I still see comments on a post I made months ago about ordering lab work. There are a lot of opinions on who should be ordering labs, which labs should be ordered, and advocating for self or loved ones.
A comment in response to my wanting Vitamin D ordered for my husband was "No Vitamin D unless CKD or osteoporosis." CKD stands for chronic kidney disease.
Now, I have no idea who this person is, whether they are a medical professional or not, but they know enough to use CKD as an acronym.
Regardless of the person behind the comment (if it even is a real person), the premise is troubling but consistent with traditional medicine. Peter Attia calls this mentality Medicine 2.0, where he personally practices in Medicine 3.0 which is evidence-based but more preventive than any current guidelines in 2.0 allow.
I call it damage control.
The idea, and blatant opposition to checking vitamin D, is that vitamin D isn't worth checking until someone has chronic kidney disease or osteoporosis. These are end-disease states. There are gradations of kidney disease but diagnostically, there is no gradation of severity of osteoporosis. That is the end-disease state. Why would we wait until the disease has happened to check for one of its biggest risk factors, vitamin D deficiency?
Vitamin D is not only cheap and easily accessible as a supplement, but it's free by walking outside in the sun.
To check Vitamin D is also inexpensive and potentially covered by insurance.
Chronic kidney disease matters in relation to vitamin D because the kidneys have an enzyme called 1-alpha-hydroxylase that converts vitamin D to its active form, 1,25-dihydroxyvitamin D.
As I've discussed in another post, the ovaries also contain this enzyme. We learn about the kidney enzyme in medical school but through all of my training, never learned about the ovarian enzyme until I researched it myself.
Let's talk about osteoporosis and how its management is flawed in traditional medicine.
What is osteoporosis?
Osteoporosis is a condition of low bone density.
As we age, the architecture of bones changes in that they become less dense. This is accelerated and particularly pronounced in women, especially after menopause.
Bones are in a constantly dynamic state of building and breaking down. With aging and menopause, the breakdown is faster than the building.
How is osteoporosis diagnosed?
Osteoporosis is diagnosed with an imaging study called a DEXA scan. DEXA stands for Dual-Energy Xray Absorptiometry, an x-ray imaging study that looks at the density of the bones.
This scan results in a score, called a T-score. This is the patient's bone density compared to a young, healthy standard for bone density.
Therefore, a low bone density is expressed as a negative number because the density is lower than the healthy standard.
Osteoporosis is diagnosed when the T score is 2.5 standard deviations below the standard, or -2.5.
Osteopenia, or low bone density, is when the T score is 1 to 2.49 standard deviations below the standard. This means the density is lower than normal but has not yet reached osteoporosis.
Why does it matter?
We've probably all known someone who has broken a hip. We've also probably known someone who never fully recovered from that fracture.
This is of particular interest for women's health as over 70% of osteoporotic fractures in people over the age of 50 occur in women.
The long term effects can be devastating. After a hip fracture, 20-60% of people who were previously independent will require assistance and 10-20% will be institutionalized.
But the medical societies will say: "Osteoporosis is silent until a fracture occurs".
What do the guidelines say for screening?
The guidelines recommend screening for osteoporosis starting at age 65.
With certain risk factors, the guidelines recommend screening earlier than 65.
Some of these risk factors include:
Osteopenia with elevated FRAX score
Smoking
History of rheumatoid arthritis
Family history of fragility fracture
Excessive alcohol use
Weight less than 127 pounds
Conditions that increase risk are:
Vitamin D deficiency
Hyperparathyroidism
HIV/AIDS
Menopause (physiologic, early and premature)
Diabetes
Medications that increase risk are:
Depot medroxyprogesterone (the "birth control shot")
Heparin
Steroid use
Anti-seizure medications
Not to mention, the guidelines recommend checking a vitamin D level after osteoporosis has been diagnosed. If this isn't ass backwards, I don't know what is.
Why would we stray from the guidelines?
The guidelines are one way to inform clinical decisions. A fallacy of the medical establishment is that guidelines are the only way to inform clinical decisions.
We also have clinical experience, our own expert opinion, and an individual patient in front of us that can drive these recommendations and decisions.
To me, age 65 is a very late start to screening for osteoporosis. We know that loss of estrogen with menopause contributes to the decline in bone density for women. With the average age of menopause being 51, that's nearly fifteen years of accelerated bone breakdown before we even look.
If we find low bone density in a woman with circulating estrogen, it's time to use that estrogen for one of its many purposes: to build bone. Combine the circulating estrogen with resistance training for optimized bone health. If there's opportunity to optimize medical conditions listed above or discontinue medications listed above, let's use it.
If a woman is menopausal but younger than age 65, we can use hormone replacement therapy to prevent osteoporosis. This is an FDA-approved use of hormone replacement therapy! If this is FDA-approved to prevent osteoporosis, why would we not perform the DXA test to see if we are preventing osteoporosis?
This means, in my personal and professional opinion in the age of biometrics, the time to build bone is earlier than we think and performing the test is the only adequate way to measure.
The guidelines have us turning a blind eye.
If osteoporosis is silent until a fracture occurs, it's time to remove the silencer.
Resources:
Some of the information contained in this article is the result of my training, medical knowledge,
and personal experience without a specific source to be cited.
American College of Obstetricians and Gynecologists. (2021, September). Osteoporosis Prevention, Screening, and Diagnosis. Retrieved from URL https://www.acog.org/clinical/clinical-guidance/clinical-practice-guideline/articles/2021/09/osteoporosis-prevention-screening-and-diagnosis
Dyer, S. M., Crotty, M., Fairhall, N., Magaziner, J., Beaupre, L. A., Cameron I. D., & Sherrington C. (2016, September 2). A critical review of the long-term disability outcomes following hip fracture. BMC Geriatrics. Retrieved from URL https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-016-0332-0
