As an adult, you should be seeing your primary care doctor (that includes family practice, internal medicine, and obstetrics/gynecology doctors) at regular intervals, depending on your age and health. Everyone over the age of fifty should see his or her primary care physician once a year—no exceptions. Everyone under fifty who has a chronic ailment should also be seen at least once a year. Women of childbearing age should see a doctor who performs pelvic exams at least once a year. Everyone under fifty should undergo periodic health screenings at least every three years. Different disease screening and routine health evaluations are indicated at various age milestones. Health recommendations such as exercise or cessation of tobacco use that lower risks of heart disease, diabetes, and obesity, boost your bone health as well.
The performance of a regular history, physical examination, and laboratory will provide an overall assessment of your health. Your doctor may uncover clues that lead to further investigation. In general, bone health and general health measures go hand-in-hand. Evaluation focused on your bone health may include the following:
Height. When was the last time your height was measured? Chances are it has been a while. When asked, most people just give the height that is listed on their driver's license. In contrast, we usually keep track of our weight. However, you should keep track of your height, too.
Your parents may have put marks up along the doorframe when you were growing up. As we grow older, height needs to be followed in the same manner. However, the concern is that your height may be moving in the opposite direction—down. Measurement of your height using a fixed measuring device, like a wall-mounted device called a stadiometer, or by simply standing up against the wall should give an accurate value, but the attachment on the doctor's scale does not.
Compare your measured height with your driver's license height. For women, if you have lost two or more inches, and for men one or more inches, the concern is the possibility of silent, underlying, spine fractures. Height loss may be the subtle clue. To know, you must be measured once a year. Any loss from year to year should be further investigated.
Pills. You may be good about sharing information with your doctor about the prescription medicines you are taking, but what about everything else? What supplements and over-the-counter medicines are you also using? Let your doctor see what you are actually taking. Yes, I mean see. Don't just take a list. Bag them up and haul them in.
Some supplements or over-the-counter medicines may be promoting bone loss rather than helping. Go over all of your products with your doctor.
Leg Strength. The quadriceps is the large group of muscles on the front of your thigh. The strength of your quadriceps is an independent risk factor for fracture. These leg muscles are critical for walking, standing up, and sitting down. As we age, they tend to decrease in size and strength. A common way to test leg strength is to stand up from a chair without using your arms.
You can try this at home, too. Sit down in a chair that does not have arms. Put your back up against the back of the chair. Place your hands across your chest. Now, stand up. How did you do? If you had any problems, it is time to work on strengthening the quadriceps muscles.
Blood Test for Vitamin D. Low vitamin D is now a worldwide epidemic. Vitamin D may have many more health benefits than just those related to bone health. If you are not taking a vitamin D supplement, you most likely have low vitamin D blood levels. If you are taking a vitamin D supplement, that is good. However, so many factors influence your vitamin D status that the only way to know if you are taking enough is to have your blood level measured.
Unfortunately, because of the price gouging of laboratories, some regional Medicare carriers have restricted use of this blood test. Your doctor will know if this is a covered test or not. The cost has decreased in many places and ranges from a low of $30 to more than $150 depending on the contracts or the laboratory. If you would need to pay out-of-pocket for this test, find out ahead of time what the cost is so that you can make a careful decision about whether you can afford it. For the moment, in most places in the country, it is still covered.
Fracture Risk Assessment. Reviewing your risk factors for fracture will help determine if it is time for a bone density or DXA scan. To help quantify your risk, a tool called FRAX® is available online or as a smart phone application for your doctor. This assessment was developed by the World Health Organization (WHO) to estimate the ten-year probability of fracture. It was designed for men and women ages forty to ninety who have not received any osteoporosis medicines. The calculation uses clinical risk factors and bone density from a region of your hip (femoral neck). If a bone density scan has not been done, height and weight can be used as a substitute for bone density to estimate probability of fractures.
The US Preventive Services Task Force suggests using a tool like FRAX to help decide whether or not to screen with a bone density test in women under the age of sixty-five. It is recommended that all women sixty-five and older get a bone density test. Likewise, younger postmenopausal women at higher risk for fracture should also get a bone density scan.
MORE RISK FACTORS = HIGHER RISK OF FRACTURE
The risk of fracture increases as your risk factors accumulate. Here's an example using the FRAX tool to assess fracture risk using height and weight. Karen, at age sixty, is 5-foot-6 inches tall and weighs 140 pounds. Three risk factors are used for the example: parental hip fracture, rheumatoid arthritis, and previous fracture. Her ten-year probability of major fracture for different risk factors present is calculated using height and weight. The model calculates probability using body mass index (BMI) if bone density is not entered. The more risk factors she has, the greater the risk of major osteoporotic fractures.
In my opinion, these guidelines do not go far enough. Any perimenopausal or postmenopausal woman with risk factors and any man over the age of fifty with risk factors should have a bone density test. Why? Because research tells us that more than half of fractures occur in women and men who have low bone mass or osteopenia. On the other hand, if you are early postmenopausal and have no risk factors, a diagnosis of osteopenia may be associated with a low risk of fracture. The lower the bone density and the more risk factors present, the higher the probability of fractures. Early identification makes a difference in lowering the risk of future fracture. If you don't measure it, you may not be managing your bone health appropriately.
Your doctor does the FRAX calculation for you. Also, some of the new bone density machines have the software for FRAX and if one of these machines is used, it will be part of your bone density report. If you are Internet savvy, you can find the FRAX tool online by typing FRAX in the Google search box. The best use of FRAX is afier you have had a bone density scan. Its use is indicated for those with low bone density who are not on medicines for osteoporosis or taking estrogen.
If a bone density DXA scan is ordered, an additional test on the same machine may be available to evaluate for spine fractures. This scan is called a vertebral fracture assessment (VFA). It is another tool that helps to assess fracture risk. If any silent spine fracture is identified, the risk of more fractures is high.
Fracture risk assessment may include a bone density scan (DXA), a scan of the spine for fractures (VFA), and the FRAX ten-year probability of fracture score. If your assessment reveals that you have low bone mass, a further look for contributing factors should be undertaken. There is no specified battery of tests; instead, your history and risk factors will guide this work-up. Doctors are medical detectives; we gather clues that lead us down various paths in search of the correct answers. The evaluation for low bone density and osteoporosis has to be individualized. Some tests may be done on most everyone; others will depend on your history.
One test I will mention that most experts agree is helpful in patients diagnosed with osteoporosis is a urine collection for twenty-four hours. Yes, an entire day. Every drop of urine is collected and stored in a jug. It needs to be refrigerated, so pick a convenient day when you can stay home. The urine may be measured for calcium, creatinine, and sodium. Sodium content will alert your doctor if your diet is too high in salt, which contributes to calcium loss. If your-calcium is high, you may be taking too much calcium or your kidneys may be leaking calcium. Use of some diuretics or water pills called thiazides may help decrease the loss of calcium. If your calcium is low, a low vitamin D blood level or celiac disease may be the cause. Your body is trying to hang on to as much calcium as possible. The twenty-four-hour urine collection can be an inconvenience but it provides valuable information.
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The Bare Bones Evaluation of your bone health at your annual doctor's visit may include:
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