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Melanie Cole, MS (Host): Well none of us wants to be that person that’s facing the ground because we’re so hunched over from osteoporosis, but is there a way to avoid it? Is it something that is inevitable? My guest is Dr. Joseph Borrelli. He’s an orthopedic surgeon with BayCare Health. Dr. Borrelli, let’s give a little lesson for the listener’s first. What is bone made of and how does it get porous?

Joseph Borrelli, Jr., MD, MBA (Guest): Well thank you Melanie. Bone is a pretty simple material. It contains, from its inorganic side, mostly calcium. There’s a few other minerals, but for the most part it’s calcium. That provides good structure, good compressive strength. Then the other component that’s important in bone is collagen. Collagen represents kind of the rebar that we place in sidewalks and cement to strength it. That gives the bone it’s tensile strength. Then, of course, there are bone cells which produce the collagen and organize the calcium. There’s really two types of cells. There’s osteoblasts, which make bone, and there’s osteoclasts with a C that actually eat away the bone. It’s these osteoclasts that are responsible for the development of osteoporosis as we age.

Host: We've heard the terms osteoporosis, osteopenia. What are those? Tell us a little bit about what that is and what’s the prevalence in the general population?

Dr. Borrelli: Well, so the World Health Organization has come up with a stratification or a classification of the different types of the bone. Basically there’s three types of bone. There’s normal bone, there’s osteopenic bone, and then there’s osteoporotic bone. It gets a little technical. What they're looking at is the bone mineral density as determined on a DEXA scan, which is a simple x-ray. If you fall within one to two and a half standard deviations below the normal, that’s considered osteopenia. But if you're more than two and a half standard deviations below the normal, that’s called osteoporosis. So it’s kind of a gradient between normal bone, weaker bone, and the weakest bone.

Host: What bones does it typically effect? Dr. Borrelli, as I said in my intro, you see those people, the older people, and they're all hunched over. Their shoulders and their head is sort of staring down at the ground. Is that the only place that you would see it is that upper neck and shoulders area? Tell us a little bit about where we might see it.

Dr. Borrelli: So osteoporosis, which is very prevalent throughout the population and the world’s population, particularly as we age, effects all aspects of the bone and bones in all areas. It tends to begin in those bones who have more bone marrow or more cancellous bone. Unfortunately, that includes the vertebral spin, our hips and our ankles, and the ends of the bones and that just happens to be in the vertebral spine. So the vertebrae, which are generally square, kind of end up wedge shaped. That’s why people lean over and fall over and sometimes end up looking at the ground.

Host: It really look painful. It looks like something that would be painful. Speak about the risk factors. Are women more predisposed to this than men? Is there a genetic component? Do we even have any control over this?

Dr. Borrelli: A lot of good questions there. So if we back up… So the process of osteoporosis—this is one of the problems—is not a painful process. A matter of fact, it’s very silent and can go on for years before a fracture or a bone scan or something like that brings it to the patient’s attention or the physician’s attention. Certainly women are more commonly effected for a couple of reasons. Obviously, women go through a period of time called menopause where the hormonal system is changing drastically. The loss of those hormones tips the scales more towards the osteoclasts, the cells that eat the bones, and away from the osteoblasts, the cells that make the bone. Men, on the other hand, go through that process much later in life and therefore are not as commonly effected by osteoporosis.

Now, there’s great data and great information coming out that the best way to prevent the development of osteoporosis—If you could prevent aging that would be wonderful, but we haven’t figured that one out yet. Is to maximize, particularly in young females, maximize your bone mineral densities early on in life with good nutritional habits, good activities, weight bearing activities, and avoiding the things that we know take the calcium out of the bones. So early in life good nutrition, good activities, weight bearing activities, and staying on the thinner side will help deposit more calcium into the bone bank. Then when we age and we lose that hormonal stimulation, you have a longer way to go before you reach into that osteopenia or osteoporosis stage.

In adults if we haven’t maintained that, the best way to avoid osteoporosis is to maximize your vitamin D as well as your calcium intake. It’s kind of difficult to do that nowadays with regards to calcium. It’s hard to eat enough foods to bring in 1200 milligrams of calcium each day. Vitamin D, we’re so petrified of the sun nowadays that we use sunscreens on everything. Cosmetics have sunscreen on it. We’re told not to lay out in the sun, and we wear hats and cover up. So we don’t process our own vitamin D. Therefore for the most part, and particularly with women we should be supplementing our diets with vitamin D. So the foundation for the prevention and certainly early treatment of osteopenia and osteoporosis is vitamin D and calcium.

Host: How much vitamin D doctor?

Dr. Borrelli: Well, that varies. In general, we should be trying to keep our vitamin D levels about 30. In order to do that, many of us need to take at least 1,000 international units a day. Some need 2,000 or up to 5,000. Now vitamin D is very safe so you can push the limit on it, but of course you don’t want to be taking vitamins you don’t need. So at the very least you should be taking in 1,000 international units per day.

Host: Then let’s talk about diagnosis and treatment or management. You mentioned earlier the DEXA scan. Current recommendations say all women 65 and older should have a DEXA scan and postmenopausal women under 65 years that meet certain criteria should also get a scan. But what if you detect that they are starting to get osteopenia or full blown osteoporosis? Speak about some of the treatment modalities you would start.

Dr. Borrelli: Sure. Well, the World Health Organization, of course, has criteria around when you start testing bone mineral density with a DEXA scan. In general, women who are 55, approaching 60 should at least have a baseline bone mineral density test, particularly if they have a family history of osteoporosis, if they’ve had a fragility fracture—that is a fracture that occurred from a ground level fall—or have other risk factors. If they're smokers, drinkers, lots of carbonated sodas. If they're less than 127 pounds that’s a risk factor for osteoporosis. Of course being Caucasian, living in northern climates—Michigan and such—would also put a said increased risk of osteoporosis.

To treat osteoporosis, again the foundation being vitamin D and calcium, there are quite a few medications on the market. They fall into two big groups. The one group, which is what most patients are familiar with, are medications that kill the cells that eat our bones. So medications that kill the osteoclasts. The idea there is obviously to slow down that destructive process so that the bone’s not taken away. The other group, which there’s only two medications on the market available in it, but they’ve been around for about 20 years now are medications that stimulate the cells that form bone. Invariably when I'm discussing this with the patient—would you like to take a drug that kills the cells that eat up your bones or a medication that stimulates the cells that make your bones. Invariably the patients chose the medications that stimulate the cells that make their bone, and those have the biggest impact. So if you're osteoporotic, you may want to take a medication that really gives you a big bang for your buck. If you're osteopenic and you don’t want to go that route, then there’s other medications available.

Host: People are concerned about the side effects of those medications, Dr. Borrelli. That’s sometimes, I think, why women or men might not want to take them. What do you tell them about that?

Dr. Borrelli: Yeah. Well the side effects have gotten a lot of press lately. There’s really two that come to mind. So there’s something called atypical femur fractures. These fractures we started seeing about 15 years ago. The first report was out of Dallas. Where patients where sustaining femur, thigh bone, fractures after very low energy trip and fall or even trip sometimes. Not even a complete fall. When we started looking at these fractures, they had a rather unique pattern. Those are usually patients who’ve been on those early osteoporosis medications that killed the cells that eat bone. At about 7/8 years we start seeing those changes in the bone, and the patient’s risk of an atypical femur fracture goes up significantly at that point.

The other complication that has gotten a lot of press with regards to those medications are what we call osteonecrosis of the jaw. That’s probably even more rare than the atypical femur fractures, which are rare. Let me just say these medications do much more good than harm. More fractures have been prevented by the use of these medications than have created. But getting back to the osteonecrosis of the jaw. That was seen in a particular subset of patients who were receiving those patients that kill the cells that eat up the bone when they were given super high doses. They were usually patients with metastatic cancer. They were given super high IV doses to treat their metastatic cancer, and then they would have a dental procedure. Those patients were at an increased risk for this osteonecrosis of the jaw. Again, a very uncommon diagnosis and uncommon situation. Only seen really in a select few patients.

Host: Wow. That was a real lot of good information Dr. Borrelli. So you’ve spoken to us about supplements, vitamin D and calcium, and our diet. What about exercise? As we wrap up, where does exercise, increasing that bone density, weight bearing exercise. What do you want us to know about lifestyle behaviors that we can do that can help keep strong bones?

Dr. Borrelli: Well, I think there’s a lot of things we can do to help keep strong bones. Certainly some of the choices we make could be better in regard to smoking and drinking alcohol and some carbonated beverages. We can minimize all that. We can also avoid medications that we know, if possible, we can avoid medications we know cause osteoporosis or osteopenia. Most of those are like steroids. Prednisone and that type of thing. If you have to be on them, you have to be on them. But if you can avoid them, you're better off avoiding them with regards to your bone quality.

With regards to exercise, exercises, in particular weight bearing exercises—so lifting weights, using a treadmill, using an elliptical trainer—all of that will help maintain good muscle tone as well as stronger bones. They don’t seem to make a huge difference in the post-menopausal patient group, but they certainly make a difference. Now, the downside is they're probably not going to cure your osteopenia or osteoporosis. But taking with your medications and with the supplements and avoiding the things that hurt our bones, you'll be better off. The problem is once you stop those exercises, the effects almost go away pretty quickly. So I certainly want to encourage weight bearing exercises, weight lifting, treadmills, elliptical trainers—although once we hit 50 treadmills are not the easiest thing for us to do. Also avoid the things that hurt our bones as well.

Host: That’s great information. Dr. Borrelli, thank you so much. You're a great educator and thank you so much for joining us today. You're listening to BayCare Healthchat. For more information, please visit baycare.org. I'm Melanie Cole. Thanks so much for listening.