Osteoporosis Screening And Prevention With Dr. Uzma Khan

Osteoporosis is one of those diagnoses that can hide in plain sight until the day a wrist snaps from a minor fall or a hip fracture changes everything. We sit down with Dr Uzma Khan, board-certified in internal medicine and endocrinology, to explain what osteoporosis and osteopenia actually mean inside the bone and why “no pain” does not mean “no risk.” 

We talk through bone density screening with a clear, listener-friendly roadmap: when women should get a DEXA scan (typically starting at 65), when men should be screened (often starting at 70), and why earlier testing matters for ages 50 to 64 in women and 50 to 69 in men when risk factors show up. We cover the big red flags to bring up at your next visit, including family history, prior fractures, long-term prednisone or other steroids, smoking, vitamin D deficiency, celiac disease and other malabsorption issues, rheumatoid arthritis, diabetes, cancer therapies that lower estrogen or testosterone, and premature menopause. 

Then we shift into prevention you can start today, no matter your age: building peak bone mass earlier in life, getting enough calcium from food, prioritizing protein and key minerals, and using vitamin D from diet and appropriate sun exposure to support absorption. We also share why walking helps, why resistance training is a bone-health multiplier, and how these habits overlap with better metabolic health overall. 

Finally, we tackle a timely question: do GLP-1 receptor agonists like semaglutide affect bone density, or is the concern more about rapid weight loss, lower nutrition intake, and less mechanical loading on the skeleton? We discuss what current studies suggest, what remains unclear, and how to think about risk versus benefit with your prescriber. Subscribe, share this with someone you care about, and leave a review so more people can find reliable, practical health information.

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Transcript

Welcome And Medical Disclaimer

Dr. Lindsay Ogle, MD 0:00

Welcome to the Modern Metabolic Health Podcast with your host, Dr. Lindsay Ogle, Board Certified Family Medicine and Obesity Medicine Physician. Here we learn how we can treat and prevent modern metabolic conditions such as diabetes, PCOS, fatty liver disease, metabolic syndrome, sleep apnea, and more. We focus on optimizing lifestyle while utilizing safe and effective medical treatment. Please remember that while I am a physician, I am not your physician. Everything discussed here is provided as general medical knowledge and not direct medical advice. Please talk to your doctor about what is best for you.

Meet Endocrinologist Dr Uzma Khan

Dr. Lindsay Ogle, MD 0:44

Welcome back to the Modern Metabolic Health Podcast. Today I have a wonderful guest, Dr. Uzma Khan. She is board certified in internal medicine and endocrinology, and she has been working at the University of Missouri Health in their health system, and she is soon joining me at Missouri Metabolic Health. So I'm so excited to have her here today to introduce herself. And we're also going to talk about a important health topic that we haven't discussed on the podcast, which is osteoporosis. So thank you, Dr. Khan, for being here. I'm so excited to have you join my podcast and my team.

Dr. Uzma Khan 1:25

Thank you very much, Lindsay. This is a very exciting, you know, a new step forward, and as you said, into the modern medicine now. Because being used to the traditional medicine, this is a totally different format for me. So I'm excited to learn some new things.

A Career Shaped By Diabetes Advances

Dr. Lindsay Ogle, MD 1:42

Yeah, absolutely. Well, I guess along that path, could you tell us a little bit about your career and what sparked you into going into medicine and then endocrinology? Yeah.

Dr. Uzma Khan 1:54

Well, it's a very long story, but I'll make it short. When I did my medical education and completed it in 1991, uh endocrinology was not a very known field at that time. In fact, a lot of people would say, why do you want to do endocrinology? Because it's only diabetes, and we didn't have many treatments for diabetes at that time. But I had an experience at the University of Missouri in Columbia where the endocrine department was very well developed. And they were at that time doing inpatient medicine. They were involved with the DCCT trial that a lot of people know about type 1 diabetes. So I got more interested in it than I had family members with diabetes. And then there was a very inspiring couple, uh, Dr. Celso Gomez Sanchez and his wife, Dr. Elise Gomez Sanchez, who were really very encouraging for me. And I learned how you can be an excellent clinician and a scientist, and how you can actually make endocrinology very exciting. So I started on it and I've looked back, and sometimes I think that's why I'm never going to really retire, because there are so many new things happening in endocrinology, things we had not even thought of before. If you look at it, uh the new medications coming out every month, actually, uh the new pathways to treatment to make people feel better because these are chronic diseases. So it's really an exciting time, and I'm so glad I got into endocrinology many, many years ago.

Dr. Lindsay Ogle, MD 3:35

Yeah, yeah. Well, we're glad that you did as well. And it's so interesting because you never know exactly what those decisions are going to bring you to later on. And I'm sure you never thought that you would eventually be transitioning um at least part-time into telehealth. Um, so that's exciting. And um I'm glad that you've been so adaptive to these new options along your career.

Dr. Uzma Khan 4:01

Um, so there was no telly health. Yeah, there was no telly held at that time, actually. Uh we used to have those big old phones. So even the mobile phones were not there. So really a big transition.

Osteoporosis And Osteopenia Defined

Dr. Lindsay Ogle, MD 4:16

Yes, yes, absolutely. Well, um, let's get into our topic today, um, which is osteoporosis as well as um osteopenia. Um, can you help even just start by defining what these conditions are and why should we care about them?

Dr. Uzma Khan 4:36

So osteoporosis is a disease of the bone. Uh, the bone is being lost too much or not being made good enough. And osteoporosis means bones that are porous. So we think of bone as just being this hard thing, but actually it's a normal bone looks like a honeycomb. It has little holes and then pillars between each of them, and those are really strong pillars. But in osteoporosis, the holes become bigger and the pillars become thinner and thinner, and then sometimes they start breaking, and the structure of the bone becomes very poor, so that it breaks very easily. So that's what osteoporosis is. The other word that's osteopenia means uh think of it like pre-diabetes. You don't have diabetes yet, but your blood sugar is out of the abnormal range. So in osteopenia, you don't have the porous bone yet, but you have lost enough bone to where it's not strong enough anymore. And it does predispose you to fractures also. Uh, and we have different ways of assessing those patients. Uh and both of these are chronic diseases that happen over time, which is why they're so important to identify and even more important to prevent them.

Dr. Lindsay Ogle, MD 6:07

Thank you for that overview.

Bone Density Screening And Risk Factors

Dr. Lindsay Ogle, MD 6:09

Um, and let's get started with how do you screen for these conditions?

Dr. Uzma Khan 6:16

So these are very common conditions. Uh, in fact, if you look at it, uh, women above the age of 50, one out of two are going to have uh bones that are in the poor or osteoporosis range, and men above 50 and then especially above 70 are at risk also, but they're not going to have any pain. So, how do we know who's the person is at risk of osteoporosis, which basically means they are at risk of having a fracture? So, who are those people? That's where this screening comes because a sad situation, but even in a very developed country like the United States, most of these patients are identified when they come to the hospital with a fracture. And they've either had a hip fracture, very common. Sometimes it's you just had a little trip and you fell and your wrist got fractured. And the other one is when there's compression fractures, which the vertebrae start becoming compressed and you lose height, and then you become sometimes even a little hunched. So we don't want to wait until that time. By screening, we are identifying patients where we can actually prevent those fractures. The most common indication for screening, which almost everybody will get, will be at the age of above 65. I call that the first test that Medicare does. At the age of 65, you come in for your Medicare visit and we include a bone density scan in it. And the idea behind that is after menopause, it takes years to develop osteoporosis. So that's why we are screening at the age of 65. The other group that we want to screen is also men above the age of 70, because men, the decrease in testosterone is slower. So their osteoporosis happens about later, and that's why we screen after the age of 70. But then what about a woman that tripped when she was 52 and had a fracture in her wrist? You know, if we catch that woman right now by screening her for osteoporosis, we might prevent that hip fracture later on. There's a group of people between the age of 50 and 64 that we would really like to actually encourage even more. Because there's a lot of public knowledge about, oh yes, I get my bone density scan after the age of 65. But not many people know that if we screen between the ages of 50 and 64, and for men between the ages of 50 and 69, we will catch a lot of people in that pre-osteoporosis range called the osteopenia. And what are those risk factors? Because to qualify for a screening test, we need those risk factors. Uh, number one, family history. If your mother had osteoporosis, your sister had osteoporosis, then we want to check that out. Uh, the other one is if you've had a fracture. You may not have thought about it, maybe didn't even go into the hospital, maybe just got something done as an outpatient, or maybe just a one-day surgery. That's the other thing. Somebody that has vitamin D deficiency for a long time because of chronic conditions, smoking, uh, be another reason to stop smoking, because uh smoking is associated with osteoporosis. Uh, people that may not be able to absorb nutrition because you need calcium, you need uh magnesium, you need protein. So celiac disease comes to mind. You know, if somebody has celiac disease, then for many years they haven't been absorbing uh the right amount of nutrition and they haven't built up bones. Rheumatological conditions, chronic conditions like rheumatoid arthritis, especially those that require a medication called steroid, so prednisone. Uh patients that are on it, whether they are on it for asthma or lung disease or some other condition, if a person has been on pregnisone for several years, that person needs to be checked. Another very important group that's coming out, two groups that are really important. One is diabetes. We don't think of diabetes, but actually diabetes doesn't allow our bones to grow normally and be healthy. People that have cancers, uh, whether it's breast cancer or prostate cancer and even other cancers, but breast and prostate are important because estrogen and testosterone are what keep our bones strong. And if you don't have enough of it, you're going to have poor bones. Premature menopause for whatever reason, whether there was the need for surgery or something else. So I think above the age of 65 for women, above the age of 70 for men, we should all be screening. But it's very, very important to catch those early people by identifying people between the ages of 50 and they're 64 for women and 69 for men that have these risk factors. And it's important for patients to bring that up because you know, you know it and I know it. So many times we are running around and we don't even think of it. That uh, but if a patient brings up and says, My mother was just diagnosed with osteoporosis, or my mother was just admitted with a hip fracture, it sort of makes me think and says, Oh, maybe I should screen this patient because she's got a family history now. And she's a smoker. So let me check. I think it's very, very important to identify that group.

Dr. Lindsay Ogle, MD 12:24

Yeah. Well, thank you for going over that detail. That was beautifully done. And I think many people in the audience are going to recognize those risk factors in themselves or a family member, and hopefully that um encourages them and empowers them to ask their doctor if they should be screened because you are absolutely correct on a busy practice. And there's so many other things that you're addressing. And this one often unfortunately does get overlooked. Um, and you're also speaking to, you know, my heart as a primary care physician, family medicine physician. I love preventative health and identifying anything early and modifying the risk factors as much as possible so we can prevent disease and at least prevent complications from those diseases. Um another, you mentioned so many great risk factors to that. Um, I also thought of would be high alcohol use, um, so high amounts of alcohol, and then um underweight individuals are two other ones that I think of as well.

Prevention With Diet Vitamin D Exercise

Dr. Lindsay Ogle, MD 13:35

Um so I guess going along those lines of prevention, what can patients do to prevent osteopenia or osteoporosis or lower their risk for it? Is there certain nutrition factors, supplements, exercise, medications, or other lifestyle modifications?

Dr. Uzma Khan 13:56

Yeah, so that's a very good question because it's too late to change our genetics now. But it's good to know when I talk about prevention. I think one thing is what can we do today? And also it's good to know where you're coming from. Uh people that are Caucasian and thin are at very high risk of osteoporosis. Identifying that, and then keep thinking that bones don't grow in a day. In fact, if we want to prevent osteoporosis, we should start from children. Um, I always give an example of you know, a middle-aged lady that comes to see me and says, My mother just had a hip fracture, and she has a daughter also. So this lady has a daughter, and I say, We need to work and prevent osteoporosis in you, but we also need to start from your daughter because we actually start making bones and we start growing and mineralizing the bones as we are going through our teenage years, and what's called the peak bone mass, which is the strongest bones we're going to have. You know, the best calcium deposit, the best structure of the bone is in our mid-20s. So if we start having a diet that is balanced in calcium and minerals, has a healthy amount of protein as a child, and we start doing an exercise and staying active as a child, we build our strongest bones when we are in our mid-20s. That's because after the age of 30, we're all going to lose bone. So if we start at a higher point, we actually that decline becomes less. But if we start from here, then by the time we're 50, we're going to have lost a lot of bone. So I think sometimes encouraging, especially because I think in this audience, there's going to be lots of young people plus people that have children. So they can actually start at that time. So a healthy diet with fruits and vegetables. And when we think of calcium, we always think of supplements. But actually, if we can have access to foods, which we are very lucky in the United States to have that, you know, we have the best cows in Missouri, the best milk in Missouri, the best vegetables in Missouri. If we can have an intake of that and get an adequate amount of calcium, which if you're less than the age of uh 50, I would say, you know, about a thousand milligrams in a day, which includes your food, by the way. And then if you're above the age of 50, then I would say about 1200 is a good number again, including the food. But it's also important to keep in mind that when we are including diet, we're putting the healthy foods, something like prunes. You know, there was a very interesting study I came across where if you eat six prunes in a day, that actually provides enough uh magnesium, potassium, and other things to make your bones healthy, also. So there are multiple benefits to it. But also to minimize things that may have a negative effect on our bones in our diet, uh, excess caffeine. A little bit of caffeine is good for you, it keeps us, you know, working, it keeps our heart in good health. But I would say more than three eight-ounce drinks in a day, maybe too much. Uh, the soft drinks, uh, especially the black sodas, there is some information that maybe the phosphoric acid component in those sodas might be a little uh might decrease the mineralization of our bones and have a negative impact on our bone because it decreases the calcium that we absorb. Uh, I give the example always, think of it as your child is having a cheese sandwich with a cola, and that is going to decrease the amount of calcium they're going to absorb, and they may not attain the peak bone mass. Also, for any person, if we can preserve our bones at any age, whether you're 30 or 40 or 50 or 60 years old, at that age, enough calcium, enough protein, enough minerals like magnesium and potassium to make our bones healthy is in our diet. But then when we put that calcium in our bones, it has to stay in the bones. And that's what the calcium at the exercise programs do. So having a regular program with exercise will keep that calcium in your bones. Um, mostly I recommend at least 30 minutes of just simple walking because the weight, when we are walking, our weight and the gravity helps us keep the calcium in our bones, but also to include a little bit of resistance or muscle building exercises. When I think of bones, I always say bone is part of a system which is called the musculoskeletal system. So if you have bones that are weak, then your muscles are weak. And if you want to make bones strong, you want to make your muscles strong. So include both those exercises in your regular regime regular regimen and see how you do. So I think those are two very important things. One thing we don't talk about very much, sometimes we talk too much, but when we're talking about osteoporosis, we don't talk too much is vitamin D. And again, most people think that vitamin D is coming from supplements and they will take vitamin D supplements, but we have access to really good foods that have vitamin D. You know, there is uh even orange juice now has vitamin D and milk has it, but uh good quality fish, the oily fish will have it. Uh, using a little bit of sardines, they have nice taste and lots and lots of vitamin D. There are times when you can go out in the sun, maybe about 20 minutes every morning between 10 and 2 will give you enough sunlight and will not cause damage, but not having enough vitamin D, especially in people that are working indoors or are you know living in assisted living or have a medical condition where they may not be absorbing enough vitamin D also, because vitamin D makes us absorb calcium from our bones. And if we cannot have enough vitamin D, then we cannot absorb calcium from our intestine and we cannot put it in our bones. So those three things in our diet, we should have enough protein, enough calcium, enough vitamin D. We should have an exercise program that includes uh just some uh weight-related uh uh exercise as well as some exercise that is muscle-building exercise.

Dr. Lindsay Ogle, MD 21:25

Wonderful. And what I'm hearing is that it's a very comprehensive approach, and the earlier you start the better. And if you have children, you know, instilling these habits um with them and teaching you know them how to um live this healthy lifestyle will have significant impact on their risk of osteopenia and osteoporosis. And also, what I was thinking when you were speaking is the good news is all of those recommendations that you made for lifestyle to prevent osteoporosis are recommended. Recommendations that are going to help maintain a healthy weight and to help reduce risk of diabetes and cardiovascular disease and kidney disease. So these are things that are going to, you know, impact your health in a positive way and also then decrease your risk for osteoporosis. So it sounds like a lot, but it's something that over time you build those habits up and it's going to make a huge impact in the long run.

GLP1 Medications Weight Loss And Bones

Dr. Lindsay Ogle, MD 22:35

Are you aware of any studies or any no links between GLP1 medications and osteoporosis, either directly or based on, I guess, just how osteoporosis and weight in general on the association between those two?

Dr. Uzma Khan 22:57

That's a very interesting question. And I think now that we are using uh GLP1 receptor agonists so many years in such a big population, it's really been a very interesting journey. If you think about it, your our bones are how we grow our bones and how we keep calcium in our bones is dependent on gravity and weight. And if a person loses weight, they do lose some bone also. And if a person loses weight very acutely, they will lose some bone also. So when it comes to GLP1s, uh there are a couple of studies, and I'll go over those in a little bit also. But the question that everybody is asking now is there seems to be bone loss with patients that are taking GLP1. Is that a medication effect, or is that the effect of weight loss? Because there is a significant weight loss and it happens very acutely. Also, we are now looking at if the weight loss is slower or if we can combine some lifestyle changes, uh, would that make the bone loss that we're seeing in these patients a little better? So there was a very interesting study that was uh presented, uh hasn't been published yet, but it was presented at the American Academy of Orthopedic Surgeons recently. Uh, the researchers had noticed in the orthopaedic surgery group that their patients were coming with uh injuries, with fractures and bones that were not as good. And they had been on some of them had been on GLP1 agonists. So they did this study, which went over five years, and what they found that there was a slightly higher risk of developing osteoporosis in patients that were GLP1 users at the end of five years. It was about 29 to 30 percent higher. Now keep in mind this was just a study looking back at the medical records. This was not the typical type of research study where you take a group of people, you expose them or give them a medication, and then see what happens to them. So we are looking back at these patients. And it was really, we didn't know how many of these patients actually continued the GLP one, what dose they were taking. Uh, it was a retrospective review of their charts. So there's much more. So, although there are some drawbacks, some limitations to the study, but it makes us think even more about should we be looking at this? And then what are we looking at? Because there was also an increase in gout in this group of patients. So, what caused that? We have to look at that. There was another very interesting study that was around 2024 that was published also, and it was presented in patients that had type 2 diabetes and were in on GLP1 agonists, and they also showed that there was a higher risk of osteoporosis in those patients. There is uh the FDA, the Food and Drug Administration, has put on the semaglutide label that there is a possible risk of increased bone fractures in older adults and women that are initiating GLP1 agonists. But again, we have also found that in people that have type 2 diabetes and osteoporosis, actually GLP1 reduced the risk of fractures. Now, was that a decrease in fractures due to the fact that they had lost weight, they were exercising, and maybe they had better balance and maybe they were more stable? But we do know that people that have that are taking GLP1 agonists, they lose weight very rapidly. There's also a decrease in their appetite. So are they taking enough nutrition? Are they taking enough protein, enough calcium, enough vitamin D? What's going on with that? So there's many things when we look at a study, we're looking at is this a cause of that condition, or is this just a connection? And then we have to look at those connections and try and find out more about it. So at this time we know there is a connection between GLP1 and osteoporosis, but we do not know that it is the cause. But we are thinking as time is going on that there are possibly some things we can do to where the effect on bones may not be as bad as we find out at this time.

Dr. Lindsay Ogle, MD 28:18

Yeah, thank you for going over that. And clearly there are so many different factors to consider, and we need more studies to really find the answers there. Um, but what you know, the couple things that it makes me think of is anytime we're starting a treatment in medicine, we're weighing the risks and the benefits. And so it's a conversation to be had with, you know, whoever is your prescriber for your GLP1. Um, and I, in my experience, for most of my patients, the benefits outweighed those potential risks, but it's something to be aware of and then monitor for and screen earlier, um, most likely for the osteoporosis potential. Um, and then it also highlights the importance of working with somebody who has a lot of education around these medications. Um, so most commonly an obesity medicine physician or an endocrinologist. More and more primary care doctors are getting education on these medications and familiar with them, um, potentially adding on a dietitian or a trainer, physical therapist, just really making sure you're getting well-rounded care to optimize uh your treatment in general. Um, but thank you so much for going over this topic. This was clearly something that we needed to address on the podcast. And I really would love to have you back and, you know, either dive in more to the treatment side of osteoporosis and or talk about another topic in endocrinology. And I'm just so excited to have you a part of my team because you're gonna bring so much um wonderful knowledge and care to our patients.

Dr. Uzma Khan 30:05

Thank you very much, Lindsay. And I totally agree with you. You know, this is osteoporosis is a chronic disease. Like any chronic disease, it has to be a group of people working together. It cannot be, you know, you have osteoporosis, here's the medicine, take it and you're done. Or same thing with GLP1. In fact, one thing we didn't talk about is the patients I start on a GLP1, they come back and say, I can walk now, my knees don't hurt, my ankles don't hurt. We know that their joint pain gets better, we know that they feel better, their depression gets better. And those are things that are also in osteoporosis. A lot of people with osteoporosis are depressed because it limits their abilities, they've had fractures. So looking at the whole person, I think that's what's so exciting about the times we are living in now. Whether it's GLP1 or whether it's osteoporosis medicine, we're not treating just one condition anymore. We're looking at the whole person. And uh whether it's a family medicine doctor, it's an obesity expert, it's the dietitian, and most important, it's the patient and their family and friends. So we all have to come together, and I'm excited about this opportunity. And, you know, anytime you have an uh interesting topic, it's so much fun to talk about it.

Dr. Lindsay Ogle, MD 31:27

I agree.

Wrap Up And Listener Next Steps

Dr. Lindsay Ogle, MD 31:28

Well, thank you so much for taking the time. Um and thank you everyone for you know staying to the end and learning about this um important condition. And hopefully you've taken away a lot of knowledge. Um, I know I it was a great review for me. Um, and again, thank you, Dr. Khan, for um being here today. Thank you for listening and learning how you can improve your metabolic health in this modern world. If you found this information helpful, please share with a friend, family member, or colleague. We need to do all we can to combat the dangerous misinformation that is out there. Please subscribe and write a review. This will help others find the podcast and they may also improve their metabolic health. I look forward to our conversation next week.