Today, I read with dismay The New York Times’ health column about vertebral compression fractures. In my opinion, it presented an inaccurate picture of what’s happening when it comes to spinal fractures. I want to address some of the points that stood out for me because I feel this article spreads a lot of fear where it’s just not necessary — and as I mentioned in a recent post, fear itself is damaging to bone!

First, let’s look at the statement that “by age 80, two in every five women [or 40%] have had one or more vertebral compression fractures.” Similar statistics have been bandied about for years, but when I took the time to look for hard data supporting them a few years ago, I found it very difficult to substantiate such high numbers. The sole large-scale study that looked at long-term risk of vertebral fractures, a review by J.A. Cauley and colleagues that came out in 2007, actually debunks this statement. As I noted in my article on spinal fractures at the time, "The results of this study suggest that earlier estimates of spinal vertebral fracture incidence have overestimated real fracture incidence. Over fifteen years, from age 68 to 84, only 18% of all US Caucasian women experienced a vertebral fracture. Overall, counting those who entered the study with an existing vertebral fracture, a little over 26% of all women had radiological evidence of a spinal fracture by age 84. This figure is significant, yet not as worrisome as the 35‐50% estimate previously reported."

I also take issue with the statement that “vertebral fractures are a telltale sign of bone loss.” They’re not — they’re a sign of bone weakness, and there is a difference between the two! While low bone density does increase the risk of fracture, most fractures occur in persons whose bone mineral density is above the osteoporotic range. The strongest predictors of fracture in the Cauley study were advancing age, having low body weight, and the presence of a prior bone fracture — not low bone mineral density.

Now, I have been arguing for years that bone mineral density alone doesn’t predict fracture risk, and the study on which this article is based seems to agree with that assessment on its surface. The study’s authors note that the presence of vertebral fractures in women whose bone density isn’t osteoporotic means that the true diagnosis should be osteoporosis, not osteopenia — and with that, I’d agree. But the follow up statement shows where all this is truly headed: “Asked if such women should receive bone-preserving medication, Dr. Ensrud said emphatically, ‘Yes!’” This position is in direct contrast to the recommendations of the U.S. Surgeon General — that persons with bone loss should be directed to make changes to their dietary and exercise habits first, then assessed and treated for the cause of the bone loss, and then put on bone medications if the situation warrants. (The implicit assumption of Dr. Ensrud’s response is that bone drugs are always warranted.)

The idea of looking for the causes behind skeletal weakness is not even suggested, and the word “exercise” doesn’t appear in the New York Times’ article until the very last line. Yet numerous studies show low vitamin D levels to be a major cause of bone loss and weakening among most of those who fracture. Exercise, as countless more studies have shown, should be the first line of defense against osteoporosis and fractures — and considering that a Mayo Clinic study has shown a 300% reduction in risk of new vertebral fractures from simple back strengthening exercises (far more than ANY bone drug can claim), it is disturbing that Fosamax is mentioned so much more prominently than exercise.

I could go on (and on), but rather than write a novella, I’ll state my primary issue thus: The overall message is that multitudes of postmenopausal women are destined to fracture in their spine, and that they should immediately be given bone drugs for even a minor, unfelt, spinal deformity defined as a “fracture”. I would hope for a more balanced, public-interest analysis of this important health issue from one of the most important news outlets in the United States, if not the world.

One other note before I stop — I also find it troubling that all of these messages are aimed primarily at women. Studies in the U.S., Canada, and several European countries show that older men often have “silent” vertebral fractures (only seen upon X-ray) just as frequently as women do, yet the article makes no mention of looking for these hidden fractures in men and giving them drugs for these symptom-less vertebral deformities.

But here’s the bottom line: women and men with osteoporosis, even those found to have a “silent” symptom-less vertebral deformity in old age, need not automatically be given bone medications. It has been the position of the U.S. government’s top health official for most of the past decade that medication is the last resort, not the first! And that is a message that I hope all my readers get — and pass along.

References

Brody, J.E. 2011. Along the spine, women buckle at breaking points. New York Times June 27, 2011. URL: http://www.nytimes.com/2011/06/28/health/28brody.html (accessed June 29, 2011).

Cauley, J. A., Hochberg, M. C., Lui, L. Y., et al. 2007. Long‐term risk of incident vertebral fractures. JAMA 298(23):2761‐2767.

O'Neill T. W., Felsenberg D., Varlow J., et al. 1996. The prevalence of vertebral deformity in European men and women: the European Vertebral Osteoporosis Study. J. Bone Miner. Res. 11:1010.

Brown, S. E. 2008. Spinal vertebral fractures among US Caucasian women: New statistics and new insights. URL: http://www.betterbones.com/bonefracture/spinalvertebralfracture.pdf.

Davies K. M., Stegman M. R., Heaney R. P., Recker R. R. 1996. Prevalence and severity of vertebral fracture: the Saunders County Bone Quality Study. Osteoporos. Int. 6:160.