Low bone density? Discover the comprehensive approach of integrating lifestyle and pharmacological therapy.
Osteoporosis is often measured using a T-score from a DXA scan, but relying on bone mineral density (BMD) alone may not provide the full picture. According to Dr. Chhaya Makhija MD, a board-certified endocrinologist at Unified Endocrine & Diabetes Care, understanding osteoporosis requires a multidimensional approach that looks beyond density measurements.
"Interpreting a DXA scan for severe osteoporosis means looking deeper—at imaging precision, bone microarchitecture, and clinical history. A patient’s true fracture risk isn’t always reflected in their T-score."
Let’s explore how advanced diagnostic strategies can better assess and manage osteoporosis in high-risk patients.
Why T-scores alone aren’t enough
DXA scans are a valuable tool, but they have limitations:
🔹 Spinal degeneration can falsely elevate bone density readings
🔹 Small positioning errors during a scan can impact results
🔹 Bone quality & structure aren’t measured—just density
This is why some patients with osteopenia (moderate bone loss) still suffer fractures, while others with low T-scores remain fracture-free. A more comprehensive approach is needed.
Key strategies for a more accurate osteoporosis assessment
1. What am I assessing as an endocrinologist?
DXA scans should be carefully analyzed for accuracy. I request access to your DXA scan images or printouts and not just a written report. In the images, I am reviewing:
✔ Spinal Alignment & Positioning
L1-L4 vertebrae
Rotation errors (even a 10-degree tilt) can inflate results by ~3-5%.
Vertebral Fracture Assessment if ordered or available: to look at entire spine alignment, any abnormalities like kyphosis or scoliosis as well as any presence of compression fractures or wedge-shaped vertebrae.
✔ Hip Positioning
The hip is reviewed as Total Hip and Femur neck for T scores. Many of my patients think that “neck” means the cervical spine, but it is the Long bone of the Femur, which has a neck that is the most common area for a hip fracture, and its T score or bone density is reported as a separate number.
2. Trabecular bone score (TBS): Measuring bone quality
Unlike DXA, which only measures density, the Trabecular Bone Score (TBS) helps assess bone structure.
🔹 Low TBS means weaker bone architecture, even if BMD is normal.
🔹 This is a software installed in the bone density machine and generated as a score for the Lumbar spine. It is clinically useful in patients who have osteopenia and low to moderate risk of fracture to assess their fracture risk and bone quality.
This tool is especially useful in postmenopausal women, patients with diabetes, and individuals with chronic glucocorticoid use, who often have fragile bones despite acceptable T-scores.
3. Lab testing to identify underlying causes
Osteoporosis isn’t just about aging—Bone loss occurs due to estrogen deficiency, testosterone deficiency, malnourishment, and even patients with obesity have a higher risk for low bone density. Hence, hormonal imbalances or nutrient deficiencies are important to assess in the evaluation: In my practice, these are the common tests:
✔ 25 hydroxy Vitamin D & Calcium Levels
✔ Parathyroid Hormone (PTH) – Excess PTH can leach calcium from bones.
✔ Bone Turnover Markers (CTX, P1NP) – These help assess active bone loss and guide treatment decisions and ordered in specific patient population
✔ TSH (Free T4) - Ruling out any thyroid disease is important
Other tests: Complete metabolic panel, Complete blood count, Magnesium, phosphorus, hemoglobin A1C, etc. Tests for ruling out multiple myeloma, celiac disease, and other conditions that can cause low bone density based on patient’s evaluation.
Treatment strategies beyond standard medications
Once a clear diagnosis is made, treatment must go beyond just taking calcium or bisphosphonates. Early screening is an essential step to prevent osteoporosis.
1. Personalized medication plans
🔹 For high fracture risk patients there are options from bone preserving and bone forming medications. A patient-physician shared decision making is crucial after reviewing all the therapeutic options.
Oral therapy with bisphosphonates
Zoledronic acid (IV therapy)
Teriparatide and Abaloparatide (anabolic therapy)
Romosozumab (Evenity)
Denosumab (Prolia)
Other less efficacious medications like Raloxifene, Calcitonin, based on a case-by-case.
Hormone replacement therapy is approved for Postmenopausal osteoporosis prevention and estrogen therapy is also used in patients with premature menopause.
Hypogonadism in men, testosterone deficiency requires treatment as testosterone replacement is essential to prevent bone loss in such cases.
2. Strengthening bone through lifestyle interventions
Dr. Makhija’s integrative approach emphasizes prevention & improvement in bone health utilizing nutrition, physical activity, supplements and/or use of medications (when indicated).
✔ Postural training, balance & strength exercises
Depending on the patient’s age, physical health, environmental health and accessibility as well as their bone density, various options are reviewed to help improve muscle mass, balance, and bone strength. These recommendations are individualized and referrals to physical therapists, orthopedic surgeons or appropriate specialists are also a part of our care.
Resistance training
Walking
Wearing weighted vests
Yoga, Tai Chi, Pilates - Balance exercises
Chair exercises
✔ Nutritional optimization
Protein intake (lean protein, beans, lentils, vegetarian, vegan options, etc)
Vitamin D intake + K2
Calcium intake (food and then supplements)
Magnesium, Zinc, Boron, etc are discussed on a case-by-case basis.
Collagen
Creatine supplement
✔ Complete wellness (Stress management and Sleep)
Review of your weekly logs including sleep, mood, stress response and menopause health are all important as part of your medical care and also support your bone health.
Final thoughts: A new era in osteoporosis care
Managing Low bone density (osteopenia or osteoporosis) isn’t just about bone density—it’s about bone quality, strength, and prevention of fractures.
"T-scores may not give us the entire picture of your bone health. By combining the right timing of DXA screening, including TBS when available, lab tests, and functional assessments, we can work on preventing osteoporosis and fractures, leading to optimizing health for our patients." – Dr. Chhaya Makhija, MD
At Unified Endocrine & Diabetes Care, we take a whole-body approach to bone health—helping patients prevent fractures, improve strength, and maintain independence.
📞 Need a personalized osteoporosis assessment?
Call (559)-272-9192 | (650)-410-0078 to schedule a consultation.
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At Unified Endocrine & Diabetes Care, we are committed to providing expert endocrine and metabolic health services to patients throughout Fresno, and the San Francisco Bay Area. Whether you're managing osteoporosis, hormonal imbalances, diabetes, or metabolic disorders, our specialized care is accessible to communities across Contra Costa County, Alameda County, and Santa Clara County.
Our practice serves patients in Walnut Creek (25 miles from San Francisco, 30 miles from Silicon Valley), Lafayette (20 miles from San Francisco, 35 miles from Silicon Valley), Orinda (17 miles from San Francisco), Berkeley (12 miles from San Francisco), Oakland (10 miles from San Francisco), Pleasanton (35 miles from San Francisco, 20 miles from Silicon Valley), San Ramon (30 miles from San Francisco, 15 miles from Silicon Valley), and Palo Alto (35 miles from San Francisco, 5 miles from Silicon Valley).
Through in-person visits and telemedicine, we make expert osteoporosis management, hormone therapy, and diabetes care more accessible to those in Danville, Fremont, Hayward, Sunnyvale, and beyond.
Our goal is to provide comprehensive, evidence-based treatment for patients across the East Bay, South Bay, and surrounding regions, helping them improve their quality of life with cutting-edge diagnostic tools, personalized treatment plans, and advanced metabolic care.