Gillian Sanson Talks About Osteoporosis (Women's Health Matters interview) (Web resource; WHM resource) Organization: Women's College Hospital, Women's Health Matters Gillian Sanson, like many of us, used to associate osteoporosis with frail older women. But, after learning that her otherwise-healthy 16-year-old daughter had ‘the bones of an 80-year-old,’ she vowed to learn all she could about osteoporosis. Sanson was surprised to discover that much of the popular belief about the condition was either misleading or wrong. Sanson, a women’s health advocate and educator based in Auckland, New Zealand, has written a book entitled The Myth of Osteoporosis: What Every Women Should Know About Creating Bone Health, which details misperceptions and controversies that surround osteoporosis — from the diagnosis and treatment of the disease to even the definition of the disease itself. Gail Balfour, Editor of Women’s Health Matters, interviewed Sanson in 2003 about what she has learned about osteoporosis, how to treat it, and most importantly, how to prevent it. Please talk about the events that prompted you to write this book — most notably the fact that your teenaged daughter has osteoporosis. My daughter Camille was diagnosed with osteoporosis in 1994 at the age of 16. While growing up she had several fractures, and eventually an observant doctor noted something unusual in a routine x-ray and sent her for a dual energy x-ray (DXA) bone density scan. The scan revealed very low bone mineral density for her age — enough to qualify her for a diagnosis of osteoporosis. Camille's entire extended family — her parents, brother, grandparents, aunts, uncles and cousins — then participated in an Auckland university study which determined we all had varying degrees of osteoporosis or low bone mineral density (BMD). Because very little was known about osteoporosis in young people and as there was no guarantee that the drug treatment offered to Camille was safe and effective, I set out to research the subject in depth. As a menopause educator I was also aware that women in general felt uninformed and worried about messages from the media and their doctors telling them that they were at risk for osteoporosis. I spent many months reading medical articles and questioning the experts, and I became convinced that many women and their doctors were misinformed. It became evident that well women are being frightened into unnecessary testing, given questionable diagnoses and urged to undergo long-term treatment for a disease they probably don’t have. My investigations have resulted in The Myth of Osteoporosis — a book that offers women reassurance and hope while challenging the diagnosis, and treatment of a disease that we are told has reached epidemic proportions. What are the causes (genetic, and otherwise) of the condition your daughter has? Extensive testing has not provided any explanations as to the cause of Camille's condition or the reason other family members have low BMD. Even DNA testing was unable to reveal a link. The conclusion is that we have 'idiopathic osteoporosis', that is, of unknown origin. It is important to note however that the diagnosis is on the basis of BMD alone. No one in the family has sustained any bone fractures in the nine years since we were diagnosed. My parents are in their 80’s and are fit and well — in fact we all are, including Camille. None of us have taken drugs of any kind to treat the condition. By the way, just to clarify, my family diagnosis situation is in a different category from the general postmenopausal diagnosis of low bone density (osteopenia) or osteoporosis. How did osteoporosis go from being a relatively uncommon bone disease to something every woman seems to be at risk of developing, according to popular belief? Twenty years ago most people had never heard of osteoporosis, and doctors reported that they saw few patients with the condition. Osteoporosis had always been recognized as a disease of fragile or porous bones that would fracture easily. But in 1994 it was re-defined by the World Health Organization as a condition characterized by low bone mineral density. The new definition coincided with the availability of bone density testing technology and treatments like hormone replacement therapy (HRT) that could influence postmenopausal bone density loss. It categorized normal age-related decrease in bone mineral density (BMD) as abnormal, and postmenopausal women were consequently warned that they have a 50 percent chance of developing osteoporosis. In other words, a single risk factor became the disease — a bit like elevated cholesterol being called a stroke, or high blood pressure a heart attack. Advertisements using frightening images of the bent older woman and older people using wheelchairs have steered millions of healthy women into repeat BMD screening and long-term HRT or other drug therapy. My process of research revealed that almost every aspect of osteoporosis is hotly debated and there are widely diverging ‘absolutes’ in the osteoporosis message. For example, the Mayo Clinic says about 21 percent of postmenopausal women have osteoporosis and about 16 percent have had a fracture; the Osteoporosis Society of Canada says that one in four women over the age of 50 has osteoporosis, while the US National Osteoporosis Foundation claims that one in two women over age 50 will suffer from fractures as a result of having osteoporosis. Explain the different ways in which measuring bone density to determine the risk of osteoporosis can be misleading. BMD testing is not able to tell you how likely your bones are to break or fracture. A low BMD reading tells you only about the quantity of bone that you have in your spine or hip. It tells you nothing about how strong your bones are, or what the micro-architecture is like — it isn't able to do that. There is so much that is not known about bone metabolism and bone health. What we do know is that bone density varies a lot between individuals, sexes, even geographically and seasonally. Most importantly, it is not a good predictor of future fracture, which is what osteoporosis is all about. The DXA machines are comparing your bone density with that of a young person. This is called a T-score. Because we all lose bone density as we age, it becomes almost impossible for an older woman to have a normal reading. Yet the definition of osteoporosis is based on the T-score, and treatments that influence bone density loss are prescribed on this basis. There can also be big differences between one brand of machine and the next. A 20/20 documentary was made when my book on osteoporosis was first released in New Zealand in 2001. My friend Sally was filmed having her bones scanned on two major brands of machines in separate cities. On one she was normal and on the other she was told she had very low bone density! [Editor’s Note: Obtaining a second opinion in diagnostic situations is always a good idea!] What are some of the other causes of fractures and bone fragility in older people, besides osteoporosis? Low bone density alone is not a serious risk factor in an older person. Older people fracture their hips because they fall. They fall because there are obstacles in the home, cracks in the sidewalks, or slippery surfaces. They can also fall because they are frail, immobile, have poor eyesight, are depressed or have dementia, are on multiple medications like corticosteroids and tranquilizers, and have poor balance. Studies have found that if these factors are addressed — such as by making home environments safer — hip fractures can be reduced by as much as 50 percent. Exercise programs for older people have also been found to be very effective in preventing falls. I found it fascinating what you wrote about the fact that ‘countries with the highest rates of osteoporosis are the biggest consumers of dairy products.’ You state in your book that one of the most common recommended methods of prevention — calcium supplementation — is not enough to build bone when used — or studied — alone. What are some of the other factors involved in absorption? Supplementing with calcium alone does not appear to prevent fractures, and too much may be harmful. Bones are complex and dynamic and have a wide range of nutritional needs. Skeletal calcium and blood calcium is kept in a state of balance by a precise and complex mechanism involving parathyroid hormone, Vitamin D and other hormones. Taking a calcium pill does not guarantee that it will end up in your bones. A diet that includes calcium, Vitamin D, magnesium, Vitamin K, boron, manganese, zinc, copper, silicon and other essential nutrients, may be more appropriate than supplementing with large amounts of calcium. Limiting heavy animal protein and sodium intake, reducing alcohol and not smoking is also fundamental to maintaining strong bones. Claims that milk consumption builds strong bones and prevents osteoporosis are misleading and do not have the evidence to support them. A review of 57 studies published in the American Journal of Clinical Nutrition in 2000 examining the evidence for dairy food and bone health concludes ‘...the body of scientific evidence appears inadequate to support a recommendation for daily intake of dairy foods to promote bone health in the general US population.’ The Nurses Health Study in the US followed the dietary calcium intake of 77,000 women over a 12-year period and found that those with the highest consumption of dairy products had the highest rate of fracture. Please talk a bit about exercise as a means of prevention, and how important it is. Exercise is probably the single most effective strategy to prevent osteoporosis. The force of muscles pulling against bone stimulates bone remodelling and bone formation. Higher impact activities like running, jumping and jogging are very effective, but regular aerobic exercise such as walking will also help prevent fracture. Weight bearing exercises, resistance training and flexibility and balancing exercises like Tai Chi and yoga are also important. Research has demonstrated that we can benefit from exercise at any age — even centenarians will experience an increase in strength, stamina and muscle mass. Exercise programs have been found to reduce the frequency of falls in high-risk older people. What advice would you give to women who are concerned about the health of their bones? Educate yourself about bone health. Understand that a diagnosis of osteopenia or osteoporosis on the basis of a BMD test alone is not sufficient reason to embark on an aggressive treatment regime. A genuine diagnosis of established osteoporosis (fragile bones) is most often linked to other factors such as corticosteroid use, Celiac disease or Crohn’s disease, hormone disorders such as hyperthyroidism, low blood levels of Vitamin D and high levels of calcium excretion. As vast numbers of women come off HRT, doctors are being urged to identify at-risk patients and proceed with alternative bone-sparing treatments like the popular bisphosphonates (Fosamax and Actonel) or the SERM Evista. But there are concerns regarding the effectiveness and safety of these drugs. Although they may influence bone density, they do not benefit the majority of people taking them. It is even possible that they may worsen a patient’s condition. Ultimately, the decision to undergo treatment must involve a careful weighing of your risk for fracture against the risk of embarking on a treatment with unknown long-term side effects that cannot guarantee prevention of fracture. It is important to try to prevent falls in older people, and well as encouraging regular exercise and appropriate diet to maintain bone health in women of all ages. Related Resources: For more information on osteoporosis and bone health, please see our detailed Osteoporosis Health Centre. gilliansanson.com offers evidence-based perspectives on the safety and effectiveness of medical approaches to menopause, osteoporosis, contraception, infertility and a range of women’s health issues. It also contains information on Sanson's books. Version française :  Cliquez ici pour voir la description en français Purpose:  Consumer information/support; Health information Information Source:  Hospital/Clinic Geographic Origin:  Canada Language of Resource:  English Groups:  Adult women; Middle-aged women; Teenagers; Young women Last Reviewed by Women's Health Matters:  May 14, 2007