Atherosclerosis and Osteoporosis: A Tale of Two Conditions

I’ve been thinking quite a bit recently about two chronic health conditions directly tied to aging: atherosclerosis and osteoporosis. Both are often seen as “old people’s diseases,” but the disease processes for both actually start in much younger years — as early as your 30s and 40s. Both are highly prevalent, affecting over 60 million people in the US.

But the paths of these two widespread conditions have diverged dramatically. In one case, the death rate declined by 60% between 1950 and 1996 and then continued to decline. In the other, there was a modest decline, which has since reversed. While both conditions affect both sexes, one is often connected to men and the other to women.

While none of us will live forever, the progress of modern medicine against heart disease since the 1950s is truly stunning. Diagnostic testing, medications to slow progression, stents to open blocked arteries, dramatic life-saving surgical procedures, the list goes on. There are over a hundred tests, medications, devices, and procedures (with more always in the pipeline) at the fingertips of highly trained doctors and relatively high utilization of these tools. Having seen parents and grandparents die dramatically of a heart attack, the next generation of both doctors and patients is often very motivated to be proactive about prevention and treatment. 

Treatments for, and attitudes about, osteoporosis and its precursor osteopenia stand in stark contrast. The death rate after a hip fracture has remained essentially unchanged for 50 years. Hip fracture rates declined by about 15% from 1990 to 2020, modest compared to the decline in cardiovascular events. But at least they had been declining. Unfortunately, that progress has now stalled. Fracture rates held steady from 2012 to 2015 and then started to increase.  

Why? Why has there been so little progress against the rate of osteoporotic fractures and the associated morbidity and mortality? The deaths are real, the pain and suffering are real — and almost all of us have witnessed it. And, of course, the cost to our health system, $57 billion per year, is real.

One explanation is pharmacological challenges. One of the core treatments for osteoporosis has been medications. While their efficacy in reducing fracture rate is undeniable, bone-active medications such as bisphosphonates come with side effects that range from unpleasant (e.g. GI distress) to rare but serious (e.g. atypical femur fractures, osteonecrosis of the jaw). Over the years, patients have come to fear these side effects to the point that the proportion of patients initiating osteoporosis medication treatment has dropped from a high of over 40% in 2002 to below 10% today. Even for those who are open to pharmacotherapy, most treatments are recommended for 3-5 years (bisphosphonates) or 1-2 years (anabolics), as after that duration the risk-benefit ratio climbs. There is also no pharmacotherapy broadly indicated for osteopenia, nor one that can be used long term. In other words, we simply don’t have the equivalent in the bone health world of a statin for high cholesterol or ace inhibitor (or similar) for high blood pressure, medications with such a safety and efficacy profile that they are initiated early and used indefinitely.

But this is only a surface explanation. There is also a business reality. After the first wave of pharmacologic interventions for osteoporosis hit the market, innovation and investment stalled and never came back. Many of the largest pharmaceutical companies, Lilly, Merck, Pfizer, and others have exited the field. Some combination of the prohibitively high cost of running a clinical trial to demonstrate a lower number of fractures and the extreme backlash against anti-resorptive drugs such as bisphosphonates and denosumab prompted the industry to reconsider the profitability of such medications. Poor reimbursement for the most effective anabolic drugs certainly hasn’t helped the business case. The result is that there is not a single new agent in late-stage testing.

It would also not be shocking that a disease affecting older women has received less attention or investment. This unfortunate intersection of ageism and bias against women has impacted attention for many health conditions, from menopause to auto-immune conditions.

But I see a root cause that is even more insidious, that is our own acceptance. Acceptance that women get frail and fracture. A belief that osteoporosis is a “natural” part of aging. That the image of the frail little old lady has become ingrained into our expectations and worldview of older women. Seeing the problem of osteoporosis as more of a lifestyle issue for women and not a critical medical problem is affecting everyone. Diseases such as heart disease and even cancer are also a “natural” part of aging, but we don’t accept them without a fight. We do our best to prevent, delay, diagnose, and treat these critical conditions. I believe we should battle against frailty as passionately as we battle against cancer.

It’s time for us to challenge this myth of inevitability and give bone health the urgency and importance it deserves. We have many good tools that are underutilized, but dramatically more investment, research, and innovation are needed. Most importantly, we need to raise our own standards and expectations for bone health. 

Let’s all commit – patients, doctors, healthcare and pharmacological and device innovators, and policymakers, to changing our perspectives. Let’s set a goal of living strong in addition to living long and reversing the disturbing trends that today stand in the way of postmenopausal women leading long, strong, active, and fear-free lives.

Photo: Computer illustration by Getty Images

Laura Yecies is the CEO of Osteoboost Health, the company behind the first and only FDA-cleared, non-drug wearable for low bone density. Under her leadership, Osteoboost secured $4.7 million in NIH grants, raised $11 million in private capital, and generated $1 million in pre-orders within weeks of announcing the waitlist. She previously led Catch, a productivity app company sold to Apple, and Neurosync, a neurotechnology company. Earlier, she was CEO of SugarSync, which she scaled to $20 million in revenue and sold to J2 Global. She holds degrees from Harvard, Georgetown, and Dartmouth.

This post appears through the MedCity Influencers program. Anyone can publish their perspective on business and innovation in healthcare on MedCity News through MedCity Influencers. Click here to find out how.