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Who is In Charge of Bone Health?


Bone Health is Connected to Overall Health

by Kimberly Zambito, MD and Andrew Bush, MD


A healthy mind resides in a healthy body. A healthy body needs healthy parts - healthy skin, a healthy heart and a healthy gut. To move all these healthy parts around we need a healthy skeleton. Our skeleton, all 206 bones, is an organ system just as our heart, our gut, and our skin are. Our skeletal system should be cared for in the same way that we care for all other parts. Unfortunately, we take our skeletons for granted. Until one day our foot gets caught on the edge of the carpet, or we forgot to wipe up the spilled water on the kitchen floor or our little dog or cat gets in between our feet causing the fall resulting in a loud “CRACK!!”. That “crack” signals a life changing event…a “bone attack”, rather than a heart attack.  It is then that the importance of a healthy skeleton becomes a very painful reality.


Bone health is not too different from heart health or gut health. We must realize that our body systems work together and when that synergy is interrupted, we get sick. The basics of good health are consistent – good nutrition, active lifestyle, minimizing stress, appropriate exercise, good sleep habits, and avoiding unhealthy lifestyle habits such as smoking and excessive alcohol consumption. These recommendations are universal.


Proper nutrition is extremely important for healthy bones throughout life, especially during the years that bone is forming – up to approximately 30 years old. After that, the amount of bone that we have in our bodies will decrease as we age. The average rate of bone loss is 0.5-1% per year following peak bone mass at age 30. This bone loss happens in both men and women, although it occurs earlier in women. Bone loss can occur at a much more rapid rate and to a higher degree in women around menopause. It has been estimated that women may lose approximately 20% of their entire bone mass in the 10-15 years surrounding menopause. For this reason, most fragility fractures occur in women. The goal of a Bone Health program is to prevent bone loss beyond the average expected bone loss which occurs as part of the normal aging process, to educate people about those factors that can be modified, and to treat osteoporosis and fractures related to bone loss (fragility fractures).  Treatment does not necessarily mean a prescription for medications.

 

Since our bones are protein and mineral-based, getting adequate amounts of protein and the appropriate minerals is imperative. Minerals crucial for bone health include calcium, magnesium, phosphorus, boron, selenium, copper, zinc and manganese and are building blocks for healthy bone. Adequate protein intake is important to make collagen which forms the scaffolding of bone. Other nutrients such as Vitamin D3, Vitamin C and Vitamin K2 are necessary for the processes of healthy bone building. Dietary sources of these nutrients are the preferred method of getting these important and essential nutrients, but supplementation is appropriate when these necessary nutrients are not obtainable through diet alone. Bone remodeling is an ongoing process, so maintaining healthy nutritional habits is also an ongoing process. If there is only one nutritional item you can improve upon, really consider optimizing protein intake, especially as you age or are overcoming an illness.


Getting physical with your bones is just as important as providing bones with building blocks through good nutrition. A factor crucial to forming and maintaining healthy bone is activity and exercise. Bone development and remodeling are driven by the applied forces that the bone “feels”. Impact (light to medium) stimulates the bone cells called osteocytes that live in the bone matrix to send out signals to the bone building cells (osteoblasts). Osteoblasts respond to those forces by building more bone. Bone health is maintained when muscles are strong, so that the bone “feels” the pull of those muscles. Strong muscles are built with exercises such as consistently challenging your muscles by weightlifting.


Posture, balance, and flexibility exercises are important to include in your exercise program. When you have a good sense of balance, falls resulting in fractures are less likely to occur. Fall prevention is part of a comprehensive bone health program.


Bone health care is preventative medicine. It is the core of fracture prevention. Early initial screening followed by routinely scheduled monitoring is essential. Many in the bone healthcare field recommend perimenopausal bone densitometric assessment around the age of 50, not at the age of 65, as is the current recommendation. By 65 years of age, a woman may have lost a significant amount of bone mineral density. By that time, treatment choices are significantly limited.  We recommend everyone start the process early. With early bone assessment, a baseline can be established, and then routine yearly monitoring can be continued. This recommendation for bone health monitoring is in line with other healthcare monitoring - blood pressure, cholesterol and diabetes screening.


The importance of a healthy skeletal system is well understood by physicians of multiple specialties. Some primary care providers include Bone Healthcare in their annual physicals. Specialists like Orthopedic Surgeons who are trained to fix broken bones may emphasize bone health and fracture prevention when they treat patients. There are several different specialties that are involved in bone health care including primary care, physical medicine and rehabilitation, endocrinology, rheumatology, OB/Gyn, orthopedic surgery and radiology. Often physicians in these specialties will work in unison towards the goal of fracture prevention. There are organizations that are dedicated to establishing guidelines for healthcare professionals to follow and educational programs for both professionals and patients. Some of these organizations are: The Bone Health and Osteoporosis Foundation, the International Osteoporosis Foundation, the International Society of Clinical Densitometry and AmericanBoneHeath.org to list a few. These organizations have established guidelines for Bone Healthcare which include healthy nutritional habits and an active lifestyle with adequate exercise and appropriate rest. Guidelines also include the routine monitoring of bone health.


Monitoring of bone health is the foundation of fracture prevention in the way monitoring blood pressure is to stroke prevention and mammograms are to breast cancer prevention. The early detection of any of these conditions allows for early treatment to be instituted to prevent the long-term consequences of the disease. Bone health assessment is looking for osteoporosis. Although some may still consider developing osteoporosis an unfortunate part of growing older, it is now understood that fracturing due to idiopathic age-related bone loss is not an inevitable part of aging, but a potentially preventable complication of bone loss. Nutrition and exercise fight against excessive bone loss by optimizing things that can be optimized naturally – monitoring makes sure that they are working.

The term for bone monitoring is known as bone densitometry – the measurement of bone density. Determining bone mineral density (BMD) has been the traditional method of diagnosing osteoporosis and predicting fracture risk. The most common way to measure BMD is by using Dual Energy X-ray Absorptiometry (DXA). DXA has been around for over 30 years and has been the backbone of Bone Healthcare. It is a method of measuring BMD by using low-energy x-ray and has been considered reasonably reliable for measuring BMD and diagnosing and treating osteoporosis. However, DXA does have an error rate reported to be up to 90% and it is not very reliable in predicting fracture risk. DXA can only measure BMD. BMD is a measurement associated with fracture risk, not a determinant of fracture risk. Fracture risk increases with lower BMD, yet it is estimated that nearly 50% of all fragility fractures happen in individuals who have either normal or near-normal BMD measured values. How can that be so?


There is another property of bone, not measured by DXA. That property is Bone Quality. Bone Quality refers to the microarchitecture and flexibility of bone tissue.  Radiofrequency Echographic Multi Spectrometry (REMS) is a newer method for monitoring bone health. REMS has been used in Europe for almost ten years and has replaced DXA as the official method of bone densitometry in Italy. REMS uses ultrasound to measure BMD. Additionally, the ultrasound is capable of measuring Bone Quality which is reflected in the Fragility Score. The Fragility Score has been shown to predict fracture risk better than DXA BMD, TBS, and REMS BMD. REMS is still very new in the United States, but its popularity is growing as more people are learning about this ground-breaking technology.


In addition to densitometry, there are other methods to assess and monitor bone health. These include laboratory assays that measure blood levels of various factors that are a direct measure of bone health or indicate other medical conditions that can affect bone health. These tests will be performed by your healthcare professional as a part of a comprehensive bone health assessment. Genetic testing may soon be part of routine bone health assessment.


Bone health is tied to our general health, so it is important to monitor general health and for us to observe and be compliant with medical recommendations. Appropriate management of many medical conditions will decrease the effect that those conditions might have on our bone health.


If levels of nutrition and exercise are not enough to maintain a healthy skeleton, or if medical conditions are affecting bone quality, then there are specific medications that can help to prevent bone loss or build bone. The decision to use any of these medications should be made in consultation with your bone healthcare professional. If you are started on any of these medications, you must be compliant with the directions of use and monitoring the effectiveness of the medications is also essential.


In conclusion, it is important to remember that your bones need to be monitored and cared for like any other part of you. Although we focused on bone health as a women’s health issue, poor bone health can affect anyone. Everyone has a skeleton, and we need to pay attention to and take care of our skeletons because if you ignore your bones, they will go away!


YOU are in charge of your bone health and your overall health.  Partner with your bone health care professional to decide what is right for you.  Be honest and realistic with yourself and your health care team about what you are willing to do to optimize your bone health.


Remember, you are more than the numbers on your DXA or REMS scan.  There is an entire YOU. 

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Part 2: Understanding the Development of the Fragility Score

March 24, 2025
I’m Active, Eat Right, and Have Never Broken a Bone…Why is my Fragility Score Yellow or Red?!?!?!
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Part 1: Understanding the Impact of Statistics and Databases on Your DXA and REMS Test Results

March 17, 2025
I’m Active, Eat Right, and Have Never Broken a Bone…Why is my Fragility Score Yellow or Red?!?!?!
A group of older women are dancing together in a room.

Fall Prevention is Fracture Prevention

September 23, 2024
Fall Prevention Week is September 23-27, 2024 . It coincides with the beginning of Autumn or Fall…how very punny. Falls are not funny though. Whenever a patient tells me they had a “bad” fall from a standing height, it sometimes indicates that they are in denial of their bone health. There are no “bad” falls from a standing height. There are falls that break bones and falls that do not break bones. Most of the resources on this website focus on technology to measure bone density and bone quality. While both components of bone are related to fracture risk, we cannot forget the importance of fall prevention. This blog post is not about high-impact injuries that result in broken bones, it is about preventing fractures resulting from a fall from a standing or sitting position. Why are these low energy falls such a big deal? These falls have the potential to become significant life changing events , especially if a fall results in a fracture. A history of fracture can increase the risk of subsequent fractures: Prior rib fracture can increase risk of vertebral body fractures by 2.3- fold Prior vertebral fracture can increase risk of subsequent vertebral fractures by 9.1-fold; new hip fracture by 7.1- fold; and wrist fracture by 2.3- fold Prior shoulder fracture can increase risk of new wrist fracture by 5-fold; new vertebral body fracture by 10-fold; and new hip fracture by 18-fold Prior wrist fracture can increase risk of vertebral body fracture by 37% The Center for Disease Control has estimated the rate of death from falls increased 30% from 2007 to 2016. If this rate continues to increase, there will be an estimated 7 deaths each hour related to falls. Falls can occur for many reasons, no matter your age. When younger people fall intact protective mechanisms may lead to a fall on an outstretched hand, resulting in a hand or wrist fracture. Older people have compromised protective mechanisms which may lead to a fall on their side, resulting in a hip fracture, or even a head injury. The CDC and National Council for Aging are excellent resources for learning about fall prevention. You can find a questionnaire to check your risk for falling here . While this information about falls may seem scary at first, it can empower you to talk to your health care provider about fall prevention. There are a number of simple in-office fall assessment tools available through your doctor or physical therapist. Ask about having your balance assessed. If your primary care doctor or orthopaedic surgeon are not able to assess you, ask for an assessment with a physical therapist. Here are some safety tips for you or for loved ones at home: Ask your loved one if they are concerned about falling. Be gentle and compassionate. God willing, we will all grow older, and most likely weaker. Notice if they are holding on to furniture or walls to move about the house, or have difficulty getting out of a chair. Discuss current health conditions. Have a list of current medications. Sometimes medications can make people dizzy, weak, or affect eyesight. Ask about their last eye exam and if they needed updated glasses. Do a home safety check. You can get a home safety checklist at the website listed above. Ask about fluid and food intake. Dehydration and low blood sugar can cause dizziness and lead to falls. Let’s not forget about pets. 66.4% of falls associated with cats and 31.3% of falls associated with dogs are from tripping over the animal Among people hospitalized for falls over pets, 79.9% were fractures 8.8% of pet-related injuries were caused by people tripping over a pet toy or food bowl Journal of Safety Research 2010 and WebMD 2010 Here are a few tips to consider: Walk the dog, don’t let the dog walk you Dog obedience training Clean food and water spills that can cause slip and falls Clear floors of pet toys and leashes Avoid bending over to pet an animal Crate your dog or put the dog outside when expecting company Be aware of your limitations and consider risk assessment before doing something you may consider stupid after sustaining an injury. If you have never tried ice-skating and you have decided that you want to try it as an older adult, you may consider doing a risk assessment. That assessment may go something like this: If I fall and break my wrist, will I be able to work and continue to earn money to pay my bills? If I broke my ankle, who will drive me around? For me, the answer is learning to ice-skate at my age is not worth the risk of a fracture. There are other activities I enjoy doing. Many patients have asked about skiing. If you have enjoyed skiing your entire life and you desire to continue this activity, do a risk assessment of the type of skiing you want to do. You may decide to stay away from black diamonds. You may decide you will be better off on green or blue slopes. You can still enjoy the activity as you age with some adjustments. At some point, you may decide that the activity no longer gives you the joy it did previously and you move on to something else. Situational awareness or mindfulness in the moment is key to fall prevention. Whenever a patient comes to me for treatment of a fracture, I ask about how the fracture occurred. Typically, the answer is related to a fall. I follow with, “How did you fall?”. A story unfolds. Many times the story involves doing too much at once, not paying attention, or not turning on a light at night and tripping on something. Slow down. Have a night light for those night-time trips to the bathroom. Avoid carrying 15 grocery bags into the house at one time. Carry 3-4 and make multiple trips. Being in the moment prevents falls. In summary, there are a number of reasons why a person may fall. Reasons may include medications or interactions of medications that cause dizziness; poor eyesight; muscular weakness, dehydration, low blood sugar, a cluttered home, lack of mindfulness, pets, and not knowing limitations. The CDC and the National Council on Aging are great resources to get started with assessing your risk or your loved one’s risk for falling. Each source provides tips for preventing falls. If you have experienced falls, please share that information with your doctor, physical therapist, or loved one. There is no shame in asking for help to prevent a fall. If you have a loved one who has fallen, please do not shame them. Treat them with the kindness and compassion you want for yourself. Respect their dignity. Preventing a fall is preventing a fracture.

Bone Health as a Healthcare Policy Issue

September 3, 2024
Why Is My Doctor Trying to Scare the $h!t Out of Me?

What is Discordance?

July 17, 2024
Guest blog by Nick Birch, FRCS (Orth)
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Why is my T-score going up or down and my Fragility Score going up or down?

June 21, 2024
I recently received a question: why is my T score going up and my fragility score getting worse? This is a great question. Let's take this step by step. First let's address the T-score. When tracking bone health over time, we must evaluate the actual numbers for Bone Mineral Density (BMD), not T-score. The T-score is a nice way to get an overall picture of your BMD compared to a 30-year-old white female. It is easy to get sucked into comparing T-scores, as we have all been conditioned to look at T-scores. However, T-scores represent standard deviations on a graph, and they represent a range of numbers and not absolute values of BMD. Therefore, tracking bone density over time can only be done by comparing BMD values in g/cm 2 and expressing those changes as percentages compared to baseline and compared to the result immediately prior. There are several factors that cause the BMD and therefore T-scores to change including age, levels of activity, nutrition and build. In post-menopausal women, there is a natural reduction of BMD and T scores over time which can be slowed, and in some cases reversed, with attention to good nutritional balance and lots of impact and resistance exercise. These changes usually occur slowly and are often not detectable on DXA scans in under several years because the Least Significant Change (LSC) is 5-6% which is not sensitive enough to measure a few percentage points difference. REMS can detect such changes, usually at yearly intervals. Changes in BMD caused by increases or decreases in weight and thus Body Mass Index (BMI) occur more quickly, and these changes can often be detected by REMS over a period of months rather than years. If the change is sufficiently large, DXA will be able to detect it in similar timeframes. For simplicity, let’s say BMD in 2022 was 0.983 g/cm 2 . Then in 2024, BMD was 0.899 g/cm 2 . The change in BMD is calculated as follows: 0.899 - 0.983 = -0.084 This demonstrates a decrease BMD (g/cm 2 ) over 2 years. To find the percent change, divide -0.084 by the original BMD (g/cm 2 ) -0.084 ÷ 0.983 = -0.085 This indicates there was an 8.5% decrease in BMD (g/cm 2 ). Remember to take into consideration the LSC which are different for DXA and REMS. A generally accepted LSC for DXA is 5-6% . So, if the change in BMD over time is less than 5-6%, it is not necessarily a real change when measure by DXA. If the change is greater than 5-6%, it does represent a real change. LSC for REMS is 0.88-1.05% (0.88% for hip and 1.05% for spine) meaning it can detect smaller changes, often in shorter timeframes. In the example provided above, there was a real change in BMD, as 8.5% is greater than 5-6% for DXA and 0.88-1.05% for REMS. Fragility Score is an adimensional number from 0-100. The lower the score, the better. FS reflects the micro-architecture of the bone. The AI in REMS technology compares the acquired spectra from the patient to a reference database. If the patient’s spectra match the spectra of individuals who have fractured, the patient will be in the RED. If the patient’s spectra match the spectra of individuals in the database who did not fracture, then the patient will be in the GREEN. YELLOW indicates some individuals fracture, and some did not. There is a natural increase in FS over time which is in the range of 1.5 – 2.0% per year in post-menopausal women. If the difference in FS over, for instance three years, is 4-5, that change may be inconsequential, considering the LSC and the expected change with age. Remember, you are more than your T-scores or Z-scores. Knowledge brings empowerment and peace of mind.
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Why are my DXA and REMS Different?

June 12, 2024
It is VERY common to see discrepancies in the values noted on DXA versus values noted on REMS. Without seeing the images from your DXA scan on a complete report, your physician is not able to pick apart the details of your DXA report. However, there are some common themes that we REMS users have seen. For a simple guide to understanding your DXA report, please see: Choplin, et al. "A practical approach to interpretation of dual-energy x-ray absorptiometry of bone density," Curr Radiol Rep (2014). During the development of REMS technology, REMS was compared to the "gold standard" of DXA. The performance of the DXAs for comparison was quality controlled, as was the performance of the REMS. In the community, DXA quality is not assured the same way that it is in a research scenario. The potential for errors is high for DXA. The potential for REMS errors is much lower given the precision of the technology. For reference, please see: Messina, et al. "Prevalence and type of errors in dual-energy x-ray absorptiometry." Eur Rad, Nov 2014. Fatima, et al. "Discordant interpretation of serial bone mineral density measurements by dual-energy x-ray absorptiometry using vendor's and institutional least significant changes: Serious impact on decision-making," World Journal of Nuclear Medicine, 2018, 236-240. Typically, the values on DXA hips, REMS spine, and REMS hips are similar. The DXA spine is typically the outlier. DXA spine values may be very negative and DXA hips and REMS spine and hips are not so negative. Why would your spine be one value and your hips a completely different value on DXA? Dr. Nick Birch and his colleague Maddy Young presented their data regarding discordance at the British Orthopaedic Research Society annual meeting in the autumn of 2023. Young M, Birch N. “Prevalence of major and minor discordance between hip and spine T-score using REMS: Implication for bone health assessment and patient management.” Orthop Procs. 2023;105-B(SUPP_16):46-46. If you are interested in learning about the development of REMS technology, or to have a couple of papers to share with your treating physicians about REMS, I recommend: Della Ciardo, et al. "Pulse-Echo Measurements of Bone Tissue, Techniques and Clinical Results at the Spine and Femur," Bone Quantitative Ultrasound. Advances in Experimental Medicine and Biology 1364. Pisani, et al. "Screening and early diagnosis of osteoporosis through x-ray and ultrasound- based techniques," World Journal of Radiology, 2013 Nov 28; 5(11): 398-410. ​Pisani et al. "Fragility Score: a REMS-based indicator for the prediction of incident fragility fractures at 5 years," Aging Clin Exp Res; 2023; 35(4): 763-773. This last paper is ground-breaking as it demonstrates the importance of consideration of bone quality in terms of fracture risk. This paper is mentioned in the 10-minute video tutorial, “ Understanding Your REMS Report ”. Here are some things you may consider: Was there a significant change between your baseline DXA and subsequent DXAs? Is it reasonable to obtain serial scans over the next couple of years? If there is no change and your bone density and quality are stable, is there a need for medication for bone health? If there is a precipitous decline in density or quality, would you consider medication? Be honest with yourself and your treating physician about what you are willing to do or not do to optimize your bone health. Have you had a fragility fracture? Fractures are the greatest predictors of future fractures. Are your labs normal? Receiving the diagnosis of osteoporosis can be overwhelming. Remember, you are more than your DXA T-score or Z-score.
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Medical terms and acronyms in plain English

December 19, 2023
Medical Science is full of acronyms and special terms. We have included a list of those commonly used on this site.

Bone-ified Thoughts on Halloween

October 21, 2023
It's the time of year when ghosts, goblins, and skeletons run the streets. Happy Halloween! I have fond memories of the excitement of making costumes and running around with friends on Halloween. Of course, getting a ton of candy was the goal, but what has lasted through the years are the memories of being with friends, having pride in making a costume, and learning how to broker deals - Bottlecaps for Dum-Dums. I continued that tradition with my son. Yep- he was a pumpkin, a Thomas the Tank Engine engineer, a TRex (his arms were not too short to grab candy), a baby tiger with mommy tiger, a SpiderMan Shark (yes, you read that correctly), Wolverine (old school Wolverine), and an Alien Hunter. The days of making costumes with him have passed, as his other interests have taken priority…for now. I enjoy sitting outside giving candy to kids in the neighborhood and reminiscing about walking around with my son as he lived up to his alter ego for the season. Whether you choose to venture out with little ones, or stay home to give out candy, take a moment to mitigate risks for a potential fall . Use a flashlight when walking the neighbor. Make sure the pathway to your calderon of candy is well-lit . Wear sensible shoes for walking. Fur babies that rush to the door when the doorbell rings, create a fall risk. Consider using a leash and have them accompany you to the door, or secure them in a crate or room during Trick-or-Treat hours. Make sure your eyesight is not blocked by a mask or costume. If you cannot see where you are going, you may find yourself kissing a curb. Ouch. Preventing a fall equals preventing a fracture. Oftentimes, people I meet with osteoporosis have fear of breaking a bone. They have been scared by other doctors who have put fear in their minds- fear of crumbling bones and falling apart. Life is meant to be lived. You will not disintegrate (unless an alien strolling your neighborhood gets you with a laser beam). Be smart. Do some risk management. And embrace living life to its fullest. Let me know if you score some Bottlecaps because I will trade some Razzles for Bottlecaps any day!
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