We all know high blood pressure and cholesterol can kill, but what about low bone mineral density? Bones are composed of calcium and phosphate, which is their mineral content. Bones low in calcium are said to have low bone mineral density, which can result in a condition known as osteoporosis. Osteoporosis develops over a lifetime and is impacted by your peak bone mass as a youth. Thus, most osteoporotic problems begin in your teenage years rather than in your 70s when they typically become apparent. Effective osteoporotic prevention strategies exist but ideally should be implemented before the age of 20, at a time when many will fail to appreciate how important their skeletons are.
The skeleton itself is an organ system, and skeletal metabolism (the physiologic process by which bones are built and degraded) has never been more important in medical care. As individuals live longer and healthier lives, they suffer more from diseases of the skeleton, like osteoporosis. In your golden years, it is your skeleton that allows you to participate in life’s most meaningful moments. These moments can be robbed from you by bone disease. As an orthopedic spine surgeon, I commonly see otherwise healthy patients in their 70s and 80s develop fractures resulting from osteoporosis that ruin their activity levels and ultimately their health. Most have no idea what could or should have been done to prevent, screen, or treat osteoporosis. In this article, we will explore why skeletal health matters and why you need to be thinking about it now.
What is the problem
Similar to organ failure (that is, heart failure), bone failure results from unchecked osteoporosis that transforms the skeleton into a moth-eaten and brittle structure. For example, breaks that occur because of slight trauma such as bumps, slips, and even coughs are termed insufficiency fractures because the bones become too weak to resist small forces. The older you become, the higher the likelihood of suffering from an insufficiency fracture. Insufficiency fractures of the hip and spine have a mortality rate of up to 40 percent in the first year. Reportedly only 50 percent of patients with a hip fracture will remain independent in the first year following the fracture. Even if one survives, insufficiency fractures can be painful and disfiguring. Impressively, only 28 percent of individuals are medically treated for osteoporosis following a hip or vertebral fracture, and treatment has declined 20 percent over the past decade.
Most young people probably think of the skeleton as static. The skeleton is a passive structure for most of our lives, and we learn to take it for granted. We fail to grasp that the skeleton is less a coat hanger for our bodies and more a dynamic living organ system that changes every day and can be noticeably different as you age. I have come to think of bone mineral density as a retirement account. In a retirement account you put money in when you are young and take it out when you are old. Similarly, you add bone density to your skeleton when you are young and depend on its strength as it degrades with age. It takes decades of preparation to prevent osteoporosis. This process of deposit and withdrawal of bone density, which I call skeletal metabolism, starts at an age when we are not thinking about our skeletons.
As an orthopedic surgeon, I was very interested in learning about this process, but when I sought out a straightforward resource on the subject, I could not find one. It also felt to me that I was not alone, as many primary care doctors and internal medicine specialists are weary of treating osteoporosis, most likely out of a lack of confidence on the topic. Anecdotally, almost all of the patients I see who have suffered from insufficiency fractures have not had the root cause, osteoporosis, addressed. Many patients and physicians simply do not recognize or believe in the treatment of osteoporosis. I was driven to understand skeletal metabolism and ultimately wrote an entire handbook on the subject.
What is skeletal metabolism
Skeletal metabolism is the process by which bones are remodeled, repaired, and degraded. It is heavily regulated by parathyroid hormone, vitamin D, and calcium. It is a complex process that occurs daily in the body and can change over time. It is influenced by factors such as diet, exercise, sleep, and exposure to chemicals and medications. Small changes in behavior can have a large impact on your skeletal structure when compounded over decades of time. Except for the knowledge that one should consume calcium in the form of dairy products, I personally felt that I had no education on skeletal metabolism as a teenager or adolescent. I had no idea what I should avoid or what I should do to make my bones strong.
Why young people should be interested in skeletal metabolism
There are several reasons young people should be interested in skeletal metabolism. Everyone will face osteoporosis as they age. The most dramatic gains in bone mineral density occur up to age 16 in females and age 18 in males. In fact, the majority of bone mass accumulation can be complete after the end of the second decade. If you are interested in longevity, you should be interested in your bone health. You will not enjoy your 70s, 80s, or even 90s without a very strong skeleton. The second reason is that skeletal metabolism represents an incredibly interesting field of study and ultimately can be useful in a medical career. Currently, there are at least three generations of medications available for the treatment of osteoporosis, yet many patients think we are still trapped in the era of the bisphosphates, which are medications that lock skeletal metabolism down, freezing it in time.
We have never been better armed to combat this disease with these new anti-osteoporosis medications. Previously, we were almost totally dependent on the bisphosphonate class of medications. Although these medications are powerful and effective, they received bad press and were unpopular with physicians and patients alike. Now we have powerful anabolic medications such as parathyroid hormone analogues that can reverse skeletal degradation rather than just freezing it. We also have increased knowledge of how lifestyle affects the skeleton over time. We now understand that weekly exercise, both aerobic and resistance, is critical for the maintenance of bones and the muscles, which just like bones undergo degeneration in a condition termed sarcopenia. We know that consuming certain chemicals such as nicotine, alcohol, and caffeine can leach calcium out of your bones and contribute to osteoporosis. These topics are typically neglected in medical school teaching but represent a unique arm of orthopedics that may be attractive to young students. I feel particularly inspired because as an orthopedic surgeon, I get to rebuild the skeleton with hardware but can also use medicine and lifestyle intervention to rejuvenate weary bone biology.
Conclusion
It is critical that young people start to understand not only that skeletal metabolism is an exciting field of study, but is also critical knowledge to ensure healthy bones as you age. Don’t lose this precious time to invest in your most important retirement account: your bone mineral density account.
Mark Polemidiotis is a medical student. Cyrus Nasr, Allen Justin, Stephanie Mendez, and Anahan Baptist are premedical students. Yoshihiro Katsuura is an orthopedic surgeon and author of The Spine Encyclopedia: Everything You’ve Wanted to Know about Back and Neck Pain but Were Too Afraid to Ask. They are members of the Surgical Fitness Research Pod.
