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Online Chat - Bone Up on Bone Health

Online Chat - Bone Up on Bone Health

Thursday May 27, 2010

Dr. Knibbe:
Hi, I’m Dr. Knibbe. Thank you for joining me today to learn how to build strong, healthy bones. While the questions are coming in, I’ll start with a definition of osteoporosis.

Dr. Knibbe:
Before I get to your questions, I thought I'd provide a definition of osteoporosis. Osteoporosis literally means “porous” or thinning bones. It’s a silent and serious disease. Often the first symptom is a fracture that occurs with minor trauma such a fall from standing height, or even from a cough or sneeze. Osteoporosis is not just a disease that affects the elderly or women. People of all ages, including men, can get osteoporosis.

Comment From Lisa Timmerman:
What is most important for women to do to have strong bones later in life... exercise or calcium?

Dr. Knibbe:
Hi to all! Thanks to all for the large amount of questions. I will do my best to help you all the best I can.

The most important thing for strong bones is not calcium or exercise, or the combination of calcium and VIT D!! Without Vit D you can't absorb calcium and without calcium you can't build bone. So get your Vit D checked and make sure your Vit D level is at least 50. Then go out and exercise as well.

Comment From Judy:
I hear a lot about osteopenia. What is it and how is it related to bone health?

Dr. Knibbe:
Osteopenia is a word that means any amount of bone loss (anything less than normal bones). After a certain amount of bone loss we change the name to osteoporosis. So if you have bone loss compared to your peak bone (which by the way happens when you are a teen ager, usually around 16 yrs old) then you have osteopenia. Much more has to be determined to be figure out how strong your bone is and that often requires a workup by your doctor or an osteoporosis center such as what we do here at the Spectrum Health Osteoporosis Center

Spectrum Health:
FACT: More people in the U.S. suffer from osteoporosis-related fractures each year than are diagnosed with heart attack, stroke and breast cancer combined.

Comment From Kara Kamps:
I'm 30 years old and am wondering when I should start getting a bone density test?

Dr. Knibbe:
So in general, when should you get a bone density test? I feel that if you are healthy then you should get your first bone density at the time of menopause. So for most people this is around age 50. For sure you should get your first by age 65 if you did not have one yet. Men can wait longer, maybe starting around age 65.

Comment From Becky Brower:
I am 40 and my mom has osteoporosis. What can I do to avoid it as my mom has it for preventatives?

Dr. Knibbe:
The best thing to do is to get your Vit D level checked and replaced. Then make sure you are on enough calcium. Then see if your doctor can find reasons why you may not absorb calcium or Vit D and if there are other specific concerns then your doctor may order a bone density before menopause.

Comment From Jon:
I was found to be deficient in Vitamin D a while back and put on 50,000 ifs of it once a week for 16 weeks. That ends tomorrow and then I go on 2,000 every day. Does this all seem a little much for a man of 62 years old?

Dr. Knibbe:
Jon, I don't know where your vit D level was when you started, but if someone checks your Vit D now then we'll know where you are at. Depending on absorption of the Vit D some people need on average 2000-3000 units a day, some a lot more, some a lot less. You can't go wrong if you check frequently enough to avoid going high. High levels of Vit D are considered anything above 100.

Comment From Judy:
Can you clarify the calcium and vitamin D connection?

Dr. Knibbe:
The connection between calcium and Vit D is that you need Vit D to absorb the Calcium from your food or supplements. To get from intestine/stomach to blood you need VIt D. Without it the calcium in milk/food/supplements doesn't do you any good.. So first priority is getting Vit D to 50 or more, then take usually 600-1200 mg Calcium daily in most cases.

Comment From Tara Evans:
Are there any food or drinks that can assist in "causing" osteoporosis? Is there anything besides milk products that can prevent it?

Dr. Knibbe:
Milk has only 125 units of Vit D per 8oz glass

It takes 10 or more glasses of milk to get enough Vit D for most people's needs.

Eggs only have 15 units per egg.

SO most food doesn't have enough Vit D

Dark colas contain phosphoric acid which harms bones.

Dr. Knibbe:
Most people are going to need to take a Vit D supplement and of course if you are going to drink something, drinking mild is better than anything else.

Spectrum Health:
FACT: 50% of women and 25% of men over age 50 will experience an osteoporotic fracture during the remainder of their lifetime.

Comment From Kara Kamps:
How do I know if I am getting enough Calcium in my diet? What is the recommended amount?

Dr. Knibbe:
To figure out how much calcium is in your diet you would have to look up what you are eating and how much calcium is in that food. There are lots of online tools to look this up. If you can get 1200 mg of calcium from what you eat then great, but total is 1200-1500mg between diet and supplements.

Comment From Sheri H:
What is a Bone mineral density test? Is it the same as a DEXA Scan? Also, can you tell us what DEXA is "abbreviated" for? Are both of these the same type of scan?

Dr. Knibbe:
A bone mineral density test is another name for a DXA test. DXA means dual x-rays absorbitometry. Simply this means that x-rays are shot at your hip or spine and the device measures how much bounces off and how much goes through the bone. This tells us roughly how dense or how hard the bone is. This is far better than using the supermarket 'heel scans' which use ultrasound to guess at how hard the bone is but isn't the proper way to truly measure your bone health.

Comment From Judy:
What does a typical appointment at the Spectrum Health Osteoporosis Center include? I didn't even know there was an Osteoporosis Center!

Dr. Knibbe:
Thanks for the question. Our team of providers will first be in touch with your primary doctor to get all necessary records to review your health history. Then we will review these records in depth with you and find out everything we can about your health history. We will do tests on strength, balance, fall risk etc. We then usually order further investigation into your bone quality and quantity and then have a second visit to go over results and recommendations. Total time for the first visit is usually 2 to 2.5 hours. It is all great fun :)

Comment From Mary:
What's the best way to insure that your body is absorbing the calcium and Vit D that we take?

Dr. Knibbe:
Calcium citrate is absorbed better than calcium carbonate so you may consider changing supplements to calcium carbonate

Dr. Knibbe:
Vit D3 is better absorbed than D2 so take D3 instead of D2. In some situations a gel pill of D3 is better absorbed than a tablet as well.

Spectrum Health:
FACT: The most common sites of osteoporosis-related fractures are the hip, spine and wrist.

Comment From Sherri:
There must be a hormonal connection to osteoporosis. I asked for one a year after my third child was born at the age of 41- no symptoms-always had been fairly active - lifelong balanced diet-under 100lbs (except for pregnancy) grandmother osteoporosis- 1st menstruated at 18 then every 3-4 months until after 1st child. My DEXA showed bones of 78 yr. old- now I've been "upgraded" to osteopenia through medication & weight lifting. There must be a hormonal connection here.

Dr. Knibbe:
Wow, you sound like a great candidate for a thorough evaluation in our center. I think that hormones have a lot to do with it since we know that natural estrogen production before menopause helps keeps the bones strong. However not everyone should continue estrogen after menopause so we need to give individual advice as to what is best to do after menopause. I think assessing your risk would be a great idea.

Comment From Carol:
Is it true that overweight, larger females are less likely to get Osteoporosis than thin smaller females/ Is so, why?

Dr. Knibbe:
Overweight females have two reasons why they are a special group.

1. Obese females have more adipose tissue that produces natural estrogen. This helps protect them.

However

2. They also have a huge storage pool for Vit D (which is stored in fat) so it takes a lot more Vit D to fill the storage tank so to speak. So once the storage tank is full they have natural protection.

Dr. Knibbe:
3. Also, weight bearing on the bones causes mechanical strain on the bone that reminds the bone to stay strong. Heavier individuals naturally are doing more 'weight bearing exercise'.

Comment From Judy:
Everyone is concerned about calcium intake for women. Do men suffer from calcium deficiency also? What is the recommended amount of calcium required for a senior male?

Dr. Knibbe:
Men need calcium supplements as well, probably closer to 600-900 mg daily. Their natural testosterone somehow protects the bone and they tend to get osteoporosis but not until they are at least 75 or older. That is when the male testosterone level starts to decrease. We joke that this is the male 'MAN-O-PAUSE'

Comment From Sherri Mead:
I am 49 and was on Fosamax 70mg-weekly dose for six years and then stopped taking it due to fears of Osteonecrosis of the jaw. I'm a dental hygienist and work in an office where an extraction of a tooth in a patient on Fosamax might be out of the question. I know that patients who receive IV Fosamax are of much greater risk. My last bone scan showed slight improvement in bone density; what % of Fosamax patients (oral) end up with osteonecrosis?

Dr. Knibbe:
There is much concern in the news about being on Fosomax or other related drugs (Boniva, Reclast,) in terms of long term use being harmful to the jaw or causing fractures. We think we are starting to understand what the problem is and fortunately the numbers of patients with problems are very low. We think that short term use (3 years or less) of these drugs is usually safe and beyond 3 years you need to have an individual assessment of your risk and what is happening in your bones to really know.

Comment From Linda:
Is biking a good alternative to walking to building bone?

Dr. Knibbe:
Biking is still considered weight bearing as you still are putting weight on your long bones (legs) and spine by sitting upright. Really all exercise is officially weight bearing except swimming so just getting out and using your body is really good for your bones.

Comment From Sue Jacobs:
Why are my T scores so different. Ap spine 1.3, left femur -0.7, left forearm 1.5.

Dr. Knibbe:
A T score is a percentile that you are in compared to a person with 'normal' bone. The farther negative you go (-2.5, -3.5) the worse your bones are in terms of 'hardness' There is big variation in various sites of the body due to changes in structure of the bones in various places and changes in blood supply to various places.

Dr. Knibbe:
In general we lose bone in our spine first and hips last. If this is reversed then it is good to find out why by having further evaluations.

Spectrum Health:
FACT: 40 % of hip fracture patients never totally regain their pre-fracture mobility and independence

Comment From Linda Flynn:
For women with ostepenia & have had chemo, what is the best thing to do to protect their bones?

Dr. Knibbe:
I assume the chemo is complete. If this is the case then we need to go to the basics and see if your bones are remodeling. We test these markers in the SH osteoporosis center. We can also plan for the future in terms of medications that can boost remodeling or can correct any other problems. It is time for an assessment.

Comment From Guest:
Does taking a blood thinner (Warfain) for years (starting at age 29) have any effect on your bones longer term?

Dr. Knibbe:
I'm not aware that warfarin or coumadin has any adverse direct effect on bones.

Comment From Mary:
Can you have too much Vit D? What are the consequences?

Dr. Knibbe:
Toxic levels of Vit D usually are around 100 or higher. If your kidneys don't work so well then levels above 70 can start to drive your blood calcium up. The main problem with over supplementing would be a gradual rise in blood calcium and a simple blood test can tell this for us.

Comment From Judy:
I know one can get Vitamin D through sun exposure. It's kind of a "Catch 22" - sun exposure has a negative side, too. What is the minimum sun exposure required for the maximum results?

Dr. Knibbe:
First, sunscreen blocks activating of Vit D in the skin, even SPF 8, no VIT D made.

Second, you only make Vit D when the sun is high in the sky, and in Michigan the angle of the sun has to be high overhead so from October to April you won't make Vit D even if you are in the sun.

20 min of direct sun exposure in July at noon will make about 15,000 to 20,000 units of Vit D and may be safe

I prefer to tell people to protect their skin, wear sunscreen and use supplements as this is the best win/win situation.

Comment From Dianne Thauer-Nanzig:
Is there any relationship between osteoporosis and ortho arthritis?

Dr. Knibbe:
No, no direct relation. osteoporosis doesn't usually hurt, but the bones will hurt once they break osteoarthritis is breaking down of the cartilage through wear and tear and doesn't weaken the bones

Comment From Roberta:
Your response regarding Calcium citrate vs. Calcium carbonate at 12:16pm was confusing. Please make it clearer.

Dr. Knibbe:
My apology if I mistyped. Calcium Citrate is preferred for absorption, but it may take a little more Calcium Citrate to raise blood levels as there is less mg of actual calcium in a Ca Citrate pill vs. a Calcium Carbonate pill

Comment From Sue Boerman:
I'm taking Forteo injections daily. Can this increase my bone density? If so how long do the results last?

Dr. Knibbe:
Forteo is the only medicine available that will actually build bone. Fosamax ,and its related drugs only prevent your bones from getting worse but never build new bone.

Forteo is an injection that can be used for 2 years only to build bone. It is reserved for those who have fractured or who are at high risk of fracture and who need to rapidly build bone.

That bone should stay with you the rest of your life if you take care of it.

Comment From Sheri H:
If you should fracture your hip, wrist etc. from minimal trauma, should you just assume you suffer from Osteoporosis?

Dr. Knibbe:
No, is it possible to fall just right and break your wrist without having osteoporosis. But if you break your back or hip with little trauma then that is the same as having osteoporosis, in other words, your bone quantity (bone density)_ may not look so bad, but your bone quality must be bad if you fractured.

Comment From Dorothy:
I have been taking a small dose of thyroid meds since 1986, suddenly, this year my Vit D was diagnosed as very low 1000 below what it should be. Should I continue to take the thyroid meds?

Dr. Knibbe:
There are 2 questions on thyroid and osteoporosis.

1. If your supplement for thyroid is correct and blood thyroid levels are good then you will not be at increased risk for developing osteoporosis.

Dr. Knibbe:
2. finding your Vit D low is coincidence; it probably was low all the time. Not related to thyroid issues or thyroid supplement. Remember to take your thyroid supplement separate from calcium and other meds to avoid problems with absorption.

Comment From Dianne Thauer-Nanzig:
Is there a relationship between alcohol and osteoporosis?

Dr. Knibbe:
Having more than 2 alcoholic beverages per day, or more than 7 per week is associated with an adverse effect on bone quality. Moderation is the key.

Comment From Linda F:
Question -- what do you mean by remodeling?

Dr. Knibbe:
In our center we have blood tests that can tell how fast your bone is repairing damage and building new bone. Our bones constantly are tearing down the old bone and replacing it with new bone. Medical conditions and drugs can impair this balance. We can now test to see if your remodeling process is working normally.

Comment From Guest:
If my mother has osteoporosis, will I get it?

Dr. Knibbe:
There are a lot of questions about hereditary issues in osteoporosis. We know for sure that the biggest risk factor after your age is whether a first degree relative had osteoporosis or a fracture. However we can't test for a genetic 'factor' that is passed through the family.

Dr. Knibbe:
Probably there are genetic factors but we can't measure them yet. However remember if your mother is elderly and has osteoporosis, it is more likely that she grew up Vit D deficient and that is why she has osteoporosis and has nothing to do with genetics.

Spectrum Health:
 FACT: Smoking doubles your risk of developing osteoporosis.

Comment From Mary:
Do we know absolutely what causes the bones to thin?

Dr. Knibbe:
We know a lot of the factors that for sure make bones thin. In women it is very clear that estrogen loss causes bone loss in ALL women. Many other factors also have an effect and it is different in everyone. When in doubt, it is useful to have a complete workup

Comment From Sherri:
Does one need a doctor's referral to make an appointment at the Osteoporosis center?

Dr. Knibbe:
Although you can self-refer, we cannot see you without the permission and approval of your primary care doctor. We also cannot see you until we get the records we need first. Feel free to call us or call your PCP to start the referral process.

Comment From Judy:
What is the recommended calcium intake for a post-menopausal woman? What is the preferred way to get this calcium - pills or through calcium-rich foods?

Dr. Knibbe:
Intake is 1200-1500mg daily

Food or supplement is fine, do a diary of food to see how much you get from food first and then add the supplements until you have reached your goal.

Comment From Cindy:
Why does smoking double the risk of developing osteoporosis?

Dr. Knibbe:
Smoking is damaging to the cells that do the remodeling in the bone. Chemicals in smoke also constrict blood vessels and prevent the healing cells to get to the bone where they do their work.

Comment From Julie:
Isn't there also a once a year drug for treatment?

Dr. Knibbe:
There is a once a year IV infusion that is considered an anti-remodeling agent. It should be used only in special circumstances and has potential of side effects that cannot be reversed (well, until a year goes by and the drug starts to come out of your system) Talk to your doctor but I prefer to use drugs that promote bone health and bone growth.

Comment From Tara:
I am 36 years old and currently on sulfasalazine for arthritis.. Are there medications that cause the vit d not to absorb?

Dr. Knibbe:
Sulfasalazine won't affect Vit D absorption but you need to have your level checked. I'm not aware of other meds that affect Vit D absorption but there are diseases that prevent you from using the Vit D and there are meds that can bind to calcium and slow their absorption (we talked about thyroid already, some seizure meds)

Comment From Dorothy:
If my bone density test showed a -6 will that need treatment and what besides taking Vit D as well as exercising by gardening and walking is needed?

Dr. Knibbe:
If your T score is truly a -6 then you truly are at high risk for fracture. You may be a good candidate for a bone building medicine (Forteo) but first someone needs to find out how you possibly got that low and a lot needs to be done to correct the underlying cause before getting into discussions about treatment.

Comment From Vanessa Lettinga:
At what age should you be tested for Osteoporosis?

Dr. Knibbe:
Usually we do baseline bone density at menopause or for sure by age 65 for women, around 65-70 baseline for men unless there are other risks.

Comment From Mary:
I have had 2 bone density tests, and according to the test, I gained density not lost it, how is that possible?

Dr. Knibbe:
Tests done on different density machines cannot be compared. If it was done on the same machine then it is possible that you were not oriented the same way on the exam table during the test. Also osteoarthritis produces bones spurs that make the bone density look like it is going up but this is not 'good bone' and doesn't count.

Comment From Mary B:
What is the Best way to obtain calcium and bone density when one can neither have dairy nor exercise due to other health issues?

Dr. Knibbe:
If you can't tolerate oral calcium tablets or dairy then you can try a liquid calcium product from the health food store (calcium lactate or calcium gluconate) Sometimes taking a lactose enzyme to help digest milk (Lactaid) can help. Any gravity effect on the bones (sit down bike, exercise bike) or stair step machine holding on to supports can help.

Comment From Lynn Bakeman:
Once you see improvement in bone mass, how frequently should you return for a bone scan?

Dr. Knibbe:
Bone density tests in most cases should be done every 2 years. Bone changes slowly and we don't have to check too frequently. In cases where meds where changed or risks have been modified sometimes we can get insurance to pay for a bone density after 1 year.

Spectrum Health:
FACT: Calcium, contained mostly in dairy products, is the most important mineral for your bones. Vitamin D is essential in order for your body to absorb the calcium.

Comment From Mary:
Whoa, how do I prevent bone spurs? My sister has them. How are they formed and how can we get rid of them?

Dr. Knibbe:
Bone spurs form when you have repeat trauma or tugging on the bone at the place where the ligaments attach or in between the vertebrae from gravity and wear and tear. The body resists the wear and tear by laying down bone in the tendons or on the edge of the bone where the tendons attach. It has nothing to do with your calcium, Vit D or your supplements. We think the body repairs damage with calcium and there is not much you can do to change this.

Comment From Cindy:
Are calcium chews a good way to supplement?

Dr. Knibbe:
Calcium chews are fine, tend to be a bit pricey, and you do have to be careful. If you are on Coumadin (blood thinner) often the chews contain Vit K and this will throw off your blood thinner numbers. So read the label first.

Comment From Jeff:
My testosterone level is also very low with my vit. D

Dr. Knibbe:
Men should have testosterone levels checked. If it is low then often your doctor has to figure out why and in some places replace it. Once testosterone is back to normal then bone strength usually returns as well.

Comment From Kara Kamps:
Can there be an adverse affect by taking too much calcium?

Dr. Knibbe:
Providing your Vit D is normal, and then if you take too much calcium your blood levels may start to creep up. Usually normal kidneys can excrete the extra, but with dehydration you can get blood calcium creeping up. If you stay within the guidelines above, and stay well hydrated you will in almost all cases be fine.

Comment from Sheri H:
Hello: I' am wondering how often do you recommend having a DEXA Scan done? Starting at what age? And does Vitamin d really make any difference?

Dr. Knibbe:
There have been questions about Dexa scans.

1. Try to do it always on the same scanner

2. Ask if they can do vertebral fracture analysis (VFA) If your doctor recommends this it can be done as part of your dexa scan and can tell if you have had a silent vertebral fracture and didn't know it. This puts you in a special high risk category.

3. Calcium and Vit D can certainly help with this.

The statistics say that even though Medicare pays for dexa scans after age 65, only 18% of women over 65 actually get one.

Comment From Judy:
What kind of exercise is the most beneficial to ensure strong bones as we age?

Dr. Knibbe:
Exercise that compresses the spine and long bones is the best. Run, walk would be the best although running can be hard on the body. Anything where the torso is vertical is great.

Comment From Judy:
Can you please advise regarding the vitamin supplements that a post-menopausal woman should take to ensure maximum bone health?

Dr. Knibbe:
Again, I can't prescribe it for you as we don't know what your Vit D level is. But if you take enough Vit D to get your level up to 50 (usually 2000 IU of D3 or so daily) and take 1200-1500 mg calcium total (between food and supplements) you can do a lot of good for your bones.

Spectrum Health:
FACT: Calcium, contained mostly in dairy products, is the most important mineral for your bones. Vitamin D is essential in order for your body to absorb the calcium.

Comment From Lynn Bakeman:
Once you improve bone mass and leave the osteopenia range, can you continue to see improvement and retain that improvement for life?

Dr. Knibbe:
 If we have corrected the other problems and your bones start improving then you can expect them to stay good. However the natural aging process starts to cause them to weaken as well. So you may not be able to always improve forever but certainly you can feel like you have improved your bones as best as you can over time.

Comment From Holly:
How important are Calcium and Vit D supplements for children?

Dr. Knibbe:
I think Vit D is far more important for children than the calcium side. Certainly if children have access to milk (3 glasses a day you know!) then we need to give them the extra Vit D to absorb it. Since children don't like having their blood draw, it is generally safe after age 1 to give 1000 IU D3 daily. Talk to your pediatrician as we don't treat children in this center.

Comment From Deb Taylor:
Will osteoporosis ever go away?

Dr. Knibbe:
Unfortunately osteoporosis, won't ever improve on its own or go away. We have to intervene, find the cause and correct it. Too many people think it is a normal process of aging but it is not. It is a disease state that must be diagnosed and corrected.

Dr. Knibbe:
Don't be afraid to ask your doctor about getting a Dexa and ask why your Vit D has never been checked. Go ahead and ask why, if your results are getting worse.

Comment From Sue:
I have had the bone density test and it was satisfactory. Should I ask my doctor for a vit D test?

Dr. Knibbe:
Yes, even if bones seem good, you need to have enough Vit D to keep the bones strong. Once you know how much Vit D your body needs to stay above 50, then you usually can stop checking the Vit D and just stay on those supplements. Great questions!

Comment From Dianne Thauer-Nanzig:
It would be nice if you could leave these Q + A's posted for us to reread and review again.

Dr. Knibbe:
Thank you all for taking time to join me today to learn more about improving bone health at any age. Please understand that it’s sometimes difficult to give detailed answers in this format, but I hope you all learned a little more about osteoporosis. Of course, the best way to determine an appropriate course of action or treatment plan is by being evaluated in person.

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