Farah Naz Khan | Vox

Doctors are blasé about bone health, and it’s leading to more broken bones in the elderly

2019-05-02T12:41:02-04:00

An X-ray image of the elbow bone. | Getty Images

At the age of 89, my grandfather walked into the family room from his bedroom, forgetting he needed his walker. We’re still not quite sure exactly how he stumbled and hit the ground, but he ended up with a hip fracture.

His doctors deemed him too high-risk for surgery, and so he was left bedbound for the next year until his immobility, along with another health issue, became too debilitating and he died.

Since his death, my family has often discussed how that one fall — and his undiagnosed osteoporosis that was revealed with the hip fracture — was the beginning of the end for him.

We also can’t get over how less than a year later, in the very same room where my grandfather fell, my grandmother stumbled and fractured her left arm in three places. Previously fully independent, she then required 24/7 care because she couldn’t even use the bathroom without assistance.

As a physician, what has disturbed me most is that both my grandmother and grandfather had the same primary care doctor, who never bothered to do bone density scans to see if they had osteoporosis.

And it’s precisely the health care system’s failure to look for osteoporosis as often as it should — along with a parallel crisis in osteoporosis treatment — that is setting us up for the acceleration of a disturbing trend that was recently highlighted in an important study.

Researchers writing in the journal Osteoporosis International found that hip fractures in women over 65 began increasing in 2013 among Medicare recipients (after plateauing for years), with an additional 11,000 estimated hip fractures between 2013 and 2015. There are two clues that point at the causes of this burgeoning crisis: There’s been a decrease in bone density screening tests and a decrease in prescriptions for osteoporosis medications (the biggest class of which are called bisphosphonates) because of patients’ fears of their side effects.

So if doctors aren’t looking for osteoporosis, and many patients are turning down treatment, how can we prevent life-altering falls like those suffered by my grandparents?

More than 10 million Americans have osteoporosis today

More than 10 million Americans currently have osteoporosis, and another 44 million are at increased risk of developing it. By 2020, the number of Americans with low bone density is expected to rise to 64 million adults, or 20 percent of the population, with a proportional increase in the number of fractures.

In osteoporosis, which means porous bone, bone density is decreased because of not enough bone formation, excess bone loss, or some combination of both.

Most commonly, this loss of bone density occurs due to hormonal changes that accompany aging: lower estrogen levels in women post-menopause and decreasing testosterone levels in men over the age of 70.

Other factors — such as the use of certain medications, autoimmune disease, tobacco use, excess alcohol intake, and low calcium levels — can amplify bone loss or dampen bone building, thus increasing the risk for osteoporosis.

The lifetime risk of an osteoporotic fracture (fractures that occur at a site with known low bone density) is estimated to be 40 to 50 percent in women and 13 to 22 percent in men. We have long known that more than 30 percent of people will die within one year after suffering a hip fracture, like my grandfather did. This same study from the early 1990s noted increasing mortality for those suffering fractures at older ages, with those over the age of 90 facing 66 percent mortality in the year following proximal femur fractures.

And if you survive the first year, increased mortality following osteoporotic hip fractures extends 10 years past the fracture itself. Even for those who survive their hip fracture, most will be unable to regain their full prefracture function and mobility.

The heightened risk of death aside, the additional health care costs following hip and vertebral fractures are staggering. In the first year following hip fracture, the incremental cost was estimated to be $10,000, according to a study published in the late 1990s.

Similarly, a study used a sample from the population of 30.2 million Medicare recipients in 2002 finding that on average, fractures created an annual medical cost of $8,600 for the 1.6 million Medicare recipients who suffered fractures that year. The quick math on this then places a cost of nearly $15 billion for the American health care system from fractures alone. And for women over the age of 55, hospitalizations and their associated costs for osteoporotic fractures are greater than for heart attacks, strokes, or breast cancer.

The diagnosis of osteoporosis is determined either by bone density screening or when a patient incurs what is known as a fragility fracture. So many of my osteoporosis patients have told me that they are careful and will make sure they do not have a fracture in an attempt to avoid additional medications.

But sadly, osteoporosis doesn’t quite work like that. When a minor fall culminates in a fracture, it is deemed a fragility fracture and can result in an osteoporosis diagnosis in and of itself. Our family was as careful as we could be with my grandfather, but one little misstep still led to a hip fracture.

How Medicare cuts drove down osteoporosis screening

If we’re not screening for osteoporosis, then we’re not going to find it. So why exactly aren’t more doctors doing screenings?

Currently, the US Preventive Services Task Force (USPSTF) recommends osteoporosis screening in women age 65 and older and in younger women who may have equivalent or greater fracture risk due to other risk factors. The USPSTF does not provide a screening recommendation for men, which is problematic in and of itself, but there are other authorities that recommend screening men for low bone density at the age of 70.

One component of decreased screening may simply be physician oversight of current guidelines. But the bigger culprit is likely the 2007 Medicare reimbursement cuts for osteoporosis screening.

The way doctors estimate bone strength is by measuring bone mineral density. The most common way to do it is with a dual-energy X-ray absorptiometry (DXA or DEXA) scans, which are noninvasive tests with minimal cost and negligible radiation risk.

It’s estimated that the 2007 Medicare reimbursement cuts ultimately led to 800,000 fewer DXA scans than expected, screening tests that might have prevented 12,000 fractures. The decline in reimbursements has made DXA screening cost-prohibitive for many physician practices, thereby making DXA tests less widely available to patients as well.

Osteoporosis treatment is not as scary as it seems

With fractures on the rise, focusing on the management of osteoporosis is now even more important. Calcium and vitamin D can improve bone mineral density, but these alone do not reduce fracture risk. So other therapies should be offered to patients with osteoporosis, including exercise with weights, fall prevention guidance, and medication.

The class of antiresorptive medications known as bisphosphonates have been used since the 1990s and remain one of the most widely used osteoporosis medications. Available as oral medications or intravenous infusions, both forms of bisphosphonates have been shown to reduce fracture risk, prevent recurrent hip fractures, and reduce the risk of death after hip fractures.

Unfortunately, bisphosphonates also have the possibility of the very rare side effects of atypical fractures and jaw osteonecrosis. And a spike in media reports of spontaneous bone breakage and crumbling jaws coincided with the 50 percent drop in bisphosphonate use from 2008 to 2012.

Three large placebo-controlled, randomized studies that included more than 15,000 patients found only 12 fractures could be related to bisphosphonate use — that’s less than a tenth of a percent of patients studied. Additionally, a task force commissioned to look specifically at the risk for jaw osteonecrosis associated with bisphosphonates used for osteoporosis treatment found that it is very low, estimated to be between one in 10,000 and less than one in 100,000 patient years.

Fears of these side effects have led many clinical guidelines to call for bisphosphonate “holidays” to try to further minimize the risk of these rare complications on patients who have been on bisphosphonates for three to five years. But Dr. Kenneth Saag, a professor of medicine at the University of Alabama Birmingham and the current president of the National Osteoporosis Foundation, argues that these drug holidays may actually do more harm than good for many patients. Saag and other physicians who have been using these medications for years in high-risk patients understand that the benefits from bisphosphonates in preventing typical fractures outweigh the risks of any of these unusual complications.

If my grandparents had been given the opportunity to gamble on a one-in-1,000 chance of an unusual side effect versus a one-in-two chance of suffering an osteoporotic fracture, then I’m sure they would have opted for bisphosphonate treatment. They just never got the chance to place their bets before the odds stacked against them.

Do we stand a chance against this osteoporosis crisis?

It’s no small wonder that a drop in osteoporosis screening and a decrease in the utilization of osteoporosis medications has caused hip fracture rates to rise. The biggest issue is that without screening, there is virtually no way to diagnose osteoporosis until a fracture occurs.

Perhaps if reimbursements for DXA scans improved, then more practices would be able to afford the machines to provide this test for their patients. The Food and Drug Administration in April approved a new medication for osteoporosis treatment, but only certain women will be eligible for it — so it may not have a resounding effect any time soon.

And with even more Medicare cuts looming, this may not be our best bet. Maybe the least we can do is “capture the fracture” and treat osteoporosis after the identifying injury.

Fracture liaison services (FLS) are designed to do just this. FLS teams try to reduce future fracture risk in patients who present to hospitals following fractures. Typically, the FLS team is led by a physician who is a bone health expert and team of other providers who help channel patients into appropriate osteoporosis care. The goal is for the FLS team to identify patients who need osteoporosis treatment as close as possible to the time they suffer their initial bone injury.

With 80 percent of fracture patients never even being offered osteoporosis screening or treatment, there is an undeniable need for the expansion of FLS programs to provide the best care for fracture patients. These services will be critical to preventing secondary fractures, and, according to Saag, osteoporosis treatment “can reduce the rates of recurring vertebral and hip fractures by up to 70 percent and 50 percent, respectively.”

My grandfather never had the luxury of an FLS team. But when my grandmother suffered a major osteoporotic fracture, I essentially functioned as her personal FLS. She left the emergency room with her arm in a sling with a follow-up appointment to see an orthopedic doctor, while her primary care doctor prescribed home physical therapy and nothing else. The only reason my grandmother saw an osteoporosis specialist for treatment after her fall was because I intervened and insisted that a referral be placed.

But the bigger problem is this: The American health care system is blasé about bone health, especially in the elderly, and that needs to change before this crisis spirals out of our control.

Farah Naz Khan is a doctor and a writer in Seattle. Find her on Twitter @farah287 or via FarahNazKhan.com. This article was first published in July 2018.

Medicine is failing obese people

2016-08-09T13:45:10-04:00

Health care providers are generally ill-equipped to deal with obese patients and their complex health needs. | Shutterstock

Watching a person die from cardiac arrest in an intensive care unit is devastating. It’s especially so when the person is a woman in her 40s who has been smothered to death by her own weight — and we doctors can do nothing to save her.

This 500-pound patient, who was at a county hospital in Georgia where I was working, had respiratory failure caused by obesity hypoventilation syndrome, a breathing disorder. It was just the tip of the iceberg of her medical problems. Her obesity had contributed to the development of heart failure, which led to kidney failure that necessitated dialysis. Her respiratory failure required mechanical ventilation, which placed her lungs at increased risk for infection. And so she developed pneumonia not too long after being placed on the ventilator.

While we “saved” her after the initial cardiac arrest, her weakened heart and body arrested again. Unable to overcome all of these odds, this patient died in the hospital’s ICU.

I cannot help but wonder what would have happened if we had managed to intervene long before her obesity sent her down this fatal path.

Patients with obesity often can’t even get standard medical procedures

We’ve long known that a body mass index over 25 can increase health risks like heart disease, stroke, diabetes, hypertension, and more. And as a huge meta-analysis in the Lancet showed, incremental increases in BMI lead to rising mortality rates. The risk for premature death was highest in those with the highest BMIs. Preliminary results from the Cleveland Clinic and New York University released in April reveal that obesity is the leading preventable cause of life-years-lost, 47 percent higher even than tobacco.

Yet health care providers are generally ill-equipped to deal with patients with obesity and their complex health needs. Over the years of my medical training, I’ve seen more and more examples of these patients unable to get the care they need.

Consider the challenges of something as simple as diagnostic testing. In medical school, we had a patient who was transferred to our academic tertiary care facility because she could not fit in the CT scanner at her local community hospital.

Occasionally, there are stories of patients having to be transported to the local zoo to have certain imaging tests done, where fitting in the machine is possible but the images are much poorer quality than what you’d get in a hospital. So after suffering from this incredibly humiliating experience, the patients are left with subpar diagnostic studies.

Weight limits are not reserved for MRI and CT scanners alone, which typically cannot handle people weighing more than about 400 pounds. Most nuclear medicine stress test tables have weight limits around 300 pounds, and cardiac catheterization tables have similar limits. After surveying more than 90 hospitals, a study in 2008 found that on average, cardiac catheterization tables can only accommodate around 450 pounds.

So for a nearly 600-pound patient with chest pain who could not do an exercise stress test due to knee problems and could not fit on either a nuclear medicine stress table or a cardiac catheterization table, what could we even do to investigate the possibility of underlying coronary artery disease? Nothing. Which is why this patient was discharged after being given a bariatric surgery referral and lots of counseling on ways to lose weight.

The burden of weight compromises the body — and makes obesity hard to treat

Most of my overweight and obese patients have been battling their weight their whole lives. And not surprisingly, the figurative and literal burden of their weight has gradually accumulated over the years. When these patients present with crippling knee pain and ask how they can ease their discomfort, it is often very hard to tell them their knee pain is likely due to wear and tear over the years.

Physiologically speaking, it makes sense that obesity and its associated weight load alone can damage joints. Rheumatologists have tracked the effect of obesity on the development of knee osteoarthritis, including the impact of increased mechanical loading and the fatty tissue–fueled inflammatory storm that can damage joints over time. Similarly, due to the increased load on the spine, increased body mass is responsible for the higher incidence of back disorders in patients with overweight and obesity.

Joints are not the only parts of the body that are literally squeezed by the burden of excess body mass. Patients, like the woman I saw, can suffocate, or experience shortness of breath as their chest wall and respiratory muscles become unable to efficiently do the work of breathing. Studies have found that even with a BMI less than 30, there can be a detrimental effect on respiratory function. So compromised respiratory function is not reserved just for the severely and morbidly obese but also the mildly overweight.

Patients with obesity deserve better care. But how?

The obvious advice for patients suffering from chronic joint pain, compromised respiratory function, and other problems linked to their obesity is this: Lose weight. And we tell patients to do so by monitoring their diet and exercising regularly. But what can we do when their shortness of breath, joint pain, and back pain precludes their exercise efforts and this frustration leads them to abandon their healthy diet habits as well?

If we want to try to curb any of the future devastating health complications our patients with obesity will face without weight loss, then we have to try to offer them something other than diet and exercise pep talks.

Despite current research efforts, there are only a handful of drug therapies available to assist with weight loss. And many insurance providers require six to 12 months of documented weight loss efforts before they will approve bariatric surgery as an option.

The medical field is working toward non-drug therapies and non-surgical interventions that can help our morbidly obese patients, with the recently approved AspireAssist being the first of many potential advances in weight management. As controversial as this device is, there is no doubt that some of our patients may need just this kind of assistance to at least start the weight loss process.

There have also been short-term studies looking at the impact of cognitive behavioral therapy as a way to approach obesity treatment from a psychological perspective. Unfortunately, these studies have not shown long-term success and have only affirmed the need for longer studies to better assess whether psychological interventions could help patients adapt better eating habits in an effort to lose weight.

With ongoing funding and research efforts focused on improving therapeutic interventions and increasing access to diagnostic modalities, perhaps our patients with obesity will actually stand a fighting chance in the battle for their health.

Farah Naz Khan is a doctor and a writer in Atlanta, Georgia. Find her on Twitter @farah287 or via her website FarahNazKhan.com.

I’m a doctor who lost a tooth because I didn’t floss enough. We should all keep flossing.

2016-08-11T11:44:00-04:00

This is not the time to abandon flossing. | Shutterstock

Last week, the Associated Press reported that there’s little scientific evidence to show regular flossing is important for plaque reduction. Reluctant flossers rejoiced: If the government had no data to prove flossing prevents gum disease and tooth decay, then why do it?

But in the wake of the revelations, the American Dental Association has stood its ground. In a statement, it said it would continue to call for the use of “interdental cleaners” as part of a regular oral hygiene regimen.

Floss, according to the ADA, is really the only way to efficiently remove food and debris from between your teeth that can ultimately lead to the plaque buildup that causes tooth decay and gum disease. (These recommendations have been handed down from past surgeon generals and the Centers for Disease Control and Prevention, among other groups, which continue to support the importance of flossing.)

As a practicing physician who has lost a tooth herself, I have to agree that this is not the time to abandon flossing. With our subpar oral hygiene trends, Americans don’t need an excuse to become lazier about our morning and evening routines than we already are.

Oral health is actually a significant public health challenge, not just here in America but across the world — if for no other reason than the simple fact that tooth decay and subsequent tooth loss negatively impacts overall quality of life. And so this is a case where the burden of proof must be forgiven: The potential benefits of flossing are clear, and the risks are few.

The state of oral health in America is pretty bad

Recent estimates suggest that only about 60 percent of Americans visit a dentist every year, and surveys have found that about 30 percent of Americans are not regularly brushing their teeth. This is particularly problematic given that the World Health Organization estimates that nearly 100 percent of adults worldwide have dental cavities. The CDC estimates that nearly 50 percent of Americans have some sort of gum disease.

Cavities can progress rather rapidly to other problems once they get past tooth enamel. And despite regular dental screenings, when one cavity gets missed and then rapidly progresses past the enamel, you can get what dental experts tell me is known as “spontaneous nocturnal pain.” This nocturnal pain is a sign of irreversible pulpitis, which is dental speak for: It’s time for a root canal.

How I lost a precious molar to gum disease

I grew up in a home where my parents always made sure I went to the dentist. But thanks to a sweet tooth and a mediocre dental hygiene regimen in college, I got a few cavities. And 10 years ago, after waking up in unbearable agony from a toothache that just would not let up, I had a root canal done.

After it was over, I continued my regular dental hygiene regimen and dental check-ups every six months. But then one day, I noticed swelling along my gum line by the molar where I’d had the root canal done.

An endodontist soon told me that my root canal had failed and I now had a giant abscess sitting underneath my crown. Even after multiple rounds of powerful antibiotics and repeat root canals, my tooth could not be salvaged.

I have always had dental insurance, and mine paid for the root canal. Without insurance, a root canal will cost upward of $1,500. The only other solution? Have the tooth removed. If your medical insurance covers extractions, then you are in good shape, except for anesthesia (in my case it was an out-of-pocket expense of about $700).

After the tooth has been removed, you’re looking at dental implants (if you want to ensure a normal bite and good jaw health). Mine cost close to $3,000, which came out of my pocket as well. But I am positive that if I had been better about my overall dental hygiene regimen in college, including flossing regularly, then maybe that cavity would never have formed in the first place and I wouldn’t be waiting to be fit for a crown that will screw into my new dental implant.

I’m lucky to have dental insurance — the CDC has found there are three times more adults without dental insurance than without health insurance. And the absurd cost of oral health care for those without dental insurance explains why 40 percent of low-income adults in US are likely to have untreated tooth decay, compared with 16 percent in higher incomes.

Most of these patients will force themselves to ignore their nagging toothache if they’re rationing funds to ensure that they can afford other medications. And this is why, unfortunately, oral health often takes a back seat to other matters of health.

What can oral health say about overall health?

Little research has been done on what oral care can tell us about one’s overall health, although one study did find that tooth loss may be associated with increased coronary artery disease and another found gum disease is risk factor for coronary disease. There is also some evidence that gum disease can worsen glycemic control in people with Type 2 diabetes by exacerbating the underlying inflammatory state that aggravates insulin resistance. It makes sense that people with chronic diseases like diabetes and chronic kidney disease may suffer from more complications from oral diseases.

But if we head in a direction where people start to care even less about their oral hygiene, then how much worse does our oral health stand to become?

Future research in the realm of oral health could work toward better establishing the benefits of cleaning between your teeth. But for now we don’t need a large body of evidence to tell us that flossing could help alleviate bacteria that contributes to plaque buildup and subsequent tooth and gum disease. Taking a few seconds to floss every night is well worth it to save you from the risk of tooth loss.

Farah Naz Khan is a doctor and a writer in Atlanta, Georgia. Find her on Twitter @farah287 or via her website FarahNazKhan.com.