Thank you for joining us for this afternoon's session on healthcare disparities in metabolic bone disease. I'm Gina Woods from UC San Diego and I'll be your moderator. It is my pleasure to introduce this afternoon's speaker, Dr. Nicole Wright. Dr. Wright is an associate professor in epidemiology at the University of Alabama at Birmingham. She earned her doctorate and master of public health degrees from the University of Arizona. Dr. Wright is a leading musculoskeletal epidemiologist whose body of work includes some of the seminal studies on racial disparities in osteoporosis and its management. She has been an investigator in numerous federally and industry sponsored trials including those evaluating osteoporosis knowledge and patient activation. She is well published in the leading bone journals and has been the recipient of numerous research and service awards. I'll turn it over to Dr. Wright. Thank you. Well thank you Gina and thank you all for being here at this late hour and thank you to the organizers for inviting me to talk about this topic. So we're going to be talking about healthcare disparities in metabolic bone disease primarily focusing on racial disparities. We know that there are other disparities in osteoporosis and its management particularly say in men we're underserving our males and then other high-risk populations. So I would just like to disclose that some of the work that's being presented was funded by the NIH as well as Amgen and I do not have any other financial disclosures. So in 2017 Dr. Ann Looker reported the updated prevalence of osteoporosis in U.S. adults aged 50 years and older using the NHANES data and this was the first time they were able to have enough sizeable population to have confidence around Asian Americans and so you can see based on a T-score of minus 2.5 at the femoral neck or the lumbar spine Asians have the highest prevalence of osteoporosis at 40 percent followed by Hispanic adults, white adults and lastly non-Hispanic black adults at 8.2 percent. So does this make sense and we think about sort of genetics and ancestry and there's been studies that have shown that okay this makes sense why we're seeing sort of these differences in the prevalence of osteoporosis particularly with non-Hispanic blacks having a lower prevalence and in this study of children they sort of compared those children who had sort of 50 percent of their ancestry from Sub-Saharan Africa from Europe or East Asian and then in comparison to those with 50 percent of their ancestry Sub-Saharan African European ancestry had four to five percent lower bone mineral density and East Asians had two and a half to almost three percent lower. So again we're thinking maybe biologically that these differences in the prevalence of osteoporosis make sense and we all know that the most important outcome of osteoporosis is fragility fractures and annually there are about two to three million fragility fractures in the U.S. with hip being the most serious and spine being the most common. Back in 2005 it was reported that osteoporosis related fractures cost the U.S. 13.7 to 20 billion dollars and they projected that in 2025 it would be 25.3 billion dollars and when this paper came out 2025 seemed really long far away but now that's just a few short years and it's actually projected that this estimate is an underestimate of the projection of the burden of fractures. When we look at trends in fragility fractures by race and ethnicity primarily the studies have focused on the hip and so this was work by my group at UAB where we looked at racial and ethnic trends and hip fracture incidents from 2000 to 2009 in U.S. Medicare data and so you can see that in the blue line at the top non-Hispanic whites have the highest incidence of hip fractures and the red line on the bottom is non-Hispanic blacks they have the lowest incidence of hip fracture and then Asian Americans and Hispanic Americans are sort of in between. Now if you go remember for the few slides below back that Asians had the highest prevalence of osteoporosis at 40 percent but that higher prevalence is not always equating into fractures in that you're seeing sort of lower rates of hip fracture in Asian adults compared to non-Hispanic whites so now we're thinking what's going on is there structural differences in the bone that is relating to the incidence rates. So prior to all of this information has pretty much been racial differences and it's okay to have difference by race and ethnicity particularly when it comes to bone since we know that there are some genetic differences but now when we get into the world of disparities that there could be potential disparities by race and ethnicity in osteoporosis and so that's where I'm going to focus sort of the next few slides on and so first is in post fracture mortality and so you have a fracture it sort of increases your risk for death as well as decreases your quality of life and so we definitely want to know sort of the estimates of mortality after fracture as well as ways that we can sort of prevent that fracture or a second fracture to reduce the likelihood of death. So way back when in 1992 it was shown that in Medicare data 1985 to 86 they looked at the probability of survival after a hip fracture in black men and women and white men and women and on this portion of the slide you can see that this is the probability of survival in males which is much higher or lower I should say than females and but there are no racial differences between black and white men with respect to mortality after fracture. However in women you can start to see separation of the probability of survival around four to six months after the fracture with black women having lower probability of survival than their white counterparts. Again in Medicare data we looked at this again more currently and saw that if you look at trends in one year mortality post hip fracture you see sort of the opposite of what you saw with the incidence with the red line at the top meaning non-Hispanic blacks had the highest one year rates of one year mortality after hip fracture followed by non-Hispanic whites. And even more recent data we started to look at not only hip fractures but other major osteoporotic fractures as well as a few other outcomes that we felt were important in the field. So you know mortality or death then we developed this outcome called debility which is stay in a long-term nursing home. So if you're in a skilled nursing facility for over a year we know that nursing home residency is associated with all other poor outcomes. And then destitution which we have defined as basically you are Medicare eligible and you've lost sort of all of your financial resources that now you're needing additional assistance from the government and you are now Medicaid and Medicare eligible. So when looking at this you can sort of see the breakdown that in comparing black and white women who had fractures and there were about 400,000 white women and about 10,000 black women that you're seeing higher mortality rates on the order of about 25% in pretty much all of the fracture types except for clinical vertebral fractures. When you look at debility then you're seeing that sort of racial differences and the debility outcome is more related to those more severe fractures of the femur or the hip. But then when you look at destitution which is in the blue triangles you see sort of now two to three fold higher incidence of becoming destitute or losing all of your financial resources after a hip fracture and you can think what that then does for the patient, for their family, and then could be related to further outcomes later on down the road. So now looking into sort of quality of life and this is where the field definitely needs to improve upon of looking at sort of things post fracture and maybe rehabilitation and surgical complications that could be related to say mobility disability and things of that nature that could sort of increase other rates of adverse events. So this was a great study out of the New York State hip fracture registry and showed that in looking at time from admission that black, Asian, and other people of other race and ethnicities had higher odds of having their surgery greater than two days post arrival at the hospital. And so you can think that maybe this will then ultimately affect some outcomes later on down the road. When you look at the other outcomes that they evaluated, so 90-day readmission, complications, or reoperation within a year, you're seeing that there's the higher odds of these events in black individuals compared to white individuals, but Asian and other racial and ethnic groups either have lower rates of these outcomes or sort of equal rates. And so again thinking on the disparity, why are we not having equity in the rehabilitation and or repair of hip fractures by race and ethnicity? And as clinicians I'm sure you can think of some of the reasons that could be related to why someone may not have their surgery, you know, within two days, but of thinking of the overall scheme of what that means, how can we sort of reduce these disparities? Again on the rehabilitation side of looking at physical therapy, this study was an early Medicare study and showed that black individuals had higher odds of no physical therapy after their hip fracture, so again thinking you're now discharged home, you don't have physical therapy, you're now mobility is limited, and potentially increasing risks of falls again, and then going down the cycle of ultimately increasing your risk of mortality. So again, as clinically thinking, why are we not seeing equity in these approaches? So in thinking of that, what are some of the contributors that we can maybe intervene upon? So I've already showed you have a fracture, it increases your risk for death, you have decreases your risk for quality of life, but in order to sort of have a fracture, it's based off sort of your bone mineral density or your risk factors. And so if you have normal bone mineral density, then all is well, but if you have low bone mass with risk factors or if you have a T-score that is related to osteoporosis, then typically you are prescribed some sort of medication. And then to ultimately know about your bone mineral density, you need to get screened. So screening and treatment are two areas that we could potentially intervene upon that could potentially reduce the racial differences in sort of fracture, death, and quality of life. So are there racial differences in osteoporosis screening? And the answer is unfortunately, yes. This was a study using the Optum commercial claims data and saw that compared to non-Hispanic whites, non-Hispanic black women had on the order of 20% lower odds of having a DEXA test, particularly in the younger years, and then that in the older years, it was say 8% lower odds of having DEXA. In the other populations, now you're seeing sort of higher odds of screening in Asian Americans as well as Hispanic Americans, but seeing this inequity for black individuals. And we know that the clinical guidelines, whether it be the ACE clinical guidelines, the Bone Health Osteoporosis Foundation, the primary care, pretty much they all agree that any woman 65 years of age should have a DEXA scan. And so why are we not seeing that when it comes with respect to race? This was another study in Medicare data that looked at say DEXA screening in a high-risk population, so those who, women who sustained a hip fracture, and then looked back to see did they have a DEXA test before their fracture and then as well as a DEXA after their fracture. And in looking again at black-white differences where this is much of the literature is focused on, that black women who sustained a hip fracture had half the rate of DEXA screening before their fracture and then two-thirds the rate after their fracture. So again, areas of improvement of equity on the standard of care of DEXA screening in women and high-risk women. This was interesting data that one of my master students was working on and again using Medicare data and sort of mapping out the prevalence of hip and femur fractures and comparing it to the prevalence of DEXA screening. And you can see in all racial and ethnic groups there's sort of this disparity. So in the top leftmost box is prevalence of hip and femur fractures in non-Hispanic white. You can see sort of in the middle portion of the United States we're seeing those deeper, darker colors, the reds, indicating higher prevalence of fractures in those areas. And then you look next to it and see the prevalence of DEXA screening and those colors don't equal out. Same thing with non-Hispanic black that you can see the darker areas where there are these higher prevalence of fractures but if you look at those states you're seeing less DEXA screening in that population. And the same is true for the Hispanic population as well as the Asian American population. Though interesting to note you can see that the prevalence of DEXA screening particularly say on the west coast and mountain states is sort of higher particularly say in New Mexico, Arizona, Nevada compared to the prevalence of fractures. So now moving on to treatment and are there racial disparities in treatment and I'm sure you can get the point of this talk and the answer is yes. Black women are less likely to receive osteoporosis treatments and one of the studies that's based out of UAB, it's a stroke study called the Reasons for Geographic and Racial Differences in Stroke and we had a fracture ancillary sort of looking at those women who were deemed high risk for fracture based off of frac scores and then looked at the report of osteoporosis medications that they sort of presented at their in-home interview. And overall the amount of osteoporosis medication use was low but it was lower in black women at 8.4 percent compared to white women 13.6 percent. Other research in Medicare shown that after a fracture which we know in the bone field we're not doing that great of a job of treating individuals after a fracture but then black women were 18 percent less likely to get treatment following a fracture and unfortunately there's little data in say the Hispanic, Asian or Native American communities around this topic and so we need to do a better job with that as well. This was a fantastic study out of Kaiser Permanente Southern California. So they, Rick Dell who's a tremendous bonehead as we call ourselves in the community in the field, wanted to optimize osteoporosis health in the Kaiser Southern California system and so they created this sort of healthy bones module. We're sending all of this information around bone health, having reminders about visits particularly those DEXA scans and then other information around treatment and so they're like, is this going to reduce racial disparities in our population with respect to treatment? And overall, it did. So in women, you can see the osteoporosis treatment rates ranging from 87.4% to 93.4%. And that difference was not statistically significant. Same thing in men. You're starting to see those sex disparities and that the proportion of treatment rate was 69%, ranging to 67%. Again, no disparities by race overall. However, when they looked within their hip fracture population, now they started to see some inequities with respect to in women. You know, 75, 76% of white women who had a hip fracture were treated compared to only 54.9, 55% in black women. And this difference was statistically significant. Really highlighting the disparities in men, you can see the treatment rates following fracture ranging from 11% to 35%. And you can see lower rates of treatment in African American and Asian men. So why should we care? And there's a couple of reasons. One, there's gonna be a big increase in adults of color in the United States with the ever aging of the population, as well as aging of people of color. And so this was sort of information from the US census that in 2010, you can sort of see the racial and ethnic breakdown of people 65 years or older. And then looking at 2018 data, you can see not only the increase in the number of people who are 65 years or age of older, as well as sort of the racial and ethnic growth that you can see particularly in the Hispanic communities and the Asian communities. So what can we do? And I'll, the next few slides are thinking more on the research end, but I'll sort of postulate and would love to hear questions clinically, what can we do to sort of reduce this inequities in osteoporosis management and outcomes? So first is around research. We need to increase the amount of information on racial and ethnic differences and bone loss and fracture rates. So most of the studies, we have a handful of osteoporosis cohorts. Most of them are primarily non-Hispanic white. We can use some NHANES data, but again, the actual numbers of people is relatively low. But from what we're seeing overall is that non-Hispanic blacks have higher bone mineral density than non-Hispanic whites, Hispanic and Asians. Again, in the Hispanic community, we are seeing sort of differences, whether it could be higher bone mass than non-Hispanic white, the equivalent to non-Hispanic white or lower. And the lower bone mass has been particularly in the lumbar spine region. And I'll sort of circle back to why that's important. And then generally the studies are showing that Asian Americans have lower bone mass than non-Hispanic whites. And there haven't been any other comparisons within between the other racial and ethnic groups. So in addition to sort of increasing the information on bone loss, also thinking about how are we defining osteoporosis? So as an epidemiologist, we know your case definition will affect the prevalence of a condition. And so we are all well aware that osteoporosis is based off of a T-score, which is a standardized score that is comparing your bone mass to that of the young, healthy, normal population, which happens to be in Hanes three, 20 to 29 year old non-Hispanic white women. So is that the appropriate reference for say Asian adults in that now we may be over inflating the prevalence of osteoporosis, knowing that Asians typically have smaller bone sizes, therefore bone mass than non-Hispanic whites. And then the same could be true, or are we underestimating the prevalence of osteoporosis in Hispanic or non-Hispanic black populations because we know again, there's more bone in non-Hispanic black populations. So referencing it to another group, is that appropriate? I know clinically I've heard that some individuals, some clinicians will sort of present their T-scores using the traditional non-Hispanic white reference, but then also telling their patients say a Z-score, which is related to their age and race. And so making decisions based off of both of those, instead of just using T-2.5 based off of this reference. And again, definitely needing more information to identify the risk factors for bone loss in communities of color. Again, our osteoporosis cohorts are 95% white for the most part. And so are some of those factors like rheumatoid arthritis and other malnutrition conditions, are those appropriate in non-Hispanic black or other communities of color? And are there different things that are maybe not related to bone loss in non-Hispanic whites that we need to be more concerned with in people of color? Another interesting piece that my colleague in UMass Lowell is focusing on is increasing information within racial and ethnic groups. So we know that race is this sort of social construct. We're grouping people together based off of characteristics, but within say the Asian population, that could mean Chinese, Korean, Filipino, Asian, Indian, Pakistani. And those people groups may have different relationships in their bone mass than each other. And so we really need to have more specific information in the communities in each specific ethnic group. Same is true for the Hispanic population, which we saw was rapidly increasing in the United States, is that Hispanic could mean Mexican, Cuban, Puerto Rican, Central American, South American. Again, in thinking those are not all the same, going back to some ancestry related things, maybe groups that have more non-Hispanic black ancestry may have different bone mass than say those who have a predominantly non-Hispanic white or white Caucasian ancestry. And some of this work has been done, but we need a little bit more information. So my colleague looked at the difference between the prevalence of osteoporosis in Puerto Ricans versus Mexican Americans. And in women, you know, it was about similar, but in men, you can see a higher prevalence of osteoporosis in Puerto Rican men at 8.6% compared to Mexican men at 3.9%. And within the Asian population, Joan Lowe, who I believe is an endocrinologist, at Kaiser Permanente Northern California has been doing work comparing sort of South Asian, Indian, Pakistani, with more of the East Asian Chinese populations and seeing sort of differences in the prevalence of osteoporosis as well as fractures. So this is information with respect to fractures by Hispanic origin and using the Nora cohort. And you can see in males, the breakdown of the bars with the darker shade is Mexican American, the next sort of gray is Cuban, and then the lighter gray is Puerto Rican. And you can sort of see the linear decline in the incidence of fractures by Hispanic origin in men, as well as in women. Now you're starting to see, you know, there are definitely statistically significant differences, say, between the incidence of fractures in Mexican Americans compared to Puerto Rican women. The same can be true in the Asian populations. Again, this is work from Joan Lowe in that looking at rates of hip fracture, wrist fracture, humerus fractures between South Asian and Chinese populations and seeing statistically significantly higher incidence of wrist fractures in the South Asian community, whereas say the Chinese community had a higher incidence of hip fracture. Another area of research that we are focusing on is to understand patient provider and system level barriers to osteoporosis management. Myself and my colleague, Dr. Noel, have been focusing more on the patient side of really understanding those barriers around osteoporosis. So in the Puerto Rican population and her mixed methods work, you know, she is finding out that, you know, the doctor will tell me I may have a condition but isn't telling me why, isn't breaking it down. They're also seeing that not having providers that say look like them or speak the same language is also playing a role in osteoporosis management. Dr. Noel also found that just actually knowing what osteoporosis is and thinking about bone health is lower in these communities and Dr. Noel's population, they were sort of describing deformed fingers and you're like that's rheumatoid arthritis, not necessarily lower bone mass and fractures. I've done similar work in comparing non-Hispanic black and non-Hispanic white women around knowledge and barriers of osteoporosis and so we did a mixed method study so had some quantitative information as well as qualitative information and saw based off of this scale that black women had lower knowledge about osteoporosis as well as in looking at this locus of control that of who is sort of in charge of your, healthcare decision making. Is it you? Are you the person who's more in control? Is it a powerful other, meaning some external source or is healthcare decisions and outcomes just based off of chance? And these domains are independent of each other and so we saw, which was interesting, that there was a higher mean score of sort of internal locus of control in black women compared to white women, but what was most surprising and most significant was the difference between the powerful others and so in black women, of thinking the role of someone else, is that the family? Is that the physician? Is that the community? Is that God, who's really, say, in control of those decision makings and so you, as clinicians, of really having that rapport with patients to really understand where they are so that you can reach them in the appropriate manner. And some of our qualitative work, we saw triangulation with what we were seeing in the quantitative work, that osteoporosis, black women had lower knowledge. There were sort of, say, differences in physical activity, dealing with multi-morbidity, and of thinking, say, osteoporosis is a lower priority in black women of maybe dealing with diabetes or hypertension. Those are rising to the, say, primary care level of what we're taking care of instead of thinking about bone health, whereas in white women, there's more that familiarity around osteoporosis, maybe fractures in their family, and so having those conversations about bone health and keeping it as a priority in their healthcare. With respect to sort of the big racial differences, we saw that physician trust is very important to black women, particularly for bone health activity activation. And I have this one woman who said, oh, my doctor prescribed this. I didn't really like him, so I threw it in the trash. And I was like, oh, okay, ma'am. I know you have osteoporosis, and I want you to continue to walking in and out of here, so I'm gonna need you to call your doctor and talk about this. The same thing is true about religion. So again, I'm in Birmingham, a southern community. There was a lot of statements of I'm giving it to God. If God wants me to be healthy or if I have this condition, God will provide. And I've heard from some clinicians, particularly orthopedic surgeons, of sort of counteracting that with, well, God brought you to me, and so we're gonna work together of helping your bone health whether it be taking the appropriate medications, modifying activities, or in the case of orthopedics, of surgery. And I've sort of alluded to patient activation in that, again, there was just such a familiarity around osteoporosis, bone health in white women that sometimes some women were even like, in my cancer treatments, I had this, and I had to talk about my bones, whereas in my black women focus groups, it was just sort of laissez-faire. Oh, I think I had a dexa, but nobody told me about it, I don't know what it means, and not wanting to seek out that information. So again, as clinicians, knowing this information, knowing where your patient is on sort of this spectrum could potentially help you get them to be more activated about bone health. Another thing is around education. So on the patient side, we're definitely seeing that having sort of culturally competent education platforms can increase knowledge around bone health. So I work together with the American Bone Health Patient Advocacy Organization, and unfortunately, this all happened during COVID, so it wasn't the most ideal, but our sort of virtual webinar around why healthy bones matter, we were seeing increased knowledge in sort of bone health, osteoporosis, fracture risk prevention, than before the seminar and after. Same thing is true with provider education. So I have given a handful of these talks, and I've heard, oh, I haven't really known that much that there's all these poor outcomes in black women who have fracture, and I didn't realize the disparity in, say, DEXA screening. And so having sort of this information and for providers to, again, look at who is in front of you, thinking about their comorbidities, thinking about what medications they're on, and following through with bone health. We have also been, I think, in the last two years, have definitely been heightened around sort of implicit bias and thinking, okay, oh, a black woman, I don't need to worry about bone health, so I'm gonna worry about other things. And so recognizing internally, do you have biases that may be affecting your clinical care? So to sort of summarize, there are racial and ethnic disparities in bone health management and outcomes, and we need more research in the Hispanic and Asian populations, particularly, but in all sort of groups of sort of understanding risk factors associated with potential causes of these disparities or loss of bone mineral density is a micro-architectural things, fractures, management, et cetera. Definitely in working with creating more culturally competent practice or education materials around osteoporosis, again, you're thinking osteoporosis, white woman's disease, and so maybe black women aren't thinking that it's a thing that they need to think about because the media is showing them images of women that don't look like them. So changing how we are presenting bone health information and then ultimately developing innovative and targeted multi-level interventions, whether it be on the patient side, the provider side, maybe even the healthcare system side to reduce the inequities in osteoporosis management. So just to end on the faces of osteoporosis, and I check on this occasionally, and that when you Google osteoporosis, you go to images, here's what you typically are seeing. So we have our celebrity spokespeople for the medications. You're seeing this old, frail, hunched over white woman. I was surprised when a man sort of came up in the scrolling. But for me, this is the face of osteoporosis. And so this is my grandma. She is turning 99 this year. But she was, in her heyday, probably about my height, 5'7". She was a maid and a school janitor, so relatively labor-intensive work. And then over the years, I sort of watched her decline over time. She's had spine fractures. She's lost so much bone and muscle mass in her legs that now she's wheelchair-bound. And so of thinking of seeing that for her, I don't want that for my mom or my aunt, and then definitely not for myself. And so changing the face of osteoporosis, I believe, can help in reducing some of these disparities. So with that, I'd like to thank all of my collaborators, particularly Dr. Sabrina Noel, my UAB colleagues, and then the Bone Health and Osteoporosis Foundation, American Bone Health, as well as American Society for Bone and Mineral Research. So I'll take questions. Thank you, Dr. Wright, for a fantastic talk. If you'd like to step forward to the microphones, I'd like to start with a question, if I may. In reading your 2020 Journal of the American Geriatric Society paper, I was struck by the inclusion of destitution as an outcome that is not one that we're accustomed to seeing in osteoporosis papers, which may speak to our own biases within the field. But your results were quite profound in terms of the disparities. And so I'm wondering, how did you come to the decision to include that outcome, and were you surprised by the findings, and what are the next steps going forward? So in thinking of including that outcome, I think it was something that it's not unique to fractures. You're primarily thinking death. That's what we're looking into. And so there are other things, thinking socially, that could be related to adverse health and increasing in mortality. And so along that spectrum, could differences in economic status be related and sort of getting at some of those social determinants and with that being based on financial. So that was sort of the impetus around including that outcome. Again, in thinking as an epidemiologist of like, how are we defining this? We made sure we excluded people who were already dual enrolled and things like that. So our sample size has changed, but you were still seeing, like you said, this profound relationship between if a black woman has a fracture, it's sort of taking all of her financial resources compared to a white woman. Nicole, excellent talk. Great to hear the update and the new information. Just a few questions. The New York State data that showed the delay in hip fracture repair that you mentioned, there must be more data behind that that would give some insight as to why that is. I can tell you as a clinician, when we admit people to hospital for hip fracture repair, it always takes a while to stabilize things enough that they'll operate. And I would assume comorbidities must play a role in this and that all the things you've mentioned would affect that delay to surgery, probably. But do we know more about that? So in that particular paper, they did a great job of sort of adjusting for those factors. So thinking we want to make sure, is it really race or is it something else that could be driving that association? So they adjusted for, I think, a comorbidity index. They adjusted for sort of the circumstances of the fracture. They adjusted for a whole sorts of things and we're still seeing these racial differences. So now that makes me think of what else is going on. And so now is that more systemic or is it something else that we can potentially intervene upon? All right, can I ask a short second question? So the way forward in all this, because we keep hearing about these disparities, the question is the data that we have apparently is relatively limited for multiple racial groups. What's the best way forward to get data on say Hispanic, Native American and other that we lack so acutely to make these decisions? I think that's a great question. And I've been talking to people about how to do this. And so I'm primarily working the administrative claims data with Medicare. And so could we potentially combine, say Medicare data with Kaiser data with other commercial claims to sort of increase the actual numbers of people within those sort of broad race and ethnic groups. And then also thinking about sort of within each race group of how can we sort of capture different ethnicities? I know in Joan Lowe's work, they were using sort of last name as a indicator of being South Asian versus Chinese. But what could we collect and maybe just providing more categories for people so that we have this information and say electronic medical records and can follow people over time. Hi, thank you. Hi, Nicole, John Kaminis, how are you? Great talk, important talk. And I think the part of the problem is I think the world has become captive of the Lyndon Johnson categorization of food stamps of people has nothing to do with human anthropology. And at some point, just knowing the fact that the HLA haplotypes in Africa are more diverse than the whole continent of Europe alone states the nature of the problem because everything becomes a regression to the mean, right? So you have a little more melatonin. I need some melatonin. No, no, no. But melanin, yeah. Melanin, sorry. End of the day, a little hypoglycemic. So a little bit more, you know. And what you see here is that you have these disparities. And for example, people from Sudan are more like people from the Levant than they are from West Africa. And yet these groupings come together. So I think at some point, you know, we have to get away from these, you know, political artifices and really look at the problem. And part of it is the socioeconomic thing, right? Which sometimes the phenotype creates a socioeconomic problem. And it has for a long time. The other part is within the groups to really trying to understand because, you know, India alone has quite a few racial groups, right? One of the second largest country in the world. Same thing with China. So this lumping, I think, creates its own disparity for getting people access. So I'd just like your thoughts on that because it seems like some people are thinking about it already. And maybe some will say it's better to self-identify. Martian doesn't count yet. But the other things I think would be important. Thank you. Yeah, so that is really great. And I think, again, the concept of lumping people together based off maybe physical characteristics or things like that is, we know that's artificial. But we also need a way of maybe lumping people together to sort of create information. So I think that's where, one, the field is of, I know I work with the Women's Health Initiative as well. So initially back in 1993, you know, you were white, black, Hispanic, Asian, the end. And then over the years, I think in the third wave of the follow-up studies, now they actually ask sort of ethnic origin. And so now we're able to go in to then provide a little more information on, say, different Hispanic groups and different Asian groups. You know, how we can do that with respect to other ways, you know, again, in your electronic medical record system or whatever, are we gonna start allowing people to self-identify and deal with that? But I think the biggest comment you said around sort of economics and sort of those social determinants of health, which right now in the field we have not studied to see, or like, okay, race may be the marker of those things. And so is it access to care? Is it economics? Is it education? Is it all of these factors that could play in where we could potentially intervene and then maybe reduce some of the racial disparities that we're seeing just because of the way we're lumping people? Can I ask a quick second one? Thank you. So the other part has to do with BMD, right? It became our crutch early in the field. It was a nice toy. We used it, but it didn't tell the story, obviously, especially amongst African groups. In fact, we were told, well, you know, osteoporosis is not an issue amongst people of African descent. So it was less. But then here comes this big plague called diabetes and you have, you know, bone disease and diabetes, and it's become the great equalizer because when we look at fracture rates in that population, they're not too dissimilar from everybody else. Thoughts on that? Thank you. I would say that is a great question. And I was talking earlier that, okay, one, there's an issue around dexareimbursement. So doctors aren't doing it because they aren't getting paid to do it. So right there, the access of issue, but then in thinking around diabetes specifically for this endocrinology community of saying, there are things pathophysiologically associated with diabetes that has impacts on bone as well as the medications being used. And so, you know, in a clinician standing of saying, okay, a black woman is in front of me, I don't have to worry about bone health, but now a person with diabetes is in front of me, maybe I need to think about bone health. Now, how to go about that? I think that's where within the bone side, where we're going of saying, okay, traditionally, dexa, you're still seeing these higher bone masses, bone mineral density in people with diabetes, but structurally, that's where we're seeing the impact. And so now how do we capture structural issues in bone? There's been the use of trabecular bone score, things of that nature, VFA, as well as utilizing CTs images that could then capture sort of the three-dimensional bone strength parameters. And, you know, sort of getting at some of that. I have a grant under review that's sort of evaluating cardiometabolic conditions and bone strength. But now we're getting back to the workflow issue of like, who's going to order that, right? So let's say there, well, there actually is a sort of secondary biomechanical analysis of previously collected CT scans. So are you, as an endocrinologist, going to say, oh, look, this person hasn't had a dexa, but had a chest CT for some other reason. Let me order this biomechanical CT test to get that information. Or is it the primary care doctor's responsibility? Or, you know, who is taking ownership of that? And I think that's where in the field of identifying, there's the barriers and things like that, social determinants, as well as some of these other workflow issues of getting the information needed to protect the bones of people with, say, diabetes. Thank you. Oh, my name's Kevin McKinney. I'm from the University of Texas, Milka Branch in Galveston. He actually asked one of the questions I was going to mention with regards to diabetes. And my thoughts on that area was that we should work with the American Diabetes Association to have some things put in their standards of medical care on screening for bone. I think that will help out a little bit there, because clearly there is microvascular disease in bone, just like there are in other tissues that are there. Yeah, I think that is a great point around sort of societies coming together and working together with respect to, say, the clinical guidelines. You know, there's the Bone Health, there's the ACE, there are the USPFTF, you know, guidelines. And some of them, they don't always agree with each other. And so if saying, say, ASBMR, the bone group, doing great work on sort of understanding metabolic bone disease, then working with, say, the diabetes organizations of saying, look at what we're seeing. Now I think you should potentially create maybe a guideline in the sense of if a person who has X, Y, and Z comes into you, maybe you should do X, Y, and Z. And so bone working with, say, the diabetes organizations or bone working with endocrinology to sort of ensure that the clinicians have that information going forward. And, you know, diabetes is a really good use case in this example, but there's other health conditions where you're thinking, okay, all those men who have COPD, what are we doing? Who's taking care of their bones? All the men with prostate cancer and on androgen therapies, women with breast cancer, you know, who is really thinking about their bone health? Is it the oncologist? Is that their role? Is it now you're going to another specialist? We all have the issues in this country around, it takes six months to see a specialist, you know, so really thinking there's ways within clinical care that we can improve the overall care of bone health in some of these conditions. So the second thing I want to talk about was the thing that I think that helps, one of the tools that we use that helps keep the categorization going is the FRAX. And that's been a big bugaboo of mine. I don't know if it is for other people, but because there is this categorization, it helps physicians just think only in boxes with regards to certain ethnicities. And one of the things that really, really gets my craw is using the Hispanic database in the FRAX, because as you've already pointed out, there are so many different varied populations. There are African-Americans in the Hispanic population, and then there are white people in the Hispanic population. So I find that database very useless, and I try to think of other ways of managing that tool. I think I'm not to the point where I say we should junk the racial categorization like we've done for the MDRD equation for kidney disease, but I'm getting pretty close to that, to be honest with you. And so you kind of hit at the point of, okay, we're lumping all these people together, but then, so it's wrong, but then maybe some of these categorizations we're gonna use this very loosely proxy for factors that either increase or decrease risk. So maybe let's keep it in. So that's sort of where we are. There's actually a task force in ASBMR that's sort of diving deeper around FRAX in the sense of what were the databases that were used to sort of create this information? In the US, the WHI was involved, the Rochester, things like that. Are they really capturing enough information on people of color to really have sort of those categorizations? And then why is it that pretty much the US is one of the only countries that has sort of these racial and ethnic differences in their FRAX calculators? So we know Canada is equally or more diverse, but they don't have sort of the boxes. Same thing in all across the world, there are other people of color living in other places, but the US, we've decided we're gonna sort of categorize people and either subtract or add to their risk based off of that. So I think with FRAX, they are definitely doing more of sort of updating the data sources. So at least providing more real-time information on fracture incidents and death rates associated with fractures, but we still have the problem with, we still have these sort of artificial categories that could mean something, could mean something, and then say like diabetes is not included in FRAX, and so are we gonna add variables to it? Is it gonna make it too cumbersome? So those sorts of issues, for me, not being a clinician and not having to worry about that, but I'm thinking more on the research side of really wanna be able to get someone's, you know, their risk and try to personalize that risk using sources that are population-based. Thank you. Thank you very much. There's no further questions. Thank you, Dr. Wright. Yep. Thank you all for attending and these great questions.

healthcare disparities

metabolic bone disease

racial disparities

osteoporosis prevalence

hip fracture incidence

fragility fractures

bone health management

cultural competence

FRAX tool