Bone Density vs Bone Quality

 Hi Chris, don't know. Not specified. I'll have a look at the references at the end of the paper. . . .. J

When you compare the lack of risk with something like Vit 3 and the results it produces, with meds that have serious side effects, it does make you need to weigh up the risk you're at,  and then do what you feel is best for you, doesn't it.  Just reading up on Actonel, for instance, that has serious side effects, but doesn't seem to reduce risk of fractures less than Vit D!  This really is SO interesting, and thank you so much for posting about it!

Hi Chris, the Vitamin D figures confused me as I had thought there was no evidence that "natural methods (vitamin,Diet) had been shown to increase BD and had to be used in conjunction with meds. for someone with OP, but COULD be used for bone protection for someone on the osteopenia range. . .PS don't be thanking me for posting this. This Dr. Licata could be a complete maverick . . ..    J

Ah thank you Juno, both re the Vit D and I am thanking you for posting it because it's all relevant isn't it:-)))  It all gives food for thought, and actually confirms some thoughts too!  I did just look on the NOF site about Vit D and they recommended 800-1,000 iu daily but said need can vary due to various factors and up to 4,000 was considered safe.

This is, really interesting. I havent had a chance to fully study these findings, but I am feeling quite positive. Never come across a blood test to measure bone turnover, but it decreses as we age, at different rates in each of us. I hope that  because of all the exercise I have done in the past, my strength is better than my density, but will certainly be finding out more. Thanks Juno for sharing these findings. Nothing is ever cut and dried which is why OP is a great subject for discussion.

It seems there is so muuch more to preventing fractures than bone density - I just found this on the ncbi nim nih gov site: Reasons for an increased risk of fracture associated with vitamin D deficiency are numerous. Inability to absorb adequate amounts of calcium for optimal bone health, as well as an increased susceptibility of falling, impaired muscle strength, and increased rates of bone loss can increase the risk of fracture (Lips 2001). It has been reported that lower levels of vitamin D are independently associated with an increased risk of falling in the elderly. In fact, supplementation with vitamin D has been shown to improve musculoskeletal function and reduce the risk of falling in elderly women (Bischoff et al 2003). Human muscle contains vitamin D receptors that may lead to increasing muscle strength and improving stability (Snijder et al 2006). The combination of 700 units/day of vitamin D and 500 mg of calcium (obtained through supplementation in addition to diet) was shown to reduce falls by as much as 65% over three years in less active women over the age of 65 (Bischoff-Ferrari et al 2006). So lack of Vit D can cause instability thus increasing risk of fractures.

Hi Chris, I think it's important that calcium, where possible, should come from diet - and only add a calcium tab (or half ) if you haven't got your !,200mg. from food that day. If daily calcium from food exceeds the 1,200 mg. , it isn't a problem but exceeding the dose with tabs. is not recommended at all and can cause other problems. Again, one can overdo the Vit D -  so again more is not necessarily better . . .  J

This is something that although I don't think I'm taking too much, does concern me Juno.  I did start eating three slices of Gouda a day but was then gaining weight, so reduced it and just take 630mg calcium citrate, and 100mcg of K2, 650 magnesium and 1,000 iu Vit D3, and we have a treadmill coming this week too - I'm understanding the importance of weight bearing exercise.  It IS very confusing though because I just downloaded something from 'natural health advisory' that said the calcium in dairy doesn't help!  I know too much calcium can block arteries, and too much K2 can clot blood and so on, but the studies all show levels WAY higher than those I'm taking, so I'm hoping I'm not overdosing on any of them????  I'd value your opinion though.

Hi, I found this a very helpful site. If you Google- " Calcium: what you should know - WebMD" it answers a few questions. There's no reason you should put on weight trying to get an adequate amount of calcium as you can always go low-fat for any of the dairy products.  Get fortified milk (higher calcium than regular milk and is also low fat), fortified cereals for breakfast, yoghurt, and cottage cheese - if you really want to keep the pounds off . . . It all adds up pretty quickly. Even a slice of white bread has apx. 50mg of calcium (check the package)  For Vit D, I use baby drops in a tiny amount of orange juice. . . .  Then, if I haven't made up the 1,200mg, I add in one calcium tab. or a half. (mine are 500mg per tab.)  Finally, if I just couldn't be bothered totting it all up or if I'm eating out etc. ,I just take the two Calcium tabs. which also contain Vit D and that does the fob for the day . . . . . Don't know anything about K2 - thought that was a mountain in the Himalayas !!.  J

Thanks Juno:-)

Hi Chris00938

I am 75 and I  have  just been diagnosed  withy  Osteoporosis with -4.3 T score equalized for age as  -3.5 Z  . I' ll see my orthopedist shortly, I have immediately started  taking Vit D with 3000 IU per diem .

Keeping in mind the ( tentative)  distinction raised by Juno-Iri-Dub between bone density and bone strength, based on dr Angelo Licata study,  Iwonder if you have any idea how fast vit D supplementation can restore bone strength  to a safe level, even if it will not completely reverse the desease in terms of bone density.  I  think I have read that while it takes up to 3 years to restore bone density with medication, a few weeks are sufficient for vit D to increase bone strength beyond the fracture risk. If so, I wouldnt care about low density!II

Another point: i live in Canada and I wonder if   there is a clinically supported correlation between our climate  and a higher risk of  osteoporosis,  due to the fact that for a long time there is no sun (or not enough of it )  to stimulate the natural production of vit D.

Are people living in the tropics perhaps less prone to O.P. or maybe  the Inuits of arctic latitudes more prone?

Any comments? Just a few passing thoughts.

Ittiandro

I'm sorry but I just don't know the answers to that.  What I've been doing for the past year or so is taking a low dose calcium and K2 (this directs it to the bones rather than the arteries) and also magnesium as well as the 3000 IU of Vit D.   I haven't had any more tests since the one ages ago but did have a knee replacement 11 days ago and the surgeon said the bones looked good.  Although they put me on bisphosphenates when they suspected I had osteoporosis, when I requested the actual results the chart showed it was osteopenia rather than osteoporosis and the tablets made me feel so ill that I only took them for a few days anyway but there has been something on the news here recently saying what we'd all found in studies a year ago anyway - that while bisphosphenates increase bone density they make it more likely to cause fractures in some bones, so I'm glad I took the decision that I wasn't going to take them anyway!

Hi Ittiandro and Chris

I'm 70 and have just been on holiday in the Caribbean to get a good dose of Vitamin D. There were a lot of Canadians there and they were great company! I'm not sure whether there is any correlation between your climate and risk but I live in the UK and our climate is not tropical! I think it is important to get out in the fresh air as much as possible, along with weight-bearing exercise. I don't take any drugs or supplements. My blood tests show I don't need Vitamin D or calcium. I think that is because I spend so much time walking, gardening or sitting in the sun in my garden (when it shines in the north of England!). The exposure helps calcium from a good diet to be absorbed. After a complicated break in my leg 18 months ago, I feel fine, stong and thankful that I decided not to take bisphosphonates, which I believe can lead to brittle, not strong, bones.

I'm sure the weight bearing exercise helps too Soozib!  I've been limited on that because of osteoarthritis but once both knees are done I'll be able to do so much more!

Hi Chris

I absolutely agree with you and was not surprised to hear the recent news about the dangers of bisphosphonates. I read extensively about osteoblasts and osteoclasts when I was prescribed AA and decided that I was not going to poison my body with any of these drugs. I have gone down the natural route of exercise, diet and sunshine. I know that I am lucky because I don't have some of the distressing conditions of others on this forum who are not as able as I am to commit to strenuous exercise. I will ask for another DEXA scan in about a year to see what improvement there has been in the strength (not density) of my bones.

Good luck with the new knees. I'm sure that you will

Thanks Soozib:-)  The actual operation was incredibly easy and I've had virtually no pain since, but have to go to get clips taken out today and the dressing off, and I had a feeling it wasn't healing as it should under the dressing, so this morning when watery blood started oozing from it, it wasn't a good sign.  I'm just hoping it isn't complications, but just a delay in healing.

Positive thoughts for you!!  I really hope that all is OK. I'm sure that you will soon be back on your feet.

Hi Chris, So you're a new woman with new knees and all!  You sound in such good form that you obviously didn't get 2 left ones or 2 right ones!!! Ha Ha.

Looking through all we've written on this post last year ( along with Mary D),   I'm impressed with all our knowledge at the time.. . . 

Re. the BF article recently - even the author  cautioned that it was a "tiny" sample but  readers will of course feel that it confirms their own views - re. whether to  take  these meds or not. This is not a unique situation for patients of all kinds eg. cancer patients' reservations re. chemotherapy - possible benefits vs awful side-effects. . . 

For me, having finished 2 years of Forteo I'm now taking Actonel for 4 years. Happy enough with that.. . but sure, who knows. . . .?

Great to hear from you. Keep well.  J  xx

 

Hi Juno:-))))  Yes, doing good, thanks LOL!  And hoping for the other knee to be done in four months time:-))))

Yes, it is interesting and that's just what my husband and I thought - that our knowledge from research that had been done was quite impressive!  It's good to hear that you're good there as well!:-))))  I wish you all the best too:-))))

 

I have been diagnosed with O.P. about a month ago by a DEXA scan  with a -4.3 T score. .

I am still waiting for my first appointment with a specialist.

Although I am very active and practising a number of sports, even at 75, I decided to take immediately the bull by the horns, by I stepping  up my training with weight-bearing and other exercises at home ( not weight-lifting yet!) ,  elliptical machine, step climbing etc and I have also started taking Calcium, Vit D and Magnesium.

Any idea of the AVERAGE time  required to see an improvement on bone density and/or strength with training an supplements? Months, years? Just curious

THanks 

Ittiandro

I'd like to know the answer to this too:-)))  When I take calcium I also take Vit K because it's supposed to help the bones absorb the calcium.  I take Vit D and Magnesium too.

HI Ittiandro (and chris), 

My answer to you would be to just do your normal activities until you see your specialist. I presume he'll have suggestions about treatment of some sort and hopefully there's an Osteoporosis (OP) team working with him who'll advise re. diet and exercise . . . IF he is working alone, (ie. not part of a team) I would say it is really important for you to have at least one apt. with a physical thereapist who is specialises in OP patients before you set up any exercise programme of your own. She will review all your relevant data, scan results, meds., previous fractures (where?), balance problems etc. It's so easy to Google stuff, which can be very helpfull, but an indevidual apt. sets you up in a safe way. 

I have no idea what the avarage time period before a person would see an improvement in their bone density as there's lots of other factors involved here eg. the type of meds. you're taking, but mostly bone density is built up very slowly . . .

I'd say it'd be a good idea to have a browse through the 'official' websites for OP - the NOF (Canada), the Irish, British, Australian OP associations etc. but please don't implement any ambitious program before you both see the specialist AND your Physiotherapist. Also if you do this, you'll have a list of relevant and intelligent questions for your specialist and will then gain the most benefit from the apt.

Kind thoughts,  J 

Sorry, just started a reply and it disappeared, so if it turns up somewhere, ignore it LOL!    Well you gave me a laugh.  What 'specialist'?????  I don't have one - never had one.  All I had was a GP who sent me for a scan, decided before he'd even got the results that I had osteoporosis, stuck me on horrific bisphosphenates which made me giddy, so I went back saw a practice manager who put me back out in the waiting room and said she'd speak to the GP (I wasn't allowed!) and came out with a similar medication prescription.  In the meantime my husband had gone to the desk and asked for a copy of the results where it showed borderline osteoporosis where medication wasn't warranted so the prescription went in the bin (where it was going anyway) and I've just done my best to eat well and exercise and take appropriate supplements.  Had a very successful knee replacement five weeks ago and the surgeon said the bone was fine.  I've a feeling my GP won't even think about doing a repeat bone density scan unless I push for it, but then if I don't want medication that they would push it doesn't really seem worth it!  Any contact I've had with physio's has ended up causing more problems than they solved (maybe because I've got hypermobility that they don't seem to realise the consequences of) apart from the physio at the hospital where I had my knee done - they've been brilliant.  But, at least once the other knee is done I can walk more!!!!  So roll on the date for that one:-))))  Thanks Juno:-))))

Chris, that was really awful treatment, totally unproffesional. Thankfully it all worked out ok in the end - thanks to  your hub getting hold of your results.

Great to hear you're doing so well. Let us know when you've got the other knee completed - and you're not hopping anymore!!

J  x

LOL!  Will do LOL!

Yes , as a matter of fact I am on the waiting list for an appointment with a well known bone metabolism/osteoporosis specialist, holding a teaching chair at a canadian University and author of  number of publications. in various medical journals .  

She should be able to sort all this out, because with my life style and all the sports  and various physical activities I do, I am indeed very surprised that my bone density is so low , to the point of being rated at  high risk of fractures , even though  I never had a single fracture, in spite of even some abuse I subjected my spine to ,over the last few years..Luck usually doesn’t last for years!

This brings me back to  a point you had raised in one of your previous posts , which gave me the occasion to join this Forum. This regards the possibility of errors and false positives in the DXA scans.

You had mentioned  a clinical study indicating that bone density alone may not accurately predict the risk of fractures , this being in function of bone strength , which depends on other factors which the DXA scan cannot detect.

For my part, I  also found other clinical studies pointing to other reasons for errors in the bone density  reading of DXA  machines :

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3683192/        indicates, in sum, that

1.the position of the spine in the machine , for inst., plays a crucial role, because if the spine is  angled even a few cm off the right antero-posterior position ,  its plane in respect to the X-ray stream may appear as having a larger surface  and since bone density is measured as a % of the surface, the larger the surface, the lower  the bone density ratio..

2.Calibration errors and other errors by the technician  administering the test

3. Artifacts  : metallic objects, coins, clips  zippers in the way of the x-ray stream

4. The type and depth  of tissue  surrounding the spine : fat or  lean tissue when penetrated by the x-rays  stream  may cause false readings of the bone tissue and its density.

Another site reports that a State of Washington MD,  doing research in this field obtained different DXA readings  for the same patient and the same machine within the time span of one hour! ( Before and after the visit) . These variations in the bone density were up to 7% !

 

Some food for thought !

 

Ittiandro

Interesting and quite concerning!!!!

Hi there, As you said there are indeed a number of factors that can affect the DXa scan result and I think that's why technicians refer to a standard  

"margin of error" when referring to a particular result. So, if a person had a score just within the osteoporosis range, it's possile that a repeat scan could give a reading that did not indicate OP . . . 

However, with scores like mine (initally spine -4) there is little doubt that, standard error or not, I had severe OP and was at high risk of fracture. I know some people have opted for exercise, vitamins and diet as a treatment for themselves and it may work for those diagnosed in the 'mild' OP range, as it were but I had no confidence in this as a treatment for myself. I just wasn't prepared to take that risk and took the meds. -  in the clear knowledge that there are side-effects to all meds. - in fact to life itself!!

Keep well, and let us know how you  get on with  the specialist. Don't forget to write down all your questions (or you'll forget them) and never worry that she'll think any question is daft - it's her job to address them all,  and they're well used to the weird and wonderful ones - just think of the fun she'll have during her coffee break !!!

J

Hi Juno and Chris

I have written down all the questions I have for the specialist ( and they are many!) .

As  an example, I have obtained a copy of the  DXA scan from my medical file and I noticed that the X-ray lay out of my lumbar spine ( completely straight , based on the position prescribed by the  technician ) corresponds exactly to  what the author of the aforesaid study  shows as the wrong angle …

It looks like I should have been positioned with the spine only very slightly turned , at such an angle that it shows  as slightly curved in the X-ray..

In the clinical study, the two positions  ( straight and curved) in the respective X-rays appear side by side: i the straight one ( like mine)  is shown as wrong.. Here, the surface of the vertebrae appear slightly larger than in the curved layout, therefore the bone density ratio ( % wise) necessarily shows lower than it might have shown at the proper angle, with a smaller surface.

I’ll find a way to suggest this to the specialist, but , even though  I believe that this question, like many others, is well grounded, based as it is on a sound understanding of the  clinical  study  ( I am university-educated,  with a good knowledge of latin and Greek at the basis of medical terminology) , yet, in the  end, I am not a doctor and I am fully aware of my medical ignorance.

This is why I am a little  afraid  to appear too naïve, simplistic or even wrong  in the eyes of a doctor , as if I were telling him/her what to do or look for….

I am perhaps too modest, in facing my ignorance, BUT some doctors are too arrogant in their knowledge.. I have to strike a middle course by discretely suggesting possibilities without appearing a “ smart a…..s” (     And there are many of them, too!)

 Kind regards from... frozen Canada

Ittiandro 

This raises some serious issues about diagnosis, doesn't it.  Interesting!  Good luck and let us know how it goes!

Mmmm that's a delicate one!  Could you perhaps talk it over with your GP first and if he agrees with you in any way, you could then mention the matter to your specialist along the lines that " my GP raised the possibility of . . . ."

I'm not an expert either but I'm absolutely sure that your DXA scan would not be the first 'botched up' one he's seen, if indeed it is that.  Also, he's the expert and if he's not happy,  he'd be well able to order a repeat scan - painless, very low risk . . . 

Don't panic.  J

In your post you seem to imply  that your T-score is too much beyond the margin of error not to be , unfortunately, correct.

AS explained below, it may also be incorrect , if incorrect reference values have been fed into the software  that the computer uses  to give the score. Not at all impossible, according to a number of clinical  studies!

By the way, If you have your medical report of the DXA exam, you should be able to double-check  it yourself: all you do is  to subtract your BMD  in  mg/cm2  from the reference BMD of a  25 years old person and you divide it into the  Standard Deviation (SD ) value .  both the reference BMD and the SD  are indicated in charts that you can find on the Web and this  formula is  given in all the O.P. professional websites .

In fact, this is what I have done and, to my surprise,  the t-score I get for the lumbar area is not -4.3 as the in hospital DXA report, but only  approximately  -2 , barely within the O.P. range ! Perhaps only at the upper limit of osteopenia , which often does not require treatment.

Equally strange is that , for the hip area the hospital T-score is  consistent with the formula!  I wonder why.

I tried to share this  inconsistencies  in a recent post, but, again, for some reasons which escape me, it has not been published..

the margin of error to which you refer is not the same as the standard deviation ( SD): the margin of error   is usually small. It cannot be 4 or 5 times  the “ correct” value,  while the t-score can be even 5 times below the  normal age  related  BMD.  Imagine if the polls indicated a 10% probability of victory for political candidate   and the margin of error were 4 or 5 times  10% !

The t-score is expressed in multiples of the Standard Deviation unit   for a particular age.

In other words,  a   t-score of -4 means that the BMD ( bone density)  is  4 times  1 SD unit, hence 4 increments away  from the  normal BMD  , while a t-score between -1 and -1.5   means that the  BMD is ONE  SD  unit below the median, which is normal.  In the charts, one SD unit is between 146 and 150, depending on age .

In my case i, with a -4.3 t-score it is as if the formula used an average  bone density  of 1350 mg/cm2 for a young person, instead of the  of the correct one of 1000 mg/cm2,  normally appearing on all the charts.

 

I’m  curious to hear from the specialist why this inconsistency . In the meantime I thought I’d share it with you’’

 

Regards

 

Ittiandro

Correction

In my last reply to you 12 minutes ago ( regarding the MARGIN of error issue and the inconsistencies found in my t-score)

the phrase in the 3rd paragraph  " ....divided into the SD.." should read : "divided by ...the SD..!" obviously.

In other words you obtain your T-score by subtracting your BMD from the BMD of a young person  and you divide the result BY ( not INTO) the SD..

Sorry

It was a long time ago that mine was done and there has been a lot of water under the bridge since then, so I can't remember it all very well but I DO remember when my husband got my results he also got a chart that was with them.  The GP had told us nothing about this.  And looking at the chart, the risks of fracture were lower than the GP had implicated.  At no point had he mentioned calcium or anything else either.  So I went home, googled it and decided I'd take Vit D, magnesium, and low doses of calcium and Vit K, the last two with 'courses' rather than constantly.  So far so good, and the surgeon who did my knee replacement said the bone looked good.

Hi ittiandro,  thanks for all that. Yes, I did think that 'margin of error' was pretty similiar to 'standard deviation'.  Good clairfication.

Like Chris above, my  first DXA result was done 4 years ago (Spine -4.5, hips ok) and my 2nd. (Spine -4.0, hips ok). Third scan due next year.

I didn't read reports for either of the scans though the radiologist gave me the result at the time - both reports went to my specialist who felt I was at really high risk of fracture and prescribed Forteo. . . .  

This may seem odd but I don't really feel I HAVE to see all my results.

Since  "a little knowledge is a dangerous is a dangerous thing," I would start consultations with Dr. Google and then be unable to sleep because of awful senarios that are discussed/stated as being certain to happen me. Had to stop this as I know myself too well !!!

J

Hi Juno and Chris

It is perhaps true that people like us, who ,not being doctors, share our suggestions, experiences and beliefs in this or other Forums  may contribute to the “Dr Google “ syndrome and replace  sound medical advice  with alternative therapies or products, which may be useless or even dangerous.

Unfortunately, however, it is also true that doctors do make mistakes  and that , in addition, the sophisticated computer-assisted technologies used to obtain  certain diagnoses further increase the possibility of errors.

As the acronym GIGO ( Garbage In Garbage Out ) implies,   the  reliability of a computer score  rests on the correctness of the data fed into the software program it and is   less within the competence and the responsibility  of a doctor than that of a  computer specialist or   technician. The radiologists who signed my e DXA report seem to  relied  on the face-value of the computerized score , without checking the data used as a reference by the software.., if they did such a verification, they would perhaps have found the same inconsistency I found..

Also,  sadly,  the all -powerful pharmaceutical industry, employing complacent doctors and research personnel as trojan horses  within the medical profession , has been able to  alter and lower, in many cases,  the threshold of pathologies in order to produce more “ sick” people and, therefore, increase the sales of pharmaceutical products.

As a child, for example , by today’s  hyper-medicated standards I’d have probably been diagnosed  with behavioral disorders of some kind, like perhaps hyperactivity or other and put on..Ritalin or similar drugs,  just because I was sometimes a bit too unruly, turbulent or energetic.

In those days  most people, including  doctors would say ( and have said) ” Oh, he  is boy. He is perfectly normal!” And all that was needed was  my father’s “ cure” which, I must say, I didn’t particularly cherish, but  which was very persuasive.    In the end , it allowed me to grow into a normal,  socially well-adapted adult. Today the fathers’ old cures would be a passport to jail for them, while the “ ritalin” cures may produce untoward and much worse results in the young because of the medication itself…

Beyond all this, one has to move from the perspective that there are NO diseases in an absolute or universal sense, but only individuals , each one responding to diseases in their own different ways.

In the end, listening to our body can tell us more than a T-score ….. If somebody who is osteoporotic was able to engage in mountain climbing, sky diving, bunjee jumping or in the Calgary Stampede  without breaking a single bone , shouldn’t one doubt the diagnosis , after all?

Assuredly, I did none of this, but what I do and I have so far done, would have been sufficient to cause fractures at one point or another!  It never did. Luck? Perhaps. But luck usually does not last for years..

ittiandro,

Do you know I can't disagree with one thing you said above - and you put it so well ?

But life can sometimes be a lonely old experience and decisions have to  be made - and sometimes that means that you sometimes have to place trust in others. 

I picked my specialist carefully, she trained in Harvard and is impressive. I myself spent 2 years researching OP and it's treatments and then decided that I'd done enough - I'm paying an expert, let her do the worrying!

 And of course a technician may not have calibrated the DXA scanner correctly or a radiologist may have misread the pictures, but it doesn't concern me unduely - because I feel that liklihood is not high - though it does exist.  Also, for me,  I know where all this questioning and doubting  would lead -  me being stressed and depressed. Others may be different.. . . . 

I also do lots of activities and have not fractured - but I'll pass on  the sky diving and bunjee jumping !!

Kind thoughts,  J