The marketing of fear

Townsend Letter for Doctors and Patients, Dec, 2003 by Irene Alleger

The Myth of Osteoporosis: What Every Woman Should Know About Creating Bone Health by Gillian Sanson

Published by MCD Century Publications, LLC, 2035 Hogback Road, Suite 107, Ann Arbor, Michigan 48105 USA Softcover, 2003, $19.95, 220pp.

The myth of osteoporosis began with the selling of hormone replacement therapy (HRT). With no evidence that HRT would even prevent or treat osteoporosis, a major promotional campaign in 1982 by the pharmaceutical company producing the synthetic hormone, suggested that it could prevent this disfiguring and disabling disease. Most disturbing, was the idea promulgated that all women are at risk for osteoporosis, after menopause.

The author of The Myth of Osteoporosis, Gillian Sanson, is a women's health advocate and educator, and was motivated to research this subject when her family participated in a study to determine genetic risk factor after her teenage daughter was diagnosed with very low bone mineral density for her age. Six of the extended family were diagnosed with osteoporosis, as defined by a BMD of - 2.5 standard deviations (SD) below norm or less. The rest of the family was diagnosed with osteopenia, or low bone density.

In her research she uncovered increasing amounts of evidence that "well women were being frightened into unnecessary testing, handed questionable diagnoses, and urged to undergo long-term treatments for a disease that they probably didn't have." In 1988, Dual X-ray Absorptiometry (DXA) machinery was developed to measure the bone mineral density (BMD) of an individual to determine the likelihood that the person will develop osteoporosis. DXA has become the internationally recognized gold standard for determining osteoporosis risks. But BMD only measures bone mass, not the factors which contribute to bone fragility. Bone mineral density naturally decreases with age in most people, but not all people are at risk for fragility fractures. In fact, the author found that "Even the most favorable reports on the effectiveness of bone mineral testing reveal that BMD testing does not accurately identify women who will go on to fracture as they age." For one thing, peak bone mass (DXA measures the BMD and then "grades" it against an average peak bone mass) varies widely from region to region, by gender, and even fluctuates seasonally.

But perhaps most disturbing is the changed diagnosis--from a disease, where bones fracture as a result of little impact because they have become thin, brittle, and have lost tensile strength--to a condition characterized by low bone density or reduced bone quantity. This definition says nothing about bone quality--that is, its strength or brittleness. "Calling low BMD osteoporosis is like calling elevated cholesterol, heart disease, or calling high blood pressure a stroke." So what used to be a rare disease has now been transformed into a common condition, presumed to affect all postmenopausal women, and no one has questioned how osteoporosis has gone from being rare to being everywhere.

Furthermore, in 1998 a large Canadian study found DXA manufacturers had not standardized their machines, leading to widely varying diagnoses. The lead investigator reported, "the most interesting thing we've learned is that peak bone mass varies across the country .... We can't find any real differences to explain it .... The difference is greater than 10%, which is more than one DXA standard deviation." Consequently, concerned scientists and osteoporosis experts are warning that the technology may be diagnosing "low bone density" when it is at a normal level for that person--a level that may never result in a fracture.

Unfortunately, the physicians are, for the most part, as ignorant of these facts as the patients, and trustingly make decisions on the basis of a DXA scan. Another major factor often overlooked is the long list of drugs known to cause bone loss: alcohol, aluminum, anti-seizure medications, cyclosporine A, lithium, Depo-Provera, Methotrexate, steroids such as glucocorticoids, and (excess) thyroid hormone .... "Glucocorticoid use is the most common form of drug-related osteoporosis. The steroid is widely used for long-term disorders such as rheumatoid arthritis and other connective tissue diseases, asthma, psoriasis, Crohn's disease, lung disease, inflammatory bowel diseases, severe allergic reactions .... " This situation is a good example of how far we have come with pharmaceutical medicine--we are now officially treating side effects as new diseases (to be further treated, of course.)

Ms. Sanson includes voluminous documentation in her book, showing that the medicalization of older women is based on skimpy to non-existent research, and massive promotions of these products. The baby-boomer statistics relating to menopause are undoubtedly behind the promotion of these questionable diagnoses and treatments.

Any woman who has been diagnosed with osteoporosis on the basis of the BMD test, should read this book and share it with her physician. In the next few years, the market will be flooded with products (drugs) aimed at women. Becoming wellinformed about health issues may now be a matter of life and death for American women.