Online Health Chat with Dr. Bruce Long and Dr. Johnny Su
June 4, 2010
Cleveland_Clinic_Host: Osteoporosis is a common, preventable and treatable form of metabolic bone disease. Ten million Americans have this condition. Four-fifths of them are women. Early identification and treatment of low bone density is most effective in increasing bone mass and avoiding painful fractures.
Evaluations, which combine (DXA) bone scans with a thorough health history and lab testing, are used to develop treatment plans, including:
- physical therapy to improve balance
- falls prevention strategies
- dietary changes and calculating the amount of calcium in your food
- vitamin D supplementation
- exercise programs to promote strong bones
- eliminating risk factors for bone loss, such as smoking
- medications to build or maintain bone density
When osteoporosis is advanced or if weak bones have fractured, pain management is incorporated into treatment. New approaches to osteoporosis prevention and treatment are under investigation. Cleveland Clinic patients are often able to participate in trials of medications that are as good as — and hopefully better than — current alternatives.
Cleveland_Clinic_Host: Bruce Long, MD, is a staff physician in the Department of Rheumatic and Immunologic Diseases. He is active in the Center for Osteoporosis and Metabolic Bone Disease. Prior to Dr. Long’s appointment at Cleveland Clinic, he was chairman of the Department of Rheumatology at Fairview and Lutheran Hospitals. He is board certified in rheumatology and internal medicine and his specialty interests include: osteoporosis and bone disorders, Vitamin D, autoimmune disorders and pharmacology. Prior to entering the profession of medicine, Dr. Long practiced pharmacy in his home state of Illinois.
Johnny Su, MD, is an associate staff physician in the Department of Rheumatic and Immunologic Diseases. He is a part of the Center for Osteoporosis and Metabolic Bone Disease. Dr. Su’s specialty interests are osteoporosis and general rheumatology including rheumatoid arthritis, osteoarthritis, lupus and gout. He is board certified in rheumatology and internal medicine. Dr. Su is fluent in both English and Chinese.
Cleveland_Clinic_Host: To make an appointment with Drs. Long or Su or any of the other specialists in our Department of Rheumatic and Immunologic Diseases at Cleveland Clinic, please call toll-free at 866.275.7496. You can also visit us online at clevelandclinic.org/rheum
Welcome to our Online Health Chat with Dr. Bruce Long and Dr. Johnny Su. We are thrilled to have them here today for this chat. Let’s begin with the questions.
What is Osteoporosis?
djas: What are the causes of osteoporosis? What are some of the diagnostic tests that are run to confirm?
Dr__Johnny_Su: There are numerous secondary causes of osteoporosis, examples of some of the more common medical conditions that contribute to osteoporosis are hyperparathyroidism, hyperthyroidism, rheumatoid arthritis, long-term steroid use, etc.
Blood tests and urine tests can be used to evaluate whether you have any medical conditions that predispose you to osteoporosis.
artworld: When you have osteoporosis, does it affect all bone throughout the body or is it generally focused in one area?
Dr__Johnny_Su: Osteoporosis tends to affect trabecular bone, such as in the spine and hips, as well as the wrist - more than long bones such as the thighs or upper arm.
mommy: Is there any connection between osteoporosis and arthritis?
Dr__Johnny_Su: Usually not. The words sound similar. Arthritis is a disease of the joints. Osteoporosis refers to porous bone, and not the joint. However, there are medical conditions, such as hyperparathyroidism, hyperthyroidism that can affect both.
There are two types of arthritis that may predispose you for osteoporosis. These are rheumatoid arthritis and ankylosing spondylitis.
MarMar: What is the story about soda pop and osteoporosis?
Dr__Bruce_Long: High levels of dietary phosphates may have a depleting effect on the calcium in your body. This may theoretically predispose you to weaker bones. Not all soda pop uses phosphates for carbonation. Many use pressurized carbon dioxide.
There is also a possible adverse effect of caffeine on bone density. Usually, this is not a significant concern unless you drink an excessive amount of soda a day.
What is Osteopenia?
janie32: Osteopenia – what is it, how do the doctors know I have it and how do I treat it? If I have osteopenia, does that mean I have or will have osteoporosis?
Dr__Johnny_Su: Osteopenia can be diagnosed in two ways - Xray or bone density. The first way is when osteopenia is a term used by radiologists when looking at xrays and the appearance of bone is not as expected. The second is osteopenia is also a term used to describe a patient's bone density if they are in the range between normal and osteoporosis. Treatment for osteopenia is based on the individual patient depending on their risk factors, including age, history of fracture, family history of osteoporosis, medications and other medical conditions that may contribute to decreased bone strength. A person with osteopenia does not necessarily progress to osteoporosis but usually does.
Interestingly, most fractures occur in people with osteopenia. There are more people with osteopenia than osteoporosis. Therefore, it should not be ignored.
Diagnosis and Symptoms
goodie: My sister, who is only 37 was recently diagnosed with osteoporosis. What causes someone so young to get this? Should I be worried about myself? I am 41.
Dr__Johnny_Su: There are many possibilities for individuals to develop osteoporosis at a younger age, including premature menopause, in adequate calcium and vitamin D intake in childhood and young adulthood and other medical conditions, including hyperthyroidism, hyperparathyroidism, rheumatoid arthritis and long-term steroid use, along with previous eating disorders and malabsorption syndromes.
First degree relative of individuals with osteoporosis are at a higher risk of developing osteoporosis. You should consult your physician for additional testing, if you are concerned.
As with most conditions, it is better to catch osteoporosis early, rather than later and begin treatment.
Georgia: I’m confused. My bone density is 4. Is that good or bad? I am 86.
Dr__Johnny_Su: A bone density T-score= 4 is in the normal range. However, if this is the T-score in the lumbar spine, this score may be false elevated due to degenerative changes or compression fractures.
eggshell: I am 75 years old and very active - snow shoveling, leaf raking, walking, weight lifting, various exercises. I am a vegetarian, eat a lot of vegetables, fruit and tofu. I have had 13 falls – 1 fracture and 3 broken bones. My bone density is 3.2. How is it possible?
Dr__Johnny_Su: Regardless of your level of bone density, you can have a fracture related to osteoporosis if one of your fractures is at the spine, wrist or hip. You may have osteoporosis, based on a clinical definition, which supercedes any diagnosis based on your bone density. If the bone density number or T-score of 3.2 is at the lumbar spine, this may be falsely elevated due to the presence of degenerative changes.
We have also seen persons with a 'normal or high' T-score of the lumbar spine who have compression fractures of the spine. This can artificially elevate bone density scores.
heppytown: How accurate are the heel scans that are done at health fairs? I had one done (I am in my 30’s) and it indicated it was low or abnormal. My insurance won’t cover a bone density test since I am younger. In addition my grandmother and aunt have osteoporosis and I think my mom has osteopenia. What would you recommend for me to do at this point?
Dr__Johnny_Su: Heel bone densities are useful as screening tests. If it is suggestive of decreased bone density, you should consult your doctor to see whether there are any current risk factors for the development of osteoporosis and whether you have an indication for a central bone density to be performed.
Georgia: I’m confused. My bone density is 4. Is that good or bad? I am 86.
Dr__Bruce_Long: The bone density measuring instrument gives two types of numbers, depending on what is measured. These include the bone density measured in grams per square centimeter, and the standard deviations from normal expressed as T-score or Z-score. From the number you give, I assume you are referring to your T-score. The number is bad because it is much different from a normal number. If it is +4 then you are much higher than we normally see, which would suggest something interfering with the test, or measuring a crushed bone. If the number is -4, then the number is much lower than we normally see, suggesting you have lost a lot of bone.
Treating Osteoporosis: Exercise
JenPT: What role can physical therapy play in the treatment of osteoporosis?
Dr__Bruce_Long: Muscle strength and good balance are extremely important in the treatment of osteoporosis. Muscle strength helps us balance. Good balance helps prevent falls. If bones are weak, the stress from a fall may be enough to break the bone. Whereas if there was no fall, even a weak bone might not break Strong muscles also enhance bone strength, but the bone response to the muscle tugging on the bone. A physical therapist can instruct people on proper balance.
NancyG: I take the required Calcium, Vitamin D along with thyroid and cholesterol meds. My mom had compression fractures in her spine; never a broken hip or wrist. For prevention at age 56 and already with mild osteoporosis, are there any local support programs? I walk 5 out of 7 days, 2 miles. Is this the minimum? It is convenient, but do I need more strength training as well? I am also on generic Fosamax®. Would an evaluation in your department be a good idea? I have an internal medicine doctor in the Clinic who is monitoring.
Dr__Bruce_Long: I don't know of any local support groups. The fact that you have osteoporosis at an early age and you have a family history puts you at a higher risk for fracture. Your walking program and generic Fosamax, is a good start to treatment. Adding impact loading exercises might be helpful, such as heel drops, and some assessment of efficacy of the generic Fosamax® would be helpful. We usually use a urine test for that.
We would be happy to evaluate your situation. You can contact us at or any of the other specialists in our Department of Rheumatic and Immunologic Diseases at Cleveland Clinic toll-free at 866.275.7496. You can also visit us online at clevelandclinic.org/rheum.
Granny: I have osteoporosis in the spine, but also have fibromyalgia. Would I do the same type of exercise (treadmill=up to 1.2 miles).
Dr__Bruce_Long: I think your treadmill exercise will help both osteoporosis and fibromyalgia but there are other exercises that are more specific for osteoporosis.
Treating Osteoporosis: Medications
punkin: If I was diagnosed with Osteoporosis will I have to take the medication for the rest of my life? Is there something I can do with diet and nutrition to treat osteoporosis instead of taking medication?
Dr__Bruce_Long: There is a lot of variability in treatments. Most people take medication for a while, but often, we use 'drug holidays' where someone is off medication for several months. That is best addressed with your doctor, in regards to your personal condition.
Diet and nutrition are important parts of treatment for osteoporosis. Generally, there are four areas of osteoporosis treatment that all need to be addressed. These are: adequate calcium intake, adequate vitamin D, strengthening and weight bearing exercises and medications to help restore the balance between the cells removing bone and the cells building bones in our body.
For most people with osteoporosis, vitamin D and calcium are not enough.
xfiles: Can we alternate Fosomax and Actonel?
Dr__Bruce_Long: You can switch from one to another, but then try to maintain taking the one that works best for you and not keep going back and forth.
Dr__Johnny_Su: These is no evidence to support alternating Fosamax® and Actonel® versus taking one medication continuously.
HegsterMom: What about the side effects of the medications used to treat osteoporosis?
Dr__Bruce_Long: Like all medications, there are potential side effects with the medications used to treat osteoporosis. The potential side effects differ according to type of medication.
Dr__Johnny_Su: I agree. Changes in treatment can be individualized depending on the side effect encountered. For example, if a patient has heartburn symptoms with taking Fosamax®, taking Zantac the night before taking the Fosamax may be helpful or switching to Actonel® may be another option.
requiem: What are some of the alternative treatments to the bisphosphonates? I really do not want to take them based on the bad side effects I have heard about? I was on Evista for a while, but it was not effective. I am now using calcium, vitamin D3, magnesium and exercise as treatment.
Dr__Bruce_Long: What you are doing is good, but may still not be enough. Some of the problems with oral bisphosphonates may be avoided by the intravenous bisphosphonates. Other alternatives included teriparatide and denosumab.
Other medications are currently in development.
Melody: Do statins prevent bone fractures as well as heart disease? What about other cholesterol medications or supplements?
Dr__Bruce_Long: We don't know of any studies that have shown the effectiveness of statins or other cholesterol lowering agents in the prevention or treatment of osteoporosis. The biochemicals pathways do have an intersecting point and researchers have looked into this interesting aspect.
Bubbles: I’ve been taking Forteo for 1 ½ years, how can I tell if my bone mass is normal?
Dr__Bruce_Long: Bone mass can be measured by a DXA instrument and the result can be compared to a normal value and to your previous value.
Osteoporosis: Calcium & Vitamin D
Abby: Is calcium and exercise enough to help bone density?
Dr__Bruce_Long: No, at a minimum one needs calcium, exercise and vitamin D. That being said, some people can make enough vitamin D from sunlight and not need supplements, but it is difficult to accomplish in Cleveland.
Dr__Johnny_Su: Although calcium and exercise are important in helping to build and maintain bone mineral density, it is usually not enough once a person develops osteoporosis. It may be adequate if a person has normal bone density or low bone mass but not quite low enough to be defined as osteoporosis.
Cherry: Can calcium cause kidney stones?
Dr__Johnny_Su: Yes, excessive calcium intake can predispose to kidney stones. Usually the daily intake of calcium should be limited to 2000mg daily but this may need to be changed based on individual risk factors.
Dr__Bruce_Long: The formation of kidney stones is actually quite complex. The amount of calcium leaving the body through the kidney has a relation to risk of forming a stone, but there are other factors. For most people the usual dietary intake of calcium is not enough by itself to cause kidney stones. Calcium citrate supplements are less likely to cause kidney stones.
ttp822: I heard there are different types of calcium supplements to take to try and prevent osteoporosis –one is better than the other? Can you tell me which one I should be taking, how much and how often? Also, should a vitamin D supplement be taken with that too? At what dose? Also, someone told me to not take the recommended daily amount all at one time, but to break it up during the day. What are your recommendations?
Dr__Bruce_Long: Calcium citrate is generally better absorbed than calcium carbonate. However, for younger people, calcium carbonate is usually adequate.
People generally need at least 1200-1500mg calcium daily, if they have metabolic bone problems. The difference between your actual dietary intake and your recommended daily intake should be made-up by taking calcium supplements, but the preferred method is to get your daily percent of calcium through your diet.
We need to have a blood level of 25 OH Vitamin D of at least 31ng/ml for healthy bones. Most adults in Cleveland need to take vitamin D supplements to achieve that level.
Calcium supplements should be broken up into no more than 500-630 mg at a time. Vitamin D can be taken all at once. This is because the body can only absorb a certain amount of calcium at a time. For example, if you need to water your plants, there is a different affect of giving it a cup of water every couple of days, versus giving it a gallon of water all at once. The extra water just spills over and is useless.
NancyG: I just read that Calcium Citrate is better absorbed than Calcium Carbonate. Should I switch? I am a 56 yr old female and a recent bone density showed mild osteoporosis. I also had one done a couple years ago, but the scanner is now different, so there was no comparison. When would you recommend another scan?
Dr__Bruce_Long: We are confused about the term 'mild osteoporosis.' You can't go wrong taking calcium citrate, but I don't usually recommend switching until mid 60's.
Most of the time, a bone density test is done every two years or so, but with steroid induced or hyperparathyroid induced osteoporosis, we recommend yearly treatment. Or, if you are currently being treated for osteoporosis, you should be tested yearly.
djas: If I move to Florida (with more sunshine than Cleveland) will it help my Vitamin D levels, and my osteoporosis!?!?
Dr__Bruce_Long: The extra sun in your skin is likely to help your vitamin D level, but increases your risk for skin cancer. It seems we can't win! Just remember - you need more than vitamin D to treat/prevent osteoporosis.
Osteoporosis & Menopause
Kathryn: I had a total hysterectomy 3 yrs ago. The bone density test yesterday indicated that my hips have the bone density of a person with osteoporosis. I am not sure what I should do next? I am not a fan of taking pills or medications. I currently have an Estraderm patch that I am suppose to change twice a week. I sometimes forget, but my headaches remind me. Do you have any suggestions?
Dr__Johnny_Su: If your bone density test shows that your T-score meets criteria for diagnosis of osteoporosis, use of medications i.e. bisphosphonates is the best choice for preventing additional bone loss. Exercise and calcium and vitamin supplementation are likely not going to be adequate.
Lil53: I recently had a total hysterectomy which is throwing me into immediate menopause. I take 1200 mg Calcium chewables, MVT and love milk/yogurt. My mother (85 yrs.) has osteoporosis but was also a smoker for many years. Am I prone to getting osteoporosis even though my calcium intake is adequate?
Dr__Johnny_Su: In terms of menopause, you are only in menopause if they also removed your ovaries at the same time as your uterus. If you still have your ovaries, you may not be in menopause. If surgery did involve removal of your ovaries, then you are in fact in menopause. Given that your mother had osteoporosis, you are at a higher risk of developing it. Appropriate evaluation, including bone density, blood test and urine test, should be performed by doctor.
Calcium and vitamin D intake are likely not to be enough.
Lil53: I am unable to take HRT after my total hysterectomy (including ovaries) due to finding stage 1 endometrial adenocarcinoma. Is this going to put me at greater risk for developing osteoporosis?
Dr__Bruce_Long: Yes. Estrogens help control the activity of a cell called the osteoclast, which is the cell that removes bone. After menopause, the osteoclast becomes relatively more active, beginning a deboning process.
Lil53: What are the bisphosphonates?
Dr__Johnny_Su: Bisphosphonates are a class of medications that prevent bone from being reabsorbed as fast by cells in our bones called osteoclasts. As a result, bone density remains higher than they would be without these medications and reduces an individual's risk of fracture.
Examples of bisphosphonates are Fosamax® Actonel®, Boniva® and Reclast®.
JBloom9: In your opinion, what is the greater risk – taking HRT or not and developing osteoporosis and taking the bisphosphonates with their horrible side effects?
Dr__Bruce_Long: You touched on a dilemma doctor’s face every day – judging the risks and benefits of a therapy to help their patient. Other factors such as: does the patient have a family history of breast cancer? Is the patient able to swallow a bisphosphonate easily?, etc need to be taken into consideration.
In my opinion, bisphosphonates are actually one of the safest medications in modern medicine. The really bad side-effects are quite rare and usually the benefits far outweigh the risks.
The risks of HRT include breast cancer, stroke, and heart attack but do help prevent osteoporosis according to the Women's Health Initiative Study.
More commonly, bisphosphonates are being recommended for patients, not hormone replacement therapy.
Kathryn: I had a total hysterectomy 3 yrs ago. The bone density test yesterday indicated that my hips have the bone density of a person with osteoporosis. I am not sure what I should do next? I am not a fan of taking pills or medication, I currently have an Estraderm patch that I am suppose to change twice a week. I sometimes forget, but my headaches remind me. Do you have any suggestions?
Dr__Bruce_Long: You can help your bone health, by proper exercises, and adequate calcium and vitamin D intake, but if you're truly ready have osteoporosis he may unfortunately have to take a medicine to help restore the cellular balance in bone.
Mcgee: Is there a cure for osteoporosis? Also, is there a true prevention? Or can you only slow it down?
Dr__Bruce_Long: The cure for osteoporosis would be to get a bone that has lost structure, back to normal, like we usually have as a young adult. The medicine teriparatide has been shown to regrow lost bone, but usually doesn’t get it back totally to normal; I think true prevention is possible, if we can combine the proper nutritional, exercise, and bone cellular mix. We certainly have capabilities to slow down bone loss.
Osteoporosis & Men
P23S: I know men get osteoporosis too, but not very often. Why is this? Is it hormonal?
Dr__Bruce_Long: Women tend to have osteoporosis more than men because of the effect of a dropping level of estrogen at menopause and because they start out with having less bone mass. As men age, they tend to “catch up” to women in incidence of osteoporosis and statistically have a higher mortality rate. Common causes of osteoporosis in men include low levels of testosterone, alcoholism and lack of exercise.
Dr__Johnny_Su: Osteoporosis in men is likely under diagnosed so the number of men who have osteoporosis is probably higher than reported. Fewer men get osteoporosis compared to women because men usually have a higher peak bone mass than women so more bone loss is required before reaching osteoporosis. Also men do not have the rapid bone loss typically associated with menopause that women experience.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Bruce Long and Dr. Johnny Su is now over. Thank you again Drs. Long and Su for taking the time to answer our questions today about osteoporosis.
Dr__Bruce_Long_-_Dr__Johnny_Su: Thank for joining us today. If you have further questions, please feel free to contact us toll-free at 866.275.7496. You can also visit us online at clevelandclinic.org/rheum.
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