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Challenging our assumptions about bone density and fractures

A research paper published in the prestigious British Medical Journal last year made a point that few of us appreciate about bone health.

It noted that most hip fractures occur in people who are not osteoporotic, and that most people who have osteoporosis never break a bone. 

That challenges the long-held assumption that low bone density increases the risk of fractures, especially the risk of a hip fracture. 

The logic has been that if a scan shows that your bone density is low, you’re at greater risk of a hip fracture, but ultimately this can be treated with drugs.

You might be surprised to know that it’s only since the mid-1990s that we’ve used bone density scans to define osteoporosis. Before that you actually had to break a bone in a low trauma way to be considered osteoporotic.

Around the same time, the idea of ‘osteopenia’ was invented. Being osteopenic implies that you’re potentially at risk and that your situation needs to be monitored.

Osteopenia and osteoporosis are measured against the peak bone mass of a healthy young woman. There are several problems with this kind of measurement and categorisation. 

Aside from the obvious issue of comparing the bones of an older woman with the bones of a 30 year old, we focus solely on density with no consideration of quality. 

We can have low bone density for a variety of reasons, including disease, the side-effects of some medications, our lifestyle, and our genes. Some of us — especially if we’re ‘light-boned’ — just don’t have bones that are as dense as other people’s, so our peak bone mass was probably never as high as the standard we’re measured against.

A diagnosis of low bone density should be a wake-up call to check that we’re adopting a healthy lifestyle with plenty of bone-building physical activity and a nutrient-rich diet, and that we’re managing our stress levels. 

If we’re ticking all of those boxes, it’s highly likely that even if our bones are on the low density side, we’re not candidates for breaking a hip. 

Older women in countries such as Africa and Asia commonly have low bone density but they’re active, they squat a lot, they’re used to carrying evenly-balanced loads, and they don’t break their hips. We need to take a leaf out of their books and avoid becoming frail.

The international team who wrote the paper concluded that our current Western approach to hip fracture prevention isn’t viable, and that we’re overdiagnosing bone fragility and overtreating well women for a disease they may never have. 

Source: Järvinen, T, Michaëlsson, K, Jokihaara, J, et al. Overdiagnosis of bone fragility in the quest to prevent hip fracture. BMJ 2015;350:h2088

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Saturday, April 23, 2016 | Rhonda Anderson