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Episode 77: Are You Getting DEXA Scammed?
1.3k Plays3 months ago
Welcome to Season 5 and Episode 77 of the Movement Logic podcast! In this episode, Laurel and Sarah dive into the history of how DEXA scans came to be so ubiquitous, what are the risks around osteoporosis medication, and whether osteoporosis and osteopenia were intended to be diagnoses in the first place. You will learn:
- How was the DEXA score for osteoporosis first decided on
- Was osteopenia supposed to be a diagnosis for treatment
- What role did Merck play in getting more women to take their new drug Fosamax
- What are the risk factors for the side effects of bisphosphonate drugs
- What is the difference between a population risk vs an individual risk
- Why it’s not recommended to get a DEXA scan before you are 65 years old
- The role of iatrogenesis in the medication choices and use for women with osteoporosis
Sign up here for our FREE Live Strength Class (and sample our Bone Density Course) on September 19th at 8:30am PT/11:30am ET with free replay!
Reference links:
North American Menopause Society
Jen Gunter Instagram
How A Bone Disease Grew To Fit The Prescription
Managing Osteoporosis Patients after Long-Term Bisphosphonate Treatment
Long-Term Drug Therapy and Drug Discontinuations and Holidays for Osteoporosis Fracture Prevention: A Systematic Review
Osteoporosis: Innovations in screening and diagnostics
Osteoporosis Treatment
Recommended
Transcript
Introduction to Hosts and Podcast
00:00:00
Speaker
Welcome to the Movement Logic podcast. Why am I so weird? Because I'm here to bring out the best weird in you. That's right. Welcome to the Movement Logic podcast with yoga teacher and strength coach Laurel Beaversdorf and physical therapist Dr. Sarah Court. With over 30 years combined experience in the yoga, movement, and physical therapy worlds, we believe in strong opinions loosely held, which means we're not hyping outdated movement concepts. Instead, we're here with up-to-date and cutting-edge tools, evidence, and ideas to help you as a mover and a teacher.
Hosts Share Personal Stories and Experiences
00:00:44
Speaker
Welcome to the MovementLogic podcast. I'm Sarah Court and I'm here, I'm actually literally here. Hello. With my co-host Laurel Beaversdorf. We are together. Hello. In Los Angeles. It is delightful. Yup. And it was so hot last week. I was like, oh God. And it's actually miraculously cooled off a little bit. Yeah. So it's not, it's quite nice today. It's quite nice. I woke up early and went on a long run on the strand.
00:01:12
Speaker
Do you know about the Strand? Let me tell you all about it. The Strand is a stretch of path for runners and bikers along the ocean. Oh, I didn't know I had a name. It's called the Strand. I thought it was just the path on the beach. I mean, it is. That's what the path on the beach is called the Strand. And I went running. And I went on my long run. So it was a little over 10 miles. That is a long run. It was beautiful and inspiring. And then at around mile five,
00:01:41
Speaker
Guess who I saw playing volleyball on the beach? I mean, I know, because you already told me. so OK. But i pretend you don't know. You saw Matthew McConaughey. No, better. way Better. Movement Maestro. Oh, that is way better. I mean, M and&M, you were close. That's true. But it was Movement Maestro, not Matthew McConaughey. Nice. And Lex Lancaster. Even better. And that was super cool because um I was running at around mile one, and I saw volleyball.
00:02:12
Speaker
courts and nets. And I actually had the thought, I wonder if I'm going to see Movement Maestro. I'm not kidding you. That's so cool. Because she posts about volleyball. Right. You used to play volleyball. And then at mile five, I fucking saw her. I was Movement Maestro. And she's like, bull. yeah I'm like, legs. And they're like, oh, hi. And I'm like, hi, follow me on Instagram. And I totally, totally was that person who was fangirling. Nice. But they were super cool. yeah And then I was like, do you know Sarah Court? And I'm like, does she do Red Court? I'm like, yes. She's like, I think I went to her clinic once. I was like, do you know Trina Altman? Yeah, everyone knows Trina. I'm like, yeah, I know. Everybody knows. trina But it was it was awesome. Pretty neat. That's so cool. Pretty neat. That was like, you had a celebrity sighting within 24 hours of of coming to Los Angeles. I mean, yes. And I have to say, it's probably one of my best celebrity sightings I've ever experienced. Nice.
00:03:08
Speaker
Nice. Well, we're going to have a great time this week. We are going to not one, but two dance classes this week, which is unusual. I mean, I, I don't know what happened. I kind of just stopped going to dance class. I haven't been in forever. It was my first one in like literally years. So I'm very excited about it. It's going to be, it's going to be so much fun. Yeah. I'm excited too. I'm also a little trepidatious because
00:03:31
Speaker
But that's okay. We're going to a hip hop class. We're going to a hip hop class. I can't even say the word. We're going to a hip hop class. I am going to look like the former ballerina trying to do hip hop, which just makes, it sort of translates to like a white girl. Like it just, you look real not cool. I'm going to use Nicki Knapp Levy's image of a pile of popsicle sticks flying through the air. That's what I'm going to look like.
00:03:58
Speaker
Popsicle sticks flying through the air. That is so amazing. I love that so much Alright, so that's what's happening with us this
Free Strength Training Class Announcement
00:04:05
Speaker
week. I mean, we're doing a bunch of other That's not the only you didn't just come here to take two dance classes I mean, I kind of did come that's true to like and then have fun on the side we're we're creating, you know more of our content Which is also fun. ah We're having a good time is the is the short Answer and we're only just getting started just getting started the fun has yet to really begun But we have okay apart from the excitement that we have about the stuff that we're doing this week We actually have something important to tell people about so we have a free class of free Strength training with barbells class coming up on September 19th at 8 30 a.m. Pacific
00:04:42
Speaker
and 1130 a.m. Eastern. And this is a class where if you've been reading our emails for the last year, you probably heard about this free class last year. We're doing it again live.
00:04:55
Speaker
We've been listening to our podcast for more than a year, you've heard of it. You are able to come to this class with whatever equipment you have. If you happen to have barbells, great, because we are going to be instructing barbell technique within the lifts, but you can kind of follow along, see what it's like, use the weights you have, if you have numbbells, kettlebells, it's all good. But we're gonna take you through a live class experience of an actual workout, the first workout in our program,
00:05:25
Speaker
So you're going to get a real life, real time feel of what this program is all about and the type of work, physical work you're going to be doing in it. You're also going to learn how to find the right weight for you. And we're going to throw in, as we always do, a lot of great context around what it is you're doing and why, as it relates to building muscle and bone. But also you're going to get to meet Sarah and I, because we're both going to be teaching the class. So that's super fun.
00:05:54
Speaker
And you'll also receive live personalized feedback as you work out with whatever equipment you happen to be using. You can keep your camera on for that feedback or you can come and just keep your camera off. We are completely comfortable with what you're comfortable with. You can also get the class and repeat it as often as you like. yeah So these are all great reasons to come and the maybe the best reason is that it's three it's free ninety nine free ninety nine And the other thing, I mean, we just had a sort of semi-funny conversation with my mom and her friend a couple hours ago about like barbells and lifting weights. And it was basically like, ah it was like the cliff's notes of all of the barriers that women put up.
00:06:36
Speaker
Yeah. I wish we had recorded it. I know. It would have been amazing. And my mom knows enough not to say any of this stuff because she's heard my responses. But my mom's friend was like, well, I mean, you could hurt yourself. And Laurel's like, well, actually, duh, duh, duh. Well, what about Rab that Rabdo? Rabdo my life. Rabdo. Yeah. We're like, this is not really going to happen. Well, I mean, I saw the people at the Olympics, and they were straining. I'm like, yes, but heavy is relative. Like, it was literally like a who's who of all of the reasons women talk themselves out of lifting heavy. I mean, it's pretty sophisticated that your mother's friend knew what rhabdomyolysis is. I mean, I was impressed with that. Most people have no clue what that is. So if you don't know, listen, rhabdomyolysis is extreme muscle damage that takes place when you go, do way, way, way, way, way, way too much.
00:07:17
Speaker
and it can happen with people of a certain personality type frankly in my opinion. I just don't know their stopping point or maybe a very high pain tolerance but you damage your muscles to the point where You get protein in your blood and it's not good for your kidneys and it's super, super rare. I will say again, she this was something she had in her head about why she maybe shouldn't. look wait like She thinks she's going to get rhabdo? No, no, no, no. What I loved about doing, we did this class yesterday. Yesterday? Yesteryear. Yesteryear. We did this class last year. when we were getting
Osteopenia and DEXA Scans: Necessity of Medication?
00:07:53
Speaker
ready to start our first iteration ever of our bone density course, Lift for Longevity. And it gives you a good sense of how it actually works really well. And there's not really any problems with it. We're going to invite some alum to join us. Oh, we are. I know that, but that's great. I mean, I just came up with that in the moment. Cool. That we're going to invite the alum to join us, yeah obviously. I mean, it's open to anybody who wants to join us. Yes.
00:08:16
Speaker
and Well, maybe they'll have something to say yeah about what their experience was like. Totally. You want that. Why don't you want that? It's free. Yeah. So go to the link in our show notes and sign up. And you'll get the link to join the class. And you'll also get our free barbell equipment guide if you have not gotten that yet. So today's episode has actually been a really interesting research process.
00:08:38
Speaker
and discovery process. I started out like my idea for this episode was I want to talk about DEXA scans and the history of how they came to be so ubiquitous, which we're still going to talk about because it's kind of wild. So then in my research, I came across some really interesting information about osteopenia, which I was not familiar with. And osteopenia is considered like the precursor to osteoporosis and both of which are diagnosed by DEXA scans.
00:09:06
Speaker
But the history of how osteopenia itself came to be a diagnosis is kind of fascinating and it's possibly a little sinister depending on whose story whose version of the story you believe. It's also probably led to a lot of women taking medications for osteopenia and a lot of questions around the necessity of this.
00:09:27
Speaker
Which is to say, have we made an osteopenia diagnosis something to be afraid of and to medicate when it may actually just be part of the normal aging process? So in today's episode, we're going to talk about DEXA scans. What are they? Why are they? Where did they come from? Do we all need to be getting them? Are too many women getting them unnecessarily? And then we're also going to talk about the current drugs that are available for osteoporosis and their various potential side effects.
00:09:55
Speaker
how to analyze the data around risk of fracture in relation to your individual risk of fracture, and if we might all just need to calm down a little bit and just pick up some heavy shit instead. All right, so before we get into it, I have to do a little medical cover your ass. The following conversation is not medical advice and should not be taken as such. If you have osteoporosis or osteopenia, please talk to your doctor about what treatment makes the most sense for you.
00:10:21
Speaker
So Laurel, I really wanted to call this episode Dex's Midnight Scanners. But here's the thing, I floated that to Laurel and she didn't know what I was talking about. I still really can't remember. I don't know what you're talking about. And I thought that it was going to be only like Gen Z who didn't know, but turns out some elder millennials also don't know. I'm an elder millennial, but I was also sheltered.
00:10:42
Speaker
That's true. But do you remember that song, Come On Eileen? Yes, I do know that one. So that band is called Dexi's Midnight Runners. Oh, OK. It's a little much. It's a little obscure. It's sort of a reference for like me and two other people. um There is an episode that's coming up that Laurel has come up with like maybe the best episode title ever. But you're hyping it. And now when people see it, they're going to be like, what no they're not supposed to be the best episode title ever they will agree because the thing is at the moment now i'm feeling like in terms of coming up with my own episode title i'm like why bother because laurel's already come up with the best title ever and nothing's gonna top it and you're gonna when you hear it you're gonna know what i'm talking about
00:11:22
Speaker
So I just went for a more kind of serious and a little bit provocative title and instead so the title is are you getting DEXA scammed? I actually think it's a great title. Thank you. All right, so let's start at the beginning and learn about DEXA scans. Laurel, what does the acronym DEXA stand for? I just want to make you say the hard part. Dual x-ray. Nope. Dual energy x-ray. Absorb geometry. It's not absorb, absorbentrometry?
00:11:47
Speaker
There's no trauma tree. There's no word with trauma tree that I know of unless it's a tree of trauma. This is my personal life. Okay. Dual energy x-ray. So it's a kind of x-ray. Yeah. With dual energy, that means two energies.
00:12:01
Speaker
Let me tell you all about it because I am clearly the foremost expert yeah in this form of technology. Well, so there's two energies. Not at all. All right. And then can you tell us about what a DEXA machine actually does? Yes. Okay. There are two kinds. There's a medical DEXA and a consumer DEXA. Medical DEXAs are far more accurate for bone density measurement. And to get one, you need a prescription from your doctor.
00:12:27
Speaker
So this is the kind that your doctor would send you to get. A consumer DEXA also measures bone mineral density. It is just not as accurate.
00:12:39
Speaker
It also measures body composition, like your lean muscle mass to adipose tissue ratio, the location of your adipose tissue, whether it's visceral or not. These consumer ones that are not as accurate, you can get them pretty easily in big cities without a prescription, and they usually cost around $100. And this is useful if you're just more interested in your body composition, you wanna work on it. Body builders use them a lot, athletes might use them,
00:13:07
Speaker
But it's not as useful if you want an actually accurate scan of your bone density. Okay, so now we have a bigger, longer question, which is, where did DEXA scans come from? Would it surprise you, Laurel, to learn that it started with a drug company looking to sell their new non-hormonal osteoporosis drug called Phosomax? That's not necessarily where they came from, but that's how they became very, very commonly used, would you say?
00:13:33
Speaker
The DEXA scan was in existence before this, but it started to be recommended at an exponentially higher rate. Now I'm not surprised.
00:13:46
Speaker
I'm not. and no it's it's No. It shouldn't ever be surprising that something becomes popular because somebody's trying to sell you something. No, not at all. And especially when it comes to drug companies, yeah in my opinion. Yeah. But I mean, hey, listen, I'm not anti-pharmaceuticals. I'm just wary of some of the ways that the pharmaceutical industry has hoodwinked people into receiving unnecessary treatment. So there's two parts to this story of how DEXA scans came to be.
00:14:14
Speaker
and how they became to be so popular. So I got a lot of information from an NPR story from 2009, as well as from the National Women's Health Network website, both of which we will link for you. I also once again called on Naomi Schwartz for some research papers, and she proved herself to be an invaluable resource for interpreting the data around fracture risks. And I mean, at this point, we just have to have her come on the pod and talk about epidemiology.
00:14:42
Speaker
Mm-hmm. I think that absolutely she is ah Someone that I'm so glad that we have as a resource and I feel like as an epidemiologist. She would have a I Think the word we often use is fuck ton. Yes of valuable information. I agree the unit of measurement is ft She would have a possibly multiple fuck tons. Yes, I yeah All right. Okay, so the first part of this story takes place in 1992 in Rome. Picture it. Which makes it sound like it's going to turn into a romantic comedy starring Robert Downey Jr. and Marisa Tomei, but I don't think that's what actually happened.
00:15:23
Speaker
So, it was a meeting of osteoporosis experts from around the world, and they were gathered under the auspices of the World Health Organization. Now, up until like the early 1990s, osteoporosis was not a word that people people were familiar with, partly because there was there was no real way to measure bone density loss. But now, there was this emerging technology that made it possible to measure bone density, and this technology was called a DEXA machine.
00:15:49
Speaker
So all of these osteoporosis experts were gathered with a specific job, and that was to figure out where's the line between you have osteoporosis versus you have what's considered a non-concerning level of bone density loss.
00:16:08
Speaker
Right. So their, their job is to get together in a room, all of these experts and figure out where that line was. Right. So before we get into this story, Laurel, can we pause and talk about the scoring system of a DEXA scan that these intrepid osteoporosis experts came up with? Yeah. The, the scoring of a DEXA scan is based on analysis of data called a T score.
00:16:36
Speaker
And so if your T score is negative one or higher, your bone is healthy. And this is measured against the bone mass of the average healthy 30 year old. Okay. So if you're negative one or higher.
00:16:55
Speaker
your bone is healthy. If you're negative one to negative 2.5, you have osteopenia, which osteopenia means bone wasting like sarcopenia muscle wasting, and then negative 2.5 or lower, you might have osteoporosis.
00:17:15
Speaker
The results that the DEXA spits out are displayed as green, yellow, red, which is, you know, pretty provocative visually for us as humans and maybe a little scary. And so how do they figure these designations out? So this is from the NPR piece, which was called How a Bone Disease Grew to Fit the Prescription.
00:17:41
Speaker
um There's no bias at all in that title. Okay. They are not burying the lead. No, no, no. Anna Tostason is a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and Dartmouth Medical School, who attended the meeting. She says that over a two or three day period, the experts in the room went back and forth and back and forth looking at research and trying to decide precisely where on a graph of diminishing bone density to draw a line.
00:18:18
Speaker
Ultimately, it was just a matter of, well, it has to be drawn somewhere, Tostason says. And as I recall, it was very hot in the meeting room and people were in shirt sleeves. And, you know, it was time to kind of move on, if you will. And I can't quite frankly remember who it was who stood up and drew the picture and said, well, let's just do this. And and can I add from my own reading,
00:18:46
Speaker
of a book called Estrogen Matters that My understanding from that book and what was shared there is that this, um, the statistical measure, uh, the standard deviation of negative 2.5 as the sort of benchmark or level to say like have osteoporosis or you don't, that it was not actually meant to determine a disease state, but wrap in an individual, but rather it was used to be a benchmark in order to estimate the prevalence
00:19:21
Speaker
of osteoporosis across different countries. So more is like an epidemiological benchmark rather than a disease state benchmark for a particular person. right okay So it's not actually originally meant to be a diagnosis and certainly not the sole clinical criterion for determining like whether or not you should get treatment of various kinds. yeah But that's what it turned into. That's what it turned into. And it's kind of wild to think that your osteoporosis diagnosis and possible medication for it could hinge on how hot a room was in 1992 in Rome. Yeah. And it makes me, again, remember how
00:20:06
Speaker
First of all, I wonder how many different benchmarks have been determined. this Because the killer's hot, when people were hungry, it was a long day. Yeah, yeah. And then also, ah it just makes me, again, remember how women Women's health, studies done on women, just the way that we are as a population treated by the medical establishment has just often been like an afterthought in some ways. If it's any amount of thought, yeah it's an afterthought.
00:20:39
Speaker
Yeah. So this is related to what Laurel was just talking about. So talking about, they also came up with the term osteopenia in that meeting. And that was a designation of someone who didn't have osteoporosis, but was close to it, like just on the other side of this line that they have designated. But from Tossison's recollection, this is collaborated by the chairman of the meeting, John Canis, of the WHO Collaborating Center for Metabolic Bone Diseases.
00:21:07
Speaker
It was done just to create clear categories for research studies. They did not intend for osteopenia to become a diagnosis in and of itself. But as we know, it sure did. So how did osteopenia and osteoporosis become a diagnosis?
Pharmaceutical Influence on DEXA Popularity
00:21:25
Speaker
Well, that's part two of the story.
00:21:27
Speaker
So for part two of the story, we have to switch our focus over to a gentleman named Jeremy Allen. He was a British man who worked for medical research companies in the United States, and he had been approached by Merck in 1995 to promote their new drug called Fosamax, which was the first ever non-hormonal drug that could stop the progress of osteoporosis.
00:21:50
Speaker
Phosomex had the potential to make millions for Merck, but the problem was nobody was using it because nobody had an idea of what osteoporosis was. So like it wasn't even on people's like brain pan, right? So Merck hired Alan to fix this problem, and he went around talking to researchers and doctors, and eventually he hit on the solution, which was that Merck needed more women to get DEXA scans. yeah right If you're going to get women to take your drug, you got to give them a reason for it. And the reason is going to be the DEXA scan. But the thing is, at the time, the machines the DEXA machines were huge and expensive, and they were few and far between. And the cost of the scans was really prohibitive for most people. So Alan set out over the course of a few years to change this. So he convinced the DEXA scan the dexacan manufacturers to make
00:22:41
Speaker
what was then called peripheral machines that were smaller, they were lighter, they were less expensive for doctors to purchase. Now, the manufacturers had a fair amount of pushback and depending on who you ask, you know, if you ask Alan,
00:22:56
Speaker
at the time, he says it was because their business model was to sell just a few big machines, big expensive machines, and he was trying to get them to sell a lot of small cheaper machines. And so he was saying the pushback was because they didn't want to change their business model. And Alan, you know, also at various points in the NPR article says things like, you know, I'm just so glad that I was able to come in and help millions of women with their osteoporosis. And I'm a little bit like,
00:23:21
Speaker
How much was Merck paying you? Was that maybe what was more exciting for you? I don't know. I can't throw someone under the bus that I've never met, but his story, and he's sticking to it, is that he was glad to be able to come in and help all these women.
00:23:37
Speaker
So then there's Richard Mazas, who is founder of the Lunar Corporation, which was one of the largest manufacturers of bone density machines. He said the reason why they didn't want to make the small peripheral machines was because it was not going to do as good of a job as the big machine and that it could lead to bad medicine. So this is a little bit of a like, he said, he said, like, who do we, we don't know.
00:23:59
Speaker
right we were We're not ever really going to know. But in any event, Merck also lo lobbied the government to get legislation passed so that Medicare would cover the cost of bone scans. And so in 1997, the Bone Mass Measurement Act was passed, which now made it and actually profitable for doctors to have their patient get bone scans because they would then get it reimbursed by Medicare.
00:24:22
Speaker
Also in 1997, Merck developed a lower dose version of their drug Fosamax that was intended for use by women with osteopenia. Well, do you remember how osteopenia was just supposed to be like a measurement for research and definitely not a diagnosis of anything? Yeah, and potentially also... Osteoporosis? Well, at least this line in the sand yeah between like what is the normal amount of bone density according to your age versus when have you lost too much right was really just used to and analyze bone loss across the, you know, world and compare different countries. Yeah.
00:24:59
Speaker
It turned into an individual marker. Here are some statistics from around that time that are very interesting. Medicare claims for screening exams went from 77,000 in 1994 to 1.5 million in 1999. That is five years and a very large increase in scans. Sales of peripheral machines went up 500% during the same five-year period. Okay, so through this five-year process, or through this whole process, right, of first the meeting that just sort of determined what is the T score, then the process of Jeremy Allen coming along, working for Merck, Merck saying, hey, we've got this drug, it's great for osteoporosis, but we can't sell it to anybody because nobody is
00:25:52
Speaker
able to figure out that they have an osteoporosis diagnosis, would you make that happen? He played hardball with these manufacturing companies. He made them make these peripheral machines. Then also Merck lobbied the government to get it covered by Medicare. And they also, in the same period of time, made a lower dose of version of their Fosamax. So in case you only had di-ostiopenia, which was not supposed to be a diagnosis anyway, you could also still take their drug.
00:26:19
Speaker
So now... So that's kind of where osteopenia became? A diagnosis. A diagnosis. Yeah. Okay. So now it's the late 1990s. I remember them well. You're in your 40s. You go to your doctor. You get a DEXA scan from one of these smaller, less accurate machines. It gives you that red, yellow, green report.
00:26:39
Speaker
And so this is something that worried a lot of women at the time. And it had this snowball effect where women like well before menopause, they were getting scans, they were getting an osteopenia diagnosis and worrying about it and then taking this lower dose Phosomax. Now, while there is scientific consensus that Phosomax can improve osteoporosis, there is not such strong consensus around whether you should take it for osteopenia.
00:27:06
Speaker
And if we consider the fact that the original doctors and scientists, the osteoporosis specialist who gathered in that hot hotel room in 1992, never intended for osteopenia to become an actual diagnosis that required treatment, we can start to wonder if we need to be so concerned about the treatment of osteopenia. And if we are, what is it, Laurel? Focusing on the wrong thing. That's right. But I will say too that we're going to get into this, but it doesn't necessarily mean that everyone with osteoporosis can or should be on Phosimax, right? Absolutely not. yeah I mean, all that that says is that they've done a lot of research studies, they've you know proven scientifically that yes, your bone mineral density density can be improved with Phosimax. It doesn't say how much it's improved. It doesn't say how long you have to be on the drug. It doesn't say any of those really like meaningful, useful things. It just says that like it makes a difference. Yeah.
00:27:59
Speaker
Okay, so let's talk about Fosamax and the other osteoporosis drugs that are available.
Side Effects of Osteoporosis Drugs and Drug Holidays
00:28:03
Speaker
So Fosamax, oh God, here we go. Fosamax is the brand name for a lendronate. It's in the drug class of bisphosphonates. And Fosamax is a daily oral pill.
00:28:14
Speaker
There's another bisphosphonate drug called Reclast, which is the brand name for zolidronic acid. That is given intravenously once a year. So those are both this bisphosphonate category. There's another drug called Prolia, which is the brand name for a denosumab. And Prolia belongs to a drug class called monoclonal antibodies. And these are drugs that are made from an immune system cells. So a totally different, it's a drug that functions differently.
00:28:43
Speaker
And there are a lot of other brand names and variations on all of these drugs as well. There's a lot of them out there. So in 2016, the American Society for Bone and Mineral Research put together a task force to look at the side effects of bisphosphonates, right? The Phosomax and Reclast and others that was published in the Journal of Bone Mineral Research. And it was called Managing Osteoporosis in Patients on Long-Term Bisphosphonate Treatment. So here's a quote from the paper.
00:29:12
Speaker
Currently, all FDA approvals of bisphosphonates for the treatment of osteoporosis contain the following important limitation of use statement. The optimal duration of use has not been determined. All patients on bisphosphonate therapy should have the need for continued therapy reevaluated on a periodic basis.
00:29:34
Speaker
So, we don't know what is the best length of time to be on the drug. And we still don't really seem to know. there there I could not find anything more recent than that that suggested that we that we had figured out sort of a timeline. But we know that it should be limited, right? We know that you shouldn't just be on it in perpetuity. And so, one tactic with this is to do something that's called a drug holiday. Now, Laurel,
00:29:58
Speaker
A drug holiday, despite what it sounds like, is not a trip to Ibiza with a baggie full of mushrooms. No, the idea of a drug holiday is you're giving your body a break from the medication in order to minimize side effects and maximize benefits. It's used a lot in other chronic disease states like rheumatoid arthritis, Parkinson's disease, you know situations where you might need to be on a drug for your lifetime, it's considered a healthy choice to take some time off the drug, just give your body a break. Yeah. And I've read as well that the side effects of taking Fosmax can be so negative that a lot of people don't remain on it for more than a year. Yeah. They discontinue use because they can't handle the stomach upset, the flu-like symptoms, the joint pain, and a bunch of other, yeah um, not as serious side effects. And you're going to tell us about some
00:30:52
Speaker
More serious side effects? Yeah. The more common side effects are the sort of GI ones and the joint pain stuff like that. There's more serious side effects, but that they're also more rare. Yeah. And so this is also from the paper. The American Association of Clinical Endocrinologists guideline suggests a drug holiday after four to five years of bisphosphonate treatment in patients at moderate risk of fractures and after 10 years for high risk patients. But The terms high and moderate risk were not defined. Okay, so why why do we need to take a drug holiday? Because it sounds like a blast. No. We need to take a drug holiday because there are two major concerns with the drug. and The ones that you said were rare. Yeah, they are rare. They are not common, but they're not great. So the first one is the most dramatic one. It is osteonecrosis of the jaw.
00:31:43
Speaker
Mm-hmm. Which basically means your jawbone starts to die. Yeah. Necro. Yeah, that's not good. The other one is something called atypical femoral fractures, which just means your femur breaks. Really bad. Atypically. Don't like that. Nope.
00:31:59
Speaker
So here's another quote, such results strongly suggest that although a rare potential complication of bisphosphonate use, atypical femoral fractures risk increases with prolonged duration of bisphosphonate treatment. And this should be taken into consideration when when continuing bisphosphonates beyond five years.
00:32:21
Speaker
However, it is important to note that for the vast majority of patients treated for osteoporosis, the bisphosphonate associated benefit of reduced fracture risk is greater than the risk of developing either osteonecrosis of the jaw or atypical femoral fractures.
00:32:39
Speaker
So right. That's pretty clear. It would have to be that way for the drug to be approved. but yeah Yeah. Yeah. If it was like fully 10% of people, their jaw falls off. They would not approve it. Right. they They found a drug that people could take. I can't remember the name of it. And they talked about this in estrogen matters that was really good at.
00:32:57
Speaker
helping people maintain or build bone density, but it would cause cardiovascular events and therefore was discontinued. but They did studies that were super positive. It was like, wow, look, it's you know I'm helping people so much with their bone density issues.
00:33:11
Speaker
that people are also getting heart attacks. yeah All right, so then I looked at a 2019 systematic review that was titled, Long-Term Drug Therapy and Drug Discontinuations and Holidays for Osteoporosis Fracture Prevention. And this was a review of 48 studies of people who were taking these medications. And this is a quote from that study. Concerns that long-term bisphosphonate use might increase fracture risk by inhibiting normal repair of bone micro-damage have led to suggestions to stop bisphosphonate treatment and to restart later called a drug holiday. Several groups advocate bisphosphonate drug holidays to minimize harms while preserving as much anti-fracture benefit as possible. However, consensus is lacking.
00:33:53
Speaker
around which patients should have bisphosphonate holidays, when and for how long, as well as criteria for restarting treatment.
Evaluating Osteoporosis Risk with Naomi Schwartz
00:34:03
Speaker
So the overall risk for the far more serious side effects of the osteonecrosis of the jaw and the atypical femoral fractures are low, but it's still recommended to stop taking the drug after a certain amount of time. And that's just not clearly outlined what that amount of time is. We still don't really know.
00:34:20
Speaker
Now, there are also concerns around the use of Prolia, which if you remember is a different class of drugs called monoclonal antibodies. Earlier this year, in 2024, it was determined that using Prolia caused a significant increase in the risk of developing severe hypocalcemia, which is very low blood calcium levels compared to bisphosphonates.
00:34:45
Speaker
The highest risk was seen in patients with advanced chronic kidney disease, but there was a risk to other people as well. Laurel, I have a question for you. What can do for your entire life and never need to take a drug holiday from or worry about your blood calcium levels?
00:35:04
Speaker
Lifting weights and impact training? That's right. Ding, ding, ding, ding, ding, ding. So with all of that said, the general consensus in the medical medical community seems to be that the benefits of Phosomax outweigh the risk. But they still only want you to take it for 10 years so that you don't excessively increase your risk of fracture. So I don't know. I don't feel great about that. I mean, no, I don't either. So that's the general consensus for osteoporosis, that the benefit of Phosomax outweighs the risks. But here's what the National Women's Health Network has to say about bisphosphonate drugs for osteopenia.
00:35:42
Speaker
And this is a quote, although many clinicians and pharma sponsored education campaigns conflate prevention and treatment, the network thinks that it is important for people considering bisphosphonates to understand how the effectiveness differs based on an individual's bone health. These drugs have been shown to reduce the risk of a hip fracture in women who have been diagnosed with osteoporosis because of a previous fracture or very low bone density. However,
00:36:09
Speaker
They have not been shown to prevent hip fractures in women who have been told that they have osteopenia. They do prevent vertebral fractures, including in women who have not previously fractured.
00:36:21
Speaker
This is completely anecdotal what I'm about to say. But I do get a fair number of people coming into the clinic who have an osteoporosis or osteopenia diagnosis, and they don't want to take the drugs for it. They may be scared about the risk factors, or they just they don't like it, right? And they want to start weightlifting instead. And I have heard through them varying responses from their primary care doctors, from sure go ahead, lift weights for six months, and then see what happens, to I really would prefer you take the drug. And again, I am not a medical doctor.
00:36:51
Speaker
Laurel, are you a medical doctor? No. No. So neither one of us can speak to each of these people's comorbidities or their individual risk regarding the drug. What's a comorbidity, Sarah? Comorbidity is a horrible word for things that you also might have going on in your body. So like diabetes or cardiovascular disease. But so the difference between the risk in the research versus the individual risk, this is a really important point because the generalized risk of a negative event versus a specific individual's risk of a negative event is not the same. So since neither one of us is as smart as our new friend, Naomi Schwartz, she wrote me an email. I had reached out to her for some articles and she wrote me back that she was so excited that we were talking about this and it's really important. And then she added into the email
00:37:40
Speaker
the advice that she gave to her aunt who was nervous about taking the drug. So Laurel's going to read you what Naomi said. So this is what Naomi wrote to Sarah. I get so many questions from my mom's friends about osteoporosis drugs, and it seems like a lot of them are being encouraged to take Prolia or Phosomax if they have osteopenia. The information out there is so confusing for the layperson. My aunt recently asked me to help her figure out the frequency of fractures in people who chose not to take medication for osteoporosis.
00:38:09
Speaker
She is very anxious about this type of thing and has been struggling for a few years with whether or not she should take medication for osteoporosis. Here was my response to her, which she found very helpful. So this is what Naomi wrote to her aunt. Number one.
00:38:28
Speaker
Knowing the overall fracture rate among individuals with osteoporosis who do not take medication is not particularly relevant. Within that population, there will be people who are very frail and have a lot of risk factors, i.e. prior fractures, smoking, advanced age, and people who are more like you, i.e. low fall risk, no other risk factors for fracture besides low bone mineral density.
00:38:57
Speaker
Knowing the population average fracture rate tells you nothing about your own risk. It only provides a population level estimate. This is where scientific communication about epidemiological studies tends to break down. You cannot extrapolate population level risk to individual risk. There also may be systematic differences between individuals who opt to take osteoporosis drugs and those who do not, which confound a raw, unadjusted comparison of fracture rates in treated versus untreated patients.
00:39:32
Speaker
So for those reasons, I do not think it is useful for you to have these numbers in your head. And I think they may do more harm than good. I have a question. What is a systematic difference? I'm not sure because I'm not a researcher, but I think it might be something like People who opt to take osteoporosis drugs often also have health insurance and people who don't do not, and therefore we maybe will see a difference in economic status, for example. All right, number two. The best way to look at these data, if you want to proceed despite my caution above, is to look at the control arm of the trials for osteoporosis medications. For example, the Proleo website has some graphics which I pasted below.
00:40:19
Speaker
You can see that the absolute risk reduction is quite low. We're talking a 5% absolute decrease in risk of fracture with Prolia versus placebo. That's not huge. Also in the placebo arm, among women without pre-existing vertebral fractures,
00:40:39
Speaker
the cumulative incidence over three years was 5.2% compared with 13.6% for those with preexisting vertebral fractures. So in the placebo arm, I'm just going to interject here, women without preexisting vertebral fractures had a cumulative incidence over three years of a sustaining fracture of 5.2%, right? Compared with 13.6% for those with preexisting vertebral fractures. So if you have a preexisting vertebral fracture,
00:41:18
Speaker
you have, I believe, a 60% higher chance of sustaining another fracture when compared to people who did not have a preexisting fracture. I might be mathing that wrong, but it's actually 160%. For the women who were not taking the medication, the greater number of fractures happened in the women who had already had a previous fracture. Right. So that's actually the bigger risk factor. The bigger thing. The bigger thing. Yeah. Yeah. Yeah. And this is in the placebo arm. Yeah. So these are people not taking the drug. Right. Right. Your risk reduction in the study that the group that was studied, right, that was taking the drug was around 5%. So that's taking the drug versus not taking the drug.
00:42:09
Speaker
Right. So you have ah you have a 5% decrease in risk, which is not huge, she says. No. Okay. In other words, your best bet for not sustaining a fracture is to just not have had a fracture in the past. Yeah. I mean, it's one of the risk factors that we're going to go into later that are actually a lot more relevant than your bone mineral density yeah as it turns out. Okay. Number three, but we do absolutely know that these drugs are effective at increasing bone mineral density. There's no question about that.
00:42:39
Speaker
Whether or not that translates into a meaningful decrease in fractures for any single individual is harder to say. I know the choice to take these medications or not is anxiety inducing. I think that if you are really anxious about the risk of fracture, you should go ahead and get treated. Your risk for fracture will increase as you age. This is true for everyone, not just you.
00:43:04
Speaker
So now is an optimal time to increase your bone mineral density if you are worried about it. We will continue to gain more knowledge about these medications as time goes on, and I'm sorry we don't have a clear answer right now.
00:43:23
Speaker
Lifting heavy and impact training are the only research proven ways to build bone mineral density and guard against osteoporosis. In our six month live online progressive barbell course, we teach you to do just that. If you'd like to sample a free workout from this progressive barbell course, join us September 19th at 8 30 a.m. Pacific and 11 30 a.m. Eastern. If you already have barbells, great. And if you don't, bring your weights and a dowel or a broomstick. You will receive live feedback on technique if you want it.
00:43:52
Speaker
camera off if you don't. If you can't make it live you'll get a replay. Click the link in our show notes to sign up.
00:44:07
Speaker
What we're starting to see a picture of is that your bone mineral density is not the best predictor of a future fracture. And that was also something that estrogen matters. This book that we'll link in the show notes corroborated. I can also add in estrogen matters, they say that a better predictor of whether you will sustain a fracture is a history of falls. So if you have fallen in the past, you're more likely to fall again in the future, or if you've fallen a lot in the past. right I don't know if there's like a certain amount you need to have fallen before that's an indicator that you're potentially going to fall again in the future, and that is a bigger predictor of fracture than your bone mineral density.
00:44:53
Speaker
right So then if we're thinking about, okay, well, what should we be doing to reduce our risk of falling? We're going to be looking at things like general physical preparedness, right? Are you, how well do you step off the curb? We're looking at things like your strength, your balance, your coordination, your, your confidence in your movements.
00:45:12
Speaker
And here's the really cool thing. Strength training will both increase bone mineral density and improve your strength and balance and coordination and your confidence in movement.
Are Early DEXA Scans Beneficial or Harmful?
00:45:24
Speaker
So in my personal opinion, as long as there are no medical reasons that you should not, and that's up to your doctor to help you determine, not me, strength training and impact training. Seem to me to be the obvious best first choice.
00:45:42
Speaker
Yeah. The thing about your patients coming in and their MD telling them, I'd rather you just take the drug is that I think a lot of MDs don't know jack shit about string training. Yeah. I think a lot of them do too, but I would say like if 80% of the population is not meeting the physical activity guidelines, this includes MDs. True. That's a very good point. There's a high likelihood that they want them to take the drug.
00:46:11
Speaker
because they know about the drugs. Right. And they don't know about strange changes. Exactly. All right. So this is a little bit of ah an aside of a topic. But when I was going through the research, I found a 2011 paper entitled, Profox, the post-HRT nightmare. It's a pretty dramatic title.
00:46:29
Speaker
um It sounds like ah like a like a new horror movie or something. But anyway. The paper was talking about, at the time, women going through menopause, being given, and having a lot of menopause-related symptoms, being given a combination of Prozac and Fosamax, which was called Profox, as their first line of therapy, when really, they would have been better off, most of them, probably, taking hormonal replacement therapy. But this was still in the time when the general consensus was that HRT was too dangerous and could cause cancer, which has now been solidly
00:47:03
Speaker
refuted Right. Can I just say a couple of things? One is the Prozac was prescribed in order to treat some of the psychological suffering. Yes. Okay. And then Phosomax obviously bone mineral density. Two is that this belief that hormone replacement therapy would cause breast cancer was largely from the women's health initiative study.
00:47:32
Speaker
which was, I think, to date, the most expensive study ever conducted and was basically data mined in a way that was and incredibly problematic. It was a little bit sort of like what you're describing with the men in the room wearing the long shirt sleeves and feeling hot and being like, can we just? But it was, it was I think, something along the lines of like a bunch of um people who had stakes in their conclusion the conclusions they drew from the study like wanting those conclusions to hold true, using statistics and data in a really irresponsible way to kind of doctor the the the truth of it. You can really like use statistics
00:48:19
Speaker
to turn a conclusion very, very wrong and still have it be statistically right. That's tricky to think about if you don't know anything about statistics. And I certainly know almost nothing about statistics, but I know from my reading on this study that it was a huge study. It was a potentially good study. The conclusions drawn from it should have been that hormone replacement therapy is not dangerous in the ways that ultimately were communicated. So just for some background, you can you can look up Women's Health Initiative and and also I think here's where we should also plug the North American Menopause Society as your resource for evidence-based information on all things hormone replacement therapy.
00:49:11
Speaker
and also a really great person on Instagram that we both love. Jen Gunter is a MD out of Canada, evidence-based, extremely talented science communicator, author of many books. So all of this to say, don't take it from us. Right. Well, I'm talking sort of casually about how this this conclusion that HRT was too dangerous it It forced a lot of women to suffer for a long time. Very, very, very true. so But that was the sort of generally held belief at the time. And yeah so there was research at the time that also showed that a large percentage of women who had esophageal cancer had been taking bisphosphonates at the time.
00:49:56
Speaker
So I cannot speak to this with any particular knowledge around the the cancer risk, but I do find it interesting that the the lack of accurate data and information around the safety of HRT meant that potentially even more women were being given Phosomax. Absolutely. And that many women who could have benefited from being on HRT at the time were given Phosomax, but they were recommended against using the HRT because it was believed to cause it breast cancer, but as Laurel said this was based on some really flawed interpretation of some research and that recommendation against HRT has been reversed. yeah
00:50:34
Speaker
okay That was a really big aside. I'm glad we were doing it, though, because I think that if you go on the internet, there is a plethora of quacks trying to sell you hormone replacement, whatever, or such and such to balance your hormones. And they have no business shilling the quackery that they're shilling. And so I think it's just really important that we understand that there is a lot of nuance to this and that you really want to take your information from evidence-based.
00:51:02
Speaker
m ds And know that like hormone replacement therapy could be right for you, but it's not necessarily right for everyone. right And anyone telling you that is probably a quack.
New Bone Health Scanning Technologies
00:51:13
Speaker
So if we now return to the world of scanners, there are some emerging alternative scan technologies that are available that may actually be more accurate than the DEXA scan in its current form. So there are two options that are currently used in research to get the most accurate picture of bone health, but they're not really used too much commercially yet. The first is called a 3T MRI. The 3Ts are tops, tails, and toes. Top, tails, and toes?
00:51:44
Speaker
No, it's actually three Tesla. It's a measure of the energy something triple energy Tesla is a unit and a car Do you know someone down the street got one of those stupid Tesla cyber trucks? I've got one in my neighborhood too and it freaks me out every time there's so creepy. They're so they're like the they're so dumb they're the that they're like the engineered embodiment of Toxic masculinity of what's his faces Elon Musk. Yes. Yes All right, so a 3T MRI, it's basically, it's an mr MRI that just gives you an even more detailed picture than your standard MRI. It shows the microarchitecture of the bone and it shows the bone texture. The negatives about it is that at the moment it's really expensive and it requires someone to interpret the data versus a DEXA scan which just spits out this result. The other one, and this is one that I think is more commercially available at the moment, is called a quantitative, computated tomography.
00:52:39
Speaker
or QCT. Okay so this is a high resolution three-dimensional image and when it's used to view the spine it provides more insight into the trabecular bone. Where's that Sarah? That is the kind of bone that is in the end of your bones and it's like it's the stuff that looks like sort of spongy and so it has a that is something that the DEXA ah testing can't measure. It doesn't have the ability to measure that. Your trabecular bone has a high metabolic rate, and so it can show deterioration in bone strength before you even see these traditional bone mineral density changes. So actually, it might be a far superior ah screener for anyone concerned about their bones than than DEXA. But, however, it does expose women to higher doses of radiation.
00:53:26
Speaker
than a DEXA or an MRI, and this has sort of curbed the general enthusiasm to invest in QCT as a technique for routine screenings. Now, there's also something called the FRAX algorithm, and FRAX stands for Fracture Risk Assessment Tool. I mean, it's an X on the end, so that doesn't actually work, but anyway.
00:53:48
Speaker
We'll take it. We're going to go with it. So this is something that actually uses your DEXA score, but it also takes into account all of these other risk factors that are really important. And and you know probably some people would say more important than your DEXA score in some ways. And so you input the DEXA score and these risk factors, and then the FRAX calculates the individual person's statistical probability of fracture within the next 10 years.
00:54:17
Speaker
And it differentiates between different populations based on geography and ethnicity, where the data is available. There are several studies out that indicate that FRAX is a useful tool for making treatment decisions. And it may be better at accurately accurately predicting fracture risk because it takes the individual person's risk factors into account. Yeah, but you have to have the bone mineral density score for your femur bone to get it. So you sort of need to have had yes some scan of some kind in order to use the FRAX. Yes. But if you were going to make a decision on treatment, you're going to make a more accurate decision with that and the FRAX plus the DEXA versus just the DEXA. Yes. And i I would love to know
00:55:03
Speaker
what percentage of MDs are not also using the Frax because it would seem like a no brainer. You can also access the Frax free online. We'll show it in two minutes. We'll link it yeah in the show notes. So these risk factors are a previous fracture, a parent who has fractured a hip,
00:55:20
Speaker
It's interesting that it's specifically a hip. I mean, that sounds like it's got more to do with... A hip fracture is really what you do when you fall down. Like a vertebral fracture, sometimes people look like if they have... They don't even know about it, right? Yeah, you could like sneeze and do it. Yeah. So, okay. Currently, are you smoking?
00:55:36
Speaker
That was a weird way to say that. Currently, are you smoking? Not currently, currently. I'm talking. Are you smoking? Are you a smoker? Are you taking glucocorticoids, which is a kind of steroid. It's used often to treat allergies, some autoimmune diseases, adrenal insufficiency. So it's a semi-common drug that's out there. Do you have rheumatoid arthritis? Do you have second day Second day, secondary osteoporosis, ost secondary is do you have an osteoporosis that is induced by medication? Yep. Are you drinking more than three units of alcohol per day? And what is your ephemeral neck bone mineral density, which is that's you're going to get that from your DEXA skin. Ephemeral neck is a landmark on the femur. Yeah.
00:56:24
Speaker
So, well, we've said a lot of things over the past hour about osteoporosis, about osteopenia, about is a DEXA scan worth it? Should you pay attention? What's the individual risk factor versus the population level risk factor?
00:56:40
Speaker
What's an older middle-aged lady to do? I'm talking about myself.
00:56:46
Speaker
ah Not listen to us about any of this stuff, just we're putting the information out there and go talk to your doctor, but also potentially look at some of the resources we link.
00:56:58
Speaker
in the show notes. That's number one. Number two. I mean don't not listen to us at all. I mean listen to us. Listen to our podcast. Listen to every word we say. But then also. But don't think that we have the best advice for you about debt whether or not to get a DEXA scan or whether or not to take the drug your doctor's telling you to take or we'll tell you that you should strength train and we are not making this up. That is advice handed down to us by the WHO and the CDC. We also know that there's solid research showing that high intensity strength training, that's heavy strength training and impact training can improve bone density. And it also can make you strong as fuck and
00:57:43
Speaker
The type of impact training that you might be doing is called plyometric training, which can also improve your power production. So these are all capacities that you want to hold on to to prevent falling, which will prevent fracture. So that's number one. Number two is that I think we need to address what I think is a very human concern, which is that we want to know whether or not we have a potential risk of having weaker bones than we want to have, right? Because we want to know that, like, our bones are strong, and if they're not strong enough, like, what more can I do to make them stronger?
Strength Training for Bone Health
00:58:26
Speaker
And there's an ethical discussion happening around this now, where more and more people, I think, are becoming aware of the fact that there is this thing called osteoporosis, there is this thing called porous bones that can happen starts happening really around age 40 and speeds up around perimenopause than menopause, right where estrogen levels deplete. And like they want to know what they can do about it. They know strength training and impact training are helpful. But they also just want to know, like m is it making a difference? What is my bone health right now? like What is my bone strength right now?
00:59:05
Speaker
So there is an understandable desire amongst a lot of women to get a DEXA scan before it is being recommended. And it is currently being recommended that women age 65… receive a DEXA scan. And it's very logical to go, that is too late, okay? Because why does it help me to know that I have osteoporosis or osteopenia when I'm 65, which is about 15 years after menopause, right? Women go through menopause an average age of 51.
00:59:42
Speaker
Okay, so that's almost 15 years after menopause. In fact, it would maybe be better to know at age 40. How am I doing? right Should I step it up right based on what I'm currently doing now? And also, can I break in for a second? Yeah. That that sort of thinking, like we look at someone like Peter Attia and his whole longevity approach, like that sort of idea of like, okay, I'm going to do all this testing and get all this information now so I can make good choices for the future. like That's very much in the water.
01:00:09
Speaker
of how people nowadays think, who can afford it, think about their health. And some people go like really nuts on it and get every single possible panel and whatever that probably is a bit too much. But we all have a sense, I think generally, that like the more information I have, the better off I'm gonna be.
01:00:25
Speaker
Yes, but that is actually not true necessarily. It's not necessarily true that the more you know about your body, the better off you're going to be. Like Sarah, for example, when people get scans showing that they have disc degeneration or they have a herniated disc or they get a scan on their knee because they have knee pain and they realize they have a torn meniscus, right?
01:00:53
Speaker
Why might that information, which is information about what's happening in your body, why might that actually not be beneficial? Well, sometimes, in some cases, the if they're trying to say, the pain in my body is because of this thing on the scan, quite often, in terms of especially for your spine, that's not actually true. But the other part that happens, and I see this frequently, and yeah and also some it's a bit of a personality thing. The people who come in who tend to be more anxious and more concerned and worried about things,
01:01:23
Speaker
the Your x-ray report or your MRI report is going to list literally everything that the radiologist sees. They're not making an opinion on what they're seeing. I mean, they are saying they summarized the most important findings at the end, but they list everything, right?
01:01:38
Speaker
So you could have an x-ray that says like there's something at L1 and there's something at L2 and something's going on in L3 and something else is going on in L4. And you by the time you get to me, you're like my entire low back is screwed, right? When a lot of that stuff is not important because it has no correlation to your physical capacity or your pain or your ability to do things, right? So a lot of the time we get a lot of information that while it might seem useful to have,
01:02:07
Speaker
it doesn't typically lead people towards making good choices for their body. Right. And one of the ways that a DEXA scan conducted at age 40 or age 50 or a 55 before the recommended, right, the medical establishment recommends it at 65, is that you might be over prescribed a medicine like Phosamax that you may not benefit from that you may actually experience detriment from. Additionally, we know that there is a lot of
01:02:44
Speaker
fear that accompanies a diagnosis of osteoporosis, like Sarah's friend calls it her crumbly bones. Right. Her crumbly bone disease. Yeah, her crumbly bone. So I'm not saying that I'm torn. By the way, and hopefully you can hear this. like i'm not i'm not I'm a little bit torn, right? Because I was i used to be on the side of like why are we not getting these DEXA scans at age 40? Because wouldn't it make more women strength train and take up activities, physical activity that would be bone building, osteogenic. On the other hand, we have this thing called iatrogenics, okay? Iatrogenics is a medical problem induced unintentionally by a physician or surgeon or a problem induced by medical treatment or a problem induced by diagnostic
01:03:40
Speaker
procedures that would not have occurred had the physician, the surgeon, the medical treatment, or the diagnostic procedure made the decision they did or acted in the way they did or occurred, okay?
Potential Downsides of DEXA Scans
01:03:55
Speaker
So in other words, it's over-medicalization. It's over-prescription of drugs, okay? And so what what might happen with something like a DEXA scan is that you might at the age of 45,
01:04:09
Speaker
come to learn that you have osteoporosis, okay? And you might go to your doctor and start on Fosamax and Fosamax might have this negative adverse effect on you, okay? You might also become so fearful of engaging in something like strength training that you will avoid strength training.
01:04:28
Speaker
Yes, especially because in the medical community at the moment, there is not very good consensus. I mean, a lot of the the recommendations out there for bone-building activities stop at weight-bearing, which is not enough, because if weight-bearing wasn't enough, nobody would have bone issues. Right. Right? And there's also the possibility that the DEXA scan you get is wrong. Yeah.
01:04:51
Speaker
Because if you don't use the accurate one or even if the accurate one is wrong, there's such a thing as a false positive. You can get false positives, which are basically results from a test that tell you you have something when you don't have something. And this is probably the number one reason to not be over tested. Right. So here's what our go to expert medical expert on women's health. Basically, she's a gynecologist out of Canada. Her name's Jen Gunter. Here's what she had to say about bone scans on Instagram. She posted, regarding bone scans for bone density, the recommended screening ages age is age 65.
01:05:34
Speaker
those with risk factors may need to be screened early. I'm going to jump in and say, the risk factors Sarah listed among potential other risk factors would be a reason that your doctor would hopefully go, we're going to get you a DEXA before age 65. If you don't have those risk factors, you can talk to your doctor about this. If you don't have those risk factors,
01:05:55
Speaker
then you are recommended to get screened at age 65. So Jen goes on to say, you can calculate your risk and hence find out if you need early screening with the FRAX or OST score, easy to find via Google, those with reds and primary ovarian insufficiency. These would be diagnosed by your physician will need screening when diagnosed. And of course, other medical conditions may lead to early screening. So obviously early screening is on the table. If you have these issues going on.
01:06:23
Speaker
Any woman who is 50 or older should have a DEXA scan if their weight is under 127 pounds or their BMI, their body mass index, is under 21. If they have a history of a hip fracture in a parent or they are a current smoker.
01:06:44
Speaker
Some of the medical conditions, medications associated with low bone mass or osteoporosis include aromatase inhibitors, steroids, rheumatoid arthritis, early surgical menopause
When Should Women Get DEXA Scans?
01:06:58
Speaker
as well. So if you have your uterus removed or if you have something with your ovaries happening, right? Testing below age 50.
01:07:06
Speaker
based on presence of significant risk factors, right? So if you have those risk factors, yes, before age 65, your doctor will potentially order you a Texas scan. There is no recommendation to get a baseline or to test people under age 65 without risk factors. In the same way, we don't recommend a baseline mammogram at age 20 to know your baseline.
01:07:33
Speaker
so There are real health concerns at play with the recommendation to not get tested. And these health concerns include the detriments of iatrogenics, the detriments of false positives, overmedicalization, the overprescription of drug use ah that you may not need or that you may actually not benefit from and actually be a detriment to your health.
01:07:59
Speaker
In the comment section of this post, which we will put in the show notes, many women weigh in with concerns that if only we knew, if only we knew what was going on with our bone strength, then we would know to strength train. But what Sarah and I think is that if the CDC and the WHO are recommending that everyone's strength train, literally almost everyone, unless your doctor says not to,
01:08:26
Speaker
Does that include pregnant people? It includes pregnant, I don't know if the CDC or the WHO says it exactly, but I know that the physical activity guidelines out of Australia do. Cool. They include women who are pregnant who have not previously strength trained, can also start strength training. Amazing. Children can strength train, right? If we're being told,
01:08:48
Speaker
that strength training is beneficial to our health in this wide variety of ways.
Strength Training Advocacy for Health Benefits
01:08:55
Speaker
We don't need a DEXA scan to know that we should do it. Exactly. At the same time, um we know that if we are strength training, not only are we probably decreasing our likelihood of getting cardiovascular disease, diabetes, but we're also potentially staving off our risks of fracture due to either osteoporosis or falling. So I think it's actually simpler than getting a DEXA scan at age 40. I think the answer is to start strength training no matter what your age is right now. Yeah. And if you if you are strength training, keep going. I mean, look, obviously our bias is towards strength training, right? But it's not just because we sell a course. Like in the clinic with my patients,
01:09:44
Speaker
I get as many people as I can, strength training, because I know it's good for them. And it's men and women and older people and younger people. like I try to get basically everyone to start doing it. And I have mixed results, depending on the person. That's the thing, too, is like and not everyone wants to strength train. Yeah. And that's OK. But it's sort of like when people want to do yoga, they try one class. And they're like, yoga's not for me. Yes. It's possible that you just haven't found the right teacher, coach, community, context. That you don't have enough tries to decide if it's not for you. And I also think that it's possible that people will just not like strength training, but listen, I don't always like brushing my teeth at night when I'm tired.
01:10:30
Speaker
I don't love eating vegetables every day as much as I'm supposed to. Oh, really? No, I'd much rather eat like carby stuff. Oh. Yeah, I'm like not a huge. I'll eat vegetables. I do. But that's not often what I crave. I don't crave it. Nobody craves vegetables. If I'm honest. No. Yeah, there's lots of things that we do because we're supposed to. We get the oil changed in our car. We pay our taxes. Sometimes we shower. We try not to watch that next episode of Love Island and instead go to bed. But that really mostly doesn't happen. We firmly believe in taking affirmative action for your body's health and not waiting until someone else comes around and tells you you should or shouldn't. We know that there's so much value to getting stronger. We both strongly believe in women getting more muscle on their body and being more competent and confident and independent as a radical political act.
01:11:26
Speaker
It is no longer time to sit down and just be quiet and do what you're told. And the one of the best ways to feel stronger in the world is to feel physically stronger.
01:11:40
Speaker
You know, so yeah, we'd like you to do that, whether you're doing it with us or anybody else. And you can always, you know, we said this when we went on Sports Physio Podcast. If you are interested in sports strength training in some capacity, you've got questions, just reach out. It might take a minute, but we'll get back to you and... It'll take Sarah a minute. It might take me an hour. Wait, which way is that rude? No, so... Oh, that I would be faster? Oh, much faster. Oh, no, no, no, no, no.
01:12:08
Speaker
i I will disagree because what I usually do is I see, I mean, this doesn't make it sound like I want to talk to people, but i I have a lot going on in my day and I see emails from movement logic people and I go, that's for a later time. Not right now when I'm about to see a patient. You're still way more responsive than I am. In any event, the bigger point is we're here to help you and we actually really truly do want to help you whether you take our course or not. So that's ah that's all I have to say about it.
01:12:37
Speaker
Cool. Sign up for our free class. Yeah. When is it again? It's on September 19th at 8 30 a.m. Pacific 11 30 a.m. Eastern. You get the recording. You can attend live. Turn your camera on. Get feedback. Meet us. Get to know us. Get to know me. Getting to know you. Getting to know all about us. That's right.
01:13:02
Speaker
We'll work on that. Alright you guys, thank you so much as always. Thank you so much for listening. I hope this episode was helpful and not just like more confusing. It does appear as though some of this whole situation was done kind of willy-nilly, but more information is needed. um Definitely check out the links in the show notes for some good resources that may help you better understand how this whole ah situation came about with osteoporosis and osteopenia and the standard deviations and the DEXA scanning. Listen to your doctor and strength train. Yeah. And finally, if you liked this episode, it helps us out. If you subscribe, if you rate and review it on Apple podcasts or wherever you listen to podcasts, are we going to see you in a fortnight? Yeah, no.
01:13:53
Speaker
See you next week. See you next week. Oh, hey. We do a lot better when we have to say see you next week. Mm-hmm. It's no longer see you in a fortnight. No, because we're going every week. Yeah. We're just going to start pelting you with episodes. Slamming episodes into your ears and your ear balls. That's right. All right. Well, see you next week. Oh, it works so much better when we're in the same room. Yeah.