By Felicia Cosman
WebMD Live Events Transcript
On-and-off screen couple Jill Eikenberry and Michael Tucker have taken on a new case. No, they're not back on L.A. Law -- they're fighting osteoporosis. Recently diagnosed with osteoporosis and osteopenia, Jill and Michael have teamed to talk about being osteo pro-active...
The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Moderator: Welcome to WebMD Live. We'll be discussing osteoporosis. Our guests today are Jill Eikenberry, Michael Tucker, and Felicia Cosman, MD, clinical director of the National Osteoporosis Foundation.
Jill, what first prompted you to get checked for osteoporosis?
Eikenberry: I have a doctor in San Francisco who is a preventative medical specialist, and he felt that because I was postmenopausal and have small bones and that my mother had osteoporosis, he felt I had risk factors and thought I should have a bone density test in 1998. And that test showed that I was osteopenic which meant my T score was 1.8 and meant I did not have osteoporosis but already had significant bone loss.
That prompted me to get an annual bone density test and by 2001 my T score had dropped to minus 2.9, which meant I had about 29% less bone mass than an average healthy woman. And I said to my doctor, "What does that mean?" He said that meant I had osteoporosis. The cutoff is -2.5 to be osteoporotic. I was shocked to learn I had osteoporosis at age 53 because I did not feel any way frail. I lead an active life, and I didn't think I had a problem with my bones. It was a surprise.
Member: What's involved in a bone mineral density test and what is a T score?
Cosman: What's involved is that you lie down on a table fully clothed. It's noninvasive and associated with minimal radiation exposure. The T score is the way we express results of a bone density test, relating your bone density to that of a person with the same gender, but younger. It can determine if you have osteoporosis and how much at risk you are for future fractures.
Eikenberry: What I find interesting is that one in two women over age 50 will have a fracture from osteoporosis. One in eight women will have breast cancer. Yet many more women go for a mammogram than go for a bone density test. The irony is that the bone density test is actually easier than a mammogram, and much more comfortable. You don't feel anything. There's no down side to getting a bone density test. And Mike and I talk about how early detection with breast cancer saved my life and early detection with a bone density test can save your bones. And your life!
Moderator: What are the risk factors for osteoporosis? Who should be getting tested?
Cosman: We know that all women by the age of 65 should have a bone density test. And younger women who are postmenopausal should have one if they have any of the known risk factors for osteoporosis, and those include certain diseases (such as rheumatoid arthritis), medications such as steroids, prior fractures during adulthood, family history of fractures or osteoporosis, being a smoker, and being very thin.
Tucker: I went along with Jill when she had her bone density test as supportive husband. The doctor told ME I was in a high risk group as well, which is men under 5' 7" and that shocked me. I got my bone density test as well. I came up with a T score of minus 1.4 and that put me in the category of osteopenia, which shows severe bone loss. I have changed certain things in my lifestyle, am taking more calcium, increasing weight-bearing exercise, and eating a better diet.
Next year, I will have my bones tested again. If the T score goes south, I will perhaps talk to my doctor about drug therapy. This condition cannot only be stopped it can be reversed. There is no reason to grow old and have weak bones.
Member: I need to understand more about the amount of calcium needed.
Cosman: The target amount of calcium for age 50 or older is between 1,200 and 1,500 milligrams per day. It's important to understand this includes total intake for the day -- food and supplement. On average, if you get between three and four calcium-rich foods each day, you are getting enough. [If] you don't get what you need [with food], take a supplement of about 300 milligrams. The average intake in this country is about 600 milligrams per day, so the average calcium requirement is about 600 milligrams per day as a supplement if you cannot modify your diet.
Member: I've heard that exercise can help. Do Jill and Michael exercise?
Tucker: Yes, we both exercise regularly. We hike every day up the mountain with our dogs. Two miles on a short day, four and a half on a long hike. We just added weight exercises with machines and free weights. Jill does Pilates on a regular basis as well.
Member: Where is the best source of information about treatment for osteoporosis in men?
Cosman: Go to the National Osteoporosis Foundation web site at www.nof.org and there you will find information about the causes and treatments of osteoporosis in women and men.
Member: I'm 41, premenopausal and was diagnosed with osteopenia at age 39. I'm 5'7", very slender and small boned, but I've always drunk lots of milk and have gotten weight-bearing exercise for years. It's a mystery. My first doctor didn't want to put me on medications, but after my second bone mineral density test showed a decrease in my hip T score from -1.3 to -1.5, I switched doctors to one who put me on Actonel. In one year my hip T score went back up to -1.3, and my spine T scores increased almost everywhere. Why don't more doctors test premenopausal women who are thin, and put them on medications? Why wait until menopause when the bone loss will be that much more severe?
Cosman: There are currently no established guidelines for routine testing in premenopausal women. The risk of fractures in premenopausal women related to osteoporosis is low. A T score of -1.3 is completely normal. It means your bone loss is a little lower than a person of your age group, but it does not mean you have a disease. And you should not be treated as if you have a disease. A T score reduction of -1.3 to -1.5 is not a significant reduction.
If I measured your bone mass five times over one day, I could see fluctuations that would exceed a different of T score -1.2. Your bones don't change over the course of a day. We have no data concerning the efficacy or safety of a medication such as Actonel in an otherwise healthy premenopausal woman. It has never been tested in this population. Actonel works primarily by returning bone remodeling levels from an elevated state in postmenopausal women to premenopausal levels. If levels are already normal in premenopausal women, their effect is unknown. Since we have no medications that have been tested in this population, it doesn't make sense to go to BMD or recommend medication.
Member: You said a T score of -1.3 is normal, but isn't anything less than -1.0 considered osteopenia?
Cosman: Osteopenia is a term that many would like to do away with. It makes some think they have a disease when indeed they don't. The term was originally described by the World Health Organization to determine the prevalence of bone density levels in different categories and to compare this prevalence across different ethnic groups and nationalities. People who have bone densities at this range might have a genetic predisposition to have slightly lower bone density, but it does not mean that they have actually lost bone. Most people with bone densities at that level will not suffer from osteoporosis, however I still advocate testing and monitoring those levels in postmenopausal women.
Member: Jill and Michael, have you adjusted your diet to deal with bone loss? If so, what have you changed?
Eikenberry: I am more focused on calcium-rich foods like leafy green vegetables, but since my breast cancer in 1986, I have been conscious to eat things I feel are good for my overall health.
Moderator: Let's talk about calcium-rich foods.
Cosman: The dairy products, particularly non-fat or low-fat, have high amounts of calcium between 200 and 400 mg per serving. And these include milk, yogurt, and cheese, as well as soy-based milks and cheeses. There are also many calcium-fortified foods including citrus juices, which are excellent sources of calcium and can provide one of the servings of fruits you need each day as well as calcium intake.
Member: I'm 48, borderline for osteoporosis and not able to take Fosamax. What other natural things that could help besides diet and exercise?
Cosman: First, I would like to make sure you have tried Fosamax in the once-weekly regimen. There are fewer side effects that way compared to every day. There are also other medications available to treat osteoporosis, which include Actonel, hormone replacement, and Evista.
There has been no clear proof that any plant-derived estrogens or phytoestrogens can maintain bone mass or reduce fractures. Ipriflavone was tried in a well-designed study in Europe and did not reduce bone turnover, improve bone mass, or reduce fractures. A large intake of soy products might be healthy, but probably is insufficient to completely prevent bone loss in a perimenopausal or early menopausal woman.
Eikenberry: I think I have heard from a lot of friends who are going off of HRT due to controversy and I want to mention we have learned that if you have gone off the HRT, your bone density may plummet right back to where it would have been had you never been on HRT. It might happen quickly. A BMD is essential for those going off of HRT.
Cosman: People who stop HRT lose bone at the same rate as people who are undergoing natural menopause. Look at risk factors and get a BMD when going off of HRT to determine if another treatment may be indicated.
Member: What is the relationship between menopause and osteoporosis?
Cosman: Menopause is a time when estrogen levels decline dramatically. Estrogen is a hormone that maintains normal bone remodeling and maintains bone mass at a stable level. When estrogen becomes deficient, bone remodeling goes up and bone loss ensues. Fractures also increase in incidence at this time.
Member: Is there a relationship between rheumatoid arthritis and osteoporosis?
Cosman: Rheumatoid arthritis is one of the diseases that increase risk of osteoporosis. The cause is probably some of the chemicals released by abnormal joint tissue getting into the blood and causing dissolution of bone. Some of the medications used to treat RA like steroids are associated with rapid bone loss and fractures.
Member: What are the symptoms for osteoporosis?
Eikenberry: I don't have any symptoms! That was what was so shocking about the last T score and that's what's so crucial for others to know. Osteoporosis often doesn't exhibit symptoms until there is a fracture. That's why BMD is so important. You need to know if you are losing bone rapidly.
Tucker: If you wait for a symptom, you will have a broken bone.
Eikenberry: In the last 10 years, it has become possible to rebuild bone, and that was not true before that. My mom, who is 83 with RA and osteoporosis, makes me realize that I have actually done something about it at age 55.
Member: At what age should I start thinking about osteoporosis?
Cosman: You should begin thinking about it in childhood or at any age when it enters your consciousness. Osteoporosis -- as true for many chronic diseases -- has its seed in youth. Positive lifestyle measures like optimizing calcium intake, exercising regularly, and avoiding unhealthy habits like smoking can have a big impact. However, it's important to realize it's never too late to begin preventive measures.
Eikenberry: There are so many teenage girls with eating disorders and they are abusing themselves at a time when it's so important to be building bone. They may never reach peak bone mass. They will start in the "red" as it were.
Member: I am currently taking Fosamax for osteopenia. May I also take calcium? If so, how much is safe to take daily?
Cosman: You should take calcium if your diet is inadequate even if taking Fosamax. These methods work separately. No medication is as effective on bone in the absence of adequate calcium, vitamin D, and physical activity. Don't take calcium, food, or anything but water when taking Fosamax and wait 30 minutes before eating or drinking anything else. Afterwards, you can have your breakfast and take your calcium.
Member: Why are short men at risk?
Cosman: To some extent, being of lower than average height results in less positive impact force on your skeleton and so the part of bone mass related to this mechanical force is going to be a little lower.
Cosman: In addition, bone mass is heavily dependent on body size and bone size and overall, whether there are genetic influences controlling both is unknown, but they often go together.
Member: I have a T rating of -5.2 in my lumbar and -3.2 in my hip since 2001. I'm a man, age 58, and I'm on Fosamax. Given the severity of my condition, is there any better medication available to assure that I start building bone before a fracture happens?
Cosman: In your case, I would want to make sure that there were no underlying causes of osteoporosis. I would check my thyroid, parathyroid, and exclude certain diseases such as celiac sprue. In terms of treatment, assuming there is no underlying disease, Fosamax is currently the most potent medication available. It usually does give a moderate increase in bone mass, but not in all individuals. Hormones and Actonel also produce moderate increases in bone mass, and smaller increases can be seen with Evista and Miacalcim. A new medication called Forteo is expected to come out on market in the next few months. It's a true bone-building agent, and is an important medication to consider in a person with such severe osteoporosis. Check the NOF web site to get more information.
Member: Dr. Cosman, my husband (58 years old) has shrunk three inches in height. He took steroids for asthma for years. He doesn't drink milk or exercise. His bone density test said he was in normal range for men, but didn't give a T score. Should we get the score and how often should he be tested?
Cosman: Yes, you should get the score. He should also have an X-ray of the spine. He might have already suffered vertebral compression.
Furthermore, sometimes the spine T score is influenced by arthritis and other calcifications that can artificially increase the level. A bone density of the hip should also be done to make sure he doesn't have osteoporosis. Obviously he should begin right away a preventive program including increase in calcium intake and exercising regularly. The X-ray is VERY important. This should be explored.
Moderator: What are the effects of osteoporosis left untreated?
Eikenberry: I always thought that osteoporosis was something you could see because the person would be curved. It's something that can happen, but the other thing that can happen is you can roll over in bed and break a rib. You can open a window and break a wrist. It's important to talk about hip fractures. More will die from hip fractures due to osteoporosis than will die of breast cancer, heart disease, and stroke combined. Hip fractures are much more serious than they seem to be when you are 50. The idea they are preventable in that there is something you can do is a real cause for celebration.
Moderator: We are almost out of time. Do you have any final comments for us today?
Cosman: Begin preventive measures as early as you can but stay hopeful. Many treatments are available for even in the latter stages of the disease. Also many are effective even if you have had a fracture. Keep up with new medications on the market and ask your doctor if any of the current medications would help you. BMD is the way to determine if you need medications, and ask your doctor at your next visit if one is recommended.
Eikenberry: Baby boomers like myself are active. We want to continue to be active. It's a different world in that sense in terms of expectation. I am learning to take care of my bones. The campaign we are doing is "Know Yourself to a T." Know where your bones are and you will be able to be active for a very long time.
Moderator: Thanks to Jill Eikenberry, Michael Tucker, and Felicia Cosman, MD, for joining us today. To learn more about osteoporosis, be sure to explore all the info here at WebMD, including our message boards and live chats.
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