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Dr. Felicia Cosman: The facts about osteoporosis

Dr. Felicia Cosman, an osteoporosis specialist and the Medical Director of the Clinical Research Center at Helen Hayes Hospital, joined the chat room on Wednesday to discuss osteoporosis and osteoporosis testing.

CNN: Who needs to be concerned about osteoporosis?

COSMAN: Everyone needs to be concerned about osteoporosis. This is an extremely common condition. About 1 in 2 women will have an osteoporosis-related fracture. Between 1 in 5 and 1 in 8 men will have an osteoporosis-related fracture.

Campaign urges osteoporosis testing  

CHAT PARTICIPANT: How much calcium does each age group need?

COSMAN: Approximately 1200 milligrams, or at least that, for all individuals above the age of 50. Below that, 1000 milligrams a day for adults is probably sufficient. In practice, I go with 1200 for most people seeing me, because most are post-menopausal and above the age of 50. It's important to realize that the calcium target amount includes what's in the diet, plus a calcium or vitamin supplement if it's required. But people who get 1200 milligrams in their diet don't have to take a calcium supplement.

CHAT PARTICIPANT: Does osteoporosis affect your entire skeletal body, as opposed to just one area?

COSMAN: It usually is a diffuse condition that affects the entire skeleton. However, in about 15-20 percent of individuals, there may be a discrepancy in the osteoporosis at one site or another. For example, a person may have osteoporosis in the spine, but only low bone mass in the hips. In practice, we can use any one of these measurements to diagnose osteoporosis.

CHAT PARTICIPANT: How do you check to test your bone strength? And is osteoporosis hereditary?

COSMAN: The only way to check for osteoporosis is through a bone density test. This is a non-invasive test that only takes a few minutes, and provides very minimal amounts of radiation exposure. We recommend that all women 65 or above get the bone density test, and younger women at the time of menopause or thereafter should get the test if they have any clinical risk factors for osteoporosis.

With regard to the second question, osteoporosis is very definitely a genetic condition. Those with a family history of osteoporosis are at a substantially higher risk. For example, if your mother had a hip fracture, your risk for hip fracture is elevated by about 100 percent. There are many genes involved, so it's not easy to figure the risk by genetic testing.

CNN: What is involved in getting a bone density test?

COSMAN: The bone density test is painless. The gold standard is the central dual energy x-ray absorptiometry test. This provides measurements of the hip and spine. For people who have access to this test, it's the preferred technique. It involves lying on a pitted table, fully clothed, but without zippers or buttons near the spine, so an elastic skirt or pants are preferable. The test involves a tiny amount of radiation that goes through the body at two different energies, and the amount of absorption is calculated, and an actual number is produced, which represents the bone mineral density at that site.

It takes less than five minutes to complete the test. We then take the bone mineral density number, and calculate T and Z scores, which relate the person's bone density to the bone density of an average young reference population, or an average age-matched population. Osteoporosis is diagnosed when the T score is -2.5 or below. That indicates that your bone density is 2 1/2 standard deviations below that of the average young reference population's bone density score.

CHAT PARTICIPANT: Is that the same as a DEXA Machine test, Dr. Cosman?

COSMAN: The DEXA is the standard bone density test, yes. DXA stands for Dual X-ray Absorptiometry.

CHAT PARTICIPANT: How do you know how much calcium you are getting?

COSMAN: You can calculate your calcium intake by adding up the number of servings of dairy products that you eat on average each day, and multiplying by 300 per serving. Then add any calcium obtained from calcium-fortified foods, using the milligram amount supplied by the manufacturer. We can't give an average number for the fortified foods, because they vary dramatically from 80 milligrams per serving to 1000 milligrams per serving. Check the box to see what you're getting. Once you add the fortified foods and the calcium from dairy products, you add 250 milligrams for calcium from trace sources, such as broccoli, other green vegetables, eggs, nuts, etc.

CNN: What should you do if you have osteoporosis? Is it reversible?

COSMAN: Osteoporosis is not totally reversible, but it is very definitely treatable. Everybody who has osteoporosis should follow the universal prevention measures. These include optimizing nutrition, exercising, and making sure that no adverse lifestyle factors are present, such as smoking. But also, people with osteoporosis should strongly consider taking one of a variety of medications that are available to treat the condition. These include estrogens or hormones, raloxifene (also called EVISTA®), calcitonin, alendronate (also called Fosamax®), and risedronate (or Actonel®).

CHAT PARTICIPANT: Can taking too much calcium potentially cause kidney stones?

COSMAN: In a small portion of individuals who excrete too much calcium in the urine, or people who have a history of kidney stones, excessive calcium could increase the risk of further stones. In general, people who have had kidney stones should have a 24-hour urine collection to see if too much calcium is present. Furthermore, we don't recommend that people take more calcium than that required to bring intake to about 1200 per day. Excess calcium can also produce abdominal discomfort, excess gas, and constipation, and if it doesn't help your bones, why take excess?

CHAT PARTICIPANT: Some foods claim that they have a full day's calcium, like cereals. How reliable is that?

COSMAN: Those cereals do contain the amount of calcium dictated on the box. However, there is no guarantee that you will absorb as much calcium when it's all taken at once, compared to spacing it out during the day. After the first 500 milligrams of calcium, the proportion of subsequent calcium that you absorb at the same time is reduced, so it's a less efficient way to get the appropriate calcium content. Still, it's a very good first step.

CHAT PARTICIPANT: What are some warning signs of osteoporosis?

COSMAN: The problem with osteoporosis is that there are very few warning signs. A fracture that has occurred during adulthood in the absence of major trauma, such as a motor vehicle accident, is a major warning sign that osteoporosis may be present. An adult woman who has a history of adulthood fractures should get a bone density test to determine if the disease is present.

CHAT PARTICIPANT: Isn't it true you must have Vitamin D for calcium absorption?

COSMAN: You must have Vitamin D for the most efficient calcium absorption, however, you don't need to take it at the same time as the calcium. Most of us make Vitamin D through our skin upon minimal exposure to sunlight, so it's not mandatory that all of us take Vitamin D supplements. We do recommend that older individuals, 65 years or older, take Vitamin D supplements, up to 800 units a day, because the diet typically contains little vitamin D, and the skin becomes less efficient at making vitamin D with advancing age. Furthermore, we absorb less of what we take in, as we get older, and we're more likely to avoid the sun, or wear protective clothing. For post-menopausal women between 50 and 65, a multi vitamin, which typically contains 400 units a day, is sufficient for most.

CNN: Why isn't screening more routine?

COSMAN: In fact, screening should be routine. I personally believe that all women at the time of menopause should have a bone density test. Because of economic and cost concerns in the public policy forum, we've limited testing in the younger post-menopausal woman to those with clinical risk factors. If you add in factors such as lifelong low calcium intake, the vast majority in this age group would actually qualify for a bone density test. If cost were not an issue at all, all women would be getting the test. The cost-effectiveness has been clearly demonstrated for woman over 65, where the risk of hip fracture starts to increase dramatically.

CNN: Do you have any final thoughts to share with us?

COSMAN: Osteoporosis is both preventable and treatable. Make sure you get enough calcium and exercise, don't smoke, get a bone density test if you're at risk, and take one of the medications that has been proven to reduce the risk of fractures related to osteoporosis if you have the diagnosis. New medications are on the horizon. One called Forteo is particularly exciting, and may be coming out sometime in the next few months. This drug offers hope for people who have severe osteoporosis, but will probably not be required for people with more mild or moderate disease.

Dr. Felicia Cosman joined the chat room via telephone from New York and provided a typist. The above is an edited transcript of the interview on Wednesday, July 25, 2001 at 4 p.m. EDT.

• National Osteoporosis Foundation

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