Think that having correct calcium and vitamin D levels will stop you getting osteoporosis, formerly known as brittle bone disease? Not so, says Professor Moira O’Brien, osteoporosis consultant and president of the Irish Osteoporosis Society.
Investigations need to be done to find the causes of the person’s bone loss and cortisol levels have to be checked, she says, because high levels of cortisol cause bone loss.
There isn’t enough awareness of how high cortisol levels increase bone loss – even among doctors. Professor Moira O’Brien is emphatic about this.
Specialising in osteoporosis after working with Irish Olympic athletes and seeing how physical stress impacted their bone health, she became very aware of how physical and emotional stress can lead to bone loss and put people at risk of fractures.
The general trend is that causes of bone loss are assumed, not investigated.
“You have to look at the cortisol (stress hormone) levels because high levels of cortisol increase the formation of cells that cause bone loss.”
The science
She explains how it works. For bones to be healthy they need adequate levels of:
Calcium and vitamin D.The sex hormones oestrogen and testosterone. Weight-bearing exercise.“They need the sex hormones in order to be able to form enough vitamin D,” she says. “If the vitamin D level is too low then a person’s parathyroid hormone level goes up. This increase in parathyroid hormone takes the calcium from the bone by increasing the number of cells that remove bone.”
High cortisol levels have a negative effect too. They act indirectly on bone by causing a reduction in sex hormones and increasing the substance known as RANKL, which also increases the formation of cells that cause bone loss.
De-stressing is vital
“If you are in a high-pressure job, not taking holidays and under stress all the time, your cortisol levels will be sky high. Often people don’t realise that they are not coping well with stress,” she says.
“You can’t be working all the hours God sends and if you’re stressed out you don’t sleep, and a lack of sleep is one of the worst causes of high cortisol levels. Unless stress levels are reduced, the person’s bone health will continue to disimprove. I tell patients that they have to de-stress. One of the best ways is with exercise – there’s dancing, music, mindfulness is good too – whatever they enjoy. Finding ways to de-stress is part of the prescription, along with medication, in rebuilding bones.”
Important blood tests
The important blood tests to get done (when getting a bone health diagnosis) are:
Vitamin D levelsParathyroidCortisol levelsRenal function tests“These blood tests are not routinely done because they cost more and the blood sample needs to get to the lab within an hour,” she says, “but they are important from the point of view of finding out what’s causing the person’s osteoporosis.
“If you don’t treat the cause you’re not going to get any better and you are at risk of fractures. The whole point of osteoporosis treatment is to prevent fractures.”
While one in two women and one in four over the age of 50 will develop osteoporosis, Professor O’Brien has been treating men, women and even children for 30 years.
“Family history has a huge bearing on who gets osteoporosis – as much as 70% – so a comprehensive medical history has to be taken first.”
DXA scans
She believes that many DXA scans are not taken or read carefully enough.
“A scan of the spine should be done, one of both hips, and if the person has lost height, a lateral view scan also. Only seven DXA scan centres in the country do these lateral view scans. People need to know if their loss of height is due to a vertebral fracture or to narrowing of the disc spaces. A lot of people may appear to have normal bone mineral density on the DXA scan because they have osteoarthritis and are complaining of back pain, but when you do the lateral view you find they’ve got several fractures.
“What people don’t realise is that bone is a living tissue and is constantly being removed and replaced,” she states.
“It takes three weeks to remove bone, but three months to build it up. Osteoporosis means that you are losing more bone than you are forming.”
Risk factors
The person’s risk factors* have to be looked at also. These include:
Age – 50+ most at risk.Gender. Bone-breakage history. Family history of osteoporosis/bone fractures.Some medical conditions, like rheumatoid arthritis.Medication, eg steroids taken over a long period.Eating disorders.Smoking.Treatment
Everyone has a thing about calcium, she says, but it’s not the most important aspect.
“Calcium and vitamin D supplements are NOT treatment for osteoporosis.
“It’s a waste of time giving someone calcium tablets if they can’t absorb it. They mightn’t be absorbing it because they are on a particular medication or have a particular medical condition. If someone has had early menopause, if they have reflux, if they are on warfarin, if they’ve had chemotherapy and radiation – all of these cause bone loss.”
The treatment she prescribes includes bone-building medication or injections over a period of time with daily amounts of calcium and vitamin D, if necessary.
“Not everyone has the courage to go through with the treatment which, depending on the patient, involves regular or daily injections.
“We’ve seen people [not have the treatment] because they still believe osteoporosis is an old lady’s disease, but this is rubbish. It isn’t. Also many people, including doctors, still haven’t woken up to the fact that osteoporosis is preventable and treatable.
“Physical exercise from childhood is so important too because bone responds to you using your muscles,” says Professor O’Brien.
Bone breaks should be investigated
If someone trips, falls and fractures a bone easily this is osteoporosis, unless proven otherwise, she states.
Costs
Charges include €100 for a DXA scan, about €150 for blood tests as well as the consultant’s fee.
Conference
A conference will be held in Trinity College, Dublin, on Saturday 20 October for World Osteoporosis Day, and will include a symposium on back pain.
Personal story: Mairead Lavery
Getting out of the red zone
Yes, it is possible to reverse certain types of osteoporosis, as former Irish Country Living editor Mairead Lavery discovered following her own treatment.
“Eighteen months ago I was diagnosed with severe osteoporosis in my spine. The diagnosis happened by accident. A short time earlier I’d been for my annual dental check-up to be told by my dentist the x-rays showed I was losing bone from around my teeth. He advised I attend to it, sharpish.
“Coincidentally, around the same time a colleague was singing the praises of Professor Moira O’Brien, a specialist in osteoporosis and head of the Irish Osteoporosis Society. As I knew no other specialist in the area, I gave her a call.
“She sent me for a Dexa scan and extensive blood tests that included tests for calcium, Vitamin D and cortisol, the stress hormone. When the tests came back I only had to look at the green, orange and red diagram from the Dexa scan to see I was deep in the red zone, and in trouble. One of the bones in my lower back was fractured and several others were at high risk to fracture. I couldn’t understand why I wasn’t in serious pain, but Prof O’Brien explained that 75% of people who have broken bones in their back have intermittent back pain. Only 25% have constant pain. The Dexa scan didn’t lie. Neither did the blood tests.
“They showed I had plenty of calcium and didn’t need to double up on the cheese. What I didn’t have though was much vitamin D and this was compounded by seriously high levels of cortisol – the stress hormone. In lay man’s language I didn’t have enough vitamin D to absorb the calcium, which is essential for healthy bones. My cortisol levels where so high that I was actually losing bone. Having too high a level of this hormone is bad news.”
Three-step remedy
“The good news was that Prof O’Brien was confident I could reverse the bone loss provided I did three things. The first two were easy. Go on a sun holiday to build up vitamin D and start Pilates classes.
“Believe it or not I’d never been on a sun holiday, I’d never sat by the pool taking in the rays and working on my tan. But oh the hardship of it, I hit for Lanzarote for two weeks and dosed myself with 25,000 units of vitamin D every month.”
No way am I doing that
“Prof O’Brien’s third recommendation stopped me in my tracks. I would have to have a daily injection of Forsteo, a bone-building medication, for the next two years. And I would have to administer the injection myself.
“I remember looking at her shaking my head and saying no, that won’t happen. I told her I blacked out at the sight of a needle. I couldn’t even take the children for their shots, my husband had to do it. There had to be another way.
“With that Prof O’Brien reached into a drawer in her desk and pulled out a catalogue: ‘Ok, so let’s select the best wheelchair for you then,’ she said in a steely voice. It was the wake-up call I needed.
“I was advised to try Cognitive Behaviour Therapy (CBT) to get over my needle phobia. To say the least, I was sceptical about how this might work, but it did work and after three one-hour sessions I knew I could do it. So for the past 18 months I have given myself that daily injection. It’s not easy, nor is it something I like doing, but I do it and it’s worked for me.
“As my osteoporosis had a lot to do with lifestyle, which was driving high levels of cortisol, I also made the tough decision to step down as editor of Irish Country Living. That wasn’t easy either, but it had to be done.”
For the full list of risk factors for osteoporosis see http://www.irishosteoporosis.ie/?/about_osteoporosis/risk_factors/
Think that having correct calcium and vitamin D levels will stop you getting osteoporosis, formerly known as brittle bone disease? Not so, says Professor Moira O’Brien, osteoporosis consultant and president of the Irish Osteoporosis Society.
Investigations need to be done to find the causes of the person’s bone loss and cortisol levels have to be checked, she says, because high levels of cortisol cause bone loss.
There isn’t enough awareness of how high cortisol levels increase bone loss – even among doctors. Professor Moira O’Brien is emphatic about this.
Specialising in osteoporosis after working with Irish Olympic athletes and seeing how physical stress impacted their bone health, she became very aware of how physical and emotional stress can lead to bone loss and put people at risk of fractures.
The general trend is that causes of bone loss are assumed, not investigated.
“You have to look at the cortisol (stress hormone) levels because high levels of cortisol increase the formation of cells that cause bone loss.”
The science
She explains how it works. For bones to be healthy they need adequate levels of:
Calcium and vitamin D.The sex hormones oestrogen and testosterone. Weight-bearing exercise.“They need the sex hormones in order to be able to form enough vitamin D,” she says. “If the vitamin D level is too low then a person’s parathyroid hormone level goes up. This increase in parathyroid hormone takes the calcium from the bone by increasing the number of cells that remove bone.”
High cortisol levels have a negative effect too. They act indirectly on bone by causing a reduction in sex hormones and increasing the substance known as RANKL, which also increases the formation of cells that cause bone loss.
De-stressing is vital
“If you are in a high-pressure job, not taking holidays and under stress all the time, your cortisol levels will be sky high. Often people don’t realise that they are not coping well with stress,” she says.
“You can’t be working all the hours God sends and if you’re stressed out you don’t sleep, and a lack of sleep is one of the worst causes of high cortisol levels. Unless stress levels are reduced, the person’s bone health will continue to disimprove. I tell patients that they have to de-stress. One of the best ways is with exercise – there’s dancing, music, mindfulness is good too – whatever they enjoy. Finding ways to de-stress is part of the prescription, along with medication, in rebuilding bones.”
Important blood tests
The important blood tests to get done (when getting a bone health diagnosis) are:
Vitamin D levelsParathyroidCortisol levelsRenal function tests“These blood tests are not routinely done because they cost more and the blood sample needs to get to the lab within an hour,” she says, “but they are important from the point of view of finding out what’s causing the person’s osteoporosis.
“If you don’t treat the cause you’re not going to get any better and you are at risk of fractures. The whole point of osteoporosis treatment is to prevent fractures.”
While one in two women and one in four over the age of 50 will develop osteoporosis, Professor O’Brien has been treating men, women and even children for 30 years.
“Family history has a huge bearing on who gets osteoporosis – as much as 70% – so a comprehensive medical history has to be taken first.”
DXA scans
She believes that many DXA scans are not taken or read carefully enough.
“A scan of the spine should be done, one of both hips, and if the person has lost height, a lateral view scan also. Only seven DXA scan centres in the country do these lateral view scans. People need to know if their loss of height is due to a vertebral fracture or to narrowing of the disc spaces. A lot of people may appear to have normal bone mineral density on the DXA scan because they have osteoarthritis and are complaining of back pain, but when you do the lateral view you find they’ve got several fractures.
“What people don’t realise is that bone is a living tissue and is constantly being removed and replaced,” she states.
“It takes three weeks to remove bone, but three months to build it up. Osteoporosis means that you are losing more bone than you are forming.”
Risk factors
The person’s risk factors* have to be looked at also. These include:
Age – 50+ most at risk.Gender. Bone-breakage history. Family history of osteoporosis/bone fractures.Some medical conditions, like rheumatoid arthritis.Medication, eg steroids taken over a long period.Eating disorders.Smoking.Treatment
Everyone has a thing about calcium, she says, but it’s not the most important aspect.
“Calcium and vitamin D supplements are NOT treatment for osteoporosis.
“It’s a waste of time giving someone calcium tablets if they can’t absorb it. They mightn’t be absorbing it because they are on a particular medication or have a particular medical condition. If someone has had early menopause, if they have reflux, if they are on warfarin, if they’ve had chemotherapy and radiation – all of these cause bone loss.”
The treatment she prescribes includes bone-building medication or injections over a period of time with daily amounts of calcium and vitamin D, if necessary.
“Not everyone has the courage to go through with the treatment which, depending on the patient, involves regular or daily injections.
“We’ve seen people [not have the treatment] because they still believe osteoporosis is an old lady’s disease, but this is rubbish. It isn’t. Also many people, including doctors, still haven’t woken up to the fact that osteoporosis is preventable and treatable.
“Physical exercise from childhood is so important too because bone responds to you using your muscles,” says Professor O’Brien.
Bone breaks should be investigated
If someone trips, falls and fractures a bone easily this is osteoporosis, unless proven otherwise, she states.
Costs
Charges include €100 for a DXA scan, about €150 for blood tests as well as the consultant’s fee.
Conference
A conference will be held in Trinity College, Dublin, on Saturday 20 October for World Osteoporosis Day, and will include a symposium on back pain.
Personal story: Mairead Lavery
Getting out of the red zone
Yes, it is possible to reverse certain types of osteoporosis, as former Irish Country Living editor Mairead Lavery discovered following her own treatment.
“Eighteen months ago I was diagnosed with severe osteoporosis in my spine. The diagnosis happened by accident. A short time earlier I’d been for my annual dental check-up to be told by my dentist the x-rays showed I was losing bone from around my teeth. He advised I attend to it, sharpish.
“Coincidentally, around the same time a colleague was singing the praises of Professor Moira O’Brien, a specialist in osteoporosis and head of the Irish Osteoporosis Society. As I knew no other specialist in the area, I gave her a call.
“She sent me for a Dexa scan and extensive blood tests that included tests for calcium, Vitamin D and cortisol, the stress hormone. When the tests came back I only had to look at the green, orange and red diagram from the Dexa scan to see I was deep in the red zone, and in trouble. One of the bones in my lower back was fractured and several others were at high risk to fracture. I couldn’t understand why I wasn’t in serious pain, but Prof O’Brien explained that 75% of people who have broken bones in their back have intermittent back pain. Only 25% have constant pain. The Dexa scan didn’t lie. Neither did the blood tests.
“They showed I had plenty of calcium and didn’t need to double up on the cheese. What I didn’t have though was much vitamin D and this was compounded by seriously high levels of cortisol – the stress hormone. In lay man’s language I didn’t have enough vitamin D to absorb the calcium, which is essential for healthy bones. My cortisol levels where so high that I was actually losing bone. Having too high a level of this hormone is bad news.”
Three-step remedy
“The good news was that Prof O’Brien was confident I could reverse the bone loss provided I did three things. The first two were easy. Go on a sun holiday to build up vitamin D and start Pilates classes.
“Believe it or not I’d never been on a sun holiday, I’d never sat by the pool taking in the rays and working on my tan. But oh the hardship of it, I hit for Lanzarote for two weeks and dosed myself with 25,000 units of vitamin D every month.”
No way am I doing that
“Prof O’Brien’s third recommendation stopped me in my tracks. I would have to have a daily injection of Forsteo, a bone-building medication, for the next two years. And I would have to administer the injection myself.
“I remember looking at her shaking my head and saying no, that won’t happen. I told her I blacked out at the sight of a needle. I couldn’t even take the children for their shots, my husband had to do it. There had to be another way.
“With that Prof O’Brien reached into a drawer in her desk and pulled out a catalogue: ‘Ok, so let’s select the best wheelchair for you then,’ she said in a steely voice. It was the wake-up call I needed.
“I was advised to try Cognitive Behaviour Therapy (CBT) to get over my needle phobia. To say the least, I was sceptical about how this might work, but it did work and after three one-hour sessions I knew I could do it. So for the past 18 months I have given myself that daily injection. It’s not easy, nor is it something I like doing, but I do it and it’s worked for me.
“As my osteoporosis had a lot to do with lifestyle, which was driving high levels of cortisol, I also made the tough decision to step down as editor of Irish Country Living. That wasn’t easy either, but it had to be done.”
For the full list of risk factors for osteoporosis see http://www.irishosteoporosis.ie/?/about_osteoporosis/risk_factors/
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