Ask the Expert: Dr. Felicia Cosman, MD

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Dr. Felicia Cosman, MD, is an osteoporosis specialist, a Professor of Medicine at Columbia University, and the Editor-in-Chief of Osteoporosis International (OI), an international multi-disciplinary journal that focuses on current research related to the diagnosis, prevention, treatment and management of osteoporosis and other metabolic bone diseases. Dr. Cosman is a Medical Advisor for Wellen.

Disclaimer: If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Well Guide contain information from peer-reviewed research, medical societies and governmental agencies; however, these articles are not a substitute for professional medical advice, diagnosis, or treatment.

1. What drew you to the field of women’s health, and specifically helping women with osteopenia and osteoporosis?

I became interested in bones during my endocrinology training. I was fascinated by the concept that bone was a living organ, loaded with cells, and was constantly renewing itself. I also found out that my mother had vertebral fractures that were diagnosed fortuitously when she was being evaluated for a different medical issue. Vertebral fractures are a clear sign of osteoporosis.

When I first entered this field, there were very few options available to treat osteoporosis. I am gratified that through extensive basic and clinical research, we’ve developed many good medications which can really change the course of this disease.  

2. What is the first thing you advise patients to do once they’ve been diagnosed with osteopenia?

How does that advice differ from what you share with patients who are diagnosed with osteoporosis?

Patients diagnosed with osteopenia or osteoporosis after a bone density test (with no prior adulthood fractures) need to ask lots of questions.  

  • Do I have osteoporosis in both my spine and hip? How severe is it in both regions?
  • Do I need a test to look for silent spine fractures?
  • What else can I do to strengthen my bones?
  • Do I need medication? What is the goal of my osteoporosis treatment and how long will I be on it? What are the medication options?
  • How will I be monitored?

3. Does osteopenia always turn into osteoporosis?

After menopause, bone loss generally continues throughout life, although the rate of loss varies quite a bit among individuals.

Osteopenia includes a broad category of women with bone density T-scores just below normal (T-score <-1) to scores just above osteoporosis range (T-score <-2.5). Women who have levels close to the osteoporosis range are likely to end up with osteoporosis if no treatment is taken whereas women who have levels closer to the normal range might never dip down into osteoporosis. Medications best for women with osteopenia are different from medications that are best for patients with osteoporosis.

4. What are the top three things women diagnosed with osteopenia can do to prevent their diagnosis from progressing to osteoporosis?

In women with osteopenia, exercise, healthy diet, and taking medication, when needed, can minimize the risk of developing osteoporosis.

5. Related to that, can a person “get over” osteopenia or will they have to take medication for the rest of their lives?

Each person has a bone density set point that is determined by factors such as gender, size and other genetic influences. On top of these, lifestyle plays a key role. Improving lifestyle and taking medication, when needed, can put bone density back into the normal range.

However, when the medication is stopped, eventually the skeleton will return to its predetermined set point. That is why patients need to be monitored throughout life after a diagnosis is made. Medications can be changed over time and even stopped for several years. Monitoring allows doctors to determine when medication might be needed again.

6. Many women turn to supplements as an immediate course of action. How effective are calcium and Vitamin D supplements?

We have learned a great deal about nutritional supplements over the last several years. One important general principle is that it is almost always better to get nutrients from food rather than supplements.

Furthermore, the supplement industry is not regulated and many of the claims for these products are not supported by any scientific information. Most women who get an average of 3 calcium rich foods daily (yogurt, milk, cheese, calcium fortified drinks) do not require any calcium supplements. For each missing calcium-rich food, a 300 mg calcium supplement might be warranted.

Recent studies on Vitamin D (Leboff et al. 2022) suggested that there are no skeletal or extra-skeletal benefits associated with routine Vitamin D supplementation. Recommendations have not yet changed because the results of these studies are so new. A multivitamin dose or calcium supplement dose of Vitamin D (400-800 IU) is not likely to cause harm, but given what we know now, high doses of Vitamin D are not really indicated in the absence of a specific medical issue such as malabsorption.

7. What’s one thing you wish more people knew about bone health?

People need to understand that osteopenia and osteoporosis are conditions which alone cause no symptoms.

They are important because they suggest the skeleton is weakened and more likely to break or fracture in minor accidents, such as a fall, banging into furniture, getting a hug or straining to lift a stuck window. When adults (over age 45) have fractures after these minor incidents, it is almost always related to osteoporosis.

Osteoporosis can be diagnosed in patients who have these fractures even if their bone density levels are only in osteopenia range, rather than osteoporosis. Some patients with spine fractures may have no back pain, but have developed stooped posture (called kyphosis) or height loss. X-rays or other diagnostic tests can help find these spine fractures. Patients who have osteoporosis-related fractures need to start medication right away because they have a very high risk of more fractures in the next several years. Bone building medications, sometimes called anabolic medications, are highly effective in these women.

8. What is more effective at preventing fractures: taking medication or making lifestyle adjustments?

Both medication and lifestyle adjustments are important to manage osteoporosis and osteopenia.  Not everyone needs medication of course, but everyone should optimize their lifestyle with diet, exercise, eliminating risk factors and reducing falling risk.

Patients with osteopenia might be able to prevent the decline into osteoporosis with lifestyle.  In general, patients with bone density in the osteoporosis range or patients who have had fractures, medication is required. Medication might also work better in patients who improve their lifestyle.‍

9. What is the biggest misconception about osteoporosis?

The biggest misconception is the lack of understanding that osteoporosis is the underlying disease that causes fractures. The precipitating event may be a minor accident, but these minor accidents should not cause fractures in patients who have normal bone mass and bone strength. 

Fractures have very serious consequences including temporary pain and disability and need for surgery in many cases. Fractures beget more fractures. Older individuals with fractures often require assisted living or may completely lose their independence and require permanent nursing home care. Some older individuals will die as a result of their fracture, especially after a hip fracture.

10. In closing, is there anything else you’d like to share with the Wellen community?

Osteopenia or osteoporosis can be managed with lifestyle intervention and in some cases medication. Having a fracture is a more important indicator of subsequent fracture risk than bone density alone. Height loss, a Dowager’s hump or round shoulder appearance might be a sign of vertebral fractures and more advanced osteoporosis. Medications for osteoporosis are safe and effective and patients should not let the fear of very rare side effects dissuade them from treating their condition.

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  1. LeBoff et al. Supplemental Vitamin D and Incident Fractures in Midlife and Older Adults. N Engl J Med. 2022;387(4):299-309. doi: 10.1056/NEJMoa2202106.

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