Built to Last-Protecting Bone Health
Aesha Tahir: [00:00:00] welcome to this episode of 9 to 5 Wellness Podcast, and today we are talking about a topic that impacts so many people. No, for real. As we get older, I think this is something that we all have to deal with, and quite honestly, in my practice, I see it happening even to younger people. And you’re like, “Okay, what is she talking about?”
Aesha Tahir: I am talking about bone health. So Today, we are gonna explore how to protect and rebuild your bone density during midlife and beyond Discovering the midlife shift, especially for women, because, our bone density and our bone health for women especially, it is related to estrogen levels. And we are gonna go [00:01:00] dive much deeper into this topic, so I don’t wanna give you any spoilers.
Aesha Tahir: But that’s why women in particular are more prone to having low bone mineral density. So we are gonna be talking about why is that happening for women, why is it so critical and important for women, and then we are also gonna talk about how can we, approach, like, testing, right? So we need diagnostic testing to understand, what’s going on in our bones. We are gonna also talk about some strategies to prevent, bone loss. So stay tuned. I think this is a topic that is very near and dear to a lot of female patients who I see, and, our guest would probably also agree with that. So that being said, you are in for a treat today, because our guest today is not only an [00:02:00] expert, but she’s also a pioneer and an educator for women’s health.
Aesha Tahir: Joining us today is Dr. Renee Fogelberg. She grew up in San Francisco, completing her training and professional career at Kaiser Permanente for over 26 years. So yeah, when I said, like, she’s bringing a lot of experience with her, not kidding. She was the chair of patient education with a focus on online resources, educational tools, and classes to reduce health disparities and improve health outcomes.
Aesha Tahir: Dr. Fogelberg is both board certified in obesity medicine and a menopause certified practitioner treating women during their perimenopause and menopause transitions, enhancing their quality of life through lifestyle medicine and medical therapy. [00:03:00] She is associate clinical professor at California Northstate Medical College.
Aesha Tahir: Her passion are her children and family, cooking, traveling, and she volunteers with the San Francisco Bouquet to Arts Auxiliary Group. Welcome to the podcast, Dr., Fogelberg.
Dr. Renee Fogelberg: Thank you so much for having me. And, you know, I have been viewing so many of your podcasts, and I so appreciate the work you’re doing on 9 to 5.
Dr. Renee Fogelberg: It’s just such an amazing look, and highlighting such important topics. A great testament to you, and I’m just so honored to be here really.
Aesha Tahir: Thank you so much. The pleasure is all mine and our listeners. And I’m honored to have you here on the podcast. And you know what? Without further ado, I actually wanna get into this story here because when we connected, it was because of a [00:04:00] personal experience of yours.
Aesha Tahir: Yeah. So I’d like to learn about your journey in medicine and why is bone health important to you?
Dr. Renee Fogelberg: Yeah. It’s such a great question. As you said, I have been taking care of women for close to three decades. Also been menopause certified for close to 10 years. And so this has been something I have been talking about for years.
Dr. Renee Fogelberg: But the interesting thing is it feels like really the focus has been on some of the more classic, more visible, more prominent symptoms around perimenopause and menopause. And historically people haven’t spoken about bone and bone health, but as we know, it’s a major indicator for longevity, for lifestyle, but it’s been relatively neglected.
Dr. Renee Fogelberg: And so, you know, my own journey is one in which, I chose to get an early, DEXA scan, where we’re looking at bone density. We’ll talk a, a little bit about that later on because I had a family history of osteoporosis [00:05:00] and fragility fractures. So I was definitely a candidate for an early DEXA scan.
Dr. Renee Fogelberg: And when I think about my own life, I’m very healthy. I’m athletic. I do a lot of sports. I had a very good diet. I had the blessing of being in California. We’ve got a lot of fresh whole foods, and certainly have taken advantage of that. And to my real shock, I had, spinal osteopenia. And you know, you could say, well, you can just normalize that ’cause many women around the perimenopause, menopause, up to 50% will have osteopenia.
Dr. Renee Fogelberg: But for me it was a real motivator, a real red flag. ‘Cause what we know is some of these women will advance to osteoporosis. So it was a very meaningful data set for me. But it was also a cry that we just need to talk about this so much more,
Dr. Renee Fogelberg: because it really can change behavior and really set yourself up to a lot greater success.
Dr. Renee Fogelberg: Um, but we’ll, again, we’ll go into that in a little bit.
Aesha Tahir: Yeah, no, I’m so glad that [00:06:00] you, uh, just shared your story because I think a lot of women don’t realize that, you should go and get a DEXA scan because you don’t know what’s going on in your body. By the time you are symptomatic, it’s probably the problem has exaggerated inside your body.
Aesha Tahir: Yeah. Let’s talk about why, why bone health matters. In my experience and for the reading that I’ve done, in literature and whatnot, bone health is often called a silent health crisis for women in midlife. And as I said, because by the time we are experiencing symptoms, it’s kind of late, right?
Dr. Renee Fogelberg: Yeah. Absolutely.
Aesha Tahir: Why do you think it’s a silent, health crisis?
Dr. Renee Fogelberg: Yeah. I mean, it’s so important that this is stated because this is true, and I think I see a lot of similarities with blood pressure issue or hypertension, where people don’t know till it’s tested. And it’s wait, you’ve been walking [00:07:00] around with this for so long?
Dr. Renee Fogelberg: And it’s exact same with the bone. Women have no indicator that they’re losing bone mass. I mean, I look at myself, and you’re absolutely right. Until you have that fragility fracture, until you fall and then are really impaired. You know, some, patients will begin to see a loss of height because of kyphosis, where you have actually compression fractures of the spine.
Dr. Renee Fogelberg: But again, it’s till… At that point, you’ve actually lost height. You’ve lost bone matter. You don’t wanna wait till that fall. You don’t wanna wait for that fracture. But again, there is no indicator for bone loss. And so, and again, we know that menopause is a key inflection point because you start losing bone.
Dr. Renee Fogelberg: In fact, the greatest loss is actually prior to menopause. That’s why they call it the silent health condition, because you don’t see it, you don’t know until, unfortunately, in many cases, uh, it’s too late. So you’re absolutely right. [00:08:00]
Aesha Tahir: Yeah, and I wanna highlight a couple of things that you commented on here.
Aesha Tahir: First, the loss of height. A lot of people don’t realize that this age-related height loss that we call age-related is not necessary. It’s not normal. It’s not something that you have to experience if you were taking care of your bone health, right? Um, but people just take it for granted. They’re like, “Hmm, well, this is age-related.”
Aesha Tahir: Well, it is age-related because you’re not taking care of your bone health. Second thing that I do want to explore more in detail with you that you said is that for women, that starts in menopause And quite honestly, perimenopause, so as soon as we start experiencing other symptoms related to perimenopause.
Aesha Tahir: At the same time, our body inside, like our bones [00:09:00] inside, they’re losing, their strength and mineral density. So what’s going on in perimenopause, Dr. Fogelberg? Why this shift is happening?
Dr. Renee Fogelberg: So the interesting thing about perimenopause, and what we know from the SWAN study, is that there is suddenly a loss of estrogen, and we know that estrogen plays a critical role in, in managing bone, bone strength because there’s this balance between resorption by the, what we call osteoclasts, and bone building, or osteoblasts.
Dr. Renee Fogelberg: And so when you see that drop in estrogen, suddenly that balance is off, and you’re going to start getting more of the resorption or the bone breakdown. So that’s a critical juncture. And the interesting thing, as I mentioned, is, you know, the challenge is what we don’t know or we don’t talk about is the peak bone mass is between the ages of 20 and 30.[00:10:00]
Dr. Renee Fogelberg: So I would argue that this is actually a conversation for pediatrics, for family practice, that we really should be thinking about that. And even we go further, the peak mass is probably built more by the time you’re 18. So really early on in those teenage years, in your early 20s, is that critical time when you’re building bone mass.
Dr. Renee Fogelberg: But between that and the perimenopause, there’s relatively low loss of bone, but that really does spike in those few years, probably about three years, uh, close to menopause. Sort of in that late perimenopausal time period, you see really big loss. But we also know in the sort of 10 years, sort of five to 10 years in that whole menopause transition, you can lose 10 to 20% of your bone mass, which is huge.
Dr. Renee Fogelberg: Again, when you know that bone loss between 30 and maybe 50, kind of low levels. But again, between that perimenopause and then beyond into menopause, a [00:11:00] dramatic loss. And it does depend upon, you know, your diet, exercise. The other thing we know is weight matters. You know, again, in the SWAN study, they looked at women’s weight and they know when you start off with a lower weight, so for Caucasian women it’s anybody below 140 pounds is one of the, groups they looked at.
Dr. Renee Fogelberg: You can lose upwards of 35 to 50% of your bone around menopause. So starting weight going into menopause also has a big influential factor in terms of what if you’re gonna be more likely to lose bone mass. Um, ethnicity matters too. We know that African American women on average have a higher starting bone mineral density around the perimenopause versus Japanese women who tend to have a much lower bone density.
Dr. Renee Fogelberg: So there are a lot of nuances besides age that make a big difference in terms of your risk factor of [00:12:00] bone loss and risk of future fragility fracture. But the… I think the one stark number that stands out to me is that approximately one out of two women are gonna have an osteoporotic fragility fracture in their lifetime.
Dr. Renee Fogelberg: So between you and me, one of us on average is gonna go through this. I mean, that’s the kind of numbers that far exceed breast cancer risk, colon cancer risk. So again, this is a profound, uh, number where we really have to be thinking proactively about this well beyond the perimenopausal years to optimize diet, exercise, to really position women to be at lower risk
Aesha Tahir: So true.
Aesha Tahir: Thank you so much for sharing the SWAN study, because I think a lot of people are not aware of it, so I’m glad that you’re mentioning that. One of the things that you mentioned and I, I wanna highlight and underscore over here, [00:13:00] uh, is the weight, how weight impacts bone health. So wh- when you’re mentioning weight, and I kind of like wanna add onto it and clarify to our audience here, is that carrying a little bit extra weight, and, you know, ideally it should be muscle mass weight, not fat mass weight.
Aesha Tahir: But in the DEXA scan studies that I have read and come across what happens is… So our body weight is also resistance. Mm-hmm. It also provides resistance to our bones and joints. Right. So, so when you have higher body weight, guess what? You’re kind of like doing weightlifting, but with your body weight.
Aesha Tahir: Mm-hmm. Because you’re moving your body, right? You’re getting out of the bed, you’re moving around. Whatever you’re doing. You’re sitting in the chair, it’s a squat. Sitting in the chair is a squat, by the way. Um, um, [00:14:00] and when you do that with a higher body weight, that provides that healthy resistance to your bones to keep that bone mineral density higher.
Aesha Tahir: So someone who carries a weight of 140 pounds and higher, guess what? They have more resistance on their bones on a daily basis. Yeah. And when they go through this transitory period, which Dr. Fogelberg was mentioning, like perimenopause and menopause, they’re already doing weight training from, with their natural body weight.
Aesha Tahir: Yeah. So that’s what it is. And we’re gonna get into those interventions a little bit later, but I just wanted to highlight that what we are suggesting here as far as weight is concerned- And in all honesty, ideally it should be coming from muscle mass. You should have higher muscle mass. Yes, there are healthier fat percentages that women should carry because it’s very important, especially if they’re in their repro- [00:15:00] reproductive years, but even beyond.
Aesha Tahir: We, we need fat. Our brain works on fat, okay? So we do need fat, in our bodies too. It’s just not unhealthy amount. Yeah. Okay. So thanks for explaining how quickly we can start losing bone mineral density, like starting in our 30s. And I, like I didn’t know that actually for women, and depending on, of course, the onset of menstruation, like our bone caps at 18 or 20 years of age.
Aesha Tahir: Mm-hmm. And a lot of the girls at that time, we’re not paying attention to our bone health and/or our lifestyle.
Dr. Renee Fogelberg: Absolutely.
Aesha Tahir: Right?
Dr. Renee Fogelberg: Absolutely.
Aesha Tahir: Yeah. Yeah. Yeah. So we need to talk about this more, and we need to bring attention to this topic, especially for younger women so that they can protect their bones and, um, increase their bone mineral density when they have the chance to do it.
Aesha Tahir: Yeah. So thanks for explaining the risk [00:16:00] factors too. So you mentioned that genetics could play a role too. How heavily do genetics and family history weigh into a woman’s fracture risk?
Dr. Renee Fogelberg: So genetics can play a really big part, because it can play into what your peak bone density is likely to become based upon your family history.
Dr. Renee Fogelberg: It could, uh, play into the strength of the bone, the muscle that you may carry. So again, it plays a major factor, so that’s why when you’re talking about a DEXA scan, if you have a family history of osteoporosis or fragility fracture, that is definitely an indicator to get an early DEXA scan.
Dr. Renee Fogelberg: Because again, we know genetics can play a significant role in bone health.
Aesha Tahir: Yeah. Genetics can play a significant health. It also plays a huge role in our hormonal profile [00:17:00] to how early we go through that transition or how late we would go through that transition. Yeah. Okay, that being said, are there any specific medications or dietary habits and/or other lifestyle habits that women should be aware of that- Yes
Aesha Tahir: can deplete bone strength?
Dr. Renee Fogelberg: Well, so first we’ll go to the positive, uh, in terms of what they can do. Uh, because you’re absolutely right. If you’re nutritionally deficient or having eating disorders, uh, protein deficient, those all can play a factor. But it’s interesting, when we look at the average American diet, only 25% of Americans get the needed calcium on a daily basis.
Dr. Renee Fogelberg: And the interesting thing is when they look at menopausal women, that number goes down to 5%, because the reason is the requirements go up. When you’re looking at menopause, you should be looking at [00:18:00] 1,200 milligrams of calcium, even above sort of 1,000. Kind of push to have more. So again, that’s one of the things you can be thinking about is being very deliberate, and this is what I tell my friends and family.
Dr. Renee Fogelberg: I mean, you’ve got to make choices now for the life you want to live in the future. So again, a lot of that is being very deliberate about your diet specific to calcium. Vitamin D is another one. You know, 800 to 1,000 international units is what you’re looking at. But people don’t always get that in their diets.
Dr. Renee Fogelberg: You know, there are definitely a number of fortified foods, different breads, there’s orange juice, there’s different things that are fortified with vitamin D. You know, some of the milk products you can get vitamin D, but frequently people can’t get enough because the traditional, recommendation of getting sunlight, you’re talking 10 to 30 minutes per day, people are wearing sunscreen.
Dr. Renee Fogelberg: People are being smarter about sun exposure. So frequently people need supplementation with vitamin [00:19:00] D. And there’s vitamin D2 and D3. You really wanna be focusing on D3 because, uh, it does a better job of sustaining calcium in the serum. And again, vitamin D will help to get, more absorption of the calcium.
Dr. Renee Fogelberg: So those are the things you definitely can do around calcium and vitamin D and being very deliberate. I also tell some of my patients, now you could take a picture of your foods and put it into your favorite AI tool, and it could actually reflect how much of these products you’re getting from natural foods, because I’m a big fan of focusing on natural food sources as opposed to supplements.
Dr. Renee Fogelberg: Of course, you can take them, if you need to. And the other thing is protein. I mean, we can’t think about the bone in exclusion of everything else because you need the protein for strength, the muscles that surround the bone. So for menopausal women, it’s about one to 1.2 grams [00:20:00] per kilogram.
Dr. Renee Fogelberg: So for 150 pound woman, you’re looking at about 68, grams, per day. But usually I just use 90 ’cause it’s just easier for me to figure out. So you’re looking at about 30 grams per meal, so three times a day. What we know is the body can’t really absorb more than 30 grams per meal. So that’s another one you could be really looking deliberately.
Dr. Renee Fogelberg: I think keeping a diary every day is too hard to do, but look at the foods that you eat, look at the things that you consume, to make sure you’re getting adequate protein, ’cause that’s also a part of that Um, but you also mentioned what are the things that can stand in the way of this besides your diet that I think you have to be really deliberate about.
Dr. Renee Fogelberg: There are a lot of medications. Over-treatment of thyroid. There’s some seizure medications that can impact, bone. We know chronic use of steroids can be, uh, really counteractive to bone [00:21:00] strength. Obviously some, cancer agents, things that reduce estrogen levels. So I think, if you’re seeing your clinician, you should be reviewing your medications early on.
Dr. Renee Fogelberg: Don’t wait till your 40s or 50s. Think about that, you know, in your 30s. You know, do you have to be on the steroids? Are there other agents? If you’re on thyroid medication, has it been optimized? Have you not over-treating it? ‘Cause again, you wanna think about this well before you go through that menopause transition, is looking at your medications.
Dr. Renee Fogelberg: Um, so lots of stuff to look at, for sure
Aesha Tahir: I love it how you just broke down all the medications, and I think this is where, um, y- every year having that physical exam with your primary care comes in very handy. Yeah. Or seeing your OBGYN comes in very handy because a- as we know, our [00:22:00] health status can change o- every year.
Aesha Tahir: Um, that’s where you wanna sit down with those practitioners and talk to them. “Hey doc, like you, you know my age or y- and you know the hormonal, you know, profile that I have at this time.” Yeah. Given all that, what do you think? I’m on these medications. What do you think about them? Is there anything else I need to do?”
Aesha Tahir: Yes. “Maybe I need extra supplements. Maybe I need something else. Maybe I need a lower dose.” You know- Yeah … whatever that looks like. Because if you ask your practitioner for help, that- that’s what they’re there for. Yeah. But a lot of times we are not really even approaching that subject with our practitioners.
Aesha Tahir: In all honesty, if you take- only one thing away from this interview, I would hope that this is it, that you t- start talking to your practitioner about these things. Start talking about even your family history. Start talking about your eating [00:23:00] habits, because a lot of times the physician doesn’t know, hey, like, y- y- that you’re not getting enough nutrition.
Aesha Tahir: They would recommend stuff to you, but as just Dr. Fogelberg said, okay, supplements are great, but, hey, I would rather have you eat, at least two or… two cups of spinach a day. Spinach is- Yeah … very rich in calcium. Yeah, it’s very rich … and I wanna highlight something you said, vitamin D3, which a lot of us, we don’t get enough of it.
Aesha Tahir: Yeah. Summertime maybe, I mean, you know, we might be going to the beach often with our kids and whatnot, but other than that, the wh- rest of the year, like nine months out of 12 months in a year, we’re not getting enough vitamin D3. We are not exposed to sun often enough. The days are shorter.
Aesha Tahir: That being said, I have a whole podcast episode about going out and get- catching those early morning [00:24:00] sun rays. Why? Because you don’t need to wear sunscreen at that time. So let’s say the sunrise is, 6:00 AM, uh, I think it’s 5:30 AM right now, but 6:00 AM, but within that hour of sun- sunrise, if you go out, you are protected.
Aesha Tahir: The UVA and UVB rays are very weak at that time. Yeah. So you’re getting all that awesome goodness from sun, which is in form of vitamin D3, that’s gonna protect your bones, that’s gonna build your bones stronger. There are certain things, and you don’t have to go out and just sit there for an hour.
Aesha Tahir: I’m talking about 10 minutes, right? Yeah. And Dr. Fogelberg just mentioned, too, 10 minutes. Yeah. So there’s some, like, smaller habits that you- Yeah … can start stacking- Yeah … maybe starting tomorrow, right? Yeah. That would pay you dividends later on. You’re paying your future self.
Dr. Renee Fogelberg: Absolutely.
Aesha Tahir: Okay.
Dr. Renee Fogelberg: So- Yeah, the other thing, oh, I have to [00:25:00] say about the…
Dr. Renee Fogelberg: ‘Cause I love the comment about getting early natural sunlight, because the other thing that does, which we talk about all the time in menopause, is helps with sleep. Because you get that early melatonin that starts the cycle, um, because sleep, uh, is critical, too. So again, you not only get the D3, but you get your melatonin going, and so that can definitely help with sleep, too, which is a big advantage, too.
Aesha Tahir: Absolutely. Absolutely. I love that you highlighted that. And I think as, I mean, one of the side effects of perimenopause, as much as I’ve read and talked to patients, is their sleep suffers. So- Absolutely … if you get 10 minutes of sunlight, guess what? Guess what? Yeah. Not only you have, better bone health, but also- Yeah
Aesha Tahir: you will, uh, regulate your sleep cycle better, too. So, uh, Dr. Fogelberg, I wanna discuss, and I say this [00:26:00] carefully, discuss, uh, the next, um, section, which is diagnosis and screening, because I think we have an issue here Yeah … in our healthcare system Let’s talk about the scan first, though. Mm-hmm. What Is a DEXA scan?
Aesha Tahir: And now the second part of the question that I had, and we talked about it on our pre-interview call, is, like, what age or what stage should a woman get her first one? And we know it, that a lot of women are not getting it because it’s not recommended, they are not aware, but then there’s another aspect of it where it’s really not covered or considered to be important by insurance companies. I wanna talk about it. What, what is a DEXA scan, and, um, at what age should, you know, we start making that investment in a DEXA scan result?
Dr. Renee Fogelberg: Yeah. So the [00:27:00] DEXA scan is a very low radiation scan that looks at bone density. It’s about 10% of a regular chest X-ray, so again, if people are worried about radiation, it is a very, very low dose.
Dr. Renee Fogelberg: Um, and as you talk about the crux of the problem is most health centers, insurance companies, et cetera, really only authorize those 65 and older to get the scans. And that is really problematic, ’cause as we just talked about, the critical juncture isn’t even menopause. It’s perimenopause. It’s before your final menstrual period, where you get massive drops in your bone density that could really have clinical imp- implications.
Dr. Renee Fogelberg: So this is where I think you need to have a real conversation with a clinician, ’cause we know there are many, many indicators to have an early DEXA scan, as I did. So again, ask your family, “Is there anybody with osteoporosis? Is there anybody [00:28:00] who had a fragility fracture?” Um, and what is your alcohol use?
Dr. Renee Fogelberg: You know, indicators are for three or more drinks a day is high risk, so that could be another one. Um, a weight of 127 and below, um, eating disorders, malabsorption disorders, um, early menopause, thyroid conditions. So there is a lot of Conditions, steroids, you know, we mentioned before, that would allow you to take an earlier scan, which I did, which I thought was critical.
Dr. Renee Fogelberg: So again, I think it’s very important to talk to your provider, um, to see whether or not you would qualify, because this is the only way to understand. I will tell you that, um, the additional thing you can do is do what’s called a FRAX assessment. And basically, it’s sort of another piece because you- the DEXA scan measures bone [00:29:00] density, but what we’re really concerned about is your fracture risk because that is the true morbidity, mortality is actually having a fracture.
Dr. Renee Fogelberg: So a lower density without a fracture is not what we’re worried about. So anybody can go in and do a FRAX analysis. It’s F-R-A-X. And you put in a number of different clinical indicators to look at your 10-year fracture for a major fracture or hip fracture. And the reason why they use hip fracture as a gauge is because the hip fracture is really where you have clinical challenges, morbidity, mortality.
Dr. Renee Fogelberg: So they use hip as an indicator. So you can do the FRAX analysis either with or without bone density. So the first thing I would do is go in and do your FRAX. And everybody should know this. They people talk about their breast cancer risk, cardiovascular risk. Everyone should know what their baseline FRAX [00:30:00] assessment is because you should know.
Dr. Renee Fogelberg: And again, if you’re in a higher risk, I mean, you have got to talk to your provider. So, but again, some DEXA reports will have the FRAX analysis because, again, that’s really important to have. Um, the one thing I will say is women who are younger, in their earlier ages of menopause, you’re gonna have more spine loss than hip.
Dr. Renee Fogelberg: So again, the FRAX is based upon the hip measurement. But I will say if there’s wild discordance between the hip and the spine, you’re gonna actually increase your FRAX risk. So, you know, if I have a lot of loss at the spine and the hip looks fine, the FRAX may say that I’m not at high risk, but that’s where I have to look at the spinal score and say, “Actually, I’m gonna be at higher risk,” because the FRAX is not taking into account my dense- my bone density at the spine.
Dr. Renee Fogelberg: So again, so those are the critical things is [00:31:00] thinking about the DEXA, really advocating it for having it earlier if you’re at risk. But independent of that, today, you can do your FRAX assessment if you don’t have the DEXA report, or if you do have your DEXA report, you may have the FRAX built into that report
Aesha Tahir: Yeah, no, I really like that you mentioned FRAX assessment because most of the DEXA scans, at least the ones that I’ve come across here, uh, in New York City and Philadelphia, both, they, they have that built in.
Aesha Tahir: They would give you your T score and then depending on where your T score is falling, so we don’t wanna see your T score below two, so below or higher than minus two, I should say. So between- Yeah … zero and two, which is a positive, we like that. Between ze- minus two to zero is where we start getting concerned.
Aesha Tahir: And then, about higher than minus two means that, [00:32:00] well, you are osteoporotic, os- osteoporotic. That being said-
Dr. Renee Fogelberg: Oh, yeah, the… Sorry, the T score of minus 2.5 and below is osteoporotic. So osteo- Oh, minus 2.5 … penia. Yeah, you had it. You… Osteopenia is between negative one and negative 2.5, and that’s the T score.
Dr. Renee Fogelberg: So that’s the, the score that we use in evaluating normal bone density, osteopenia, and osteoporosis. So again, osteoporosis is negative 2.5 and below.
Aesha Tahir: I’m glad that you mentioned that. Thanks for correcting. Yeah. You’re welcome. I was i- incorrect in that, so thank you so much for clarifying that.
Aesha Tahir: Yeah. Um, so okay. So those are the T scores, and I do wanna emphasize something and, underscore what you just mentioned, that for most women and men, too, um, as they get older, hip bone mineral [00:33:00] density is what we are looking at. The- Yeah … so we are looking at the head of your femur to see y- you know, your bone mineral density and, that’s normally done on your non-dominant side, uh, because we know that the non-dominant side would have a ch- a little h- lower than the dominant side.
Aesha Tahir: Um- The reason hip is, so critical and such an important joint to look at is because if you get a hip fracture, which mostly the fracture we are worried about is the hip fracture, the, i- i- the mortality rate associated with it is very, very, very high. Because, yeah, if you break your hip, chances are that, after you get hospitalized, it, it, there are a lot of complications that can develop.
Aesha Tahir: Yeah. So that’s why it’s very important. I do wanna, um, ask you a follow-up question, [00:34:00] Dr. Fogelberg, here, because you mentioned that as, women who are in perimenopause or in early menopause stage, you mentioned that their bone loss is majorly in their spine. So- What can women do to prevent, um, bone loss in spine?
Aesha Tahir: And, or is there, specific lifestyle interventions that they can im- start implementing knowing that they are already going through pe- perimenopause?
Dr. Renee Fogelberg: Yeah. Yeah, yeah, yeah. So a couple things just to build on. You mentioned the risk of the hip fracture, and yeah, the mortality is estimated 20 to 30% in the first year after the hip fracture.
Dr. Renee Fogelberg: And the, the highest risk time is a few months, one to three months after that hip fracture. So as you mentioned, it’s really real. Um, and then as I talked about with the perimenopause, it’s not [00:35:00] that it’s the most or the only with spine, but there’s a slight increase in loss in the spine versus the hip. So in the perimenopause, those late perimenopause time years, the loss is gonna be about 2 to 2.5% per year in the spine versus the hip, it’s more like 1.5 to 1.8.
Dr. Renee Fogelberg: So it’s just a subtle difference that you may see more spine bone loss in the perimenopause because you’ve got that differential loss, in the early, uh, peri- or I should say late perimenopause. So in terms of what we, we should do, I mean, obviously we talked extensively about diet, we talked about medications, but there’s definitely lifestyle, pieces because I think that’s one of the fallacies where, you know, “Oh my God, I walk, I’m busy, you know, I’m, I should be fine.”
Dr. Renee Fogelberg: But the bone needs resistance and resistance training. So we’re talking about weights, [00:36:00] we’re talking about being very proactive, about lunges, about jumping, about doing things that are sort of putting a discrete impact on the bone. And this is where I think it is I think important to potentially do, make an investment.
Dr. Renee Fogelberg: Think about finding an actual coach, uh, somebody that can actually walk through. Because I think in the perimenopause, menopause, and ideally even before that, our exercise pattern needs to change. Because some sports, you know, you’re not gonna get that same amount of resistance or impact to the bone, so you’re not gonna build that strength in the same way.
Dr. Renee Fogelberg: The other thing is that I don’t think we think about balance, but that’s the other thing. Besides actual resistance training, I think we need to be much more proactive about balance. Because frequently these fractures will occur if there’s [00:37:00] not the same degree of balance. So it’s simple things like brushing your teeth, going back and forth between two different legs, or trying like
Dr. Renee Fogelberg: Frequently when you go upstairs, you may preferentially use one leg over the other, but how can you create greater symmetries? So really thinking not just about resistance training, but also about balance training so that strengthens sort of sidedn- sidedness. ‘Cause obviously you could have a preferential side, a preferential strength, but you really wanna be proactively, actually managing that.
Aesha Tahir: Absolutely. I’m so glad you mentioned balance training, because we start losing balance way faster than even we are losing our bone mineral density. And a lot of times, the reason behind the fracture or the hip fracture, well, of course, the secondary cause is that, yes, the bone mineral density was low, but it is the balance. And people [00:38:00] fall. I’ve seen patients falling, from the last step of their staircase at their own home.
Dr. Renee Fogelberg: Yeah, absolutely. They’re like- Absolutely … ”
Aesha Tahir: I have no idea, like, how that happened. I’ve been living in that house for 20 years, and I just, I just missed the step.”
Dr. Renee Fogelberg: Yeah, yeah. ”
Aesha Tahir: That’s how I fell.”
Dr. Renee Fogelberg: Yeah. Yeah.
Aesha Tahir: Right?
Dr. Renee Fogelberg: Well, I think there’s so many competing factors. One, you can have vision. Uh, you know, you really wanna make sure you’re keeping up with that, because sometimes women, women will find their vision will drop. I’ve also been at friends’ house where they have these area rugs, and I’m like, oh my God, at this point in your life, you have got to get rid of those small little rugs that are at the bottom of the stairs.
Dr. Renee Fogelberg: Those seem slip. So it’s almost like thinking about falls prevention, besides building bone, building balance, looking around at your home. What are the risk factors you’ve lived with all of your life that really could set you up? Banisters. Like, I walk into the garage and I have three stairs. I’m [00:39:00] very deliberate about walking slower, looking at my… cause again, you get used to these things. You habituate to things in your homes. But all of a sudden, you need to be, you know, really thoughtful in your movements, to avoid all those things that you said is your falls.
Aesha Tahir: Absolutely. Absolutely. And I do wanna underscore something you just mentioned, that yes, take a look around your home.
Aesha Tahir: What is, what are those things that can actually put you at a higher risk of falling down? Second, I also wanna mention something, is that when we talk about balance, we are not just talking about as in physical balance. Yes, definitely, I, I think while you’re brushing your teeth, balance on one foot and then the other, all of that, like practice helps.
Aesha Tahir: But it goes beyond just physical balance, because your brain is trying to orient your body in the [00:40:00] space that you’re occupying, and guess what? It, it takes that input from your eyes, just like Dr. Fogelberg mentioned. Are you going to the optometrist every year or every two years to make sure that, you know, your vision is fine?
Aesha Tahir: Um, th- and then third thing that I think a lot of people don’t relate and realize, the vestibular balance that’s inside your ear. So are you going to the ENT? Are you going to your primary care and mentioning, “Hey, something just feels off to me”? Like- Yeah … you know, maybe there’s ringing in your ears and whatnot, so that they can refer you out to an ENT to make sure everything is okay.
Aesha Tahir: So there are a lot of things, like, which we don’t realize, till it’s too late, right? Absolutely. So those are the things that I would highly recommend someone who’s listening to this podcast, bring those up to your primary care, your physician who- [00:41:00] whose care you’re under. I do wanna go back a little bit towards the, uh, DEXA scan, because I think we skipped over, a couple of terms that I don’t know if our, our audience members, know about or know the difference about. What is the difference between osteopenia and osteoporosis?
Dr. Renee Fogelberg: Yeah, so it’s a gradation of bone loss. So osteopenia is gonna be the first sign where you have that mild amount of bone loss. And again, it’s exceedingly common. About 50% of women around 50 years of age is gonna have osteopenia. But to me, even though it’s common, it is a red flag.
Dr. Renee Fogelberg: We really have to be thinking about proactively managing things through exercise and diet, as we had talked about, to really potentially reverse that so you don’t go on. Because osteoporosis, again, [00:42:00] is that next phase. You’re gonna have much more significant bone loss where you may have greater risk of fragility fractures, issues with mobility.
Dr. Renee Fogelberg: So again, it’s a gradation. Early bone loss versus one that’s much more, uh, significant and can lead to increased morbidity and mortality.
Dr. Renee Fogelberg: And the T score is what we use for
Aesha Tahir: that Awesome. That sounds great Yeah, T-score we use for that. At the end I wanna go into, you know, some of the lifestyle interventions that we can do. We already talked a little bit about strength training, and thanks for highlighting that. I think a lot of women have been fed this narrative that if you lift weights, you’re gonna start looking masculine and, you know, gain too much muscle mass.
Aesha Tahir: And I tell women all the time, “Hey, the amount of testosterone you need for that,”
Dr. Renee Fogelberg: Yeah.
Aesha Tahir: That’s [00:43:00] probably not happening anytime soon unless, you have some other therapy going on which would increase your muscle mass dramatically. That being said, what is the current medical consensus on using HRT or hormone replacement therapy for women in perimenopause and/or menopause?
Aesha Tahir: And of course, I’m talking about women who are really struggling with the symptoms that they are having, and also to protect bones.
Dr. Renee Fogelberg: Yeah. So we know, uh, that hormone therapy is, one of the, indicators for bone loss prevention. It’s actually been FDA approved for that specific indication. Um, ideally when you’re thinking about bone loss prevention, uh, you want to start it, that is hormones, within 10 years of the final menstrual period or before somebody is 60 years of [00:44:00] age ideally.
Dr. Renee Fogelberg: So early on, ’cause we know about that bone loss. So when you’re looking at long-term estrogen and usually combination with progesterone, you know, you can see bone increase, bone density increase about anywhere from 5 to, you know, almost close to 15% over, a decade of use. So hormones can make a profound difference.
Dr. Renee Fogelberg: So I think as women approach menopause or even in sort of their mid-40s, late 40s, you need to be thinking about your risk for bone loss. And then having those conversations with your providers, ’cause we know it’s an absolute indicator. You know, the recent, endocrine meeting, went on just recently and, and they did a retrospective study looking at women on hormones.
Dr. Renee Fogelberg: And bone loss was defined as either osteoporosis or osteopenia. And when they looked at DEXA scans, they found women who were on hormones had a [00:45:00] 67% less chance of bone loss being on hormones. So this is not new data. We’ve known this for years. But again, hormones can make a profound difference. But, there’s a broader conversation that you need to look at your risk factors, other indicators.
Dr. Renee Fogelberg: But again, hormones can make a Big, big difference, uh, in terms of medical therapy. Certainly there are also bisphosphonates and other agents, uh, that women can use if they cannot take hormones. Uh, but again, if you are a good candidate for hormones, they are a great tool in terms of what we know to be, and that is osteoporosis prevention.
Dr. Renee Fogelberg: ‘Cause as we know, estrogen has a major, uh, play in terms of bone metabolism, bone strength. So again, if it’s clinically the, appropriate tool for you, you can definitely use it. But know there’s a lot of other agents out there if you can’t. And really being proactive about it, ’cause again, you don’t want to wait.
Dr. Renee Fogelberg: When you look at alendronate or, uh, these agents, [00:46:00] again, these are for women ideally who are early in the course, meaning osteopenic, not people with osteoporosis. You don’t wanna start these agents late. But again, have those conversations and be proactive about it. You know, you take medications for blood pressure, you take medications for exceedingly high cholesterol levels.
Dr. Renee Fogelberg: In the same way, women need to be advocating for themselves for their bone health because we know it has a major play for longevity and health
Aesha Tahir: Absolutely, and I couldn’t have said that better. Really stop downplaying your bone health. Like, don’t think about it like, “Oh, no, it’s gonna get better,” or, you know, “I’m fine.”
Aesha Tahir: No, you are not.
Dr. Renee Fogelberg: Yeah.
Aesha Tahir: You are not. Yeah. So this is the time. If you are experiencing perimenopause and/or you know that you are post-menopausal within that first 10 years, start that [00:47:00] conversation with your practitioner. This is the time to do it. The earlier you start on a pharmacotherapy and/or hormone replacement, whatever route is best for you, because, depending on, again, if you’re at a high risk for certain types of cancers, estrogen receptors, they have been tested for you in your blood tests, and you’re like, okay, you’re not a…
Aesha Tahir: probably the best candidate for it. That’s okay. Your practitioner would help you find another therapy, right? Yeah. But take action. And same thing I would wanna recommend and suggest and encourage a lot of women who are listening to this show is that start taking the steps towards those positive lifestyle interventions tomorrow.
Aesha Tahir: Yeah. Don’t wait. Don’t wait on those. Yeah.
Dr. Renee Fogelberg: Yeah.
Aesha Tahir: Start exercising, start doing [00:48:00] weight-bearing exercises at least three days a week. So strength training, three days a week is a minimum. And when I say three days a week, I’m talking about 30- to 40-minute session. And honestly, strength training is not As challenging as we have made it out to be.
Aesha Tahir: Like- Yeah … it’s easier than cardio, I can tell you that. You won’t have to necessarily, like, sweat buckets or anything, but it would protect your bones tremendously. And one of the things I wanted to highlight over here, because we are on the topic of, actionable takeaways, I wanna give you tips that you take home today with you that you can start implementing tomorrow, uh, is start using weights that load your spine.
Aesha Tahir: Yeah. So those are free weights, okay? We are talking about dumbbells, kettlebells, and I’m a big fan of barbell. Why? Mm-hmm. Because if you don’t load your spine, remember what Dr. Fogelberg just [00:49:00] mentioned? In early pe- perimenopause and, uh, early menopause, what are you losing most of? Your spinal bone density.
Aesha Tahir: So you want to, stop it in its tracks right now, and the ideal way to do it is start loading that spine as well. A, a lot of our patients, they wear weighted vests too, too, and they have found that, you know, over time it helps them. Just buy a vest on Amazon, like a 10-pound we- vest.
Aesha Tahir: Start there, and then you can progressively build up that weight, too. If you go, if you enjoy walking, you know, that’s a great way to add resistance while you’re walking. Yeah. Take care of your nutrition Like you, you are what you eat. And I think a lot of women are just, they don’t, they’re not mindful about their nutrition because of course, I mean, we are fed again a n- narrative here [00:50:00]that we need to look a certain way.
Aesha Tahir: Guess what? If you eat better, if you’re eating whole foods with good nutritional profile that have high protein, you know, high, high in calcium, high in vitamin D3, high in vitamin K2, that’s also important for bone health, you’re gonna look fabulous. Like, people are gonna start complimenting on how much your skin is glowing and, “You look great.
Aesha Tahir: What are you doing? Like, you look better than when I saw you five years ago.” Right?
Dr. Renee Fogelberg: Yeah. Yeah, yeah, yeah.
Aesha Tahir: So, so it’s all a mindset. So s- let’s start shifting that mindset over here.
Dr. Renee Fogelberg: Yeah.
Aesha Tahir: So yeah, and take care of your balance, take care of the environment that you are operating in, in your household, and if you’re at work, make sure there’s nothing that, that increases your risk of tripping and falling.
Aesha Tahir: Yeah. So that is what it is. But I want to leave our listeners when… with [00:51:00] an important takeaway, Dr. Fogelberg, and I think we have emphasized it during our interview today, but I want to, you know, end with that, too. I think it’s so important for women, no matter what age they are, like even e- in their early 30s and/or late 20s, to get a baseline.
Aesha Tahir: Get a baseline for their hormonal profile and get a baseline for their bone health. What do you think about that? That’s what I recommend.
Dr. Renee Fogelberg: Um, so I don’t know what you mean by hormonal profile.
Aesha Tahir: Profile. So get, get the blood test done because when we, um…
Aesha Tahir: So m- our annual, blood test does not, include all the hormonal profile for women, like the, estrogen, progesterone levels, uh, on a cyclical basis. It doesn’t include that, right?
Dr. Renee Fogelberg: Yeah, but I think this has been really discussed at length in the Menopause Society and [00:52:00] ACOG. There’s so much volatility to hormones.
Dr. Renee Fogelberg: There isn’t that much clinical utility in getting hormone levels regularly. Uh, I think definitely, you know, thyroid, you want your blood count. You wanna make sure you’re checking, for kidney disease or liver disease, but regular hormone levels, unless you’re concerned somebody’s going through an early menopause.
Dr. Renee Fogelberg: But the problem is day to day, your hormones change so much based upon your diet, based upon your exercise. In general, we don’t recommend getting regular, like, estrogen, progesterone levels. ‘Cause again, it doesn’t have clinical validily- validity and it doesn’t… It’s just too volatile. So again, I, I think if there’s extreme conditions where, oh my gosh, we may think you’re in menopause, we’re not sure.
Dr. Renee Fogelberg: Or certainly thyroid we wanna get. But, the hormone levels has been out there a lot on social media, but I think we have to be a little cautious because it, it’s hard to, to measure, to have clinical relevance and applicability. Um, and then bone [00:53:00] scan in general at a young age, you know, it just depends.
Dr. Renee Fogelberg: Again, you ha- early menopause, certainly you would think about doing that early. But, I think we do have to be a little cautious. There’s a lot of, vendors out there who are doing body scans. I actually had it done because I was really curious, and it did not detect my osteopenia. And so when I emailed them, I said, “Listen, your…
Dr. Renee Fogelberg: People are, you know, getting these things done all the time.” And they said it checks total body calcium levels. I can’t remember what they said. So I think you have to be a little careful when you go out and get these body scans because they may not be clinically valid. I mean, I think tracking bone strength over time, but again, given my own experience, I just don’t know about the clinical accuracy.
Dr. Renee Fogelberg: So I think people are looking more for visceral fat and body fat, but I think you have to be a little bit careful about these inexpensive full body scans, ’cause I’m not sure about the clinical accuracy. So I would just say just to be cautious, [00:54:00] um, and know the sources when you’re going out and getting scans, which I think increasingly a lot more people want to do and are interested to do, because it may not be clinically valid.
Aesha Tahir: Oh, I’m so glad you mentioned that because I was under the impression, not with the body scans, and I do wanna talk about that, under the impression with your hormonal profile that, while you’re healthy or in your healthier years, if you get it done, maybe that would give us like, um, reference point to restore you to.
Aesha Tahir: But maybe that’s not how it’s supposed to be done. No. So I’m glad you mentioned that. Yeah.
Dr. Renee Fogelberg: Yeah, yeah, yeah. I think, again, there are a lot of people out there that are selling these products. There are a lot of people on social media, but there is no normal for one person. And of course, if people are on hormones, on birth control, that’s gonna change their hormone levels, so it’s not gonna be clinically accurate.
Dr. Renee Fogelberg: So again, we don’t strive for a particular clinical level of hormones, so a lot of it has to do with patient symptoms. So for [00:55:00] the vast majority of cases, we do not do routine hormone levels ’cause there’s, you know, a- again, it’s not clinically validated. Maybe as we have more studies, we can know a little bit more.
Dr. Renee Fogelberg: So again, there are some cases where we do it, but the vast majority of time, most of us are… I- it’s just, it’s not clinically meaningful ’cause it’s, there’s too much volatility
Aesha Tahir: I’m so glad that you mentioned that and that you added actually a lot to my knowledge today too, and this is one of the things.
Aesha Tahir: As far as,
Aesha Tahir: like the whole body scans that are out there on, in, on the market,
Aesha Tahir: yeah. So they can have, the results are not always 100% accurate. Um, but DEXA scan is the gold standard.
Dr. Renee Fogelberg: Yeah, absolutely. So- Absolutely …
Aesha Tahir: if you go for a DEXA, it, again, you can get it done to establish a baseline, and I don’t know how much clinically valid it would be, but I’m seeing [00:56:00] patients in their early 30s wi- without any symptoms, without any- Yeah
Aesha Tahir: perimenopause symptoms or, and even male patients, because we are sedentary now. Very few of us are doing strength training even now, although there is a lot of like push, on it, and I, I’m very happy about it. But that being said, I’m seeing like, T-scores around -2.0-
Dr. Renee Fogelberg: Interesting,
Aesha Tahir: yeah … for healthy male and female patients.
Dr. Renee Fogelberg: Interesting, yeah. Yeah, I think that’s where you have those conversations with your provider. If you’re finding that you’re, you know, meal deficient or you’re having certain lifestyles that are unique that really would lend itself to that, yeah. I mean, I think you’re absolutely right. Um, so y- that’s where the nuanced conversation is really important.
Aesha Tahir: So if you if you can invest in a DEXA scan, which is the gold standard at this time. I know there are some other ther- sorry, [00:57:00] diagnostic tools coming along.
Aesha Tahir: I think MRI is probably gonna be the next one. I’ve read a few studies on it. Not implemented yet, I don’t think so, it’s available, or at least af- affordable for a lot of patients to go and get it. But yeah, DEXA scan, I think it’s becoming more and more accessible, more and more affordable.
Aesha Tahir: So get it done. Just understanding like what’s going on within your body. Even like it would give you accurate muscle mass, and guess what? Muscle mass protects bone mass, so they’re both related. Absolutely. Yeah. Even if it comes down to, hey, you’re good with your bone, mass and bone strength, but you’re low on muscle mass- It would help you take action to increase your muscle mass, and then once you increase your muscle mass, your bone health will improve just, with, along with that.
Aesha Tahir: So, uh, Dr. Fogelberg, any parting words for our audience? [00:58:00]
Dr. Renee Fogelberg: I just think, again, for so long the bone has been neglected, and we know now there are just m- just really traumatic changes that take place. But I think we can prevent some of these things, and I think the biggest thing is going way upstream, as you talked about, is really looking thoughtfully and having those conversations with your provider.
Dr. Renee Fogelberg: What puts you at risk? What are the… What are your medications? What is your diet like? You know, what is your training like? You just don’t wanna wait till menopause. And, and also, as you said, being deliberate about your diet. You know, you don’t wanna wait till you’re 60 or 70. Think about that calcium, vitamin D, and protein.
Dr. Renee Fogelberg: Um, and then be a big advocate for screening. I think if you’re a candidate, you don’t wanna wait to 65. So I think now is the time, and I think it’s getting greater visibility, but we need to be thinking about our bones. You know, what would it look like to have bone health as a vital sign, right? I think we’ll, we’ll try to get [00:59:00] it there but, I think the nice thing is there’s a lot more information out there and hopefully people are talking about it a little bit more. Now it’s in your hands ’cause there’s a lot of things people can do, um, in terms of lifestyle, in terms of management that can really make a profound different difference as you’re going into those changes, uh, in the, uh, late, uh, perimenopause.
Aesha Tahir: Absolutely. Thank you so much, Dr. Fogelberg, and I couldn’t agree more that do not wait for a fracture to occur.
Dr. Renee Fogelberg: Right.
Aesha Tahir: Your health is your responsibility. Start discussing bone density screening, medications, your lifestyle that you have currently, and/or any symptoms because a lot of times I see especially women downplay their symptoms too.
Aesha Tahir: Like, “Oh, it’s just something. It’s been going on.” Because then that becomes your new normal, [01:00:00] but it doesn’t have to be. Talk- your physician-
Dr. Renee Fogelberg: Absolutely …
Aesha Tahir: because they’re gonna help you. And try to get the assessment for osteopenia and or osteoporosis early on, because the sooner you start the, uh, therapy, the sooner you’ll start feeling better.
Aesha Tahir: This… That would also help you improve your longevity and health span as you go along. So thank you again, Dr. Fogelberg. Of course. And thank you everyone for listening to us today.
Aesha Tahir: I have a disclaimer to share that the opinions and everything that we discussed here today are just scientific-based opinions of my guest and myself, and they are just a conversation between two friends, so none of this constitutes a clinical diagnosis. [01:01:00] If you are experiencing any symptoms or any health concerns, please consult with your physician and or healthcare provider because they can help you with your specific conditions. Bye for now.
Dr. Renee Fogelberg: Take care.
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