What should be done for osteopenia? Part 1, Assessing Risk

Most people are aware that osteoporosis is a disease characterized by "thinning" of the bones. The reduced bone density in osteoporosis is associated with a susceptibility to fractures, especially of the hip and spine. In the U.S., it is estimated that 10 million individuals, mostly women, have this condition.

It is less well understood by the public that an intermediate stage between normal bone mass and osteoporosis exists, known as osteopenia. Osteopenia is not a disease per se, but an indication that the bone mineral density is below the statistical norm. An estimated 34 million Americans have osteopenia. If measures are not taken to slow down bone loss, many of these individuals will develop osteoporosis.

How do you know if you have osteopenia? Bone mineral density (BMD) testing is required to determine if you have osteopenia or osteoporosis. BMD testing (e.g. DEXA scan) compares the bone density of the person being tested with younger individuals who are at peak bone density. Depending on the variation from this ideal, an assessment of the extent of loss of bone mass can be made. BMD has been shown to correlate with bone strength and is an excellent predictor of future fracture risk. As currently defined, someone with osteoporosis has a BMD that is at least 2.5 standard deviations below the mean of a young person at maximum bone density. This is reported as a T-score of –2.5 on the DEXA report. A higher negative T-value, e.g. –3.0, indicates that the osteoporosis is even more severe. Osteopenia is defined as a BMD that is between 1 and 2.5 standard deviations below the younger person's mean. This would be indicated by a T-score between –1.0 and –2.5.

Does osteopenia always develop into osteoporosis? The short answer is no. A T-score in the osteopenia range does not necessarily mean that you are losing bone, or tell you at what rate that this is occurring. Age, genetics, body stature, and certain diseases or conditions can all affect the baseline bone density. Often a second bone density test is needed to determine if bone loss is occurring at an accelerated rate. Typically, however, a year or more is required before getting a repeat study in order to note a significant difference.

Does everyone with osteopenia require treatment? Most people with osteopenia can be managed by lifestyle measures that will be discussed in next week's "Health Tips". Situations in which it is reasonable to consider treatment with medications to prevent further bone loss and to reduce the risk of more fractures include:

1. Postmenopausal women with low bone mass (T-score between –1.0 and –2.5 at the femoral neck or spine) AND a high probability of sustaining an osteoporosis-related fracture.
   
   
2. Individuals with T-scores between –1.0 and –2.5 may be considered for treatment with a medication when risk factors are present, such as taking certain medications (e.g. corticosteroids), a strong family history of osteoporosis or fractures, broken bones as an adult, or being very thin.
   
   
3. Individuals with osteopenia due to secondary causes, such as chronic kidney disease, celiac disease or chronic corticosteroid use.

How is the probability of fracture determined? An assessment tool called the FRAX is helpful in deciding when someone with osteopenia is at increased risk for a fracture, and may benefit from treatment with medications. The FRAX tool uses information about bone density and other risk factors for breaking a bone to estimate the risk of sustaining a fracture over the next 10 years. To perform the FRAX test, you will need to enter your T-score from DEXA testing along with other personal information, such as height and weight. Based on FRAX testing, the National Osteoporosis Foundation recommends that treatment be initiated in postmenopausal women and men age 50 and older with osteopenia AND a 10-year hip fracture probability ≥ 3% OR a 10-year major osteoporosis-related fracture probability ≥ 20%. Osteoporosis-related fractures are defined as those that are diagnosed on physical examination (although they may not appear on x-rays), affecting the vertebrae, hip, forearm or upper arm. FRAX testing is intended for postmenopausal women and men age 50 and older and is not intended for use in younger adults or children.

Next week we’ll look at the lifestyle measures that can help slow the progression of osteopenia. We also will look at medications that may be beneficial in someone with osteopenia and high risk for progression to osteoporosis or for the development of a fracture.

Enjoying your skiing vacation

Most of the sources that provide information on preparing for ski season focus on building physical endurance and strengthening specific muscles groups. I certainly have no arguments with a gradually increasing cardiovascular exercise program that incorporates some interval training, particularly for those in whom skiing represents a one or two week vacation. Likewise, strengthening exercises, focusing on the quadriceps (front of the thigh) muscles, hamstring (back of the thigh) muscles, and “core” muscles (abdominals, lower back, etc.) will also help with being able to perform what for most people is an infrequent and not altogether familiar activity.

As someone who averages around 60 days on various types of skis each winter, however, I would like to offer a little different perspective on how best to prepare for and enjoy a ski area vacation.

1) Prepare yourself physically. As mentioned previously, preparing yourself through physical activity, both aerobic and strength training, will help you to be able ski more proficiently and to avoid post-exercise soreness. Many articles that you read about exercises to prepare for ski season have merit. A couple of the better articles can be found here and here.

2) Respect the altitude. Particularly during the holiday season and spring break, most people at my local ski area are “flatlanders”, living thousands of feet lower than the base elevation of 10,700 ft. It is virtually impossible to travel from near sea-level to this elevation without experiencing some symptoms of altitude sickness. Not to mention the effect of altitude on physical exertion in an environment with a reduced partial pressure of oxygen. While it can take several weeks to acclimatize to a higher elevation, after just a few days, the body becomes more efficient at extracting oxygen from the air and physical performance improves. Altitude-related symptoms can include difficulty sleeping, dizziness or light-headedness, headache, fatigue, loss of appetite, nausea, rapid heart rate, and shortness of breath. Any of these can be accentuated by overexertion, dehydration or alcohol consumption. Most can be lessened by a more gradual increase in elevation or by moderating activity levels during the first few days at altitude.

3) Don’t try to squeeze every minute out of your daily ski pass. Lift tickets are usually cheaper if purchased on a multi-day basis. Many ski areas also offer a “buddy pass” program where someone with a season pass can buy a friend a discounted lift ticket. One gas station in my town even offers a coupon for a 2-for-one pass just for filling up your gas tank. When looking into lodging near ski areas, check to see if discounted passes are included. With a little work, you can almost always figure out a way to avoid paying full rate. The importance of this is that if you spend a little less for your ticket, you will be less likely to feel compelled (as I used to) to ski from the time the lifts open until after the lifts close. Six or seven hours of skiing for someone who is not used to skiing can be extremely fatiguing, leading to a higher risk of injury toward the end of the day. During the first couple of days of a skiing vacation, periodically assess how you are feeling and performing. If you start falling more often and your performance becomes sloppy, you are getting tired, and it’s time to take a break or stop for the day.

4) Learn from a professional. One of the most alarmingly entertaining activities that I observe while riding up the ski lift are friends or family members of a novice skier or boarder attempting to provide instruction. Not only can this lead to resentment between teacher and learner, some of the techniques that I see demonstrated are not only incorrect, but in some cases downright dangerous. Although it may seem incongruous, one of the most important things that a ski instructor can teach is how to fall safely. Statistics have shown that most injuries to the anterior cruciate ligament (ACL) of the knee occur from improper technique, particularly during falls. Learning from a certified instructor will keep you from developing bad habits, accelerate your skiing ability, and help you to avoid injuries.

5) Plan your days to maximize enjoyment. Be sure that your equipment is ready (bindings adjusted, boots fitted, skis tuned, etc.) in advance. Study the ski area map in advance to determine the terrain that best suits your abilities. The last thing that a beginner skier wants to do is find themselves at the top of a double black diamond run with no other way down! If you aim for getting in the first wave of skiers for the day, you will enjoy less ski traffic on the slopes and often the best snow of the day. Ski for a couple of hours and then take a break. Since most people start skiing mid-morning, you should find the lodge relatively quiet at this time. Then you can be back out on the slopes before the lunch mob hits. Take another break mid-afternoon, in order to avoid fatigue toward the end of the day.

6) Eat and drink to maintain your energy and hydration. As mentioned previously, going to a higher elevation can lead to dehydration. Make a conscious effort to drink enough liquids to stay well hydrated. Keeping your urine volume high and its color clear is one way of accomplishing this. If you drink alcoholic beverages, save them for an “après ski” activity. There is absolutely nothing about alcohol that will improve your skiing technique, lower your risk of injury, or enhance your persona on the slopes. Since the price of food in ski lodges can be astronomical you may want to bring your own food or snacks. Most ski areas will have a “sack lunch” area with tables to accommodate this. You may want to also keep an energy bar or two in your pocket to eat on the lift if you need an energy boost.

7) Dress appropriately. While fashion often reigns over practicality when it comes to skiing attire, proper clothing choices will enhance your comfort on the slopes considerably. Most people know by now to dress in layers for the cold, with "wicking" fabrics next to the skin. The outermost layer (both top and bottom) should ideally be both windproof and breathable, such as Gortex fabric. A well-fitting helmet serves both as an essential piece of safety equipment and as an insulating layer for the head. Many skiers wear a balaclava under the helmet to keep the neck and ears even warmer. One of the most underappreciated articles of ski clothing is a neck gaiter. These seal the top of your jacket to keep wind out and can be pulled up over the mouth or nose when riding up the lift. Assuming an equal amount of insulation and similar fabric covering, mittens are warmer than gloves.

Most ski areas in the country are reporting excellent conditions this winter. A little preparation will go a long way to enhancing your enjoyment of your skiing vacation.

Understanding Food Product Dating

Everyone has seen the dates posted on various food products - "Use-By …", "Best-By …", "Sell-By …". What do these different categories of food dating mean and are there exceptions to these designations?

With the exception of infant formula, food dating is not required by the Federal government. Several states, however, impose dating requirements on some foods to assure that they remain safe and are consumed at optimal times.

"Open Dating" refers to the calendar dates that are seen on food products. The three most common of these dates are:

• "Sell-By" date
• "Use-By" date
• "Best if Used By (or Before)"

"Sell-By" date is perhaps the most important of the dating designations. It tells the store how long to keep the product up for sale. Food should not be purchased if this date has expired. Once at home, food past the "Sell-By" date may be able to be consumed safely for varying lengths of time, depending on the type of food (poultry, eggs, canned meats, etc.) and the way that the food was processed (sealed at plant, fresh, or uncooked).

"Use-By" date is established by the manufacturer of the product and refers to when the food is best eaten. The quality of the product is thought to decline after the "Use-By" date, but it does not always mean that the product is unsafe or should be discarded. If the food has been handled property and refrigerated at 40 degrees F or below, most foods remain safe for a period of time, even past the "Use-By" date. An exception to this is baby formula which should not be purchased or used after this date.

"Best if used by" date is similar to the "Use-By" date. It is recommended by the manufacturer for best flavor or quality. It is not a purchase or safety date.

In addition to calendar dating, "Closed" or "coded" dating may be used, particularly in foods in cans or boxes that can be stored for longer periods of time. This enables manufacturers to rotate their stock as well as to locate their products in the event of a recall. According to the U.S. Department of Agriculture (USDA), "In general, high-acid canned foods such as tomatoes, grapefruit and pineapple will retain best quality on the shelf for 12 to 18 months; low-acid canned foods such as meat, poultry, fish and most vegetables will retain best quality on the shelf for 2 to 5 years — if the can remains in good condition and has been stored in a cool, clean, dry place."

Obviously, food product dating alone is not always the best guide for determining when a food if safe to consume. Use of the dating criteria, along with the following guidelines, however, will help insure food safety:

1. Purchase foods prior to the "Sell-By" or "Use-By" date.
2. If the food is perishable, refrigerate or freeze promptly.
3. Most foods with a "Use-By" date should be consumed prior to the expiration of that date.
4. Eggs purchased prior to their "Sell-By" or "EXP" date, and kept refrigerated will maintain their quality for 3 to 5 weeks.
5. Infant formula should not be purchased or used past the "Use-By" date.
6. Foods that have a "Sell-By" date or no date should be cooked or frozen following guidelines from the USDA.
7. Once a perishable product has been handled and frozen properly, the expiration date can be disregarded.

In spite of the dating designation, food that smells bad, tastes bad, or looks bad probably is bad and should not be eaten. Typically, these changes are related to spoilage bacteria that can cause foodborne illness. Remember that, when in doubt . . . throw it out!