One in three women and one in five men over the age of 50 will experience bone fracture due to osteoporosis. And in the U V体育官网入口. S. , as our population is aging, the prevalence of the disease is expected to rise.
On this episode of Aging Forward, we talk with Dr VSports在线直播. Jad Sfeir about the key components of bone health and the need for a multidisciplinary approach when it comes to musculoskeletal care.
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Dr VSports. Christina Chen: This is “Aging Forward,” a podcast from Mayo Clinic about the science behind healthy aging and longevity. Each episode, we explore new ways to take care of our long term health, the health of our loved ones, and our community, so we can all live longer and better.
I’m Dr. Christina Chen, a geriatrician and internist at Mayo Clinic in Rochester, Minnesota. And this episode, we’re talking about Osteoporosis: understanding the risks, how to prevent it, and how to keep our bones healthy VSports app下载.
In this episode, we are talking about osteoporosis and bone health. One in three women and one in five men over the age of 50 will experience bone fracture due to osteoporosis. It’s a condition that impacts bone integrity, causing pathologic brittleness, such that something very minor, like bending over or coughing, can cause a break V体育官网. Here to tell us more is our guest for today, Dr. Jad Sfeir who has a really unique clinical background.
He’s a triple boarded clinician in internal medicine, endocrinology, and geriatrics, assistant professor at the Mayo Clinic College of Medicine and Science in Rochester, Minnesota VSports手机版. He also does aging research with a focus on bone and metabolic disease. A wonderful teacher and educator, he’s my go-to person for all questions related to bone health and really delighted to have him today on the podcast. Welcome Dr. Sfeir.
Dr. Jad Sfeir: Thanks for having me. Delighted to be here V体育安卓版.
Dr V体育ios版. Christina Chen: I know you live and breathe endocrinology and osteoporosis management every day, but for the rest of us, to start off, can you share a little bit about just how osteoporosis happens. What happens to bone integrity over time.
Dr. Jad Sfeir: As you mentioned, osteoporosis is a condition of bone, brittleness or what we call bone fragility, which predisposes to breaking the bone, what we call fractures.
This actually happens as we grow older, we develop deterioration in the integrity of the bone.
Bone is made up of multiple cells that are constantly changing and an evolution where you have some cells are chewing the bone. We call this bone resorption and cells that are building the bone. We call that bone formation, and the balance between the two changes significantly with life. It’s really a big function of age. But also a function of sex hormones — in women estrogen, and in men testosterone — that is at the bone level transformed into estrogen that impacts the bone.
The changes that happen to these sex hormones as we grow older, as well as aging itself combined, can cause significant imbalance in the bone formation and the bone resorption leading eventually to a brittle bone that can break easily with minimal trauma.
Dr. Christina Chen: How is this different from just degenerative bone conditions like osteoarthritis?
Dr. Jad Sfeir: This is different from what happens at the generative areas. As you mentioned, osteoarthritis, this is more related to the joints. Where two bones meet, and they usually have a lubricant between these two bones, that joint area, that lubrication can deteriorate with age and cause something like arthritis when bone is rubbing on bone.
These are two separate processes, although combined, they do have a very common feature, which is aging as the mechanism of aging can turn into many conditions that accumulate as we grow older.
Dr. Christina Chen: It’s so helpful to understand the science behind that, because we all assume that things change with age, but just to understand the hormonal changes, what happens at the molecular level is so helpful to get that baseline understanding. How do you know how one knows if they have osteoporosis? Because with osteoarthritis there are signs of pain and aching. Do people feel that with osteoporosis too?
Dr. Jad Sfeir: That’s something I get asked a lot by patients. How do I know if I have osteoporosis? I don’t feel it. That’s because you don’t develop symptoms with osteoporosis. Everything we talked about, those changes that are happening in the bone are happening at the molecular level inside the bone. You don’t feel any of that.
Unfortunately, the only symptom of osteoporosis is breaking a bone, and having a fracture. This highlights the importance of screening for osteoporosis, even before we have a fracture, because you wouldn’t know it exists until then.
Dr. Christina Chen: Are there certain groups or populations that are at higher risk of developing osteoporosis so that we can be more proactive in those situations?
Dr. Jad Sfeir: We talked about the importance of sex hormones, and so, automatically you think about postmenopausal women, right? After menopause, we lose a lot of estrogen around the age of 50, which is the average age of menopause in the United States. You start having a significant imbalance, where you’re losing a significant amount of bone, at menopause and in the first few years following menopause.
Men do have a deterioration in the level of testosterone, but this happens more gradually, rather than abruptly. That’s why we always consider postmenopausal women to be the higher risk group when it comes to osteoporosis within that group.
Caucasian women seem to be at the highest risk. Right after that would be American-Indians and Hispanics. In general, Asian-Americans and Blacks have much less incidents of fractures with age. They have more resilient bones, to the effect of aging, and you see it much less.
Then, one other category of people that always need to be thinking about that are those who are taking medications that may affect the integrity of the bone, or have conditions that can affect that.
Dr. Christina Chen: It’s all wrong. I thought that Asian women were at the highest risk. I’ve been worried about my mother, especially because she’s very underweight. She doesn’t eat much and had early menopause, so thank you for setting that straight for me.
Dr. Jad Sfeir: Something to keep in mind, and this is something we do everyday in the clinic, is individualizing the risk to each individual person. What we’re talking about are these population-based studies that showed us that, in general, White women are more at risk than others, but it doesn’t mean that everybody else is protected from fracture.
Dr. Christina Chen: I see. Knowing those risks. One of our goals on this podcast is to help all of us recognize what we are doing now that could be either helpful or harmful downstream. Are there certain lifestyle habits that we’re doing now that could increase our risk of developing osteoporosis?
Dr. Jad Sfeir: Something to keep in mind is that the skeleton bone doesn’t exist in silo. It has a very tight relationship with the muscles. We call this combination the musculoskeletal system. Also, we’re learning more and more that it also has a very tight relationship with the fat tissue or adipose tissue in our body.
It is very important for us to realize the communication that happens between these systems. You asked me how my lifestyle is going to impact that? The better muscle you have, the more protection on the bone, the less fat and adipose tissue you have, the healthier your overall distribution of your body composition, the healthier it is for the bone and the less likely you are to break a bone.
It’s very important for us to exercise early on, build very good habits in our lifestyle to have strong muscles, to protect our bones, but also to have a very good diet and a healthy diet where we’re not missing any nutrients in our diet that are important for the bone metabolism.
Specifically those would be Calcium and vitamin D that are essential for that bone metabolism we talked about. We need calcium and vitamin D to build healthier, stronger bones and also, to control any other diseases that may contribute to a negative impact on the bone. One big one is diabetes, because it can have a negative impact on the bone.
Dr. Christina Chen: I love that you mentioned both the exercise and diet component as the key pillars because those are things that we can be doing right now as early as possible, between strength training and being very thoughtful about which foods we’re eating that are beneficial. You mentioned calcium and vitamin D. What are the best foods that are beneficial that have the highest amounts of calcium and vitamin D?
Dr. Jad Sfeir: Let’s separate the two. Calcium. First of all, it’s actually quite prevalent in the diet. The biggest thing we think of when we think of calcium are dairy products, milk, cheese, yogurt, and ice cream. When they are dairy-based, they contain a lot of calcium. However, there are many other items, and I know many people are either lactose intolerant or they’re avoiding dairy for some other reasons.
There are other items that contain calcium, but what you need to be cognizant about is the serving size. Dairy will give you much more calcium in a smaller serving size, whereas other items, such as green leafy vegetables. Kale and spinach are very good sources of calcium, but you need to eat a larger volume of those to get a good amount of calcium. Another very good source are nuts. Almonds and walnuts contain a lot of calcium and are very good sources of that as well.
Dr. Christina Chen: Thank you for those alternatives. I’m lactose intolerant myself. It’s nice to know that I have other choices to choose from.
Dr. Jad Sfeir: Now the other thing is vitamin D. Vitamin D is much less prevalent in the diet. We know vitamin D is the sunshine vitamin. Vitamin D comes from our sun exposure. Having a good sun exposure means that exposing both arms and both legs to the sun at around peak time, midday, about 10 minutes to 15 minutes everyday.
This changes depending on where you are in terms of latitude and what area you are living in. But that’s roughly the estimated need to get that. However many people are at risk of skin cancer and they try to avoid exposure or put on a lot of SPF containing creams to protect themselves from sun exposure. It’s very important for us to find other sources of vitamin D in these situations.
Vitamin D in the diet, as I said, is a little bit limited. The biggest sources are fatty fish. Salmon, tuna, and mackerel are very good sources.
Some foods have been fortified with calcium and vitamin D. You may go to the drug store and see orange juice or milk that has been fortified. It’s written on it, fortified with vitamin D. Eggs are also considered a reasonable source of vitamin D. In general, because of those limitations, we don’t find it that much in the diet, and some people limit their sun exposure for other reasons. Vitamin D ends up being something that you need to take as a supplement, as opposed to the calcium that you can easily find in the diet.
Dr. Christina Chen: What I’m interpreting from all this is that I should go to the beach more, eat more ice cream and fish. I’ll just take that.
Dr. Jad Sfeir: Absolutely. That’s what I do.
Dr. Christina Chen: Let’s move on to prevention and screening here. For those of us who are at higher risk of getting osteoporosis, what sort of lifestyle changes should we be doing now to prevent bad outcomes? What can we be doing as early as possible?
Dr. Jad Sfeir: We talked in general terms about exercise, but let me be a little bit more focused on that because what exercise you do matters a lot in terms of bone. Remember, we talked about bone formation to boost healthy bone formation.
We need something called weight bearing, meaning that we are on gravity when we’re doing the exercise so that the skeleton feels that there is a need for it to build stronger bones to support our body. Weight-bearing exercise is different from weight-lifting exercise. A lot of people confuse the two. You don’t have to lift to be weight-bearing. Walking, for example, is weight-bearing because you’re putting your own body weight on your spine and your axial skeleton, and that pushes it to build healthier bones.
Biking is less weight-bearing because you are in a seated position. Swimming, you’re off gravity and are less weight-bearing. These have health benefits by themselves, but not much for the bone itself. The first thing I recommend everybody do is really walk. A lot of people feel they’ve been walking a lot and they’ve maximized how much they can do. I tell them to challenge themselves a little bit more by adding some weights when they’re walking.
Hold on to some weights in your hands. Some people buy a weighted jacket or put some additional weights in a backpack. This is adding a little bit more weight on the skeleton while you’re walking and that pushes healthier bones.
The other thing to focus on with exercise is remembering that a big part of protecting the skeleton is keeping us from falling down because most fractures happen after a fall and the muscle groups that are going to prevent us from falling down and giving us the best balance when we grow older are the core muscles.
Abdominal exercise and upper leg exercises are very, very important. Then the last group of muscles that I’d like to focus on are the back muscles. Osteoporosis, if you look up osteoporosis on a search engine online, or you look around, people associate osteoporosis with kind of losing your height as you grow older, having a curved back, a hump.
Many people tell me grandma had a hump, known as the Dowager’s hump. This happens as we grow older because we have less and less muscle that are supporting our posture and our spine. It’s very important to exercise those back muscles to keep a very tall and steady posture as we grow older, because fractures in the spine or what we call the vertebrae that make up the spine, can happen even without falling down simply with our own body weight if we don’t have strong back muscles to support the posture.
Dr. Christina Chen: Thank you so much for all these useful, practical exercises. People just think like all I can do is a walk and there’s so many more things that we can do. I just have to share this. I’m part of a gym and they have guided exercises to help us be creative with our exercise routine and this morning we were doing something called a farmer’s carry. I’ve never heard of it before, but you take Kettlebells and hang on to two 25 pound kettlebells on both sides and just walking a hundred meters, and you feel the weight on your legs and knees and spine and I was just thinking as you were mentioning the weight-bearing exercises that would be a perfect thing to do.
You don’t need kettlebells. You can just use even milk jugs. When you come back from the store, instead of going straight to the fridge, do a couple of laps around the house with the milk jugs. That’s if you have two of them. That’s 10 pounds.
Dr. Jad Sfeir: That’s what I tell my patients, split your grocery bags into two, and then one on each hand kind of balance, and then you can walk with those. Absolutely.
Dr. Christina Chen: With these exercises, can you actually reverse osteoporosis by doing weight-bearing exercises?
Dr. Jad Sfeir: Unfortunately no. Remember that osteoporosis is the beginning function of age. We are not able to reverse those aging processes with exercise, but we can certainly limit their impact on our body. Even if you are not reducing the degradation of bone that happens as you grow older, by having very strong muscles, you are supporting that skeleton. You can still protect yourself from breaking the bone by having strong muscles, even if the bone itself is still having slight deterioration over time.
Dr. Christina Chen: I see. When should we start screening for osteoporosis? Does everyone need screening?
Dr. Jad Sfeir: The recommendation from the United States Prevention Task Force is to start screening women after the age of 65. That’s roughly 10 to 15 years after menopause when the women have lost their hormones and estrogen. A decade later, you can start seeing the impact on bone, and you detect it with a screening tool. However, we need to keep in mind that any adult is at risk of osteoporosis. There are groups that need screening earlier than the age of 65. That would be someone who had a broken bone or a fracture for an unexplained reason, or, without having a big accident, a bone that’s been broken or someone where you have a lot of family history of osteoporosis, a lot of fractures in the family that happened at an earlier age or someone, as I mentioned earlier, taking medications or have conditions that can contribute to brittleness of the bone.
Another group, we should not forget about our men. I see that a lot of men get passed on when it comes to screening for osteoporosis. As I mentioned earlier, the sex hormone deterioration in men happens a little bit later in life and it is a little bit more gradual. In general, men after the age of 70 are at very high risk of osteoporosis and should also be screened with a screening tool.
Dr. Christina Chen: What is the best way to screen for osteoporosis?
Dr. Jad Sfeir: The easiest tool we have available is something called a bone density scan, or some people know it as a DEXA scan. That is easily obtained. It gives a very low dose of radiation, but gives us a lot of valuable information about where the bone metabolism is standing.
Dr. Christina Chen: Even if someone has bone density in the osteopenia range, when the bone mineral density is lower than normal, but not quite low enough to be considered osteoporosis – they could still be at high risk. That’s where the FRAX scores can be helpful to make that additional assessment. Can you talk a little bit about what the FRAX score is and how does that differ from the bone density scan?
Dr. Jad Sfeir: Bone density scan that we just mentioned, or the DEXA scan, gives you an x-ray image of the bone. We can tell a lot about the situation of the bone, but it does not give us any information about the patient themselves in general, what their age is, which contributes to the risk of fracture.
We mentioned earlier that fractures follow, usually a fall. What is the risk of fall of that patient? Person. Are they taking medications that can contribute to the bone metabolism, or to the risk of falling down? Have they fractured before? All these, we call them clinical risk factors and these risk factors, you want a tool to try to add more value to just the x-ray that we obtained with the bone density to tell us overall about the risk of fracture of an individual.
One such tool is the FRAX that you mentioned. FRAX is an acronym for fracture risk assessment tool, and this is available online. It accumulates a lot of clinical risk factors of the patient that asks about 10 to 12 questions, and it includes the bone density measurement to come up with an evaluation of the risk of fracture.
There are also some other tools that other people use in other parts of the world. And that has to do with what other risks are you including in your clinical assessment of the patient?
Dr. Christina Chen: Moving on to treatment and care. We’ve talked a lot about diagnosis and prevention. For those who do have osteoporosis, what are the current treatments that are available?
Dr. Jad Sfeir: Someone having an appropriate amount of calcium in their diet. They’re taking vitamin D or getting good sun exposure. We’re already doing very healthy exercise, strengthening our core muscles and our back muscles. Usually the combination of these three does not prevent a fracture from happening and someone who already has established osteoporosis based on the bone density, they help protect us.
They help improve bone metabolism, but they have not been shown to reduce the risk of fracture. Medications, however, have been used in the past, and we’ve had about three decades of exposure to research that looked at medications for osteoporosis that actually significantly reduce the risk of fracture.
Going back to what I initially mentioned with the bone metabolism, the cells that are causing bone resorption and the cells that are causing bone formation, we have medications that address both of these separately. Medications that address bone resorption. These are called antiresorptive medication.
These are very common medications. The oldest that have been available to treat osteoporosis because they are quiescing down the bone resorption. The bone formation that is normally happening is now taking over and you’re tipping the balance towards a little bit healthier bone formation over time. We also have medications that are pushing the bone formation to a greater extent. We call them anabolic medication or bone building medications. They push those bone-forming cells to build a stronger bone and healthier bone.
Dr. Christina Chen: A common scenario that I see often in my practice is a 95-year-old who fractured her hip for the first time and was discovered to have osteoporosis late in life. The question is, would a 95-year-old or someone in the oldest old category, benefit from treatment?
Dr. Jad Sfeir: I do get asked this question a lot and these are the highest risk patients. The older we are, the more bone degradation is happening. There is another entity we did not talk about called frailty.
As people grow older, they become more frail, meaning they are more at risk of falling down and breaking a bone. In those high risk populations, the more impact any small intervention can have in terms of reducing the risk of fracture.
Even if we are screening someone who’s in their 10th decade of life, and we discover osteoporosis, it is actually the right time to treat them. It is not too late to treat them to prevent the fracture. Especially hip fracture, like you mentioned, but also vertebral fractures are associated with high risk of mortality.
The older the patient, the more frail the patient, the higher risk of them dying within the first year following a fracture. It makes it even more crucial to prevent that fracture from happening, even if they had not fractured before.
Dr. Christina Chen: Do you encounter scenarios where people are worried about the potential harms of treatment who are maybe resistant or concerned about treatment? How do you have effective communication strategies to discuss managing their osteoporosis in that situation?
Dr. Jad Sfeir: I mentioned earlier, the number of medications we have available for us to treat osteoporosis. A lot of these medications have been having kind of a bad rep’. People talking negatively about their side effects. I see a lot of patients who come to me having this background of reading all the negatives and coming to us asking why they would even try these medications?
It is very important for us to communicate the appropriate research that we’ve had with these medications to the patients because you can read a lot of misinformation online. Asking them why, what have they read? What are the concerns that they have, and then addressing those with the correct research and data that we have regarding these.
Dr. Christina Chen: Right. I love that you said to listen to their concerns because you get information online that you don’t know what’s true and what’s not. It creates a lot of fear. Understanding what is creating that fear is the first thing we do when it comes to any sort of resistance, not just medication treatment.
Dr. Jad Sfeir: Absolutely. Patients are exposed to all kinds of information these days, and it’s actually quite prevalent. Very important for us to direct them. There are very good resources available online. Obviously, mayoclinic.org has a lot of patient education material that has been vetted, based on and backed by research, and very solid, research and experience from our experts.
Dr. Christina Chen: We have a lot of caregivers in the audience as well, and I’m sure they are all wondering, how can caregivers help their older adult loved ones maintain bone health?
Dr. Jad Sfeir: Something we talked about earlier is preventing a lot of the falls that we see happen at home. There are a lot of modifications that can be done within the household that can actually reduce the risk of falling of the patient. I see a lot of patients who have been recommended by a physical therapist to use a cane or a walker and they come to the clinic, not bringing the cane or the walker.
I asked them, “Where is it?” It’s somewhere at home. They don’t even use it. And this is something that a caregiver can really impact by reminding the person who’s supposed to use, for example, a cane or a walker, to use it all the time. Even inside the house because it is very important to prevent a fall.
Modifications that can be done in the household, depending on the situation and the mobility of the patient, but also the exercises we talked about. Many of us need a buddy to do the exercises. We won’t be motivated to do them on our own. It’s very important to maybe match up. I just saw a patient earlier today. I recommended exercises. She looked at her husband, she was like, “We are both doing this.”
Dr. Christina Chen: I love that. Actually, that’s the motivator to do the exercises, maybe having the buddy with you, your spouse or the caregiver. That’s a great idea. Or getting a pet. It’s always nice to have something to motivate you, a dog to walk or a cat to take care of.
What would you say to someone who has osteoporosis, who has had, perhaps, multiple fractures and have exhausted all measures in terms of treatment and prevention. I feel like there’s really not much more to do moving forward. How do you help these people feel hopeful and feel like there’s still something that can be done?
Dr. Jad Sfeir: A couple of years ago, I had a patient, an old woman who had taken treatment for osteoporosis to prevent these fractures, but at some point later, when she went off the medication, she was holding her grandchild, and then noticed acute pain in her back. Then investigation showed that she had multiple fractures in her spine.
When I first saw her, she was in a brace to try to support her spine. She was in severe pain. We worked with her, over the course of a year, to give her the best possible way to protect her back and prevent her from having more fractures. She went through a very aggressive physical therapy plan to strengthen the back muscles, to improve the posture. She got off the brace. She was pain-free. We worked on providing one of the most recent medications we have to improve the bone density of the spine, help with the healing of these fractures and, reduce the risk of future fractures.
It’s been 2 years since that episode. I saw her just recently and she is now planning to finish her course of therapy when it comes to the medication, but she’s in great shape. Her mobility is great. Now she’s not in pain. She has a good posture. I told her this time, try not to hold your grandkid again, to lift them up, but if they’re already next to you, they can sit on your lap.
Some modifications to our daily life may be needed, but there is hope even if we already sustain the fracture, with osteoporosis. What an inspiring story. I love that. Just instill hope, even if it’s small goals. One thing at a time.
Dr. Christina Chen: There is always hope when we have a fracture with osteoporosis. There is always hope when we’re looking forward, but also we need a multidisciplinary approach when it comes to musculoskeletal care. We don’t only address medications for the bone, but we include physical therapy. We include exercise, and we include lifestyle. Lastly, to conclude our podcast, Dr. Sfeir, what do you do personally to live well and age well?
Dr. Jad Sfeir: We always say physicians preach very well, but they don’t do what they preach. I try as much as possible to do the exercise that I actually recommend to my patients. I try to make it to the gym and do a general exercise plan as much as I can. But a couple of things that I actually do, which we did not talk about, relieves the stress from my life.
Most of us in 2024 have high stress. Life is stressful. I actually travel a lot to relieve stress, go to good destinations. You mentioned the beach. This is one of the great destinations to go to. Also, another thing that we did not talk about, is intermittent fasting.
I’ve been trying in the past few years to really apply intermittent fasting, maybe in a modified way that works more for my lifestyle, but intermittent fasting has actually had good data to back it up in terms of healthy aging and reducing the impact of aging on our system. That’s what I try to do.
Dr. Christina Chen: Well, you may have just given us our next topic idea of nutrition, intermittent fasting, because all of this is interrelated. Thank you so much, Dr. Sfeir for being here today and sharing your expertise and wisdom to the world.
If this conversation can help even just a small fraction of the population be more active and protect their bones and prevent fractures, this can potentially avoid a lot of hospitalizations, surgeries, nursing home stays and suffering and really promote independence like we talked about.
Dr. Jad Sfeir: It’s been a pleasure having this discussion, and thank you again for having me.
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