Prevention Magazine - Special Report - June 2002

Patricia Smith's osteoporosis should have been diagnosed when she was 55 and broke her wrist in a minor fall. Her doctor should have known that any postmenopausal fracture suggests the bone-crippling disease "unless proven otherwise," as one expert puts it. Plus, her mother died of complications of a broken hip in her early 60s, a family history that puts Smith in a high-risk category for the disease that affects more than 28 million Americans, 80% of them women. And Smith is thin (only 113 lb), another risk factor.

Yet Smith wasn't diagnosed until more than a decade after her broken wrist had healed. In 1995, while struggling to pull a chair out of a closet, she felt a sharp pain in her back. Her doctor prescribed muscle relaxants. Though her pain worsened over the next few months, her physician never mentioned the possibility of osteoporosis.

It wasn't until Smith's pain became so severe she could barely walk that she was finally diagnosed. A bone density test revealed measurements "so bad they weren't even on the chart," says the Newman, GA, mother of five, now 72. An X-ray showed nine vertebral fractures caused by osteoporosis, which may have been eroding her bones long before she broke her wrist.

A Condition Overlooked

Unfortunately, Smith's experience is all too common, say a growing number of experts, who call this widespread failure to diagnose and treat osteoporosis after a fracture a near scandal.

The Washington, DC-based National Osteoporosis Foundation recommends that adults who suffer a low-trauma fracture (such as breaking a bone after falling from ground level or a low height) have a bone-density test followed by medications if necessary.

"But 75 percent of these fractures in this country do not get followed up by diagnosis or treatment," asserts endocrinologist John Bilezikian, MD, a Prevention advisor and director of the Metabolic Bone Diseases Program at Columbia-Presbyterian Medical Center in New York City. "In virtually all the reports that have been published in the past 2 years, physicians who deal directly with the fracture event rarely take appropriate action to diagnose and treat osteoporosis."

This happens despite the availability of highly accurate diagnostic tests and drugs that can help prevent the bone deterioration that often leads, as it did in Smith's case, to more fractures.

"When an adult fractures a bone, it should be a call to action to prevent the next one," says Bilezikian, who notes that the vast majority of fractures in adults over age 40 are associated with osteoporosis and are highly predictive of future fractures. "Having a fracture at least doubles your risk of sustaining another fracture within a year."

These studies bear out the shocking negligence.

• In one study of 1,162 women over age 65 being treated for distal radial (forearm) fractures, only 2.8 percent were sent for bone density testing to evaluate and document the presence of osteoporosis and only 22.9 percent received any subsequent anti-osteoporosis medical treatment.
• Among 170 elderly patients with hip fractures treated in a large New York teaching hospital, only 3 percent were referred for bone density testing and only 5 % were prescribed calcium, vitamin D or bisphosphonate medication, such as Fosamax and Actonel, which can help prevent fractures.
• Fewer than one-third of all cases of osteoporosis have been diagnosed and only one-seventh of American women with osteoporosis receive treatment, according to the American Association of Clinical Endocrinologists, which updated its treatment guidelines in 2001 to improve osteoporosis care.
• And a recent nationwide study of more than 200,000 postmenopausal women aged 50 and older, published in December in the Journal of the American Medical Association, found that nearly half had thinning bones and didn't know it.

Why It's Happening

One common reasons why many physicians are currently "dropping the ball on osteoporosis," says Dr. Bilezikian, is a "mindset that their job is just to fix the fracture" and "an out-dated notion that there's nothing we can do to prevent the next one."

Many physicians were not trained in osteoporosis care and prevention, notes Washington, D.C., orthopedic surgeon Laura L. Tosi, MD, chairperson of the Rosemont, IL-based American Academy of Orthopaedic Surgeons' Women's Health Issues Committee. "But that's changing as we're working to alert orthopedists that a fracture is a big time warning sign.

"All too often, a woman with a wrist fracture will end up getting a hip fracture later one," she says. "And serious fractures can result in a loss of independence." An estimated 30% of patients with a hip fracture become permanently disabled.

Inadequate federal funding for research also has been a problem, notes Dr. Tosi, who says early osteoporosis studies "offered a maze of conflicting protocols." Costs frequently present barriers to proper care, too, she says. Although Medicare covers bone mineral density testing, Dr. Tosi notes that "in order to take the most effective preventive action, the best time for the first bone-density test is at the onset of menopause, which usually occurs many years before the patient is eligible for Medicare." Plus, Medicare doesn't pay for medications that can prevent the disease from progressing.

Many health insurers won't cover the $140 cost for the most accurate bone mineral density test, called a dual energy x-ray absorptiometry (DEXA), which measures the spine and hip. But some will pay for less-expensive ($40 to $60) ultrasound tests that measure the heel or wrist.

In addition, many patients--and some doctors--don't realize that healthy bones generally don't break when someone falls from a standing position, says endocrinologist Carolyn Becker, MD, associate director of the Toni Stabile Osteoporosis Center at Columbia-Presbyterian Medical Center in New York City. "Unless you're in a high trauma situation, such as falling off a ladder or getting hit by a truck," she says, "a fracture usually means there's some problem with the quality or quantity of bone."

What Women and Doctors Don't Know

Other myths surround the disorder.

"Many women think taking calcium is sufficient to prevent osteoporosis, or they think supplements like glucosamine will help, neither of which is true," says rheumatologist Timothy Harrington, MD, director of the University of Wisconsin Medical Foundation's Bone Density Center in Madison. While healthy lifestyle behaviors--such as sufficient calcium intake, exercise and not smoking--are essential to optimum bone health, he says they are not a substitute for medications in postmenopausal women at greatest risk.

Doctors also may have mistaken beliefs about osteoporosis treatment, he says. "Some physicians still believe that hormone replacement is an effective treatment for osteoporosis," Harrington notes. "But its main role in bone health is to prevent bone loss in early post-menopausal women at risk."

For women with osteoporosis, he adds, bisphosphonates has been shown to reduce vertebral, hip and long bone fractures in women by 50 to 90 %. And other promising treatments are expected to be widely available soon, including parathyroid hormone.

The most important message, Dr. Harrington says, is that "women need to understand that they have to be advocates for their own best health care. When it comes to getting diagnosis and treatment, you can't take no for an answer."

Smith learned this lesson the hard way, and she is determined to break the fracture cycle experienced by females in her family. "I insisted that all three of my daughters get tested, and they all have osteoporosis," says Smith, who now takes bone-sparing medication, as do two of her daughters. "My oldest daughter already broke her wrist. But hopefully we've gotten treatment in time to prevent all of our bones from getting worse."

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CALL TO ACTION: A Letter to Your Doctor

Need a tactful way to get your doctor to order a bone-density test? Use the letter we've prepared that allows you to check off all the risk factors you have for osteoporosis. Make sure you read the other side of the card where you'll learn the best ways to save your bones.

Letter to My Doctor about Osteoporosis

Dear Doctor:

I'm sure you're aware that a recent study of 200,000 postmenopausal American women indicates that nearly half of them have thinning bones, yet they have not been properly diagnosed or treated for this condition. That research was published in the December 12, 2001, issue of the Journal of the American Medical Association.

I think I might have osteoporosis because I have the following risk factors, identified by the National Osteoporosis Foundation (NOF):

___ I'm a woman over age 65
- or -
___ I'm a postmenopausal woman with at least one or more of the following warning signs:

__ I've broken a bone as a adult.
__ I have a family history of osteoporosis or hip fracture.
__ I'm thinner than normal (less than 127 pounds).
__ I take corticosteroid medication (such as Prednisone) for a chronic medical condition, such as rheumatoid arthritis.
__ I'm a smoker.
__ I have persistent back pain.

Please schedule me for a bone-density test and, if necessary, referral to an osteoporosis specialist for appropriate treatment.

Thanks for ensuring that I receive the highest quality of care and greatly reducing my risk of future fracture!

My appointment will be with _____________________
On this date___________________________________
At this address_________________________________