dr-kim-zambito

Stewardship and Responsibility

Mon, 02 Mar 2026 18:13:37 GMT

Stewardship and Responsibility for Health and Vitality

Authors:

Dr. Kimberly Zambito — https://www.qualisos.com/about

Marsha Samuels — https://www.osteoscanusa.com/

Health is the platform for everything else in your life.

When you have health of mind, body, and spirit, you have hope.

When you have hope, you have everything.

Inputs Shape Your Internal Environment

When your inputs are clean, your system works according to design. Consider what you consume mentally, emotionally, spiritually, socially, and physically. Inputs shape your internal environment long before they show up as symptoms or success — long before resilience or disease ever appears on a lab report or an imaging study.

Consider the following:

· What conversations do you allow? Do you gossip or participate in disparaging another person? Do you share hope and bless others?

· Have you become part of the media you absorb? Do you live life via social media or are you present, really present, in a moment?

· Do you ask whether the food you eat truly nourishes your body?

· Do you understand that your thoughts shape your health? Do you speak to yourself with kindness and love?

· Consider the people you keep close. Are they uplifting — or draining?

These inputs are not neutral. They either nourish you or deplete you. They tell your nervous system whether you are safe or threatened; your hormones whether to repair or deplete; and your mind whether to expand or brace.

From Awareness to Agency

When you become aware of how these inputs affect your mind, body, and spirit, you realize you have far more agency than you were ever taught. Staying healthy stops being abstract and becomes personal — and actionable. Health is no longer something that happens to you; it becomes something you actively steward.

Inputs Become Outputs

Your energy, clarity, mood, patience, resilience, strength, creativity, and capacity to show up for others are not acts of willpower — they are reflections of the love and care you give to yourself.

Endeavor to dramatically reduce negative inputs. You will find that you think better. You will feel better inside your body: calmer, stronger, more grounded, more regulated, more alive.

Guarding your inputs is not selfish. It is stewardship.

Healthspan, Not Just Longevity

Health is more than adding years to your life. Longevity without vitality is a hollow win. True healthspan is built quietly, day by day, through the inputs you allow into your system — mentally, physically, spiritually, socially, emotionally, and nutritionally.

This is the real work of longevity: not chasing hacks, but curating an internal environment that supports repair, resilience, and purpose over decades. When your inputs are aligned, your outputs naturally become steadier, more generous, and more life-giving.

That is how staying healthy transforms from being a goal into a way of living.

This blog was inspired by attendees of the IIMHE webinar about nutrition and bone health(https://iimhe.org/webinars/nutrition-musculoskeletal-health/). I spoke of nutrition for our bodies, our minds, and our spirits- the things we choose as inputs. The body, the mind, and the spirit work together. Here are a few simple practices I do to nourish my mind, body, and spirit:

Each day I write 3 reflections of gratitude . Sometimes, I am simply grateful for another day; or seeing a bird at the birdfeeder; or a good night's sleep.
Forgive. Forgive myself. Forgive others. Then I let go of the burden I have carried in my heart. This has given me more freedom than I could have imagined. Holding a grudge is like holding a hot coal in your hand with the intention of throwing it at someone. The only person who get burned is the one holding the hot coal.
Pray, or enjoy a moment of silence and stillness. I learned long ago to be careful what I ask for in a prayer. Reflect on what you pray for or what you worry about. I started using the Hallow app for guided prayer and meditation. I have found the reflections and guidance helpful.
Read something that uplifts you , even if only a sentence or two. Reading about T-scores is not uplifting.
I choose to stay off of social media . If someone shares with me that an internet troll has said nasty things about me, then so be it. I forgive them, offer blessings, and find peace knowing that what energy is put out into the world will come back. I'm going for the good energy!
I say something nice to myself each day. This is a challenge sometimes. I look in the mirror and tell myself that I am a beautiful creation of God who made me with intention and purpose. And...yes, sometimes I look in the mirror, I say, "Girl, your hair looks great today!"

I will be remiss if I do not end this blog with the statement:

You are more than your T-score. You are an entire beautiful, wonderful you!

Deciphering and Decoding Research

Wed, 17 Sep 2025 17:00:00 GMT

Apply the Knowledge You Have Gained from the Blog Series on Statistics and Databases in Parts 1-5.

Authors:

Kimberly Zambito, MD, Orthopaedic Surgeon and Owner of Qualis Os

www.qualisos.com

Nick Birch FRCS (Orth), Consultant Spine and Bone Health Specialist and owner of OsteoscanUK

www.osteoscanuk.com

A Step by Step Guide to Reading a Research Article

Are you ready to apply the knowledge you have gained from our 5-part series on statistics and databases in bone health? As you prepare to read this blog, please do three things:

1. Review Part 5 : Understanding Relative Risk and Absolute Risk…Relatively Speaking It’s Absolutely Crazy!

2. Download, print, or have ready the article to review: FRAME Study: The Foundation Effect of Building Bone With 1 Year of Romosozumab Leads to Continued Lower Fracture Risk After Transition to Denosumab . This is in the Journal of Bone and Mineral Research (JBMR). (Journal of Bone and Mineral Research, Vol. 33, No. 7, July 2018, pp 1219–1226 DOI: 10.1002/jbmr.3427). This is a free article and can be accessed easily.

3. Roll up your sleeves and get ready to have fun as we go step-by-step on understanding a research article.

We chose this article, as many clients have asked about medications for the treatment of osteoporosis (OP). Specifically, clients want to know if they should take bone-building medication, then transition to a medication that prevents bone resorption. Recently, the medical community has recognized that the order medication is given in, which is termed “sequencing”, has an impact on bone mineral density and thereby fracture risk. The purpose of this blog is to teach you how to critically review a research paper using the knowledge you have gained about statistics, specifically Relative Risk Reduction (RRR), Absolute Risk Reduction (ARR) and the Number Needed to Treat (NNT).

FRAME was a pivotal study which supported the clinical benefit of building bone with Romosozumab before transitioning to Denosumab. Romosozumab is a monoclonal antibody that binds to and inhibits sclerostin, a molecule formed in bone that limits the ability of osteoblasts to create new bone. Sclerostin is a key component in the process of bone remodeling, and it prevents over production of bone when it is not needed. Therefore, Romosozumab increases bone formation and decreases bone resorption by blocking sclerostin's action. Think of sclerostin as an “off” switch to prevent excess bone formation. Romosozumab disables the “off” switch.

Denosumab is also a monoclonal antibody that is a very powerful inhibitor of osteoclasts. The antibody binds to RANKL, a molecule that is required to turn osteoclast precursor cells into osteoclasts. By doing so it inhibits bone resorption.

The FRAME study looked at the effect of administration of Romosozumab for 1 year, followed by Denosumab for a year. The idea behind the sequencing of these medications is to build bone with Romosozumab, then to use Denosumab to prevent resorption of the bone that was built, so locking in the treatment benefit in the longer term.

Step 1: Each research article has a title, a list of authors, the institutions of each author, and an abstract. This part is largely self-explanatory. The abstract summarizes the key points of the article and typically includes an introduction and reason for the study, the study design/methods, results, and conclusions. The abstract provides a “Cliff Notes” (“brief summary” for non-US readers) version of the article. And you know, the devil is always in the detail.

Step 2: Disclosures and Acknowledgements are typically found at the end of the article. Authors are required to inform readers of potential conflicts of interest. Funding and work done by individual authors can be found in the Acknowledgements. Disclosures and Acknowledgements for this article are found on page 1225. Note that this study was sponsored by three pharmaceutical companies, Amgen Inc, UCB Pharma and Astellas Pharma. All but one of the authors was either a paid advisor to one or more of the companies or was employed by one of the companies. Therefore, there is a notable risk of bias.

Step 3: The Introduction section of a research article provides background information to put the purpose of the study in context . The introduction section of this article reviews the drugs involved in the study, results of previous relevant studies including animal model studies and phase 3 of FRAME in which Romosozumab administered for 1-year was compared to placebo. The methodology of the FRAME study is described in a previous paper, but in summary it was a Phase 3, international, randomized, double-blind, placebo-controlled trial in 7180 postmenopausal women with osteoporosis. Half were treated with romosozumab for one year and the other half had placebo for a year. Both groups went on to have Denosumab for a year.

There is also mention of the FREEDOM study and its Extension which evaluated Denosumab alone. FREEDOM was the pivotal study for denosumab to assess its effect on fracture rates. It lasted three years and its Extension went on for a further seven years. When describing the comparison that has been made between the FRAME and FREEDOM studies, the authors state, “…changes in BMD observed with Romosozumab and then Denosumab in the context of changes seen in the FREEDOM and its Extension studies with Denosumab alone during which continued BMD gains were observed over 10 years of treatment, to qualitatively assess the magnitude of BMD changes with Romosozumab relative to the only OP treatment shown to increase BMD over an extended period.” What does this mean? The authors describe the comparison as being “qualitative” rather than “quantitative” which should sound some alarms. It is very difficult to draw firm conclusions from a qualitative comparison when the studies being compared have used quantitative measures unless it is part of a “mixed methods” analysis. If that is the case the insights and conclusions can be very helpful to understand a particular research topic. However, the authors of the current study did not used mixed methods. So, let’s now dive into the methods of this study and see how they performed their analysis.

Step 4: The Methods section describes the nuts and bolts of the study. The methods should be descriptive enough to replicate a study. The Methods section of this article includes the study design, outcome measures, and statistical analysis. The first sentence of this section states, “This secondary, post-hoc analysis was based on FRAME, a phase 3, international, randomized, double-blind, placebo-controlled, parallel-group trial…” Let's decode this sentence.

Secondary post-hoc means a statistical analysis was performed on a study once it has concluded. The results of the initial study may have shown there were some differences between groups but did not specify what the differences were, or which groups were different. A post-hoc study helps to tease out the differences between groups.
Phase 3 refers to a stage of clinical trial. Phase 3 trials evaluate the effectiveness and safety of a new treatment compared to a standard treatment or placebo.
Randomized means participants and researchers did not assign a participant to a group.
Double-blind means that neither the participant nor the research know what treatment (placebo or drug) was given to each participant.
Placebo-controlled means one group receives a placebo (no treatment) while the other group receives treatment (drug being studied)
Parallel group is a type of clinical trial design. Participants are randomly assigned to one a group, each group receives a different intervention. Participants are in their assigned group for the duration of the trial.

The methods describe the inclusion and exclusion criteria , how the study was conducted, and the endpoints for the study. The main, or “co-primary”, endpoints for this study were the incidence of new vertebral fractures through month 12 and through month 24. Secondary endpoints were other fracture types. Data collection included BMD measured by DXA at the lumbar spine and total hip at various time intervals. The analysis also used BMD data from FREEDOM and its extension.

All research articles should have a statement regarding the ethical treatment of participants and approval by an ethics committee or institutional review board. Also mentioned in the methods are what will be measured, or intended endpoints.

Outcome measures are specific and quantifiable metrics that can be used to determine if treatment was effective. The outcome measures for this study were:

Percent change from baseline in BMD by DXA of varying magnitudes; chosen empirically with 3% representing the approximate least significant change (LSC). Comment from the peanut gallery about this 3% LSC. We know from previous blog posts that the commonly accepted LSC for DXA is approximately 5%. Why was 3% used in this study?
Mean absolute change from baseline in lumbar spine and total hip BMD T-scores (read the additional details in the article) …the authors are comparing 1 year of Romosozumab followed by 1 year of Denosumab (FRAME) to 10 years of Denosumab (FREEDOM). Hold on now…when we evaluate changes in BMD, don’t we use the actual BMD in g/cm2 and not T-score? If you recall, a T-score represents a range of values. Maybe T-scores were used because a change in T-score might mean a change in diagnosis classification.
Subject incidence of fractures in the second year of FRAME.

The Statistical analysis section describes how the authors evaluated the data collected during the study. Statistics help researchers determine whether or not a treatment produced the desired effect. To assess BMD T-score changes, treatment groups in FRAME (Romosozumab + Denosumab v placebo + Denosumab) were compared to those in FREEDOM (Denosumab alone). A couple of questions asked by the researchers were:

Does one year of treatment with Romosozumab followed by a year of Denosumab increase BMD T-score and decrease fracture rates when compared to placebo (no medication)?
Does one year of Romosozumab followed by a year of Denosumab increase BMD T-score and decrease the incidence of fractures when compared to those who took 10 years of Denosumab?

Step 5: The Results section describes…the results! Results in this article are subdivided into Subject disposition, BMD responder analysis, BMD T-score changes, and FRAME and FREEDOM T-score changes. There were 7180 participants in the FRAME study divided into two groups. Group characteristics were similar. There were 7808 participants in the FREEDOM study, also divided into two groups. However, for the comparison to be valid, the two large groups of participants should have had similar baseline characteristics i.e. gender, ethnicity, height, weight etc. but this was not actually be the case. The FRAME participants were slightly younger by on average 1.4 years. However, the authors did not provide details of the statistics of that difference which means even a 1.4 year mean difference in such large cohorts might make them unequal. The geographical locations from where participants were recruited were also different. This difference is important as it means the results of the FRAME study might not reflect the main target population for the drugs i.e. North America, Western Europe and Australia and New Zealand. However, the FREEDOM study was more representative. There was quite a large difference between the studies in the numbers of participants with pre-existing (prevalent) vertebral fractures and a history of non-vertebral fractures. Vertebral fractures were almost 30% more common in the FREEDOM participants compared to those in the FRAME study and non-vertebral fractures almost twice as common. The fracture rate is important when considering the bone mineral density. The average T-scores for the lumbar spine were similar across the two studies, but for total hip and femoral neck they were much lower in the FRAME participants. Average hip T-scores in the FREEDOM participants, for total hip and neck of femur, indicated a majority with osteopenia, while for the FRAME participants the majority had osteoporosis. Therefore, the FREEDOM trial participants had a much higher fracture rate with better T-scores at the hip compared to the FRAME trial volunteers. This is further reflected in the average FRAX scores for Major Osteoporotic Fractures that were close to the low-risk range for FRAME triallists (10.9%) but in the high/intermediate range (16.3%) for FREEDOM participants. As both trials used change in bone mineral density as primary outcomes, the difference in fracture rate, bone density and risk stratification between the two groups might be important.

The table below summarizes the percentage of participants who experienced a >3%, >6%, and >10% BMD gain in the FRAME study.

In each group there were participants who did not gain BMD and those who lost BMD. When reading the details, you may notice that of the participants who received placebo, 47% did not increase BMD at the lumbar spine, and 15.6% had a decline of 3% or more. Let’s ponder this for a moment. Yes…Romosozumab increases BMD more than placebo.

Yet it is not impossible to increase BMD while not taking a drug for osteoporosis.
Of the 47% who did not increase in BMD in the placebo group, was their BMD stable? Consider that 15.6% had a decline in 3% or more.
If you recall, the authors stated the LSC for this study was set at 3%. Commonly accepted LSC for DXA is 5%. Why did the authors use an LSC of 3%? Perhaps making a statement that 96% of participants increase BMD by 3% is more impressive than 89% increasing by 6%. Knowing that commonly accepted LSC for DXA is 5%, one may ask if the change in BMD seen in this study real? Mathematics gymnastics!

Apply the same mathematics gymnastics to the total hip data.

Let’s look at Figure 3 on page 1224. Are you ready to apply your knowledge of Absolute Risk and Relative Risk ? Look at graph labelled “A” in the upper left corner of the figure. This graph is titled, “New Vertebral Fractures”. Let’s focus on the Year-by-Year subheadings.

Through Year 1

The RRR was 73%. This means there was a 73% relative risk reduction for new vertebral fracture for participants on Romosozumab. How was this calculated? The numerical values are below the words “New Vertebral Fractures”.

Relative Risk Reduction is calculated as follows:

(Control Group – Experimental Group) divided by the Control Group

59/3322 in the placebo group (approx. 1.8%) and 16/3321 in the treatment group (approx. 0.5%)

1.8% - 0.5% = 1.3%

Divide 1.3% by 1.8% = 72%

Note the article reads 73% which may be the result of using calculated values rather than rounding to the nearest whole integer.

Relative Risk compares the risk of a certain event occurring in two groups. It tells you how much more (or less) likely the event is in one group compared to another. Relative Risk is 0.5%/1.8% = 0.277. Recall if RR <1 then risk of fracture has been reduced. If RR is >1, then the risk of fracture has not been reduced.

Based on this Relative Risk , Romosozumab has reduced the risk of new vertebral fractures when compared to placebo.

Absolute Risk Reduction is not discussed in most research articles. Absolute Risk Reduction (ARR) is the risk of something happening minus something happening with an intervention. Absolute Risk Reduction can be calculated as the difference between 0.5% and 1.8% which is 1.3% decrease in New Vertebral Fractures for those taking Romosozumab for 1 year. Which number is more impressive - Relative Risk Reduction or Absolute Risk Reduction? Why is Absolute Risk Reduction not included in the results?

Let’s practice again and focus on Figure 3, graph A, “Year 2 alone”. This graph compares incidence of new vertebral fractures in those who had Romosozumab followed by Denosumab to those who had Denosumab alone. Relative Risk Reduction is included in the image. What is the ARR for Year 2 and Year 2 Alone?

Year 2 ARR is 2.5% - 0.6% = 1.9%

Year 2 Alone ARR is 0.9% - 0.2% = 0.7%

Let’s reframe the results for New Vertebral Fractures based on RRR and ARR.

In Year 1 participants had either placebo or Romosozumab. RRR is 73%. Recall, RRR shows how much the risk changes proportionally between the two groups. Much more impressive than ARR of 1.3%. Recall, absolute risk is the risk of something happening minus something happening with an intervention .

In Year 2 participants had Denosumab having had a year of either placebo or Romosozumab. The RRR is 76%, showing how much the risk changes proportionally between the two groups. The ARR is 1.9%. These numbers tell us that taking Romosozumab followed by Denosumab versus placebo followed by Denosumab decreased incidence of new vertebral fracture by 1.9%, but proportionally by 76%.

In Year 2 Alone investigators compared incidence of new vertebral fractures between those who had Denosumab alone to those who had Romosozumab followed by Denosumab…why? Because an RRR value of 81% is even better than 73%! Holy cow…sequencing medications produces even more impressive results! The ARR was 0.7%...not very impressive. What does this tell us about sequencing these medications? Patients who take Romosozumab followed by Denosumab decrease fracture risk by 0.7%!!! Whoa!!! But proportionally , new vertebral fracture incidence is decreased by 81%.

Let’s look at hip fractures in the same figure, graph D. You do the calculations and check your answers on the table below.

Take a moment to interpret these numbers knowing the definitions of RRR and ARR. What do the numbers tell you about hip fracture reduction in those who had placebo versus Romosozumab; those who had placebo followed by Denosumab versus those who had Romosozumab followed by Denosumab; and those who had Denosumab versus those who had Romosozumab followed by Denosumab?

Next, we can calculate the Number Needed to Treat (NNT) to prevent a fracture . The data that allows this analysis is found in a supplementary data file which includes Supporting Tables 1 and 2. In many journals access to supporting data is via a hyperlink in the text, but not on this occasion and to access this data, you have to know where to look on the journal webpage.

To save you the bother, here is the table with some notable additions:

We have highlighted in yellow results that show statistically significant differences. You will see that most results did not reach statistical significance. Also, we have added the NNT values for each comparison.

To calculate the NNT per year take the difference in the number of fractures that occurred in the two arms and divide the number of participants in the treatment arm by that number (or take the reciprocal of the ARR).

Here is a summary of the results:

To prevent one new hip fracture in the first year when participants were treated with Romosozumab, 598 needed to take the drug. In the second year, when Denosumab was the treatment, 637 needed to have the injections. Wow!

Let’s wipe the sweat from our brows and move onward from the results.

Step 6: The Discussion section is an opportunity for the authors to summarize the results of the study, reflect on its strengths and weaknesses and to offer direction for future research. The authors summarized the results of this study, as well as, preclinical trials in ovariectomized monkeys with increased bone mass and strength; and improvements in cortical thickness and estimated bone strength using CT and finite element analysis in post-menopausal women. Based on this study and the prior studies, the authors support sequential therapy using Romosozumab followed by Denosumab.

The authors reviewed the strengths and weaknesses of the study. The greatest strength of the study was large sample size, complete data on all study endpoints, and quality control of all BMD measures. However, if you dig deeper in the article in the methods section, you will find that BMD was measured at different intervals in Argentina. Also, in the Statistical analysis subsection “missing BMD values were imputed by carrying forward the last post baseline observation”. This means that if a result was missing, it was estimated from the previous result in the same patient. This is a well-validated method, but it does rely on the test being accurate.

How were BMD measurements quality controlled? It is well established that DXA scans can show significant errors unless they are performed with strict quality controls. There is nothing in the current paper to show that the level of quality was checked, which means the BMD results might not be as accurate as the authors would like to believe. Perhaps this information is described in another article?

Limitations of the study included the post-hoc nature (looking back in a rearview mirror), and “overall low fracture rates in the study limiting the power to detect between-group differences”. Furthermore, the authors recognized that they were not able to “perform quantitative correlation between BMD attained and fracture rates in the FRAME study because of the low rates of fracture events in the study…” Then they double down stating that “previous studies have shown that BMD attained on therapy correlates with fracture rate” and cite one study in the superscript reference number 38 which is an article from the FREEDOM study.

Step 7: The Conclusion section summarizes the authors take away message from the study. The authors noted large improvements in BMD in participants taking Romosozumab. The authors felt their data supported the potential clinical benefit of sequential treatment of Romosozumab followed by Denosumab. Based on your review of this article, do you agree with the authors? Reflect on your knowledge of Relative Risk Reduction, Absolute Risk Reduction and Number Needed to Treat. Is there enough reduction in fracture risk that you can make a decision that is best for you? Do you take the medication or not?

Step 8: Thinking practically and realistically.

Patent expiration: Both Romosozumab and Denosumab are made by a single pharmaceutical company. The Denosumab patent in the US expires in 2025, and in Europe in 2026. The Romosozumab patent in the US and Europe expires around 2035. Once the patent expires on any medication, then generic brands are made available and its time to bring to market the next big medication.

Cost of medications: This is a major concern for many patients, especially those on fixed incomes. Some pharmaceutical companies have programs for discounts, but let’s look at the average cost for these medications.

The average cost for Romosozumab is $2,628.92/month in the US, if a patient has insurance. If there is no insurance, the average retail price is $3,294.56. The annual cost if a patient has insurance is $31,547.04 in US dollars.

Denosumab on average costs $1,875.43 per injection. Injections are given every 6 months. If a person has no insurance, the retail price ranges from $1500-$2000. The annual cost if a patient has insurance is $3,750.86 in the US.

If a patient undergoes sequential treatment as described in the study, then cost is estimated at $31,547.04 + $3750.86 = $35,297.90. This is for just 2 years of treatment. However, patients are often told they will need to remain on Denosumab for the remainder of their lives or go onto a bisphosphonate.

Both medications are administered in a physician’s office. The cost listed above does not include the physician office visit. Although reimbursement for an office visit for an injection is not enough to buy lunch and definitely not enough for a physician to pay the office overhead.

These calculations and statements are designed to illustrate the cost of treatment for osteoporosis and should be taken as estimates. You may consider comparing this to a cost of care for a fracture.

We hope the information in this blog has empowered you with knowledge to make decisions that are right for you. Keep in mind that these medications have been beneficial for many people. We encourage you to optimize the things you can optimize on your bone health journey - building good nutritional habits , maintaining muscle mass , working on balance and falls prevention , choosing a positive mindset and being present in the moment . Those are the things medication cannot do for you. The power resides in you.

Don’t forget – you are not just a T-score! You are an entire beautiful and wonderful YOU!

Part 5: Understanding Relative Risk and Absolute Risk…Relatively Speaking, It’s Absolutely Crazy!

Tue, 10 Jun 2025 17:53:53 GMT

A Little Knowledge Lights The Way

Authors:

Kimberly Zambito, MD, Orthopaedic Surgeon and Owner of Qualis Os
www.qualisos.com

Nick Birch FRCS (Orth), Consultant Spine and Bone Health Specialist and owner of OsteoscanUK
www.osteoscanuk.com

Welcome to Part 5 in our series of databases and statistics. In keeping with the Star Wars theme from Part 4 (the fourth is with you). You are about to enter the final stage of Jedi training. Please review Part 4 before beginning Part 5.

Having discussed relative risk as a ratio in comparison to the odds ratio in Part 4, we now need to turn to the very heart of this matter: What are Absolute and Relative Risks and how are they important in judging whether treatment is effective?

Absolute and Relative Risk

Like risk and odds, absolute and relative risk sound similar but are not the same. To begin with we should define the terms:

Absolute Risk (AR) is the actual probability or chance of an event occurring in any defined population over a specific time period. It tells you how likely an outcome is and can be thought of as the baseline likelihood.

Relative Risk (RR) compares the risk of a certain event occurring in two groups. It tells you how much more (or less) likely the event is in one group compared to another. It is therefore the proportional difference between groups. We have already seen one example in Part 4 of our series.

Here are five medical examples that demonstrate the difference between absolute and relative risk.

Heart Disease and Statins

The 10-year risk of a heart attack for a group of individuals could be 10% without statins. With statins the risk might drop to 7%. This represents an absolute risk reduction of heart attacks of 3% but a relative risk reduction of 30%.

Breast Cancer Screening

Without screening, 5 in 1,000 women die of breast cancer over 10 years. With screening, 4 in 1,000 die. The absolute risk reduction is 0.1% (1 in 1000), but the relative risk reduction is 20% (1 fewer death per 5).

Covid-19 Vaccine

In unvaccinated people, the risk of hospitalization might be 2%. In vaccinated people it may be 0.1%. The absolute risk reduction is 1.9%, but the relative risk reduction is 95%.

Aspirin for Stroke Prevention

In high-risk patients, the stroke rate could be 6% without aspirin, but with aspirin 4%. This represents an absolute risk reduction of 2%, but a relative risk reduction of 33%.

HPV vaccination to prevent cervical cancer

The cervical cancer risk in unvaccinated women may be 0.2%. In vaccinated women it could fall to 0.05%. The absolute risk reduction is therefore 0.15% and the relative risk reduction is 75%.

Here’s a chart showing the absolute risk for each medical scenario, comparing outcomes with and without treatment or intervention . This helps illustrate the actual risk reduction patients might experience.

The distinction between absolute risk and relative risk is really important when reviewing research on a clinical trial of an intervention as we want to understand if the intervention is clinically relevant. For example, will taking a medication decrease risk of fracture? Let’s return to Arizona and the Grand Canyon adventures.

In our example (from Part 4), the risk of sustaining a hip fracture while on an adventure in the Grand Canyon is 22.5%. Now, let’s make a change so all participants no matter the chosen adventure are wrapped in bubble wrap. Wrapping participants in bubble wrap decreases the risk of sustaining a hip fracture to 10%.

The absolute risk reduction (ARR) is the risk of something happening minus something happening with an intervention. In this example, ARR is 22.5% - 10%, or 12.5% . This means that if a participant does 100 adventures, 12.5 hip fractures will be prevented by using bubble wrap. Another way to think about it, a participant would have to be wrapped in bubble wrap 12.5 times to prevent 1 hip fracture while doing an adventure in the Grand Canyon. This is referred to as Number Needed to Treat (NNT) which we’ll come back to below. ARR is interpreted in the context of baseline risk.

Relative Risk Reduction is the probability of something happening in one group compared to another group. RRR is an estimate of the percentage risk that is removed because of a new intervention . For example, we have 100 people with flabby muscles. Fifty of these people get treated with a new drug called “pump-you-up” and 1 person falls and sustains a hip fracture. The risk of hip fracture in this group is 1/50, or 2%. The other 50 people do not get the new drug and 2 people fall and sustain a hip fracture. The risk of hip fracture in this group is 2/50, or 4%. In this example, the relative risk is 2%/4%, or 0.5.

If you recall, if RR <1, then risk has been reduced. If RR equals 1, then risk has not changed. If RR >1, then risk has increased.

Things are going to get tricky now. Relative Risk Reduction (RRR) shows how much the risk changes proportionally between the two groups. In our example, the group that received “pump you up” sustained a hip fracture 50% less often than the group that did not receive “pump you up”. This is calculated as control group minus treatment group. This difference is then divided by the control group. In our example, calculation of RRR is as follows (4-2)/4, or 2/4 which is 50%. Advertising for “pump you up” may state “pump you up” decreased hip fracture by 50%. Sounds great!

Not so fast…the Absolute Risk Reduction (ARR) is the difference between 2% and 4%. ARR is 2%, meaning use of “pump you up” decreases hip fracture risk by 2%.

Which one of these seems more impressive- RRR or ARR? Many pharmaceutical companies advertise RRR. You are more likely to want to take “pump you up” to prevent hip fractures if risk decreases by 50% rather than 2%. Each is mathematically correct, but RRR seems better than ARR.

Absolute risk gives us perspective on how much benefit a patient is likely to have from a particular treatment or intervention. Relative risk help identify disparities in outcomes. Medical professionals may overestimate the efficacy of a treatment when results are framed in relative risk, rather than absolute risk. ARR considers baseline risk and is a more useful measure than RRR to express efficacy of a particular treatment.

Let’s go back to Number Needed to Treat (NNT) as this reflects the real world of medical treatment. NNT is the number of people who need to receive a treatment for one person to benefit (e.g., avoid an event such as a heart attack or death).

The formula to calculate NNT is: NNT = 1 / Absolute risk reduction (ARR)

Where: ARR = Absolute Risk (control group) − Absolute Risk (treatment group)

So NNT is based on absolute risk , not relative risk. Even if relative risk reduction sounds impressive (e.g. 50% for “pump you up”), the NNT could be high if the baseline (absolute) risk is low.

Low absolute risk = higher NNT (less efficient treatment)

High absolute risk = lower NNT (more efficient treatment)

NNT is a very patient-centric measure and is one of the best ways to look at a treatment if you want to know whether it is likely to benefit you.

Returning to the five medical examples we looked at earlier, the NNTs are:

Condition Absolute Risk Reduction (ARR) NNT

Heart Disease (Statins) 3.0% 33

Breast Cancer (Screening) 0.1% 1000

COVID-19 (Vaccine) 1.9% 53

Stroke (Aspirin) 2.0% 50

Cervical Cancer (HPV Vaccine) 0.15% 667

A lower NNT means the treatment is more effective in preventing one adverse event. A higher NNT still might be acceptable if the intervention is low-risk, low-cost, or applied to large populations, such as breast cancer screening.

Here’s a chart showing the Number Needed to Treat (NNT) for each medical example. Lower bars indicate more effective interventions in terms of how many people need to be treated to prevent one adverse outcome.

NNT and Bone Health

Both Hormone Replacement Therapy (HRT) and bisphosphonates are employed to reduce fracture risk in postmenopausal women, but their effectiveness varies based on individual risk factors and the type of fracture.

Hormone Replacement Therapy (HRT) at or after menopause

HRT replaces a woman’s natural estrogen that is lost when the ovaries stop producing the hormone at the time of menopause which on average is around the age of 50. It is well-established that bone mass reduces as a result of menopause and the risk of fragility fractures increases.

NNT : Approximately 8 postmenopausal women need to undergo HRT to prevent one fracture.

Bisphosphonates

Bisphosphonates are a class of drugs that prevent the loss of bone density but do little to improve bone toughness. Their effectiveness in fracture prevention varies:

Vertebral Fractures : NNT : Approximately 20 women need to be treated to prevent one vertebral fracture.

Hip Fractures : NNT : Approximately 100 women need to be treated to prevent one hip fracture.

Here is a chart showing the difference between the NNT to prevent one fracture if a woman uses HRT or bisphosphonates:

Anabolic agents

The bone building drugs (“anabolic” agents) increase bone density and bone toughness. The three in common use are: Romosozumab (Evenity), Teriparatide (Forteo) and Abaloparatide (Tymlos).

Treatment Fracture Type NNT (Approximate) / Comparator

Romosozumab Vertebral (FRAME trial) 77 Placebo

Vertebral (ARCH trial) 44 Alendronate

Major osteoporotic (MOF) 35 Alendronate

Hip 84 Alendronate

Clinical vertebral 79 Alendronate

Teriparatide Vertebral 11 Placebo

Non-vertebral 28 Placebo

Major osteoporotic 75 Placebo

Abaloparatide Vertebral 28 Placebo

Non-vertebral 55 Placebo

Major osteoporotic 34 Placebo

Here is a graphical representation of these numbers:

We hope you have enjoyed our series on databases and statistics. We did our best to keep each blog fun and educational.

Remember the wise words of Yoda, “A dark place we find ourselves, and a little more knowledge lights our way .” Allow the knowledge you have gained to illuminate your path forward on your bone health journey.

Remember, you are more than your T-Score. You are an entire wonderful you!

Part 4: Risk and Odds…C’mon, what are the odds something bad will happen???

Fri, 30 May 2025 20:57:24 GMT

Authors:

Kimberly Zambito, MD, Orthopaedic Surgeon and Owner of Qualis Os
www.qualisos.com

Nick Birch FRCS (Orth), Consultant Spine and Bone Health Specialist and owner of OsteoscanUK
www.osteoscanuk.com

Do you remember the scene: Alec Guiness as Obi One Kenobi in the bar on Tatooine telling the inquisitive Imperial war troopers that “there is nothing to see here. Move on.” He was using a Jedi Mind trick. Have you ever wondered about the use of similar Jedi mind tricks in medical research? Seriously, statistics can seem like Jedi mind tricks depending on how numbers are presented or manipulated. Many of our clients and blog readers have requested information about understanding “risk” as it pertains to results in research studies. In keeping with the Star Wars theme, the Force is Strong with our readers. Thank you for the inspiration.

Risk and Odds

“Risk” is the likelihood of something “bad” happening or a loss resulting from a particular action, decision, event, or situation. It involves uncertainty about the future and can apply to various areas such as finance, safety, business, and for readers of this blog, bone health.

There are three key aspects to risk :

Likelihood (Probability): How likely it is that an event will occur?

Impact (Consequence): How severe is the outcome likely to be if it did occur?

Exposure: What is the extent to which someone or something is vulnerable to that risk?

An everyday example of each is:

In finance, how likely am I to lose money if I invest in a risky venture?

What will the impact be on my family and me if I lose all my savings and get into a lot of debt?

Am I particularly exposed to the risk of financial ruin because I don’t know enough about stock markets or have been misinformed about a particular investment?

The term “odds” is often used instead of “risk” e.g. “Doctor, what are the odds that I will break my hip if I trip and fall?” However, “Odds” refer to the probability of an event occurring versus the probability of an event not occurring. It is not the same as risk. A bone health example would be:

Odds = Hip fracture occurs versus Hip fracture does not occur

Using the same scenario, an example of risk might be:

Risk = Chance of hip fracture versus All possible outcomes (no fracture, fracture anywhere, death)

Let’s look at a hypothetical example of a randomized controlled trial of hip fractures during adventure trips in the Grand Canyon, specifically, hip fractures sustained while tightrope walking across the Grand Canyon versus bungee jumping from a hot air balloon in the Grand Canyon.

The overall risk of hip fracture while on any adventure in the Grand Canyon is the number of hip fractures divided by all outcomes (all hip fractures and no hip fractures). For this instance, risk = 45/200 which is 22.5%.

The overall odds of a hip fracture while on any adventure in the Grand Canyon is the number of hip fractures/number of no hip fracture. For this instance, the odds = 45/155, which is 29%. The odds of breaking a hip are greater than the risk of breaking a hip during these activities. So which measure is “correct”?

The risk of hip fracture in the Tightrope Walking group is 15/100, is 0.15 or 15%.

The odds of hip fracture in the Tightrope Walking group are 15/85 is 0.18, or 18%.

Try applying this to the Hot Air Balloon Bungee Jumping group . What is the risk of hip fracture in this group? What are the odds of hip fracture in this group?

Risk = 30/100 = 0.30, or 30%. Risk equals number of hip fractures/all outcomes while hot air bungee jumping (or number of hip fractures + no hip fractures).

Odds = 30/70 = 0.43, or 43%. Odds equal number of hip fractures/no hip fractures while hot air bungee jumping.

Let’s consider comparison of risk and odds. Relative Risk , or risk ratio, is the ratio of risk of an event in one group versus the risk of an event in another group. In this instance, risk of a hip fracture in the tightrope group versus the risk of hip fracture in the hot air bungee jumping group.

Relative Risk (Risk Ratio - RR) = 0.15/0.30 =0.50

Odds Ratio (OR) = 0.18/0.43 = 0.41

A ratio (RR or OR) of 1.0 indicates there is no difference in sustaining a hip fracture between the two groups. A ratio of more than 1.0 indicates an increased risk among one group compared to the other. A ratio of <1.0 indicates a decreased risk in one group versus the other.

In the example above, the risk ratio is below 1.0 meaning there is less risk of sustaining a hip fracture in the tightrope walking group than the hot air bungee jumping group. The odds ratio of sustaining a hip fracture while walking a tightrope versus bungee jumping is also less than 1.0, so the odds of sustaining a hip fracture while tightrope walking versus bungee jumping are also less. So, if we want consider the Grand Canyon adventure activities on offer above, taking into consideration risk or odds of sustaining a hip fracture, then we may be better off tightrope walking over the Grand Canyon instead of hot air bungee jumping.

Having discussed relative risk as a ratio in comparison to the odds ratio, we now need to turn to the very heart of this matter: What are Absolute and Relative Risks and how are they important in judging whether treatment is effective?

Part 5 coming up…Feel the Force! (Remember…Stars Wars theme we are doing.)

Part 3: Estimating your risk of a future fracture due to impaired bone health: Is Fracture Risk Really Age-Dependent?

Mon, 28 Apr 2025 20:57:39 GMT

Authors:

Kimberly Zambito, MD, Orthopaedic Surgeon and Owner of Qualis Os

www.qualisos.com

Dr Nick Birch FRCS (Orth), Consultant Spine and Bone Health Specialist

www.osteoscanuk.com

Andrew Bush, MD, Orthopaedic Surgeon

www.centralcarolinaortho.com

For decades doctors have known that fracture rates increase as people get older, the primary reason being impaired bone density and bone toughness. As a result, in the 1990s there was a big push to develop screening tools to predict future fracture risk and allow earlier intervention to prevent fractures if a person’s risk was high. Many methods have been developed over the years including FRAX, Q-Fracture, the Osteoporosis Self-Assessment Tool (OST), DXA T- and Z-scores, and more recently REMS T-scores, Z-scores and Fragility Scores.

The simplest of these tools is the OST which uses a formula based on gender, age and weight to estimate whether a person has osteoporosis and by inference, whether their fracture risk is elevated. By definition this tool is age dependent. However, it turns out not to be particularly helpful in predicting future fracture risk as osteoporosis by itself only accounts for about a third of fragility (low trauma) fractures.

A more complicated prediction tool is FRAX which was originally developed in Sheffield, England in the 1990s. It was later adopted by the World Health Organisation as their official fracture prediction device, and it is now the most commonly used screening tool for fragility fracture risk. FRAX works by comparing a person’s characteristics to information about fracture rates in a very large database that matches their age, weight, gender, country of origin and a variety of clinical features. The fracture data from the database was recorded when FRAX was developed and from this matching process a risk profile is generated. Importantly, that data has not been updated in the years since it was first collected and given the change in lifestyles and wellness characteristics that have emerged since the 1990s, it is no longer certain that the matching process used by FRAX is accurate in relation to the current population and FRAX may now be systematically over-estimating future fracture risk.

The clinical risk factors (CRF) in FRAX include a past history of a fracture, history of a parental hip fracture, current use of steroid medication, current smoking and / or heavy drinking plus whether a person has a range of other medical conditions that might lead to impaired bone health e.g. malabsorption in the gut, thyroid disease, long-term liver or kidney disease, diabetes and rheumatoid arthritis. Each CRF adds a certain level of risk to the estimate of how likely a future fracture is. So, a person would reasonably expect to have a low FRAX risk if they remain healthy and active even in to their 70s and 80s. Not so! It turns out that FRAX is highly age dependent which means that however healthy you are, your risk when using FRAX to estimate fracture risk inexorably increases as you age.

Initially, FRAX was derived to determine fracture risk without input from diagnostic densitometry (DXA). Subsequently, an algorithm was developed that allowed DXA-derived BMD values, or T-scores, for the hip to be included in the fracture risk estimate (REMS-derived BMD values cannot currently be used in FRAX calculations). This goes some way to improve the estimate as it uses real data from the person being assessed rather than just comparing that person to broad categories of physiological features. Trabecular Bone Score (TBS) is a DXA method that was developed to estimate bone toughness in the spine and TBS values can now be included in FRAX as well. The addition of these values increases the accuracy of fracture risk prediction via FRAX, but the age bias remains.

This blog focuses on how increasing age affects FRAX generated fracture risk, irrespective of how healthy you are, and how this might lead to medical decision-making that might not make much sense.

Let’s explore the use of FRAX in prediction of fragility fracture risk. FRAX can be found on the internet at https://frax.shef.ac.uk/FRAX/ .

FRAX estimates fracture risk by using demographic information (Questions 1 - 4) and Yes / No responses for the clinical risk factors (Questions 5 – 11). The 12th entry is T-score or bone mineral density values if a person has had a DXA scan. After the questions are answered, FRAX calculates the likelihood that a fracture will occur in the next 10 years. The results are presented as two percentages – the percent chance of Major Osteoporotic Fractures (MOF: fractures in the upper limb, spine and lower limb) and the percent chance of Hip Fractures. Treatment algorithms for osteoporosis recommend medical intervention when the value of the MOF risk is 20% or higher and when the hip fracture risk is 3% or higher. It is because of the treatment algorithms that your physician may recommend medical treatment of osteoporosis.

The FRAX questionnaire above was completed for a healthy 62-year-old Caucasian female born in 1963. The results indicated an 8.8% risk of major osteoporotic fracture (MOF) and a 1.5% risk of hip fracture. Since MOF is less than 20% and hip fracture is less than 3%, medications to treat OP may not be recommended by this patient’s physician.

Let’s put a twist on FRAX and see how age input affects FRAX to demonstrate the bias of age on the database used in determining fracture risk. Let’s repeat the FRAX calculation at ten years older by changing the year of birth from 1963 to 1953. Go ahead, try this on your computer.

Then repeat the FRAX score using an age 10 years younger than the correct age (change from 1963 to 1973).

Each of the results are different. When age is increased, with no other CRFs being changed, MOF risk increases from 8.8% to 14% and hip fracture risk increases from 1.5% to 5.4%. When the age is decreased by 10 years, fracture risk of the spine decreases from 8.8% to 4.6% and hip fracture risk decreases from 1.5% to 0.5% with no changes in any other CRF.

The databases used by any method to determine fracture risk are designed for the general population . Age is a significant factor in determining fracture risk based on the statical assessment of the general population. We all know that the overall American population is not healthy. There are potentially many reasons for that but there is consensus that the average American diet is the reason most Americans suffer from many diseases as they get older. In addition, lack of activity and exercise, lifestyle choices (smoking and alcohol use) and stress ravage the body and bring about many diseases associated with age (heart disease, kidney disease, cancer, and osteoporosis, to list a few). Therefore, the databases represent an overall, unhealthy population, especially in the older age groups .

These current databases may not be particularly useful for individuals who are physiologically young because of healthy lifestyle choices. There is no appropriate database for physiologically young people . Fracture risk assessment tools including FRAX, REMS, and DXA do not know whether you are healthy or physiologically young. Whether you are healthy or not healthy , the information entered is what it is and therefore, each person’s fracture risk is estimated the same way, with the same level of risk being assigned .

In our experience with REMS, we have noticed that fracture risk may be overpredicted by REMS starting around age 66-67 years old . There are some attempts to try to address this issue, but there is no standardized method because the age-dependent database is universal . Even though there is concern that the absolute measurements may not be correct, REMS (and other methods) are still useful because the tests will establish a personal baseline which can then be used for comparison for future testing.

Remember, you are more than your T-score. You are an entire you! T-scores, Z-scores, BMD and Fragility Scores are pieces of the puzzle for your bone health, not the whole picture

Next in the series: Part 4: Risk and Odds…C’mon, what are the odds something bad will happen???

Part 2: Understanding the Development of the Fragility Score

Mon, 24 Mar 2025 16:46:11 GMT

I’m Active, Eat Right, and Have Never Broken a Bone…Why is my Fragility Score Yellow or Red?!?!?!

Authors:

Kimberly Zambito, MD, Orthopaedic Surgeon and Owner of Qualis Os

www.qualisos.com

Dr Nick Birch FRCS (Orth), Consultant Spine and Bone Health Specialist

www.osteoscanuk.com

Andrew Bush, MD, Orthopaedic Surgeon

www.centralcarolinaortho.com

Databases are used in many aspects of our everyday lives. When making a database, information from the general population, or a specific activity such as scientific research, is collected and then compiled in a centralized location in an organized manner for consistency and accessibility. Once the information is collected and organized in the database the information can be searched in multiple ways to answer a range of questions, and it therefore becomes very valuable. The information in a database, when correctly evaluated and analyzed, can then be used to help make decisions or predictions. With information gathered into an organized database, patterns will be observed and trends can be determined.

Often the collected data in a database will be represented in scattergrams or scatter graphs. These can be used to compare a range of “variables”. Variables are the things that change when something is being observed. For instance, if you were plotting the change in the temperature at noon each day, you would need to record the date as one variable and the temperature as the other. The illustrations below demonstrate scattergrams that show what the kinds of relationships between variables might look like. If the variables are highly correlated (noontime temperature and month of the year for instance) the scattergram shows a strongly positive trend (the “r” number is “+”). The opposite trend is strongly negative ( “-r”) which might for example reflect the relationship between the bank balance and level of gambling activity of a person who habitually loses at the tables when they visit Las Vegas. Both strongly positive and strongly negative trends reflect a narrow range of variables in well-defined situations. Weakly positive and weakly negative correlations are common in life, particularly in medicine, usually because there are a range of variables affecting an outcome and picking just one to try to correlate to that outcome means that only part of the picture is shown. The relationship of fracture risk and age is a good example of a weak correlation as there are many more factors that affect a person’s likelihood of fracturing than just their age.

Statistical analysis can be performed on the data from the database that contributes to a scatterplot. When the appropriate statistics are applied to the contents of a database an average can be calculated. The average will provide the data value with the most common property or feature that would best represent all the data in the database. This information can then be used to anticipate patterns and trends and develop expectations to be used in the general population.

In REMS, a value known as the Fragility Score is obtained during testing. The obtained value is applied to a scattergram to determine the chance of sustaining a fragility fracture:

The Fragility Score graph on the second page of a standard REMS report represents the likelihood that someone will fracture based on age (x-axis) and the measured Fragility Score (y-axis) . The result for any one scan is shown as circle with a cross inside and this is part of a “scattergram”, the rest of which is hidden. The database that allowed the scattergram of the FS values to be created came from people who had had REMS scans and whose fracture history was known. When this database was being created, the FS of individuals who had no history of a fragility fracture were placed on the graph with a green dot. The FS of individuals who had sustained a fragility fracture were placed with a red dot. This means that no one in the green-zone has fractured , whereas everyone in the red-zone has fractured .

The yellow is an add-on color covering up the zone of overlapping green and red dots. In the yellow-zone, near the green-zone , most people have not fractured but a few have (if you could peek under the yellow ribbon you would see many green dots and only a few red ones). In the yellow-zone near the red-zone most individuals have had a fragility fracture, but a few have not (mainly red dots under the yellow ribbon with a few green). Fracture risk can then be determined by combining the information from the first two pages of the REMS report- bone mineral density and Fragility Score. As a preventative medicine tool, the Fragility Score which is a reflection of the bone quality has impact on fracture risk assessment.

REMS is a powerful bone health screening tool, and it has similarities to other screening technologies such as mammography. Mammography is recommended on a yearly basis not to assess the health of the breast but to identify a density or mass that was not present on the prior exam. Similarly, REMS assessments are recommended on a yearly basis for women who are postmenopausal to look for significant (catastrophic) bone loss as could happen with a change in lifestyle or the development of medical conditions that affect bone health. The REMS FS slowly rises with age, but if the trend does not significantly vary from what is expected as “normal” it will indicate stable bone health. Refer to a prior blog regarding understanding changes in DXA or REMS.

While the Fragility Score is more predictive of fracture risk than BMD by DXA or REMS, it is not perfect. Like all the other methods used to estimate fracture risk, it is based on statistics, and statistics are based on data collected from a defined population. There are factors that can affect how statistics can be applied in an individual clinical scenario that are dependent on the data collection technique and the population chosen:

Who collected the data and how was it collected?
Who comprised the database?
How many individuals are in the data base?

As the scattergrams above show, for a weakly positive trend, there is a large range of data points that do not lie near the trend line. Many of these will represent individuals who will be considered “outliers”; therefore, the statistics and the graphs may not correctly represent such an individual’s condition.

Statistics when used appropriately are powerful predictors of trends and the likelihood that an event will occur. However, there are circumstances when the prediction will not be correct.

REMS is a technology we use to screen for fracture risk. The information gained from this powerful medical screening device does not define you , but helps medical professionals advise you on how to mitigate your fracture risk. It is critical to engage a trained medical professional who knows how to apply this information in the correct context for your health .

Coming soon - Part 3: Estimating your risk of a future fracture due to impaired bone health: Is Fracture Risk Really Age-Dependent?

Part 1: Understanding the Impact of Statistics and Databases on Your DXA and REMS Test Results

Mon, 17 Mar 2025 19:31:56 GMT

I’m Active, Eat Right, and Have Never Broken a Bone…Why is my Fragility Score Yellow or Red?!?!?!

Authors:

Kimberly Zambito, MD, Orthopaedic Surgeon and Owner of Qualis Os

www.qualisos.com

Dr Nick Birch FRCS (Orth), Consultant Spine and Bone Health Specialist

www.osteoscanuk.com

Andrew Bush, MD, Orthopaedic Surgeon

www.centralcarolinaortho.com

Why is it that some people who do everything right still have a dismal T- score or Fragility Score? The answer to this question has many facets, but the underlying science is based on statistics, population health and screening for diseases.

DXA is considered the “gold standard” for screening for osteoporosis. Since DXA is considered the current gold standard, all other technologies used to evaluate bone mineral density (BMD) are compared to DXA. REMS is an ultrasound technology used in the evaluation of BMD that has been extensively verified against DXA. However, it is unique in being able to measure bone quality of the hips and spine through the fragility score (FS).

BMD is expressed either as g/cm2 or g/cm3. The first represents the value of an area of a bone surface that is being examined and the second the volume of the relevant bone. Areal values are obtained from DXA and REMS machines and volumetric values are obtained through a CT scan. In general, DXA and REMS are the more commonly used technologies, so your results are more likely to be reported as g/cm2.

The REMS Fragility Score is a measure of the structural quality of bone that is independent of the BMD. It measures bone toughness, which has been established as the most important contributor to future fracture risk. Bone quality, or toughness, is comprised of bone density, microarchitecture, shape, along with other variables.

Whenever a screening technology is developed, data from a large number of people who have had the test are accumulated and stored in a database. As that database is progressively built, it comes to represent the variety of values of the test the target population will have. The larger the database, the more representative it will be of the general population. When we look at a “picture,” or graph, representing these data, most often it is in the form of a bell-shaped curve. This is called a “normal distribution” / “normal curve”. Most of the data points fall within a central band and clusters of values taper symmetrically on either side, creating the bell-shape.

If we examine various parts of the curve the middle value is called the “median”. The “mean” is the average of all the datapoints and the “mode” is the most frequent value. In a perfect bell-shaped curve, all three fall at the highest point of the curve.

Normal distribution curves can be subdivided into equal segments which are called “standard deviations.” These represent the "spread" of the data where a larger standard deviation indicates a wider bell-shaped curve, and a smaller standard deviation indicates a narrower curve.

In general, when we interpret the information in a bell-shaped curve, we follow the “68-95-99” rule. Approximately 68% of data falls within one standard deviation of the mean, 95% within two standard deviations, and 99.7% within three standard deviations.

How is this applied to information in your DXA or REMS scan results for BMD? The first value to look at is your “Z score”. This represents the difference between your bone density and the average bone density for people of your age who are the same gender and ethnicity as you. If your BMD (in g/cm ² ) is close to the middle (or mean), then your Z-score will be close to “0”. If your BMD in g/cm ² falls away from the middle, it will be given a Z-score that shows how far away from the average your BMD is. Z-scores can be positive or negative depending on whether your bone density is above or below average for your age. Therefore, if your Z-score is -1.0, your BMD is 1 standard deviation lower than the average population for your age, gender, and ethnicity. If your Z-score is -1.5, then your BMD is 1.5 standard deviations lower than the average population for your age, gender, and ethnicity . The same applies with positive Z-scores with +1.0 being 1 standard deviation above average and +1.5 being 1.5 standard deviations greater than the average population for your age, gender, and ethnicity.

At this point you might wonder why there is all this talk about Z-scores when everyone knows that bone density is expressed as T-scores. The reason is because the two types of score show bone density by reference to different populations. As we have said, Z-scores compare you to people your age who are the same gender and ethnicity. T-scores compare your BMD to the BMD of young healthy adults, who happen to be white women between the ages of 20 and 29 years, irrespective of your gender and ethnicity. The intent of using T-scores is to express how much bone loss has occurred since the age of 30 in the general population and from these values the World Health Organisation (WHO) diagnostic categories of “normal”, “osteopenia” and “osteoporosis” are derived. The table below shows how a diagnosis of osteoporosis is made in different groups of people.

Considering post-menopausal women, their T-scores show how much difference there is between their bone density and the bone density of young healthy white women, up to the age of 30, which is used as a reference. By 30 years of age, most women have reached “peak bone mass” which means they have the best bone density of their lives. From 30 to 40 years, bone mass is expected to remain stable, but after 40 there is a progressive loss of bone mass which is most rapid at the time of menopause and for the first 10 years afterwards. Unfortunately, most women do not know what their BMD or T-scores were at the age of 30 and if you do not know your starting point or baseline, how can it be assumed that you have lost a large amount of bone density by the time of the menopause? What if your baseline was low? Is it possible you have not lost much bone since you were 30? Is it possible you have lost bone density no more than anyone else through the aging process? After the age of 40 average bone loss is 0.5-1.0% per year except for women during the first decade after menopause when it can be as high as 2% per year (more statistical information from a database). How can we then understand who might be at risk of future fractures because of a deterioration of bone health after the age of 30? The simple answer is: Screening.

Screening is a process that involves checking for a disease or condition in people who appear healthy. So, screening for osteoporosis means we need to measure the bone density of people in the community by appropriate tests from which their T- and Z-scores are derived. Some people will have osteoporosis, and the test will show that to be the case because their T-scores or Z-scores are below the thresholds that define the diagnosis. These are “True Positive” results. Others won’t have osteoporosis, and the test will also show that to be the case as the T- or Z-scores will be above the diagnostic threshold (“True Negative” results). However, the test might not be completely accurate which means it could show a person who has osteoporosis as not having the condition (“False negative” result) or vice versa, a person who doesn’t have osteoporosis is shown as having the condition (“False Positive”) result. The accuracy of any screening test depends on the relationship between the four possible outcomes. The higher the proportion of true positive and true negative cases the more accurate the test. Why is this important?

When we identify people at higher risk of having a disease, then we can offer preventive measures or treatment. Let’s look at an example of a screening tool used in general medicine. An electrocardiogram (EKG) is used to evaluate electrical impulses of the heart and can be useful in identifying irregular heart rhythms which can be life threatening. Bradycardia is defined as a low heart rate. Let’s say a cardiologist is reviewing an EKG. The EKG demonstrates a very low heart rate of 44 beats per minute. Is this a cause for concern? The answer is “it depends.” If this person is a 30-year-old endurance athlete, then there is, most likely, no cause for concern. If this person is an 80-year-old on cardiac medication who is feeling dizzy, then yes there is cause for concern. The information from these screening tools must be interpreted within the appropriate context.

DXA and REMS are technologies we use to screen for osteoporosis, and by implication, fracture risk. However, knowing a person’s T-score or Z-score in isolation is only part of the picture and the information gained from these tools does not define a person. The results from DXA and REMS are in essence “medical statistics” that need to be properly interpreted by a trained professional who knows how to apply the information in the correct context of your general health, specifically as it applies to your bone health. Remember, you are more than your DXA and REMS results. There is an ENTIRE you!

Part 2: Understanding the Impact of Databases on Your Fragility Score and Fracture Risk

Fall Prevention is Fracture Prevention

Mon, 23 Sep 2024 20:51:33 GMT

Fall Prevention Week is September 23-27, 2024 . It coincides with the beginning of Autumn or Fall…how very punny. Falls are not funny though. Whenever a patient tells me they had a “bad” fall from a standing height, it sometimes indicates that they are in denial of their bone health. There are no “bad” falls from a standing height. There are falls that break bones and falls that do not break bones.

Most of the resources on this website focus on technology to measure bone density and bone quality. While both components of bone are related to fracture risk, we cannot forget the importance of fall prevention. This blog post is not about high-impact injuries that result in broken bones, it is about preventing fractures resulting from a fall from a standing or sitting position.

Why are these low energy falls such a big deal? These falls have the potential to become significant life changing events , especially if a fall results in a fracture. A history of fracture can increase the risk of subsequent fractures:

Prior rib fracture can increase risk of vertebral body fractures by 2.3- fold
Prior vertebral fracture can increase risk of subsequent vertebral fractures by 9.1-fold; new hip fracture by 7.1- fold; and wrist fracture by 2.3- fold
Prior shoulder fracture can increase risk of new wrist fracture by 5-fold; new vertebral body fracture by 10-fold; and new hip fracture by 18-fold
Prior wrist fracture can increase risk of vertebral body fracture by 37%

The Center for Disease Control has estimated the rate of death from falls increased 30% from 2007 to 2016. If this rate continues to increase, there will be an estimated 7 deaths each hour related to falls.

Falls can occur for many reasons, no matter your age. When younger people fall intact protective mechanisms may lead to a fall on an outstretched hand, resulting in a hand or wrist fracture. Older people have compromised protective mechanisms which may lead to a fall on their side, resulting in a hip fracture, or even a head injury. The CDC and National Council for Aging are excellent resources for learning about fall prevention. You can find a questionnaire to check your risk for falling here .

While this information about falls may seem scary at first, it can empower you to talk to your health care provider about fall prevention. There are a number of simple in-office fall assessment tools available through your doctor or physical therapist. Ask about having your balance assessed. If your primary care doctor or orthopaedic surgeon are not able to assess you, ask for an assessment with a physical therapist.

Here are some safety tips for you or for loved ones at home:

Ask your loved one if they are concerned about falling. Be gentle and compassionate. God willing, we will all grow older, and most likely weaker.
Notice if they are holding on to furniture or walls to move about the house, or have difficulty getting out of a chair.
Discuss current health conditions.
Have a list of current medications. Sometimes medications can make people dizzy, weak, or affect eyesight.
Ask about their last eye exam and if they needed updated glasses. Do a home safety check. You can get a home safety checklist at the website listed above.
Ask about fluid and food intake. Dehydration and low blood sugar can cause dizziness and lead to falls.

Let’s not forget about pets.

66.4% of falls associated with cats and 31.3% of falls associated with dogs are from tripping over the animal
Among people hospitalized for falls over pets, 79.9% were fractures
8.8% of pet-related injuries were caused by people tripping over a pet toy or food bowl

Journal of Safety Research 2010 and WebMD 2010

Here are a few tips to consider:

Walk the dog, don’t let the dog walk you
Dog obedience training
Clean food and water spills that can cause slip and falls
Clear floors of pet toys and leashes
Avoid bending over to pet an animal
Crate your dog or put the dog outside when expecting company

Be aware of your limitations and consider risk assessment before doing something you may consider stupid after sustaining an injury. If you have never tried ice-skating and you have decided that you want to try it as an older adult, you may consider doing a risk assessment. That assessment may go something like this: If I fall and break my wrist, will I be able to work and continue to earn money to pay my bills? If I broke my ankle, who will drive me around? For me, the answer is learning to ice-skate at my age is not worth the risk of a fracture. There are other activities I enjoy doing. Many patients have asked about skiing. If you have enjoyed skiing your entire life and you desire to continue this activity, do a risk assessment of the type of skiing you want to do. You may decide to stay away from black diamonds. You may decide you will be better off on green or blue slopes. You can still enjoy the activity as you age with some adjustments. At some point, you may decide that the activity no longer gives you the joy it did previously and you move on to something else.

Situational awareness or mindfulness in the moment is key to fall prevention. Whenever a patient comes to me for treatment of a fracture, I ask about how the fracture occurred. Typically, the answer is related to a fall. I follow with, “How did you fall?”. A story unfolds. Many times the story involves doing too much at once, not paying attention, or not turning on a light at night and tripping on something. Slow down. Have a night light for those night-time trips to the bathroom. Avoid carrying 15 grocery bags into the house at one time. Carry 3-4 and make multiple trips. Being in the moment prevents falls.

In summary, there are a number of reasons why a person may fall. Reasons may include medications or interactions of medications that cause dizziness; poor eyesight; muscular weakness, dehydration, low blood sugar, a cluttered home, lack of mindfulness, pets, and not knowing limitations.

The CDC and the National Council on Aging are great resources to get started with assessing your risk or your loved one’s risk for falling. Each source provides tips for preventing falls. If you have experienced falls, please share that information with your doctor, physical therapist, or loved one. There is no shame in asking for help to prevent a fall. If you have a loved one who has fallen, please do not shame them. Treat them with the kindness and compassion you want for yourself. Respect their dignity.

Preventing a fall is preventing a fracture.

Bone Health as a Healthcare Policy Issue

Tue, 03 Sep 2024 14:30:03 GMT

Why Is My Doctor Trying to Scare the $h!t Out of Me?

by Nick Birch FRCS (Orth), Andrew Bush MD, and Kimberly Zambito MD

Rates of osteoporosis and fractures associated with poor bone quality, which are known as fragility fractures, are at epidemic levels.

Osteoporosis is a systemic skeletal disease characterized by low bone mass and deterioration of bone structure which increases the risk of fractures.

It is estimated that osteoporosis affects approximately 200 million people world-wide.

Currently, it is estimated that 10 million individuals over age 50 in the United States have osteoporosis.

Each year approximately 2 million individuals suffer a fracture due to osteoporosis .

The risk of a fracture increases with age and is greatest in women.

Approximately 1 in 2 women and 1 in 5 men age 50 or older will experience a hip, spine, or wrist fracture sometime during their lives.

Approximately 40% of individuals are unable to return to their homes following a fragility fracture , requiring relocation to a nursing facility.

As many as 20% of individuals will die within 6 - 12 months of a fragility fracture .

An additional 43.4 million older adults have low bone mass or “osteopenia” and thus are at risk of osteoporosis and fragility fracture.

These are the statistics which are shared by physicians when talking to patients about osteoporosis.

Where do these statistics come from and why is my doctor trying to scare the $h!t out of me?!

Sources:

Osteoporosis. Juliet E Compston, Michael McClung, William D Leslie. The Lancet, 2019; 393: 364 - 376

The Recent Prevalence of Osteoporosis and Low Bone Mass in the United States Based on Bone Mineral Density at the Femoral Neck or Lumbar Spine. Nicole C Wright, PhD, MPH, Anne C Looker, PhD, Kenneth G Saag, MD, MSc, Jeffrey R Curtis, MD, MS, MPH, Elizabeth S Delzell, ScD, Susan Randall, and Bess Dawson- Hughes, MD. J Bone Miner Res. 2014 November; 29(11): 2520–2526. doi:10.1002/jbmr.2269.

Osteoporosis or Low Bone Mass in Older Adults: United States, 2017–2018. Neda Sarafrazi, Ph.D., Edwina A. Wambogo, Ph.D., M.S., M.P.H., R.D., and John A. Shepherd, Ph.D. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Health Statistics: NCHS Data Brief; No. 405: March 2021

An overview and management of osteoporosis. Tümay Sözen1, Lale Özışık2, Nursel Çalık Başaran. European Journal Of Rheumatology, 2017; 4: 46-56

Persistence of Excess Mortality Following Individual Nonhip Fractures: A Relative Survival Analysis. Thach Tran, Dana Bliuc, Louise Hansen, Bo Abrahamsen, Joop van den Bergh, John A. Eisman, Tineke van Geel, Piet Geusens, Peter Vestergaard, Tuan V. Nguyen, and Jacqueline R. Center. J Clin Endocrinol Metab, September 2018, 103(9):3205–3214 https://academic.oup.com/jcem

Osteoporotic-related fractures have an annual cost in the United States that parallels or exceeds the annual cost for myocardial infarction (heart attacks), breast cancer, and/or cerebrovascular accidents (strokes). We have been educated about heart attacks and various forms of cancer, but not about diseases that affect bone health. What if we think about a hip fracture or a vertebral body fracture as a “bone attack” , similarly to how we see the result of cardiovascular disease as a “heart attack”?

The cost of fragility fractures to society is financially burdensome. Fragility fractures are a source of significant human suffering, lost productivity and lost independence. Costs of providing care for osteoporotic fractures among Medicare beneficiaries was approximately $14 billion in 2018. The cost is expected to increase to over $25 billion in 2025. Keep in mind that statistics related to cost are often based on treatment and hospital costs and may underestimate the true costs associated with fragility fractures.

Ponder these questions:

· Is the financial burden related simply to the aging population breaking bones?

· Does the financial burden relate to my loved ones taking time from work to care for me if I sustain a debilitating fracture?

· How do the other conditions I have (“co-morbidities”) play a role in bone health and falls resulting in fractures?

Sources:

Treatment rates and healthcare costs of patients with fragility fracture by site of care: a real world data analysis. A. Singer, M. R. McClung, O. Tran, C. D. Morrow, S. Goldstein, R. Kagan, M. McDermott, A. Yehoshua. Archives of Osteoporosis (2023) 18:42 https://doi.org/10.1007/s11657-023-01229-7

Bone Health and Osteoporosis Foundation. Osteoporosis Fast Facts. Available at https://www.bonehealthandosteoporosis.org/wp-content/uploads/Osteoporosis-Fast-Facts-2.pdf

To stem the exponential rise in fragility fractures and the associated suffering and financial burden on society, our colleagues and policymakers are encouraged develop and implement public-wide screening programs and educational programs to increase awareness on the importance of bone health. DXA scans have been the mainstay for screening for osteoporosis, yet DXA scans are not accessible to everyone. Location and distance may be a factor, or a long waitlist, or obtaining a DXA scan may be cost-prohibitive if a patient does not meet insurance criteria for a DXA; and as mentioned in a previous blog, over 90% of DXA reports have at least one error. Some patients are concerned about the cumulative effect of radiation exposure.

You may consider there are other ways to screen bone health. Fracture risk assessment tools are available online. Look for a fracture risk assessment tool specific to your area of the world.

Check out the website for FRAX found at https://frax.shef.ac.uk/FRAX/

REMS scans are cost-effective, accurate, and portable. The portable unit (EchoS+) has immense potential to address bone health care disparities that are present in our healthcare system.

As you choose to empower yourself , start by taking inventory of your overall health .

· List your medical issues.

· List any medications you are taking.

· Does each medical issue or medication taken for a medical issue affect my balance, eyesight, or ability to focus my mind?

· How is my balance?

· Am I strong or are my muscles flabby and weak?

· How long can I stand on one leg (a good test of balance and strength)?

· Am I doing myself harm by smoking or drinking too much?

This list can certainly be expanded. Every journey starts with one single step and that first step is taking an honest look at where you are. The direction of that first step is up to you. If waiting for a policy maker or a system to tell you where to take that first step, it may be in a direction you do not want to go.

You can empower yourself and take responsibility to optimize your bone health and to minimize the risk of fracture. Open yourself to learning from credible and reliable sources. Realize that no one has all the answers and only you have the answers that are right for you. Partner with your healthcare professional to optimize your bone health.

And… one more resource for you …

https://www.niams.nih.gov/health-topics/bone-health-and-osteoporosis

Who is In Charge of Bone Health?

Fri, 23 Aug 2024 20:18:11 GMT

Bone Health is Connected to Overall Health

by Kimberly Zambito, MD and Andrew Bush, MD

A healthy mind resides in a healthy body. A healthy body needs healthy parts - healthy skin, a healthy heart and a healthy gut. To move all these healthy parts around we need a healthy skeleton. Our skeleton, all 206 bones, is an organ system just as our heart, our gut, and our skin are. Our skeletal system should be cared for in the same way that we care for all other parts. Unfortunately, we take our skeletons for granted. Until one day our foot gets caught on the edge of the carpet, or we forgot to wipe up the spilled water on the kitchen floor or our little dog or cat gets in between our feet causing the fall resulting in a loud “CRACK!!”. That “crack” signals a life changing event…a “bone attack” , rather than a heart attack. It is then that the importance of a healthy skeleton becomes a very painful reality.

Bone health is not too different from heart health or gut health. We must realize that our body systems work together and when that synergy is interrupted, we get sick. The basics of good health are consistent – good nutrition, active lifestyle, minimizing stress, appropriate exercise, good sleep habits, and avoiding unhealthy lifestyle habits such as smoking and excessive alcohol consumption. These recommendations are universal.

Proper nutrition is extremely important for healthy bones throughout life, especially during the years that bone is forming – up to approximately 30 years old. After that, the amount of bone that we have in our bodies will decrease as we age. The average rate of bone loss is 0.5-1% per year following peak bone mass at age 30. This bone loss happens in both men and women , although it occurs earlier in women. Bone loss can occur at a much more rapid rate and to a higher degree in women around menopause. It has been estimated that women may lose approximately 20% of their entire bone mass in the 10-15 years surrounding menopause. For this reason, most fragility fractures occur in women. The goal of a Bone Health program is to prevent bone loss beyond the average expected bone loss which occurs as part of the normal aging process, to educate people about those factors that can be modified, and to treat osteoporosis and fractures related to bone loss (fragility fractures). Treatment does not necessarily mean a prescription for medications.

Since our bones are protein and mineral-based , getting adequate amounts of protein and the appropriate minerals is imperative. Minerals crucial for bone health include calcium, magnesium, phosphorus, boron, selenium, copper, zinc and manganese and are building blocks for healthy bone. Adequate protein intake is important to make collagen which forms the scaffolding of bone. Other nutrients such as Vitamin D3, Vitamin C and Vitamin K2 are necessary for the processes of healthy bone building. Dietary sources of these nutrients are the preferred method of getting these important and essential nutrients, but supplementation is appropriate when these necessary nutrients are not obtainable through diet alone. Bone remodeling is an ongoing process, so maintaining healthy nutritional habits is also an ongoing process. If there is only one nutritional item you can improve upon, really consider optimizing protein intake, especially as you age or are overcoming an illness.

Getting physical with your bones is just as important as providing bones with building blocks through good nutrition. A factor crucial to forming and maintaining healthy bone is activity and exercise . Bone development and remodeling are driven by the applied forces that the bone “feels” . Impact (light to medium) stimulates the bone cells called osteocytes that live in the bone matrix to send out signals to the bone building cells (osteoblasts). Osteoblasts respond to those forces by building more bone. Bone health is maintained when muscles are strong, so that the bone “feels” the pull of those muscles. Strong muscles are built with exercises such as consistently challenging your muscles by weightlifting .

Posture, balance, and flexibility exercises are important to include in your exercise program. When you have a good sense of balance, falls resulting in fractures are less likely to occur. Fall prevention is part of a comprehensive bone health program.

Bone health care is preventative medicine. It is the core of fracture prevention. Early initial screening followed by routinely scheduled monitoring is essential. Many in the bone healthcare field recommend perimenopausal bone densitometric assessment around the age of 50, not at the age of 65, as is the current recommendation. By 65 years of age, a woman may have lost a significant amount of bone mineral density. By that time, treatment choices are significantly limited. We recommend everyone start the process early. With early bone assessment, a baseline can be established, and then routine yearly monitoring can be continued. This recommendation for bone health monitoring is in line with other healthcare monitoring - blood pressure, cholesterol and diabetes screening.

The importance of a healthy skeletal system is well understood by physicians of multiple specialties . Some primary care providers include Bone Healthcare in their annual physicals. Specialists like Orthopedic Surgeons who are trained to fix broken bones may emphasize bone health and fracture prevention when they treat patients. There are several different specialties that are involved in bone health care including primary care, physical medicine and rehabilitation, endocrinology, rheumatology, OB/Gyn, orthopedic surgery and radiology . Often physicians in these specialties will work in unison towards the goal of fracture prevention . There are organizations that are dedicated to establishing guidelines for healthcare professionals to follow and educational programs for both professionals and patients. Some of these organizations are: The Bone Health and Osteoporosis Foundation, the International Osteoporosis Foundation, the International Society of Clinical Densitometry and AmericanBoneHeath.org to list a few. These organizations have established guidelines for Bone Healthcare which include healthy nutritional habits and an active lifestyle with adequate exercise and appropriate rest. Guidelines also include the routine monitoring of bone health.

Monitoring of bone health is the foundation of fracture prevention in the way monitoring blood pressure is to stroke prevention and mammograms are to breast cancer prevention. The early detection of any of these conditions allows for early treatment to be instituted to prevent the long-term consequences of the disease. Bone health assessment is looking for osteoporosis. Although some may still consider developing osteoporosis an unfortunate part of growing older, it is now understood that fracturing due to idiopathic age-related bone loss is not an inevitable part of aging, but a potentially preventable complication of bone loss. Nutrition and exercise fight against excessive bone loss by optimizing things that can be optimized naturally – monitoring makes sure that they are working.

The term for bone monitoring is known as bone densitometry – the measurement of bone density. Determining bone mineral density (BMD) has been the traditional method of diagnosing osteoporosis and predicting fracture risk. The most common way to measure BMD is by using Dual Energy X-ray Absorptiometry (DXA). DXA has been around for over 30 years and has been the backbone of Bone Healthcare. It is a method of measuring BMD by using low-energy x-ray and has been considered reasonably reliable for measuring BMD and diagnosing and treating osteoporosis. However, DXA does have an error rate reported to be up to 90% and it is not very reliable in predicting fracture risk. DXA can only measure BMD. BMD is a measurement associated with fracture risk, not a determinant of fracture risk . Fracture risk increases with lower BMD, yet it is estimated that nearly 50% of all fragility fractures happen in individuals who have either normal or near-normal BMD measured values . How can that be so?

There is another property of bone, not measured by DXA. That property is Bone Quality. Bone Quality refers to the microarchitecture and flexibility of bone tissue. Radiofrequency Echographic Multi Spectrometry (REMS) is a newer method for monitoring bone health. REMS has been used in Europe for almost ten years and has replaced DXA as the official method of bone densitometry in Italy. REMS uses ultrasound to measure BMD. Additionally, the ultrasound is capable of measuring Bone Quality which is reflected in the Fragility Score . The Fragility Score has been shown to predict fracture risk better than DXA BMD, TBS, and REMS BMD. REMS is still very new in the United States, but its popularity is growing as more people are learning about this ground-breaking technology.

In addition to densitometry, there are other methods to assess and monitor bone health. These include laboratory assays that measure blood levels of various factors that are a direct measure of bone health or indicate other medical conditions that can affect bone health. These tests will be performed by your healthcare professional as a part of a comprehensive bone health assessment. Genetic testing may soon be part of routine bone health assessment.

Bone health is tied to our general health , so it is important to monitor general health and for us to observe and be compliant with medical recommendations. Appropriate management of many medical conditions will decrease the effect that those conditions might have on our bone health.

If levels of nutrition and exercise are not enough to maintain a healthy skeleton, or if medical conditions are affecting bone quality, then there are specific medications that can help to prevent bone loss or build bone. The decision to use any of these medications should be made in consultation with your bone healthcare professional. If you are started on any of these medications, you must be compliant with the directions of use and monitoring the effectiveness of the medications is also essential.

In conclusion, it is important to remember that your bones need to be monitored and cared for like any other part of you . Although we focused on bone health as a women’s health issue, poor bone health can affect anyone. Everyone has a skeleton, and we need to pay attention to and take care of our skeletons because if you ignore your bones, they will go away!

YOU are in charge of your bone health and your overall health. Partner with your bone health care professional to decide what is right for you. Be honest and realistic with yourself and your health care team about what you are willing to do to optimize your bone health.

Remember, you are more than the numbers on your DXA or REMS scan. There is an entire YOU.

What is Discordance?

Wed, 17 Jul 2024 15:34:17 GMT

Guest blog by Nick Birch, FRCS (Orth)

The diagnostic categories of bone density include normal, osteopenia and osteoporosis. The reference level of bone density is that of a healthy 30-year-old adult, an age that is chosen as it represents “peak bone mass” i.e. the best bone density a person can expect to have in normal circumstances. If everyone was the same, it would be expected that they would all have normal bone at the age of 30 and that over time there would be a reduction of bone density with age and in women with the onset of menopause. However, everyone is not the same. There is considerable variation in height, weight, levels of physical activity, diet and background medical conditions. As a result, the three diagnostic categories, which are very much a “one size fits all” set of labels, do not adequately describe the bone health of significant proportions of the population.

Bone density varies with build. People with a higher body mass index have an increased bone density compared to people with a lower body mass index. In women sustaining a low-energy fragility fracture, only a third have a DXA diagnosis of osteoporosis i.e. low bone density. The other two thirds have diagnoses of osteopenia or normal bone density. This demonstrates that it is not just the bone density that determines fractures, but other factors as well. One of the most important of these is bone toughness (bone quality or bone strength). Toughness comes about as a result of repeated impact exercise when the underlying condition of bone is normal i.e. there are no medical reasons for bone to be weak.

For example, a person with a low body mass index who is extremely active will have a low bone density commensurate with their build, but their bone toughness is likely to be good. Therefore, they may be less likely to fracture than an overweight, unfit person who will have better bone density but poor bone quality.

In most people the diagnostic category for the hip and the spine will be the same, but if the T-scores are close to the boundary between diagnostic categories they can be different. This difference is called discordance. But does this mean there is more like to be a fracture in one part compared to the other because one diagnosis is worse than the other? To understand these questions the original definitions of Normal, Osteopenia and Osteoporosis need to be revisited.

Osteoporosis is defined by the World Health Organization (WHO) as: A systemic condition characterized by low bone mineral density (BMD) in the osteoporosis range measured by bone densitometry (T score < -2.5) or a significant fracture risk based on fracture risk assessment e.g. FRAX with or without fragility (low trauma) fractures.

Systemic means affecting the whole body and, in this case, refers to the whole skeleton. Generally, in premenopausal women, it is expected that the bone density of the spine and hips will of the same order of magnitude unless there are specific reasons for them to be different such as playing sport where the impact is taken more on one lower limb than the other.

In postmenopausal women there often is more variation, which can also be the case in people who have specific reasons not to use certain parts of their bodies such as those who have suffered paralysis because of a stroke or an injury resulting in prolonged off-loading of a lower extremity.

When the T-scores fall into the same WHO diagnostic category (normal, osteopenia, osteoporosis) they are defined as being concordant . If they fall into different WHO diagnostic categories, they are discordant .

A minor discordance is defined as T-scores in adjacent WHO diagnostic categories of bone density:

A major discordance is present if either the hip or spine T-score is normal and the other is osteoporotic.

Even if T-scores at hip and in the spine put a woman’s bone density into the same WHO diagnostic category, large differences between T-scores e.g. -2.5 at the hip and -4.7 in the spine need to be explained if there is no clear clinical reason why such a difference exists.

There are several reasons for discordance:

Physiological The skeleton’s adaptive reaction to mechanical strain

Pathophysiological A disease state affecting the skeleton

Anatomical Differences between sites in content of cortical and trabecular bone and/or rate of bone loss

Artefactual The presence of manmade items within the region of interest of the test

Technical Faulty device hardware or software or the technologist’s method of acquiring or analyzing the test

Physiological, pathophysiological and anatomical reasons for discordance refer to clinical variation and they are therefore unrelated to the actual bone density test.

Anatomical reasons include the different distribution of hard (cortical) bone and softer (cancellous) bone in the hip and spine. With advancing age, an increased incidence of degenerative conditions in the spine and hip (e.g. arthritis) can cause errors in DXA analysis leading to discordant results. Other factors include ages of onset of menarche (puberty) and menopause (more discordance with late menarche and early menopause), Body Mass Index (less discordance with obesity) and secondary causes of osteoporosis (chronic inflammatory conditions and long-term use of some medications can predispose to discordance). In addition, some populations that are prone to vitamin D deficiency (women in Muslim communities wearing the Burka and Niqab) show different rates of discordance compared to populations that are more exposed to sunlight.

Artifactual and technical reasons for discordance are the result of equipment calibration and operator error and can be eliminated by strict adherence to correct bone densitometry principles and practice. For DXA the latter include correct patient positioning and interpretation of the x-ray images. Neither of these are relevant for REMS scans.

Six studies published between 2000 and 2014 showed the rates of concordance and discordance as:

Concordance 48% - 58%

Minor discordance 35% - 46%

Major Discordance 2% - 17%

Reference Files:

Summary of studies reporting the rates of T-score concordance and discordance

Details of concordance and discordance rates in studies of DXA performance

In 2023 Young and Birch presented their results of REMS discordance rates showing a minor diagnostic discordance rate of 15%, a numerical discordance rate (i.e. a difference between T-scores of the hip and spine of < 1.0) of 6.5% and a major discordance rate of 0.0%.

If a woman has a DEXA scan showing a major discordance, or a T-score discrepancy of more than 1.0 and she has no obvious reasons for such a result, she should query the DXA result with the local unit. If a reasonable answer is not forthcoming, asking for a second opinion with a bone density scan performed either on a different DXA machine or with alternative technology e.g. REMS, is entirely reasonable and appropriate.

Why is my T-score going up or down and my Fragility Score going up or down?

Fri, 21 Jun 2024 17:22:51 GMT

I recently received a question: why is my T score going up and my fragility score getting worse? This is a great question. Let's take this step by step.

First let's address the T-score. When tracking bone health over time, we must evaluate the actual numbers for Bone Mineral Density (BMD), not T-score. The T-score is a nice way to get an overall picture of your BMD compared to a 30-year-old white female. It is easy to get sucked into comparing T-scores, as we have all been conditioned to look at T-scores. However, T-scores represent standard deviations on a graph, and they represent a range of numbers and not absolute values of BMD. Therefore, tracking bone density over time can only be done by comparing BMD values in g/cm ² and expressing those changes as percentages compared to baseline and compared to the result immediately prior.

There are several factors that cause the BMD and therefore T-scores to change including age, levels of activity, nutrition and build. In post-menopausal women, there is a natural reduction of BMD and T scores over time which can be slowed, and in some cases reversed, with attention to good nutritional balance and lots of impact and resistance exercise. These changes usually occur slowly and are often not detectable on DXA scans in under several years because the Least Significant Change (LSC) is 5-6% which is not sensitive enough to measure a few percentage points difference. REMS can detect such changes, usually at yearly intervals. Changes in BMD caused by increases or decreases in weight and thus Body Mass Index (BMI) occur more quickly, and these changes can often be detected by REMS over a period of months rather than years. If the change is sufficiently large, DXA will be able to detect it in similar timeframes.

For simplicity, let’s say BMD in 2022 was 0.983 g/cm ² . Then in 2024, BMD was 0.899 g/cm ² .

The change in BMD is calculated as follows:

0.899 - 0.983 = -0.084 This demonstrates a decrease BMD (g/cm ² ) over 2 years.

To find the percent change, divide -0.084 by the original BMD (g/cm ² )

-0.084 ÷ 0.983 = -0.085 This indicates there was an 8.5% decrease in BMD (g/cm ² ).

Remember to take into consideration the LSC which are different for DXA and REMS. A generally accepted LSC for DXA is 5-6% . So, if the change in BMD over time is less than 5-6%, it is not necessarily a real change when measure by DXA. If the change is greater than 5-6%, it does represent a real change. LSC for REMS is 0.88-1.05% (0.88% for hip and 1.05% for spine) meaning it can detect smaller changes, often in shorter timeframes. In the example provided above, there was a real change in BMD, as 8.5% is greater than 5-6% for DXA and 0.88-1.05% for REMS.

Fragility Score is an adimensional number from 0-100. The lower the score, the better. FS reflects the micro-architecture of the bone. The AI in REMS technology compares the acquired spectra from the patient to a reference database. If the patient’s spectra match the spectra of individuals who have fractured, the patient will be in the RED. If the patient’s spectra match the spectra of individuals in the database who did not fracture, then the patient will be in the GREEN. YELLOW indicates some individuals fracture, and some did not.

There is a natural increase in FS over time which is in the range of 1.5 – 2.0% per year in post-menopausal women. If the difference in FS over, for instance three years, is 4-5, that change may be inconsequential, considering the LSC and the expected change with age.

Remember, you are more than your T-scores or Z-scores. Knowledge brings empowerment and peace of mind.

Why are my DXA and REMS Different?

Wed, 12 Jun 2024 17:08:51 GMT

It is VERY common to see discrepancies in the values noted on DXA versus values noted on REMS. Without seeing the images from your DXA scan on a complete report, your physician is not able to pick apart the details of your DXA report. However, there are some common themes that we REMS users have seen.

For a simple guide to understanding your DXA report, please see:

Choplin, et al. "A practical approach to interpretation of dual-energy x-ray absorptiometry of bone density," Curr Radiol Rep (2014).

During the development of REMS technology, REMS was compared to the "gold standard" of DXA. The performance of the DXAs for comparison was quality controlled, as was the performance of the REMS. In the community, DXA quality is not assured the same way that it is in a research scenario. The potential for errors is high for DXA. The potential for REMS errors is much lower given the precision of the technology. For reference, please see:

Messina, et al. "Prevalence and type of errors in dual-energy x-ray absorptiometry." Eur Rad, Nov 2014.

Fatima, et al. "Discordant interpretation of serial bone mineral density measurements by dual-energy x-ray absorptiometry using vendor's and institutional least significant changes: Serious impact on decision-making," World Journal of Nuclear Medicine, 2018, 236-240.

Typically, the values on DXA hips, REMS spine, and REMS hips are similar. The DXA spine is typically the outlier. DXA spine values may be very negative and DXA hips and REMS spine and hips are not so negative. Why would your spine be one value and your hips a completely different value on DXA?

Dr. Nick Birch and his colleague Maddy Young presented their data regarding discordance at the British Orthopaedic Research Society annual meeting in the autumn of 2023.

Young M, Birch N. “Prevalence of major and minor discordance between hip and spine T-score using REMS: Implication for bone health assessment and patient management.” Orthop Procs. 2023;105-B(SUPP_16):46-46.

If you are interested in learning about the development of REMS technology, or to have a couple of papers to share with your treating physicians about REMS, I recommend:

Della Ciardo, et al. "Pulse-Echo Measurements of Bone Tissue, Techniques and Clinical Results at the Spine and Femur," Bone Quantitative Ultrasound. Advances in Experimental Medicine and Biology 1364.

Pisani, et al. "Screening and early diagnosis of osteoporosis through x-ray and ultrasound- based techniques," World Journal of Radiology, 2013 Nov 28; 5(11): 398-410.

Pisani et al. "Fragility Score: a REMS-based indicator for the prediction of incident fragility fractures at 5 years," Aging Clin Exp Res; 2023; 35(4): 763-773.

This last paper is ground-breaking as it demonstrates the importance of consideration of bone quality in terms of fracture risk. This paper is mentioned in the 10-minute video tutorial, “ Understanding Your REMS Report ”.

Here are some things you may consider:

Was there a significant change between your baseline DXA and subsequent DXAs?

Is it reasonable to obtain serial scans over the next couple of years? If there is no change and your bone density and quality are stable, is there a need for medication for bone health? If there is a precipitous decline in density or quality, would you consider medication? Be honest with yourself and your treating physician about what you are willing to do or not do to optimize your bone health.

Have you had a fragility fracture? Fractures are the greatest predictors of future fractures.

Are your labs normal?

Receiving the diagnosis of osteoporosis can be overwhelming. Remember, you are more than your DXA T-score or Z-score.

Medical terms and acronyms in plain English

Tue, 19 Dec 2023 15:48:28 GMT

Medical Science is full of acronyms and special terms. We have included a list of those commonly used on this site.

Bone Mineral Density (BMD) is a measure of the unit mass of your bone per unit of area and it is written as g/cm2. BMD is considered an “areal” measurement (derived from “area” since it comes from a flat surface area measurement and not a volumetric measurement). BMD is expressed in terms of T-score and Z-score. T-score compares BMD to the BMD of a 30-year-old caucasian female. Z-score compares BMD to an age-related match.

Bone Quality is a term encompassing microscopic structural properties of bone that include bone microarchitecture, the presence of micro-fracturing, and collagen crosslinking. Bone quality is one of the factors that determines bone strength. Bone strength is the ability of a bone to withstand an applied force and not fracture.

Bone Strength is the measured ability of a bone to withstand applied forces and not fail (fracture). Bone strength is determined by BMD and Bone Quality. Some research has indicated that bone geometry plays a role in bone strength.

Dual Energy X-ray Absorptiometry (DXA) is a commonly used method of determining bone density using two X-ray beams of relatively low and differing energy levels to assess the capacity of the bone to attenuate the beams.

Fragility Score (FS) is a REMS-derived measure of bone quality. FS has the highest level of sensitivity and specificity for fracture risk prediction when compared to DXA-derived or REMS-derived BMD values. It appears to have the best predictive value for fracture risk.

Least Significant Change (LSC) is the error margin of a particular densitometry unit. An appropriately calibrated DXA machine has an LSC of 3% to 5%, meaning it has an error rate of up to 5% for any study done. Any changes in a sequential series of DXA-derived BMD values that are less than 5% cannot be considered statistically significant and therefore cannot be used for treatment assessment and/or treatment recommendations. In other words, you would have to have a greater than 5% bone loss or gain between two serial DXA studies in order for that change to be meaningful. The LSC is the main reason that DXA scans are indicated every two years - it is statistically more likely that you will lose 5% of your bone mass over two years vs one year. REMS has an LSC of 0.5% to 1.05% and therefore REMS studies, if medically indicated to monitor the effectiveness of an osteoporosis medication, can be done yearly or even every 6 months.

Normal BMD is defined by a T-score of 0 to -1

Osteopenia is not a diagnosis. It is a description of low bone mineral density or mass and is defined as a T-score of -1.1 to -2.4. Current terminology used “low bone mass” or “low bone mineral density”.

Osteoporosis is the state of very low bone density and is defined as a T-score of ≤ -2.5.

Quantitative Ultrasound (QUS) is a screening tool used to evaluate for osteoporosis. It cannot be used to diagnose osteoporosis or monitor bone health. This is different than REMS.

Radiofrequency Echographic Multi Spectrometry (REMS) is an ultrasound-based method of assessing bone density and quality.

Region of Interest (ROI) are the areas of the body that are imaged during bone densitometry to determine a clinically significant BMD measurement. Both REMS and DXA have the same axial ROIs - vertebral bodies L1 through L4 in the lumbar spine and both hips that include the femoral neck and total hip. DXA has an additional ROI which is the distal 1/3 of the non-dominant forearm which can be useful in certain clinical cases. These sites were determined by the WHO to provide clinically relevant measures of bone density.

T-score is a statistically derived number that also serves two purposes. First, it gives a numerical representation of the comparison of an individual's BMD measurement to that of a reference BMD. The mean BMD value of a large database of 30-year-old Caucasian females is the benchmark for all comparisons). To determine how we compare to that database, we use the concept of standard deviations which represents a certain percent value away from the established average value as determined on a bell curve. For example, if a person has lost a certain amount of bone as compared to a 30-year-old then we can say that we are a “negative one standard deviation away” or the T-score is -1.0. If BMD matches the mean BMD of a 30-year-old, then the T-score would be 0. The T-score is also used to determine a diagnosis. The WHO has set parameters that a T-score value of 0 to -1.0 is considered normal bone density, and that a T-score value that ranges from -1.1 through -2.4 constitutes “low bone density (or osteopenia). A T-score of -2.5 or lower (more negative number) establishes the diagnosis of osteoporosis.

Trabecular Bone Score (TBS) is a method of determining a measure of bone quality using otherwise unprocessed data obtained during a spinal DXA scan to evaluate bone quality. Not all DXA units are TBS capable, as it is a software add-on. The quality of the TBS is dependent on the quality of the index spine DXA scan.

Vertebral Fracture Analysis (VFA) is a spine assessment to evaluate for or to monitor spinal compression fractures. A VFA can be performed on a DXA unit if the DXA has the appropriate software. A VFA will show the entire spine on a single image. VFA or lateral x-rays of the thoracic and lumbar spines are indicated for screening once a woman reaches 70 years old and a man 80 years old. This type of imaging is indicated for sudden onset of back pain following a traumatic event, severe back pain and/or as a yearly screening tool for someone with a history of compression fractures or any kind of fragility fracture.

Z-score is conceptually similar to a T-score, except it is the method of comparing BMD value to the mean BMD of a 5-year bracketed age and gender-specific cohort database (5-year interval). A Z-score is 0 if it falls exactly on the mean (average) BMD value of individuals in the age and gender-specific cohort. Similar to T-score, Z-score is measured in SDs along a bell curve. The Z-score has no clinical relevance between the ages of 40 and 90 years old. Outside of the 40–90-year-old age bracket, the Z-score establishes a diagnosis – the benchmark for osteoporosis is a Z-score of -2.0 SDs or lower.

Bone-ified Thoughts on Halloween

Sat, 21 Oct 2023 16:00:04 GMT

It's the time of year when ghosts, goblins, and skeletons run the streets. Happy Halloween! I have fond memories of the excitement of making costumes and running around with friends on Halloween. Of course, getting a ton of candy was the goal, but what has lasted through the years are the memories of being with friends, having pride in making a costume, and learning how to broker deals - Bottlecaps for Dum-Dums. I continued that tradition with my son. Yep- he was a pumpkin, a Thomas the Tank Engine engineer, a TRex (his arms were not too short to grab candy), a baby tiger with mommy tiger, a SpiderMan Shark (yes, you read that correctly), Wolverine (old school Wolverine), and an Alien Hunter.

The days of making costumes with him have passed, as his other interests have taken priority…for now. I enjoy sitting outside giving candy to kids in the neighborhood and reminiscing about walking around with my son as he lived up to his alter ego for the season.

Whether you choose to venture out with little ones, or stay home to give out candy, take a moment to mitigate risks for a potential fall . Use a flashlight when walking the neighbor. Make sure the pathway to your calderon of candy is well-lit . Wear sensible shoes for walking. Fur babies that rush to the door when the doorbell rings, create a fall risk. Consider using a leash and have them accompany you to the door, or secure them in a crate or room during Trick-or-Treat hours. Make sure your eyesight is not blocked by a mask or costume. If you cannot see where you are going, you may find yourself kissing a curb. Ouch. Preventing a fall equals preventing a fracture.

Oftentimes, people I meet with osteoporosis have fear of breaking a bone. They have been scared by other doctors who have put fear in their minds- fear of crumbling bones and falling apart. Life is meant to be lived. You will not disintegrate (unless an alien strolling your neighborhood gets you with a laser beam). Be smart. Do some risk management. And embrace living life to its fullest.

Let me know if you score some Bottlecaps because I will trade some Razzles for Bottlecaps any day!