The Paid Leave Podcast

Osteoporosis Awareness and How to Strengthen Bone Health

• The Connecticut Paid Leave Authority • Season 3 • Episode 48

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In this episode of The Paid Leave Podcast, I speak to a professional about osteoporosis and bone health. In October it is International Osteoporosis Day on October 20th, National Health Education Week October 21-25th, and is also International Day of Older Persons on October 1st. Two out of three women with postmenopausal osteoporosis will break a bone in their lifetime.

I speak with Joan Doback, a certified Physician Assistant celebrating 36 years in the field. Doback, who works as a Bone Health Coordinator at the Connecticut Orthopedic Institute, explains the importance of bone health, particularly for women post-menopause. She highlights the significance of DEXA scans for diagnosing osteoporosis and osteopenia, and the role that lifestyle factors plays in bone health like diet, exercise, and avoiding smoking and excessive alcohol. She recommends weight-bearing exercises, resistance training, and balance exercises to improve bone density. Doback also discusses medical treatments for osteoporosis and the impact of fractures on caregivers of patients. She emphasized the importance that the Connecticut Paid Leave program is for caregivers. She says the good news is that Osteoporosis can be reversible. 

For more information on the Bridgeport Bone Health program at the CT Orthopedic Institute at St Vincent's Hospital: Bone Health Program | CT Orthopaedic Institute | St. Vincent’s Medical Center


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Nancy Barrow:

Hello Connecticut, and welcome to The Paid Leave Podcast. The title basically says it all. I'm Nancy Barrow, and I will be delving into this new state program and how it can help you and your family. This podcast will give you information you should know about Connecticut Paid Leave and maybe just a little bit more. Connecticut Paid Leave brings peace of mind to your home, family and workplace. Welcome to The Paid Leave Podcast! In October. It is International Osteoporosis Day on October 20. It's also National Health Education Week October 21 through the 25th and International Day of Older Persons on October, 1. Two out of three women with postmenopausal osteoporosis will break a bone in their lifetime. And joining me to talk about osteoporosis and bone health is Joan Doback. Joan is a certified physician assistant who is celebrating 36 years as a PA this year, she worked in neurosurgery for many years, before orthopedics, where she has worked for the past 21 years. She currently works as a bone health coordinator at the Connecticut orthopedic Institute at St Vincent's Medical Center in Bridgeport, and hopes to expand osteoporosis care in the Hartford healthcare community. Welcome to The Paid Leave Podcast Joan, I'm so happy to have you here.

Joan Doback:

Thank you so much for having me.

Nancy Barrow:

Well, congratulations on 36 years as a PA. By the way!

Joan Doback:

Thank you. Thank you so much. It's a great, great occupation. I really love it.

Nancy Barrow:

Well, I would hope that you would love it. If you've been in it for 36 years, that's a long time. So congratulations on that. Tell me about the Orthopedic Institute and what you do as the Bone Health Coordinator.

Joan Doback:

So I'm thrilled to talk about this. In addition to all of those October milestones and days set aside, September is Fall Prevention Month, so this is really opportune to be talking about. The Connecticut Orthopedic Institute is essentially a hospital in a hospital dedicated to orthopedic service. It provides our orthopedic patients with seamless care, safe educational process throughout their orthopedic procedure, mostly elective orthopedic procedures such as joint replacements or spine surgeries. And it's at both mid State Medical Center in Meriden and St Vincent's Medical Center here in Bridgeport. And I work on the orthopedic team as one of the Orthopedic PA's and I'm also the Bone Health Coordinator here for the hospital.

Nancy Barrow:

And so how do you help people who may come in with osteoporosis?

Joan Doback:

The Bone Health Coordinator is both an inpatient and an outpatient role. So on the inpatient role, I help to identify our fractures here in the hospital, because in orthopedics, we know that when you've had one fracture from a slip and fall from standing height, and it doesn't matter what the reason it could be a slip and fall on ice here in Connecticut, it could be the small dog ran between my feet, or it could be the big dog pulled me over, but you're not the roofer on a roof who fell a great distance, and you're not in a high speed car accident. Those would be the scenarios where we would expect you to probably fracture. But when you slip and fall from a standing height and you're over 50 years old that in the orthopedic mind, is saying we really need to put eyes on the bone health. And it really gives us a great opportunity to investigate your bone health and to see where you're at in the continuum.

Nancy Barrow:

And women versus men, who gets osteoporosis more frequently,

Joan Doback:

women do, and for good reason. So you grow your bones through childhood, and you're at your best bones ever at 25 and women support those bones with estrogen, and men support those bones with testosterone. So with women at 2535 45 we're good. We got great bones, but at early 50s, or thereabouts, by average, we're going to go through menopause, in which case we're going to lose most of our estrogen. And General gentlemen, will continue. They don't have an event such as menopause, where they wane in their testosterone and don't fully lose it until 65 or 70. So if you compare a lady who lost her estrogen at 50 to a guy who lost his his testosterone at 70, he's got two decades on us of good bone support. So there are more. Women with postmenopausal osteoporosis, as opposed to guys. However, this is not just a lady's disease.

Nancy Barrow:

So it's not just women's disease, but it usually affects the men a little later.

Joan Doback:

That's correct, because of that testosterone.

Nancy Barrow:

Let me ask you what is the Bone Health and Osteoporosis Foundation, and how are you connected with them?

Joan Doback:

So the Bone Health and Osteoporosis Foundation is the largest health entity that is solely dedicated to bone health and osteoporosis. So they have education and they've got research that that supports all of the providers across the country for the roles that we play in the trenches with our patients, but one of their important roles is also to educate our patients. So I give that that website to my patients all day, every day, and direct them to those websites, because they're really great for patient education.

Nancy Barrow:

Let's start with the basics. Though, for some people, they think osteoporosis a little old woman and she's bent over and she has a hump on her back, like that's what I think people believe osteoporosis to be and to look like, and that may not be correct. So I wanted to ask you, what is osteoporosis?

Joan Doback:

That is absolutely correct. That lady probably has osteoporosis. When you say little, being little, that's one risk factor. Being older, that's another risk factor. But the fact that she's humped over aims at probably she's got spinal compression fractures, and we never, never want it to get that far so we can aim at primary convention or prevention. Sorry, where we're we have eyes on on people's bone health, starting at 60 years old, or 70 years old for the men where we do the gold standard in investigation for bone health is called the DEXA scan. And so at 60 years old, the guidelines tell us we should be having a DEXA scan every two years, unless we have risk factors that we needed earlier than that. And then the men start their DEXA scans every two years, at 70 years old, unless they have risk factors that cause us to to get that DEXA scan prior to that.

Nancy Barrow:

So let me ask you about the risk factors so and the diagnosis is always the DEXA scan. Is that correct?

Joan Doback:

Well, no, if you slip and fall from a standing height and you have a hip fracture or a vertebral compression fracture, those, by definition, give you a diagnosis of osteoporosis. So you don't typically have to send a person who has a lot of pain or or whatnot with their hip fracture or vertebral compression fracture and ask them to lie flat on the scanner. Right? We're not going to delay the treatment for that DEXA scan. We can catch up to that when they're feeling better, but yes, the most people will be diagnosed with osteoporosis by their DEXA scan.

Nancy Barrow:

So what is osteopenia? Because some people get an osteopenia diagnosis, and does osteopenia always go to osteoporosis?

Joan Doback:

So let's talk about the continuum of bone health. So when our bones are supported prior to menopause, or when we have testosterone, we're in the normal range of bone, and then once we lose that support, we're going with some natural aging. You tend to have more breakdown of your bone than you have build up. So your bones are a living organism, right? They're living tissue, and they are constantly remodeling themselves with a build up and breakdown process. And when we have the estrogen or the testosterone in place, those processes are very even. So you have as much build up, then you have breakdown after menopause and after you lose your testosterone, you have a little bit more breakdown than you have build up, okay, and so then you start to go decline in your bone health. So your first stage, after normal bone density, you'll go into osteopenia. And you asked if people always continue downhill to osteoporosis. No, not at all there. There's some people who stay in the osteopenia range all of the rest of their life. But remember, this is a chronic disease, just like something like diabetes or hypertension. And you got to keep your eyes on this and see if you're going down that hill really quickly toward osteoporosis. We might want to do something about that.

Nancy Barrow:

And what are some of the things that you can do about that? So if you have an osteopenia diagnosis, Is there stuff that you can do so you can say, hey, I want to put off osteoporosis as long as I can. Can I do hormone replacement therapy? Does that help women? Because it seems that it's a you know, when we lose estrogen, we lose bone density.

Joan Doback:

Right, exactly. So the whole idea of hormone replacement therapy, you're absolutely right. We love women to have estrogen, and it has been shown to be safe right after menopause to a certain age, and your GYN provider can have full discussions with you about that. If you're using estrogen for something like your menopausal symptoms, like terrible hot flashes, then that's a really great reason to be on estrogen. And then the side effect of that estrogen, in that case, is going to be longer bone support, but, but it also comes with its risks, the estrogen support hormone replacement therapy, and so we do not use it as a front line treatment for osteoporosis, because it has more risks than benefits in that situation. Let me go over those, because those are important. So the the age is a risk factor, because the older you get, the farther you are from your estrogen or your testosterone, and so your risk increases with age. Gender is a risk because more women have a higher risk, especially after menopause. Ethnicity plays into it, as Caucasian and Asian women are at higher risk than African American ladies or patients, men and women. Family history, if your parents had a hip fracture, particularly before age 80, that may give you a little bit of a genetic component to this so that you want to maybe look at your DEXA scan a little bit earlier than 60 years old, if your mom had, if your mom was that lady you just described with the hump in her back and leaning over a walker, then you really want to put eyes on your own bone Health, and then bone size, small, thin, boned individuals, they're at greater risk as well. Everything we do in medicine is by guidelines, and that guideline is if you weigh less than 127 pounds, which is an odd number, but the rest of the world is on metric, and it's 58 kilograms. So 58 kilograms or less, 127 pounds, that's a risk factor for osteoporosis, so you want to pay attention to that. And then you have some Those are, those are risk factors that you can't do anything about, right, right? Burly. What we do is just acknowledge them and then and count them up, and then maybe that leads us to do a DEXA scan a little bit earlier than 60 or 65 years old. But there's other modifiable risk factors that you can look at, and that's things like the estrogen or the testosterone that we're talking about, nutritional deficiencies, you can do a lot with your diet, and particularly the building blocks of bone are calcium and vitamin D. So I spend a lot of time on diet with our patients and making sure they understand that we want them to get their calcium in their diet, rather than taking a chunk pill of calcium every day, which is a little bit easier, but it's just a matter of setting some some changes in your diet and making them a routine. So the guideline for calcium, how much calcium do you need? For good bones, ladies, need 1200 milligrams of calcium and and then need 1000 so both of those are around three to four dairy choices or green leafy vegetables. That's where you're going to get your calcium in your diet. So if you have cereal in the morning and drink the milk out of the bowl, there's one. Have a yogurt with lunch and a small glass of dit of milk with dinner and you've got your calcium for the day. Really works into our three meals a day.

Nancy Barrow:

That's so fascinating. You know, a lot of people don't think that green leafy vegetables have calcium, but they do.

Joan Doback:

Right exactly they they do, and it's it. You can consider that one of your servings of getting your calcium, right? Yeah, the a number one way of helping yourself is to exercise. So exercising includes weight bearing exercise, resistance exercise and balance training. So weight bearing exercise is about going to walk in the neighborhood, and your legs are carrying your upper half and so they're weight bearing. But if you carry some small dumbbells, two pounds, three pounds, or maybe up to five pounds, for men, now you're inviting your arms for the walk with you. I advise our patients that if you're going to stop and shop or Big Y to do your groceries, just park in the back of the parking lot, if it's a nice day, and get your steps that way, or do a circuit around the outside of the store. Before you pick up your carriage and do your groceries, you're just adding steps, and it might be raining out, but you're getting your walk in.

Nancy Barrow:

Is there a certain amount of steps that you say is good per day, or amount of ?

Joan Doback:

Okay remember, we started it, I think it was like 7500 then they went up to 10,000 and the more recent literature is more like some somewhere about 7000 or 8000 is what, what's optimal, and that's pretty doable, if you're intentionally putting in some extra steps every day.

Nancy Barrow:

Yeah, I think that you can get to that seven to 8000 pretty easily, right?

Joan Doback:

And I think that's the current research so and so you have the weight bearing exercise, and you have the resistance exercise, and then the third kind of exercise you need is balance training, and that really lends itself to getting good at your balance. And then you're not going to be the 80 year old who falls a lot, right? So things like just standing at the counter, hold on to the sink and practice standing on one leg, 30 seconds on each leg, you might just do 10 seconds at the beginning, realizing that your other leg is pretty hard to hold up, right? So you have to build up. And if you can stand 30 seconds without holding on. That's really good balance, but the better you can get at it, the more you practice, the better you're going to get, the better you can get, the less you're going to fall as an older person.

Nancy Barrow:

Yeah, so lifestyle factors really matter. Diet, exercise. What about like alcohol and smoking? Can they affect your bone health?

Joan Doback:

Absolutely. And so those are the base those two round out the five universal recommendations that everyone can do. So from the top exercise, then two and three are calcium. And then we're going to talk about some vitamin D. But let me ask answer that question. When you smoke, nicotine floats in your blood, and it just poisons everything. It certainly we all know it poisons our heart, it poisons our lungs, but it definitely poisons the bones as well. And so any smoking, vaping, it just it counts. There's no excuses. Any nicotine products are just bad for you, and they cause cancer, so, but so they need to be eliminated. And nobody says that lightly. We all understand that that's not an easy thing to do, right? It can take several times or many times in a lifetime of trying to quit before you're successful. But I encourage our patients, just please keep trying, because you're going to be successful one of these days of leaving that bad habit behind and then alcohol. What is too much alcohol? How much alcohol is good for my bones or not good for my bones? Yeah, that comes out to two drinks a day is okay? Three or more that's too much for the bones.

Nancy Barrow:

Okay? And is there something that's better? Is wine better? Or does it matter?

Joan Doback:

Yeah, so that's a good question, actually, because when we're talking about alcohol, one ounce of liquor in a drink is the same as one beer is the same as four ounces of wine, and they all have the same effect.

Nancy Barrow:

They all have the same effect okay. Mmm-hmm.

Joan Doback:

September is Fall Prevention Month, and so I don't want it to go away without talking about it. So fall prevention. 90% of our broken bones are fractures, are because of a fall, and it's a simple slip and fall, I took one step out on the deck to get the morning paper, and my life changed because I was on the ground before I knew it. Nobody expects to fall, and most of the falls happened in the bathroom, so taking care of things like on as. Slippery surfaces and things make sure you have grab handles, by the toilet, by the tub, where you're most likely to slip or lose your balance. That can help two things that people do not think about that increase your fall risk is decreased vision and decreased hearing. So getting annual checkups on both of those is really important, because if your vision, if your eyeglass prescription, is just not what you really need right now to give you clear vision, trying to maneuver stairwells and things around the house or outside, might be much more difficult if you're trying to adjust your glasses and move your head around to make sure you have a clear path ahead of you.

Nancy Barrow:

So what are some current medical treatments available for osteoporosis?

Joan Doback:

Once we determine that by the guidelines you you have undertaken, the universal recommendations, and you're doing what you can to to take care of your home, your bone health. Sometimes we add in a medicine, and we've got several safe and effective medicines, and they all do. There's two different categories. So they do different things. So depending on what your situation is, I if I'm doing primary prevention, and you're a post menopausal lady and you're just getting from osteopenia into osteoporosis, we might give you a pill once a week. Those are called bisphosphonates, and they're so easy and they're very effective and safe, and millions of people are on them worldwide that also if you that one of the side effects of those medicines is they just love to cling to the esophagus, the food tube on the way down, and they can cause heartburn. So we drink those pills with a big glass of water in order to wash it down. So that is usually fine, but if somebody has trouble with their swallowing already, we don't want to add to that, right? So we can give that medicine by the IV form once a year, and that avoids all of the swallowing problems that we might get into. So for different reasons, we pick different medicines, right? Yeah, and then so there's that, that one category that's called the anti resorptive medicines, and those are used in primary prevention, and often after we use the second category of medicine. Those are called anabolics, and that's we use those when we really want to build up the bone, when we know someone is really in trouble because they've had a fracture, they're at high risk for more fractures. And we don't want to give them a medicine that's just going to hold them where they are and then slowly turn them around and move them toward toward osteopenia. We really want to help them to move quicker. And we so we would use anabolic medicines, and those are self injections, or injections at an infusion center, more like that. I try to educate them that the one of the best things about osteoporosis is it's reversible and it's preventable. So if we keep eyes on it and we look early and get them before the fracture, it's not such a devastating diagnosis where people are really distraught over it, because they've got a lot of power to do something about it, and that's really encouraging to them, right? It's not there are many diagnosed, several diagnoses, right off the bat, I can think of them, but that you say to a patient, you have this, and I'm really very sorry we don't have any good treatments for that. That's not the case with osteoporosis, and so I spend a lot of time letting them know this is reversible, and you've got a lot of power to take care of this.

Nancy Barrow:

You said that osteoporosis can be reversible. How is that possible that you can reverse the diagnosis of osteoporosis? That's fascinating to me.

Joan Doback:

Yeah, so studies show so we take these big studies that are done at universities worldwide, and they have participants in them, sometimes 10,000 or 10s of 1000s. And we take those large studies and we know that things do happen if you do X and Y right, and that way, we can bring our conversations to one on one in the provider's office. So we know that x or. Size, plus getting enough calcium in your diet, plus taking your vitamin D, is those three things together can move you from osteoporosis up into osteopenia, and as you improve your bone density, you are decreasing your fracture risk. Those are opposites usually. I do want to talk about vitamin D, because once you get the calcium in your gut, you you're drinking your milk and you're eating your yogurt and and getting your green leafy vegetables, you really have a hard time using that calcium if your vitamin D tank is empty, right? So I get my patients to think about a vitamin D tank, and we want that full, and full is by a blood draw, and we can check your level, and we've got guidelines that tell us what's good, what's what's better, what's not so great. So vitamin D, actually, the skin is a miracle worker, and it can take sunshine and it hydroxylates it once in the kidneys and once in the liver. So everybody's working and we it turns it into a usable form of vitamin D. But that's only if the if the sunshine is directly overhead. So if we all lived in sunny Costa Rica, we would be great, but we live in cloudy Connecticut, right? So we're going to take our vitamin D. And actually, studies have shown that most of us north of the Carolina latitude are vitamin D deficient.

Nancy Barrow:

So let's talk a little bit about caregivers of people who have osteoporosis and have fallen and had fractures. Do you see the caregivers as well with the patients?

Joan Doback:

I do and our very typical older patients who are here at Saint Vincent's after a hip fracture, a slip and fall at home, and it might be that they're they're doing well at home, I go from very spry and active and they are out in the community every single day, volunteering, etc, etc, and this is truly life changing for them. And then I it goes to people who are still living at their house, but they're in a precarious situation, and this is just going to be life changing for them. But the imagine that they're attached to a daughter or a son here in the community, and they tend to be working age, and they're trying, they're in they might have children of their own that are, you know, do it, going to high school or going to college, and they're a sandwich in between these two competing priorities, right? Sure. So and, now we have a hip fracture, and we have hospital visits, and we have an operation, perhaps. And now where is dad or mom going to go after St Vincent's? And then they've got visits to the short term nursing facility, because typically you won't go straight home after a hip fracture, although that is changing, but you need a lot of support, so maybe now they have to take more time off from work to help with care at home or transport to doctors visits. Right? It really weighs on the minds of our caregivers how much time they need to take off after a fracture, particularly while they're caring for their parents.

Nancy Barrow:

Yeah, and that's something that Connecticut paid leave really does. It gives you up to 12 weeks of income replacement away from work to take care of your own serious health condition or that of a loved one with caregiver leave. And one thing that I find that is really important to note is that with caregiver leave, it is related by affinity, so it doesn't have to be a blood relative. It can be a neighbor or a best friend or a co worker or a partner that you live with, but maybe aren't married to someone who is like family. So you can take time away from work to care for them and get income replacement from Connecticut Paid Leave. And how important do you think Joan, these programs are to the people that you treat?

Joan Doback:

They are going to be very important for people with fractures, particularly because that's a process of mending where you just need more care. You need more support at home once you get there, even after, if you leave St Vincent's and you go to a short term nursing facility, you're there for four maybe, maybe a little more four weeks, say, and then you're returning home, and you're just not back to normal, back to your baseline. Yet, it takes a lot of care, and I see the stress that this causes, on on families, on children, particularly who have so many competing priorities, one of them being, I really need to go to work. I'm taking too much time off, and they're worried about not losing their their position at work.

Nancy Barrow:

Right? Yeah, and it's great. You can take it all at once. You can take it intermittently. You can take a reduced schedule from work. So there's a lot of flexibility with the program, and I think that's important for caregivers to have that flexibility

Joan Doback:

Exactly. And I love that you don't need to be a family member, per se, because so many people in the community, the older people, maybe their their children don't live around here. They may be, you know, as far as California or or whatnot, but the neighbor is who typically is the one that checks on on them daily, like that. So there's all types of situations that this this will play to.

Nancy Barrow:

Yeah, and I'd love to get any information I can to you so you can get it into the hands of the caregivers, because I do think it's an important segment of the population that you probably see, and they do need those resources and help. So we'd love to help you any way we can great.

Joan Doback:

And I'd love to pass it on to the people who are stressed, both financially or with their work constraints while they're trying to help their family.

Nancy Barrow:

Joan Doback is certified physician assistant who is celebrating 36 years as a PA this year, so congrats again on that one, Joan. Thanks so much. She currently works as the bone health coordinator at the Connecticut Orthopedic Institute at St Vincent's Medical Center in Bridgeport. And thank you so much for joining me on The Paid Leave Podcast. It was a pleasure.

Joan Doback:

So welcome. It was a pleasure to be with you.

Nancy Barrow:

For more information or to apply for benefits, please go to ctpaidleave.org. This has been another edition of The Paid Leave Podcast. Please like and subscribe, so you'll be notified about new podcasts that become available. Connecticut Paid Leave is a public act with a personal purpose. I'm Nancy Barrow, and thanks for listening.

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