How to Keep Your Bones Healthy and Assess Your Osteoporosis Risk with Dr. Andrea Singer
Show Snapshot:
Think osteoporosis and brittle bones are inevitable as we age? Think again.
Dr. Andrea Singer, the Chief Medical Officer of the Bone Health and Osteoporosis Foundation, walks us through some of the most common risk factors for osteoporosis and lifestyle choices and exercises that can keep our bones healthy for the long haul.
Plus, when to get a bone density test, supplements to have on your radar, and the menopause bone health link. Bonus!—how to help your aging parents care for their bones.
In This Episode We Cover:
What is osteoporosis, and is it inevitable?
The shocking stat about menopause and bone loss.
Yes, you need a bone density test. We walk through a variety of factors that help you decide when to get this critical test.
The single most important risk factor for osteoporosis and bone loss.
The arthritis/diabetes bone health link.
The low down on HRT, diet, exercise, and preventative strategies.
Bone up on how much Calcium, Vitamin D are needed for optimal bone health.
A bone health superfood every midlife woman needs in their diet.
Sandwiched! How to help your aging parents care for their bones while you take care of your own.
Quotable:
What many people don’t know is that in the first five to seven years following menopause, women can lose up to 20% of their bone density.
Transcript:
Katie Fogarty [0:28]:
Welcome to A Certain Age, a show for women who are unafraid to age out loud. Beauties, we have a great and important show today, we are diving into bone health and osteoporosis and how to keep your bones and body healthy for the long run.
We are doing so with an incredible leader in the bone health world, Dr. Andrea Singer, who is the Chief Medical Officer of the Bone Health and Osteoporosis Foundation and an associate professor and director of bone densitometry at MedStar Georgetown University Hospital. Dr. Singer’s clinical areas of expertise are women’s primary care, osteoporosis, bone densitometry, secondary fracture prevention, menopause, sexual health, and medical and gynecologic disease. If you want to keep your bones and body working through menopause and for the long run, stick around this show is for you. Welcome, Dr. Singer.
Dr. Andrea Singer [1:21]:
Thanks so much, it’s a pleasure to be here.
Katie [1:23]:
I’m very excited, I’ve had a number of listeners reach out to me to say, “When are you going to talk about osteoporosis? I really would love you to focus on bone health,” and I am delighted that you are here. We’re recording this show during World Osteoporosis Month, World Menopause Day, all happen in October. I would love to talk a little bit about the menopause-bone health connection. What role, if any, does menopause play in our bone health?
Dr. Singer [1:53]:
Menopause is often the defining event in many ways for osteoporosis or bone health issues in women and that’s because estrogen is good for the bone and its bone protective, if you will. When a woman goes through menopause and loses the protective effects of estrogen because the ovaries stop producing as much, there’s less circulating estrogen, that can cause bone loss. I think what many people don’t know is that in the first five to seven years following menopause, women can lose up to 20% of their bone density.
Katie [2:31]:
That’s shocking.
Dr. Singer [2:32]:
So, if they’re already at risk, that may put them at much higher risk.
Katie [2:36]:
So, 20% is an enormous number. Is there an optimal time to be getting a bone density test? Should you do this before menopause? Should you do it in that seven-year window that you talked about?
Dr. Singer [2:51]:
That’s a great question and I don’t know that I have an exceedingly simple answer [Katie laughs] because there’s a little bit of controversy in terms of when bone density tests should be done. All of our guidelines and societies agree that if a woman reaches age 65 and has not yet had a bone density, then she should be tested, just based on age alone. For a younger post-menopausal woman, generally we’re figuring 50 years of age and up, but it depends on when one reaches menopause because sometimes that’s earlier. If someone has one or more additional risk factors, then they should get a bone density test as well. And when we think about the long list of risk factors, many people have something and I’m happy to further elaborate on some of the common things. For many women, we do actually get a bone density test somewhere around the time of menopause.
Katie [3:48]:
And so, what are some of the risk factors that we should be thinking about that will help us assess at what age we get this important bone density test?
Dr. Singer [3:58]:
The total list of risk factors is probably too long to go through on air, and we can certainly talk about where we can direct people who would like more information. But some of the common things include age, this is a disease of increasing age. Now, aging is better than the alternative, [Katie laughs] but the older one gets, the greater the risk for fracture. The lower the bone density, also the greater the risk for fracture. The single most important risk factor is having had a prior fracture because once somebody has had one fracture, that significantly increases the risk for future fractures. Family history is important, especially history of a hip fracture in mom or dad, but osteoporosis in the family and any fractures should be noted. Smoking, excessive alcohol intake, low vitamin D levels, poor calcium intake, being sedentary or inactive.
And then there are a number of other medical conditions or diseases, just as an example, diabetes, which unfortunately is extremely common in the US and worldwide, rheumatoid arthritis, and there are a number of others, as well as other medications that we use to treat other diseases that can be bad for the bone, so to speak. I’m not going to break into song but can be bad for the bone and increase the risk for bone loss as well as fracture. So, lots of things for us to think about. People who are very small framed and of low weight tend to have less dense bones and often reach lower peak bone density so they may be at increased risk as well.
Katie [5:45]:
Okay interesting. So, it’s a complex interplay of factors that can determine your bone health. So, what exactly is osteoporosis? Is that just simply bones that are... What is the medical definition of that term?
Dr. Singer [6:04]:
I was hoping you were going to ask that; I was thinking maybe we ought to back up a little bit [Katie laughs] and talk about what we actually mean. So, osteoporosis literally means porous bone. It’s a serious bone disease that occurs when the body either loses too much bone, makes too little bone, or both. And if we look under a microscope, healthy bone looks like a honeycomb. When osteoporosis occurs, the holes and the spaces in the honeycomb are much larger or more numerous than in healthy bone so the bones lose density or mass, and the tissue structure becomes abnormal. Bones become less dense and more fragile, and as they become more fragile, they’re more likely to break.
Katie [6:54]:
Okay, so is this something that’s inevitable? I know you outlined some of the risk factors. So, for a listener who is thinking, I’m not a big drinker, and I never smoked, and I don’t have a family history of this... Have they skated through? Or is osteoporosis inevitable as we age?
Dr. Singer [7:15]:
Osteoporosis and having fractures are not inevitable. Some amount of bone loss, may, to a degree be somewhat inevitable as we get older because we’ve talked about the importance of increasing age and obviously spending a longer period of time in the post-menopausal state without the protective effects of estrogen. But not everybody gets osteoporosis and waiting for that to happen, and expecting that at some point, somebody might break something or break a hip, that’s not normal and that should not be a normal or inevitable expectation.
This is a disease that we can diagnose, we can try to prevent with preventive strategies, and if somebody does develop it, we can treat to reduce the risk for fractures. The unfortunate thing is that it is an underdiagnosed and undertreated disease, and it doesn’t need to be.
Katie [8:15]:
Okay, well this is exactly why we’re having this conversation. Women need to have this on their radar, they need to ask themselves, do I have any of the risk factors that we’ve just outlined? I should be talking to my medical provider about how to assess my bone health and how to incorporate some of these preventative strategies that I want to explore with you next.
I’m curious, does hormone replacement therapy, is that one of the preventative strategies? Does adding estrogen through hormone replacement therapy help our bones?
Dr. Singer [8:48]:
The simple answer to that is yes, if I had to give a one-word answer. It’s obviously a little bit more complicated than that because when we talk about any medication but using estrogen and hormones as well, we certainly have to balance the upside, the pros, the potential cons, and the sort of benefit-risk ratio in terms of other effects that estrogen might have on different systems in the body. But from a bone health perspective, if losing estrogen is bad for the bone, then replacing it, potentially, is helpful. And indeed we know from studies like the Women’s Health Initiative that from a bone health perspective, there is a decreased rate of fracture in the women in that study who were on estrogen, both in the estrogen-only arm as well as in the combined estrogen-progesterone arm.
We also know that the amount of bone density that one might preserve or potentially build, is also related to the dose of estrogen. So, lots of different nuances, but in younger women who may be at risk, the use of hormones can certainly be a very good option to help prevent that rapid loss that comes at the time of menopause.
A caveat: if and when somebody stops using hormones, later on, one will then get the rapid loss that would have gotten around the time of menopause, but you might have delayed that by five years, 7 years, 10 years, however long somebody is on hormones, and waited until a time based on age when they’re at higher risk and then think about therapies that might follow.
Katie [10:36]:
Okay, this is fantastic advice. So, for listeners who have had early menopause, either by hereditary, or perhaps have gone into surgical menopause because of cancer treatments or other health factors, this is definitely something that you should be talking about with your medical provider. We are taking a quick break but when we come back Dr. Singer, I want to ask you about other preventative strategies beyond HRT.
[Ad Break]
Katie [12:20]:
Okay, Andrea, we’re back from the break. We talked about how hormone replacement therapy could potentially be an option for women to protect their bone health. What are some other preventative strategies that you want women to have on their radar?
Dr. Singer [12:36]:
Before I answer that, I just want to add something to what you mentioned before the break. The woman who reaches an early menopause, what we might call premature menopause, which is usually under the age of 45, or has primary ovarian insufficiency where they reach menopause in their 30s, or as you said, have surgically induced menopause; in those women, if there’s no contraindication to using estrogen, they should seriously consider and be treated with estrogen at least until the natural age of menopause. Because if not, we are putting them at risk for starting to experience significant bone loss at a very early age. So, they’re a different group of women than the group that goes through menopause... The average age of menopause in the US is about 51-and-a-half years. So, I just wanted to clarify that.
Katie [13:31]:
Yeah, that’s an important clarification. Thank you.
Dr. Singer [13:34]:
Other preventive strategies. All the things that we, as clinicians always hammer our patients about. So, healthy, well-balanced diet, in particular when it comes to bone health, making sure that people are getting in adequate calcium, preferably through dietary sources, but sometimes we use supplements to make up the short fall if somebody can't get enough calcium in through the diet.
Katie [13:58]:
And what’s adequate calcium? How do we define that?
Dr. Singer [14:02]:
For women 50 years of age or older, it’s a total of 1,200 milligrams of calcium daily, not all taken at once, so in divided doses. And that’s from all sources; dietary sources as well as any supplements.
Katie [14:19]:
Great.
Dr. Singer [14:19]:
Adequate vitamin D is also important, I feel like I’m opening Pandora’s box because there’s a little bit of controversy but with some newer publications. But if we’re talking about somebody who is at risk for fracture or has osteoporosis, the recent studies that looked at giving everybody vitamin D looked at a general, healthy population, mostly without bone disease and so we need to make that distinction.
Katie [14:46]:
What’s the Pandora’s box that you referred to? Some people should not be taking vitamin D, is that...?
Dr. Singer [14:51]:
No, the vital trial which looked at tens of thousands of healthy individuals and looked at giving supplemental vitamin D to people whose vitamin D levels were largely normal and who didn’t have underlying bone disease. If somebody already has a vitamin D level, giving them more doesn’t necessarily make a difference.
But for somebody who is vitamin D-deficient or at risk, that could be the elderly who don’t get outside in the sun, that could be people who are darker skinned who don’t make as much vitamin D based on UV ray absorption through their skin, could be people who have malabsorption or gastrointestinal issues, where they may not absorb fat-soluble vitamins or have had bariatric surgery. It can be those who are obese, there are a number of people who may be at risk. Those people and people who have known osteoporosis or have already had fractures, are a different group. And I don’t think we can extrapolate or carry over the data from the vital trial to this other group of individuals who are different.
Katie [16:07]:
Yeah, that makes total sense. Dr. Singer, for people who are thinking, I have not been to the doctor lately... because I know this, I know this from women in my life and friends, and I don’t want to throw my husband under the bus, but he’s not great about getting to the doctor. So Mike, if you’re listening, schedule that check-up. If people are thinking, how do I know if my vitamin D and calcium levels are appropriate, would you push them to make an appointment with their provider to get these levels checked? How does one learn this?
Dr. Singer [16:41]:
One doesn’t necessarily need levels checked, there’s certain circumstances in which we do check vitamin D levels, again largely in the group that I mentioned who are at risk. But I think people should make appointments with their healthcare providers and talk about their overall bone health. If a provider doesn’t bring up the topic, then women and men too, but I know we’re mainly talking about women, but just so your husband can be proactive too.
Katie [17:08]:
[laughs] Thank you, thank you. Thank you for pushing him, Andrea. I appreciate it.
Dr. Singer [17:14]:
I’m an internist, I see both men and women, so I get it. Women need to be proactive about their bone health and take charge of their bone health, and it’s fair to ask at a visit, “Can we discuss risk factors I might have for osteoporosis or something that might put me at risk for bone loss and fracture?” To ask, “Do I need a bone density test? Do I need any other testing based on my individual characteristics or risk factors, or medical problems, that would help us better assess my risk?” And so, I think there isn’t one size that fits all but the idea of everybody at least having the conversation to figure out what the most appropriate approach is for them, does fit all.
Katie [18:03]:
That makes total sense. So, this has sort of sparked a question for me. My listeners on this show really range in age from 45 to 65 plus. Do these bone health recommendations change as we age? In a healthy population. I understand that if people went into premature menopause, you’re in a different bucket. But if you’re moving forward, if you’ve had decent vitamin D levels, you’re in generally good health, at age 53, do I need to be doing different things than I would be, say, at 63?
Dr. Singer [18:39]:
The basic tenants are very similar. A healthy diet, as we talked about, includes adequate calcium and, vitamin D, and adequate protein. That is something... Protein is important to keep muscles strong; if muscles are weak and people become more frail, they’re more likely to fall, and a fall is often the precipitating event for a fracture. We know that fall risk goes up as people age, and each year, about a third of people over the age of 65 will fall. As people age, their diets don’t always have adequate protein in them. So, that’s important at all stages, but might be something to focus on as we get older.
The exercise aspect from a prevention standpoint, weight-bearing, muscle strengthening, resistance exercises, activities where you move your body weight, or some other resistance against gravity is important. Balance exercises, especially as we get older; again, the whole idea of preventing falls. So, the basic tenants are the same, some of what we employ or the importance of pieces of it may become a little bit more prominent as we get older.
Katie [19:56]:
Got ya. So, I had always heard that the exercises where you’re doing... I don’t want to say pounding your bones, but when you’re maybe hopping around a tennis court, or you’re walking briskly, and your heels and bones are hitting surfaces, that is good for your bones. Is this true?
Dr. Singer [20:14]:
Yeah, weight bearing exercise and some of the things that you have mentioned certainly, some of what you talked about are a little higher impact, but there are different varying degrees of impact, but that helps to stimulate bone remodeling. So, exercise in those forms is good. What we have to balance that against, and there are different exercise recommendations in terms of if we’re talking to somebody who is healthy, hasn’t ever had a fracture, is not at increased risk for falls, versus the person who may have significant osteoporosis with very low bone density, has already had fractures or broken bones, or maybe at increased risk for falls. We might choose different types and different intensity of exercise so that we’re not increasing the likelihood that somebody might fall while they’re doing exercise. Or, particularly in the patient or person who has had a history of spine fractures, we have to be careful with some of the load on the spine and exercises that can increase load on the spine that might increase their risk for fracture. So, you’re absolutely right. It’s again, individualization of an exercise program, based on the person sitting in front of you.
Katie [21:33]:
And so, if somebody has had the challenges that you’ve outlined, fractures, they do have these more porous and brittle bones, is it possible to reverse that with medicine and exercise? We talked about preventative strategies. What treatment strategies might be that you recommend?
Dr. Singer [21:56]:
It’s never too late to diagnose or treat osteoporosis.
Katie [22:00]:
That’s great to hear!
Dr. Singer [22:01]:
Yeah, absolutely. Now, the more bone loss there is, the more damage that has been done. We don’t necessarily get somebody back to where they started, obviously. But there are always things that we can do to reduce risk.
I think what people have to understand is that osteoporosis is a chronic disease, just like other chronic diseases that we’re familiar with: diabetes, high blood pressure, and high cholesterol. We can treat them effectively; we can reduce the risk of complications and events, but we don’t generally cure them, and the same is true with osteoporosis. So, if somebody has osteoporosis or has broken bones, we are talking about the need for long-term or lifelong management. Management can look like different things overtime and may very well change over time, but it’s not as though we’re going to treat somebody for a year and say, “It’s nice knowing you. We never need to do anything again.”
Katie [23:00]:
Right. We fixed it. You’re done!
Dr. Singer [23:03]:
Right. So, all of the things that we’ve been talking about, those so-called preventive strategies, remain important and are always part of the treatment plan; the diet, calcium, vitamin D, exercise, avoiding things that are bad for the bone like smoking and alcohol, et cetera. But in the patients who are at the highest risk for fractures, because that’s ultimately what we’re trying to prevent – fractures, broken bones; they mean the same thing, people sometimes use the terms differently – can be life-altering events. That’s where medications and prescription medications come into play and can be very important in terms of improving bone density,, most importantly, reducing the risk for fracture, and hopefully preventing some of those life-altering events.
Katie [23:58]:
Yeah, so preventing these life-altering events is something that everyone who is listening to this show is focused on. We are living longer, fitter, and healthier than ever, and we want to make sure that our bones keep up with us. For listeners who are thinking, I want to stay on top of this. I want to be ahead of this. Where might you direct them to for resources where they can learn more about bone health, perhaps where they could learn more about nutrition and exercise that helps, or to find a provider that might help guide them?
Dr. Singer [24:28]:
I think a valuable resource is the bone health and osteoporosis foundation. The website is all one word, BoneHealthAndOsteoporosis.org. On the website, under the patient section, there is all kinds of information about much of what we have discussed, the consequences of fracture, and there are links to calcium calculators, for instance, and other dietary sources and recipes, and other sites that speak to exercise including Bone Fit. So, I think it’s a good place to start, and then you can link to other resources as well.
Katie [25:06]:
And sounds like a wonderful resource. I had no idea you could look at a calcium calculator. I’m curious about that myself. I love the idea of finding some bone health recipes that I might start incorporating. Does this website also provide providers in different states for listeners who are thinking, I want to work with a specialist?
Dr. Singer [25:28]:
There is a list of members and providers. We are actually revamping that to make that more robust and to include others across different states but it’s certainly a place to start in terms of looking for those who may specialize or have a special interest in treating bone health.
Katie [25:47]:
Fantastic. So great to have that as a resource. Thank you for sharing that. Dr. Singer, I know that you write about and talk about osteoporosis frequently. This is a big part of your medical practice. Doing my pre-dive into Google to learn more about you, I see that you’ve shared a lot of information about how you’ve been helping your own mother juggle her osteoporosis care, and this caught my eye because we’re part of a sandwich generation, we have maybe an adult or young adult children that we’re helping, but we’re also helping our parents navigate their own health care. How can we help our parents when they are navigating bone health challenges? What have you learned on your own, with your own experience?
Dr. Singer [26:34]:
I often joke about this. It’s sort of like the shoemaker’s child who has no shoes. It’s the osteoporosis or bone health expert’s mother who not only has osteoporosis but then has a spine or vertebral fracture, probably sustained at my house, helping me with one holiday in terms of preparation and doing more than she should have. I often say that osteoporosis is a family affair. Fractures certainly are because not only do they affect the patient, but they affect those who help to provide care, want to make sure that their parents remain safe, don’t have additional fractures. In the acute setting, and thankfully my mother is very independent still, there weren’t significant limitations following the fracture, although she had pain. But for many who have fractures, even completing normal activities of daily living or being able to drive and get themselves to appointments becomes difficult, if not impossible. And so, the time that it might require family members to take off from work to help take care of a loved one, or to get them to their appointments or to take them to physical therapy, this really becomes a family issue.
Katie [27:53]:
Absolutely. Everything that you just outlined, the way that it impacts the caregivers and the people around them too. With your mother, you learned this maybe the hard way when she had this fracture in her spine. If someone is thinking, my parents aren’t there yet, but I’m worried. What would you encourage them to do to get their parents on these preventative strategies?
Dr. Singer [28:16]:
That’s where I was actually just going to go or segue to, so that was perfect. I think if a parent isn’t taking the initiative themselves to speak with their healthcare providers about bone health or if they have not yet had a bone density, that might be the first thing that we do or encourage them to ask about or to get so that we have an assessment of the status of their bones.
But it’s more than just bone density. That’s a very important piece of things. It’s also having someone take an overall look at their clinical risk factors because there are many ways, both identify people who are at risk. Obviously, the more clinical risk factors one has, the greater the risk, and it also to help decide when somebody might need testing and/or intervention. So, bringing the topic up, going with them to a visit or encouraging them to discuss bone health with their providers, and then talking about all the preventive strategies we’ve talked about, or if you live nearby your parent, going over and saying, “Let’s go out for a walk together,” or “Let’s look at healthy ways to incorporate calcium into the diet, together.” So, we think about that mother-daughter, mother-daughter, perhaps granddaughter relationship, that doesn’t mean bone health is not important in grandsons or sons but again, just thinking about those alliances and where we can all help to take care of each other and raise awareness.
Katie [29:49]:
Those are wonderful recommendations. As a New Yorker, I was raised walking sidewalks, my parents are both still really active walkers, so I know they’re taking care of their bones in that way. But you know, even though I talk to them every week, I’ve never thought to ask them, “Hey, have you had a bone density test? Is this something that’s on your radar?” So, I thank you for that suggestion because that’s a very innocuous and easy thing to ask. Sometimes I think...
Dr. Singer [30:21]:
It’s also a very easy thing to do. A bone density test done by DEXA scanning or Central DXA scan takes about 20 minutes. It’s noninvasive. If you don’t have any metal in your clothes, zippers, snaps, you don’t even have to get undressed. It is exceedingly low risk and gives us a wealth of information in terms of helping to evaluate risk status.
Katie [30:46]:
Yeah, I did my own at age 50, and I agree, it was simple and easy to do. I was in and out. All you do is pull down your pants from one hip, and the machine takes a picture through your hip. It was absolutely easy to do, it’s not like the colonoscopy which everyone fears, which by the way, everyone should put on their list too after a certain age.
Dr. Singer [31:08]:
Absolutely, they’re very different
Katie [31:10]:
They’re very different, and this is not remotely scary, and it was super easy to do, and I was relieved to discover that my bones are in good shape, at least they were when I did this two years ago. So, put this on your list, listeners, if you haven’t done it yet.
Dr. Singer, we’re nearing the end of our show. We’re going to head into a quick speed round because I can always spend more time with my guests than we have allotted for the show. This is very simple, just one-to-two-word answers to some questions so we can close on a high-energy note.
The first question is: best exercise for bone health _____.
Dr. Singer [31:49]:
Let’s go with walking.
Katie [31:50]:
Nice. This bone health food is always in my shopping cart: _____.
Dr. Singer [31:55]:
Yogurt.
Katie [31:56]:
An under-the-radar food for bone health: _____.
Dr. Singer [32:00]:
Kale and other leafy greens.
Katie [32:03]:
Yes, I love spinach! It took me about 40 years, but I adore dark, leafy greens. Best vitamins for bone health: _____.
Dr. Singer [32:13]:
Calcium and vitamin D.
Katie [32:14]:
Surprise, this symptom of osteoporosis that you may not know about is: _____
Dr. Singer [32:21]:
Height loss.
Katie [32:22]:
Height loss, ooh. Okay, that one does sound... You’ve got to pay attention to that. Worried about your bones? Avoid this one thing: _____.
Dr. Singer [32:32]:
Smoking.
Katie [32:33]:
If I could wave a magic wand, all women would do this to take care of their bones: _____.
Dr. Singer [32:40]:
Get a bone density test.
Katie [32:42]:
Perfect. What a great note to end on. Thank you, Dr. Singer.
Before we say goodbye, how can our listeners find you, your work and learn more about the Bone Health and Osteoporosis Foundation?
Dr. Singer [32:55]:
Again, the website, BoneHealthAndOsteoporosis.org is probably the best way to access all of those things. I also can be found on the website at MedStar Georgetown University Hospital, in the Departments of Medicine and Obstetrics and Gynecology.
Katie [33:11]:
Fantastic, I will put all of those in the show notes. Listeners can find those over on ACertainAgePod.com. Thank you, Dr. Singer.
This wraps A Certain Age, a show for women who are aging without apology. Join me next week when I sit down with fitness leader, Liz Hilliard, to talk about midlife epiphanies and following your heart. Liz was married for 37 years and at 64, realized she was in love with her best friend.
Special thanks to Michael Mancini, who composed and produced our theme music. See you next time, and until then: age boldly, beauties.