot ID which I told you and then there’s one that that was supposed to be coming new but we are waiting for FDA approval so in the interest of time I would love to come back and talk to you much more in detail about all those treatments and that talk would probably take about 45 minutes to an hour so today I just wanted to update you on the latest in prevention but I do want to tell you some neat things we have at UCSD we do have shared medical appointments for osteoporosis which I run where you can come in a group setting we do have a bone health education group so if you feel you want to come and talk about this I’m actually giving the next talk and I will talk about therapies um it’s the first Wednesday of every month and I have an email list so if anybody wants I didn’t list my email here but you can contact me I run an email list about this bone health group and we meet and we have a curriculum throughout the year so we have our listings and who’s our wonderful orthopedic nurse practitioner who works with dr. Garvin’s team she’s great we run the group the bone visits together and she does a talk on fractures and is really helpful in everything we do with bone here at UCSD we have Deb Cato another one of our endocrinologist who comes and talks about treatment Karen Mc. Gowan we talk about calcium we talk about vitamin D we have Diane Schneider who many of you may know who comes and talks about the latest topic so throughout the year it meets once a month and there’s information on our osteoporosis website at UCSD and then the other big thing I just wanted to mention which is a hot topic just to put in your ears there is a relation with the sarcopenia the loss age related loss of muscle mass strength and functionality and we are running a big clinical trial here at UCSD as I said the this is very important as you know the muscles generate the mechanical stress to keep our bones healthy so this is a new topic if you go to any of the websites they’re really talking about that and it is looking being looked at now there is a medicine that we’re looking at here called a myostatin inhibitor that actually improves muscle function in people with true sarcopenia now how sarcopenia diagnosed it’s diagnosed actually through a bone density scan but you have to do it a certain way we don’t do that now but I just wanted to put this because you’re gonna hear this term I’ve been noticing in the news papers and different things that’s that it’s becoming a hot medical topic and especially in osteoporosis so it is that muscle mass so we are running a clinical trial here for that to help and hope that improves prevents Falls and helps with other things related to osteoporosis so any questions or comments I do apologize I know many of you may have come for the treatments and to hear all about them and I’m more than happy to come back but I think a lot of what we do now is more the prevention aspect and learning and learning the right questions to ask because I may put someone here on one of those therapies I may give you a bits phosphonate or do not submit but if your vitamin D is inadequate and you’re have some underlying cause that needs to be identified first so I think I wanted to explain that to all of you today because we don’t just jump to the treatments and so I think you needed to hear that and I’m more than happy in the future if you ask to come back and do a whole treatment lecture so thank you for your time thanks for the support of the Styne it’s such a great organization and I’m so honored to be able to talk to all of you today so thank you and I’ll take yes women are more likely to have an osteoporotic fracture and woman more commonly have osteoporosis so we loo when we start we go through menopause at age 50 we lose our estrogen supply right so much earlier the men as men age many of them still do produce testosterone adequately into their 80s or 90s and they lose this later than we do so the only thing that I caution though with yoga because occasionally with yoga and Pilates I do see people that fracture so I’m talking about Yoga for balance not crazy twisting moves but yes it’s excellent for balance training muscle mass all of that and there are studies actually looking at that now as a weight bearing exercise too so we will find out more info so the question is do we still use the term osteopenia and we’re trying to move away from the International Society of bone densitometry is trying to recommend that because really it was created kind of I think low bone mass is a it’s more of a label and they’re trying to create it back that it’s a low bone mass when you say osteopenia it’s really a disease date and after and and carries weight in it and it wasn’t created it was created more when the drug companies were trying to define the terms and when to treat so we are trying to move away from that and we know and also in age less than 50 we’re not trying to use the term osteoporosis anyway so we move away from even both of those terms when you’re less than 50 we when you have what would have been caught osteoporosis we use the term low bone mass is there a relationship between osteoporosis and scoliosis is the question and the one relationship that there is is that when you have scoliosis which you cannot prevent right that’s curvature of the spine I mean you can do exercises and things to help but the one relationship is that it can increase your risk for fracture because of the curvature yes so that’s a good question the question is if you do localized or if you do exercise such as walking does it produce a systemic effect all over your body to increase bone density and the answer is yes the weight bearing when you’re walking on your body you’re stimulating your osteoblasts those bone building cells and telling them to make new bone so it have a systemic effect so the question is did I mention I’m saying to take so what does I want you to take some calcium 1200 milligrams daily in your diet is what I recommend if you can get it through your diet as we discussed but too much may be a bad thing so that’s why we’re limiting to 1200 so the question is why could calcium e be bad well there are a couple reasons one I didn’t mention too much calcium can lead to kidney stones and it can also they think it could deposit in your heart and cause heart disease but then they’re not sure what’s my answer there’s been conflicting studies so the question is do we need magnesium the answer is no unless you’re magnesium deficient there’s a lot out there in the health food stores that you actually need magnesium to absorb your calcium and that is not true your own body does that for you we there is rare to see a magnesium and phosphorus deficiency I look for it because it can happen in my world but not everyone out there needs it do we take magnesium for other things sleep leg cramps things it’s fine but do we need it for osteoporosis no great question so as you probably read this week they are making even more so the United States tasks prevention force is trying to create cutoff so the question is you know for colon cancer screening do we need to do a colonoscopy when you’re 80 do we need to do a mammogram when you’re a hundred you know that’s kind of thing but what happens with bone density we do we always need to think about it because when do the fractures happen 80 and up fractures are more likely to happen when you’re in your 80s so we are thinking about it until you are 102 so actually the question is can we address young young people and get their bones address so actually when my colleagues is doing a great job of that so dr. Diane Schneider she has a website for as in number for bone health org for than the number for bone health org and she is local in San Diego she’s retired here and she’s doing an excellent job she created programs with high school students and so if you’re interested contact her because her emails are contact me and I can get in touch with her because she would she loves to do this and this is what she wants to do is running probably better weight bearing exercise I’m walking yes but it’s walking adequate yes so it’s hard to say and studies haven’t really shown one than the other we also have an issue in that our ultra athletes and long distance so we know that people who over exercise actually lose bone density and have a lot of fractures right and especially in females and the female athlete triad and things like that so I think that when I say oh well walking is good we know that that is a healthy exercise that builds back bones is good running do better could you do better sure do we have the adequate studies to say that they’re mixed it was probably the answer so we don’t have the best answers so that’s why I do recommend trying to walk especially for my patient population I think walking is a great exercise if you can it’s one of the easier ones to do so what and faster walking is probably a faster pace we do know is probably a little bit better for creating the bone density but once again the studies are mixed whether it truly is improving bone density and preventing fractures there’s a lot of mixed literature out there the astronauts that are up in the air for a year they lose bone density that’s why we know that people who are in mobile and that can’t move they lose bone density that being said this whole exercise those people that are out there five miles a days may not be better off than someone work walking 30 minutes a day so it’s all in gradation so the point is to get out and move we’re not still clear on how much but it doesn’t hurt we do know 30 minutes a day you know running may be better than walking but if you walking is good so that’s what I’m trying to say that it all helps perfect thank you so much for being here today everyone ..