Year: 2024

We are are finally breaking the stigma and talking about mental health. Men grow moustaches in November to raise awareness and talk about prostate health. It is time to move past embarrassment to talk about rectal health —and ways to reduce the incidence of some very painful conditions. This article opens that conversation. 

Hemorrhoids are usually thought of as painful sores on the anus that are resolved with a few days of over-the-counter ointment, and that are frequently (pardon the pun) the butt of jokes. These are external hemorrhoids, but there are also internal hemorrhoids located on the lining of the rectum and that remain entirely painless, until they aren’t. In fact, they can be excruciatingly painful and while previously thought to be preventable mainly through dietary changes, diet is only part of reducing the likelihood of getting hemorrhoids. More than two-thirds of Canadians and Americans engage in a daily habit that significantly increases the risk of developing hemorrhoids and simple lifestyle changes can help reduce that risk.

Internal hemorrhoids are normal structures that are aligned in three columns in the rectum and function like bubble wrap —cushioning the rectum against irritation from the stool until a bowel movement[1]. Internal hemorrhoids are in the upper two thirds of the rectum, above what’s called the dentate line and since they don’t have nerve endings, they are painless and remain that way until one becomes irritated — or worse, becomes inflamed and protrudes from the rectum like a large, angry grape.

While internal hemorrhoids are totally normal, the term is usually used to refer to one (or more) that is inflamed and symptomatic, and the term will be used that way in this article.

Half of adults will have had hemorrhoids by age fifty yet it’s rare for people to talk about them. Only 4% of people go to their doctor for help because they’re embarrassed, and the last thing they want is to have someone having a look “down there” and poking around. They just want their hemorrhoids to stop hurting and to go away— and the faster, the better. Most people will self-treat with Epsom salt baths and over the counter topical creams or wipes, and only seek medical help if the symptoms persist, or get worse.

As a Dietitian, I have routinely asked my clients about their bowel function, including how often they poop and its texture — and most are fine with answering these questions because they know this is within my scope of practice. Even though I was taught that part of what can help people avoid hemorrhoids is dietary, until recently I never asked anyone whether they’ve been experiencing hemorrhoids. This has changed. While getting enough of the right type of fiber and drinking sufficient water is important, there are also two lifestyle factors that are thought to contribute to the development of hemorrhoids, and these are the focus of this article. 

Hemorrhoids, sometimes called “piles,” are swollen, inflamed veins in the rectum or on the anus that can be painful, itchy and may bleed.

External hemorrhoids form under the skin around the anus, and can easily be felt. 

Internal hemorrhoids are natural structures on the lining of the lower rectum. Most people are unaware that they are there until they get irritated and swollen, or worse — prolapse, and protrude from the anus. 

There are four grades of internal hemorrhoids based on the degree of prolapse. 

Grade 1: Not at all prolapsed.

Grade 2: Prolapses with a bowel movement, but retracts by itself. 

Grade 3: Prolapses with a bowel movement and has to be manually pushed it back in. 

Grade 4: Prolapsed but can’t be pushed back in, or only with a lot of pain.

Internal hemorrhoids are located on the left lateral side, the right anterior side, and the right posterior side [1,2]. If they become inflamed or prolapsed, sitting becomes very painful, and sleeping on one side, or on one’s back becomes painful, too. Furthermore, a blood clot may form within a hemorrhoid, causing it be become thrombosed and if this causes the blood supply to get cut off, a strangulated hemorrhoid results, which is excruciatingly painful. 

The pain of hemorrhoids ranges considerably. It’s only once an internal hemorrhoid becomes irritated, swollen and inflamed that they become painful. If they prolapse, an internal hemorrhoid can go from a 1-3 on a Likert pain scale of 1- 10 (with 10 being the worst) to an 8 or 9 on 10 — and this can occur suddenly, without warning. A person can literally go from having no awareness of having internal hemorrhoids, to having a Grade 3 prolapsed hemorrhoid and experiencing significant pain. As a result, learning what leads to the development of inflamed internal hemorrhoids is essential to avoid experiencing this. 

Most external hemorrhoids and Grade 1 and 2 internal hemorrhoids will clear up by themselves after a week or so of self-treatment, however a Grade 1 or 2 hemorrhoids that does not get better, or gets worse, as well as Grade 3 hemorrhoids requires intervention —usually with rubber band ligation (RBL) which is the most common first line treatment [3]. This is where a very small rubber band is applied to the base of the internal hemorrhoid which cuts off the blood supply to it. In essence, this is a planned strangulated hemorrhoid. Over a week or two (depending on the hemorrhoid’s size), the walls will thicken, and the overall size of it will shrink. After approximately 10-14 days, the rubber bands fall off the hemorrhoid, leaving an ulcer. The ulcer may bleed a bit with bowel movements over a few days, as it heals [3]. Finally, what will remain is a bit of scar tissue on the rectum wall and that may continue to bleed lightly during bowel movements, until it heals over completely over the following few weeks. While the banding procedure itself is painless when done properly, and is usually performed without anesthesia, the pain from the hemorrhoid its self can be significant until it finally falls off after ligation, and heals. 

If the inflamed internal hemorrhoid is located on the left lateral side, it may be too painful to sleep on that side, and if it is located on the right posterior side it may be too painful to sleep on one’s back. Regardless where it’s located, a Grade 3 or 4 hemorrhoid may make it too uncomfortable to sleep much at all — and since people are generally too embarrassed to talk about hemorrhoids, this pain is largely endured in silence.

The good news is that by adopting a few simple dietary changes and modifying two lifestyle habits the risk of developing hemorrhoids occurring, or reoccurring after treatment can be reduced. 

Most people know that avoiding constipation is important to reduce the risk of getting hemorrhoids and think that drinking enough water and eating lots of “roughage” is the way to accomplish that. What few realize is that some types of fiber can make constipation worse — especially if there is insufficient water intake. But, reducing the risk of hemorrhoids involves more than diet. The length of time that we sit on the toilet, as well as the position that we sit on it both play a significant role in the risk of developing hemorrhoids. 

Squatting versus Sitting Toilet   

In much of Asia, South East Asia and Africa, the squatting toilet is the norm. The user positions themselves in a squat position over a floor-level porcelain bowl which results in the colon and rectum being positioned in a straight line. This enables bowel movement to occur significantly faster and without straining than what occurs when using a western-style pedestal toilet. These are more than “holes in the ground” but are real toilets with a flush mechanism that the user engages to empty the bowl — just like on a Western toilet. 

In Europe and most of the West, the pedestal toilet is the norm which is used in a sitting position. This type of toilet results in a bend in the alignment between the colon and the rectum, causing it to take longer to have a bowel movement, and frequently requiring more than one “visit” to accomplish it. Of importance, the seat design of a pedestal toilet results in increased pressure on the rectum and anus which significantly increases the risk of developing hemorrhoids.

Middle Eastern and North African countries have both squatting and pedestal toilets, depending on the region. 

There are various types of squatting platforms available for purchase that can be placed over a standard Western pedestal toilet, converting it into a squatting toilet. These are popular with people who have emigrated from countries where squatting toilets are the norm. 

Also available online are various types of squatting footstools that are placed in front of a standard Western pedestal toilet and enable the user to sit in a semi-squatting position. These squatting stools allows for better alignment of the colon and the rectum, and are frequently recommended to people recovering from hemorrhoids, hemorrhoid ligation (banding), and hemorrhoid surgery. These squatting stools allow for less pressure on the anus and pelvic floor, and as a result, may help reduce the development of hemorrhoids or deterioration of unknown internal hemorrhoids. 

The Length of Time Sitting on a Pedestal Toilet 

Due to the shape of the seat on a Western-style pedestal toilet, the length of time that one sits on it increases the risk of developing hemorrhoids. This is due to the increased pressure on the pelvic floor, lower rectum, and anus resulting from the seat’s shape. 

Think of a single hole paper punch. 

The pressure exerted over a small hole is what makes a one-hole paper punch so effective. Good for paper,  not good for rectums.

To limit pressure on the rectum and anus, it is recommended to limit “seat time” to 3-5 minutes at a time, 10 minutes maximum in 24 hours [1]. 

Washrooms as Phonebooths

In the early 1950s, most houses only had one washroom or bathroom, so multiple members of the same household had to do what they needed to in a limited time, and get out. It was rare to have the luxury of being able to sit on the toilet for extended period of time, reading the newspaper. Now, 97% of new home construction has more than one washroom or bathroom [4] — most often having two full washrooms, plus an additional 1/2 bathroom containing a toilet and a sink. 

With three toilets per house for an average family size of three in Canada [5] means that each member of the average household has access to a toilet on demand, and can — and does spend inordinate amounts of time sitting on it.

A recent study found that 2/3 of Canadians and even more Americans are on their smartphones while sitting on the toilet [6]. The washroom is the new phone booth. It is one of only places in the house that many can have time alone — and all this increased sitting on the toilet scrolling on the phone is thought to be related to the increased rates of hemorrhoids seen in younger and younger adults. 

Final Thoughts

There are simple things we can do to lower the risk of developing hemorrhoids.

We can drink more water and eat enough of the right types of fiber.

A squatting stool can help align our colon, making defecation time shorter, while reducing the amount of pressure on our rectum.

It is recommended to limit “seat time” to 3-5 minutes. Not scrolling on the phone while sitting on the toilet will make it possible to do what is needed in the recommended amount of time—significantly reducing the risk of developing hemorrhoids.

Remembering how a one-hole punch works may be a helpful reminder. 

For those who have never experienced the debilitating pain of a large, prolapsed hemorrhoid, implementing these changes may help avoid the experience.

For those who have, I hope that learning how to minimize the risk of another will be welcomed news. 

To your good health. 

Joy 

 

You can follow me on:

Twitter: https://twitter.com/jyerdile

Facebook: https://www.facebook.com/BetterByDesignNutrition/

References 

1. UT Southwestern Medical Centre, Treating hemorrhoidal disease: Conservative vs. surgical approaches, April 14, https://utswmed.org/medblog/best-ways-to-treat-hemorrhoids/ 
2. McKeown DG, Goldstein S. Hemorrhoid Banding. [Updated 2024 Feb 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:https://www.ncbi.nlm.nih.gov/books/NBK558967/
3. Hawkins AT, Davis BR, Bhama AR, Fang SH, Dawes AJ, Feingold DL, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2024 May 1. 67 (5):614-623. 
4. Eye on Housing, Number of Bathrooms in New Homes in 2021, November 3, 2022, https://eyeonhousing.org/2022/11/number-of-bathrooms-in-new-homes-in-2021/
5. Statistics Canada, Average Family Size in Canada, 2021 https://www.statista.com/statistics/478948/average-family-size-in-canada/
6. Toronto Sun, Two-thirds of Canadians take smart phones into the bathroom: Survey, May 16, 2022, https://torontosun.com/news/national/survey-65-of-canadians-take-their-smart-phones-into-the-bathroom

 

Copyright ©2024 BetterByDesign Nutrition Ltd.

 

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the ”content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

 

Approximately 90% of Canadians (87%) have extended health benefit plans; 64% of people have them through their employer, another 14 % access them  through another type of group plan, and 9% of people buy private health insurance [1] and most major insurers (7 out of 10) cover Registered Dietitian services in their standard plan [2]. 

While all Canadian insurers provide coverage for Registered Dietitian services [3], each individual company chooses to purchase (or not) different amounts of coverage for their employees. As a result, insurance coverage varies significantly company to company, even with the same insurer, so it’s important to check with your insurer, or group benefits representative to determine what your yearly limits are for coverage for a Registered Dietitian, as well as how much they cover per visit.

Yearly Limits

Yearly limits for Registered Dietitian services on extended benefits plans frequently range from $500/year to $1500/year however this is only one aspect of what determines the amount that each insurer will reimburse.

Reasonable and Customary Fees

In addition to yearly limits, each plan sets how much they will cover per visit.

Some benefit plans set out how much they will cover for the initial assessment visit and how much they will cover for each subsequent visit. Other plans reimburse the same amount per visit, regardless if it is the initial assessment visit or not — up to the maximum of the yearly limit.

The insurer uses what is called “reasonable and customary fees” to determine the basis for pricing their benefit plans, as well as the basis for reimbursing claims, and these limits are based on the usual cost for a service in each province.

Multi-Province Dietetic Registration

Since the “reasonable and customary fee” is based on the usual cost for the service in each province, my clients in British Columbia, Alberta and Ontario (the three provinces that I am licensed in) have different reasonable and customary amounts related to my services.

Below are the reasonable and customary limits for Dietitian services from five of the major benefit insurers in Canada. As can be seen, the range that the same provider covers in each province for the same service varies widely. 

In pricing my services, I not only take yearly limits into consideration, I also factor in the reasonable and customary fee amounts in each province that I am licensed. 

British Columbia – reasonable and customary limits

For an initial Assessment visit to a Registered Dietitian, benefit plans in British Columbia reimburse from $200/hour, to $180/hour, to $170/hour, to $150/ hour.

For subsequent visits to a Registered Dietitian, benefit plans in British Columbia will reimburse from $170/hour, to $155/hour, to $150/ hour, to $120/hour.

Alberta – reasonable and customary limits

For an initial assessment visit to a Registered Dietitian, benefit plans in Alberta will reimburse from $210/hour, to $195/hour, to $180/hour.

For subsequent visits to a Registered Dietitian, benefit plans in Alberta will reimburse from $190/hour,  to $180/hour, to $165/hour, to $150/ hour, to $127/hour.

Ontario – reasonable and customary limits

For an initial assessment visit to a Registered Dietitian, benefit plans in Ontario will reimburse from $215/hour, to $195/hour, to $150/ hour, to $145/hour.

For subsequent visits to a Registered Dietitian, benefit plans in Ontario will reimburse for from $155/hour,  to $145/hour, to $140/ hour, to $122/hour.

Pricing Based on Inter-Provincial Reasonable and Customary Fee Limits

When planning to go to any paramedical practitioner, including Registered Dietitians, it is important that people keep in mind that because of these reasonable and customary fee limits, how receipts are issued determines how much reimbursement they will get.  Packages must broken down into the individual services that make up the package, and each service must have the date and time it was provided, and the individual cost for that service. 

I ensure that the receipts provided contain all the information that a client’s benefits plan requires, so that reimbursement is maximized, and occurs quickly. Since many extended benefits plans reimburse per visit, all the packages that I offer are broken down into their respective services, beginning with the Initial Assessment visit, and each subsequent visit. The date and time of each service is listed, and the cost of each service.

Below is an example of a receipt for the Comprehensive Dietary Package, but all packages are broken down similarly to maximize refunds and to make reimbursement easy.

I have been in private practice since 2008, and I have always charged $150/hour for an Initial Assessment visit, and $100/hour for all subsequent visits in a package. That’s a long time. 

I recently found out that in 2024, the minimum amount covered for subsequent visits from the above five major insurers in the provinces to which I provide services was $127/hour.  I have been billing $100 since 2008.

Beginning January 1, 2025, the costs of subsequent visits will increase to $120/hour — and even with the increase, the new price will remain lower than the Reasonable and Customary Fees for each province to which I provide services. Prices for the Initial Assessment visit will remain $150/hour — the same price it has been since 2008.

Final Thoughts…

The amount that each extended benefits plan reimburses for visits to a Registered Dietitian is based on the reasonable and customary fees in each province.

Beginning on January 1, 2025, the cost of subsequent visits will change to $120/hour, and this is still lower than the Reasonable and Customary Fee limits in each province that I provide services. The cost of an Initial Assessment visit will remain unchanged at $150/hour — the same price it has been since 2008.

If you would like to learn about the many Routine Services, Digestive Health Services, and Therapeutic Diet Services that I provide please have a look the Services tab and to learn about pricing, payment options, and clinical hours, please visit the Book an Appointment tab.  

If you want to maximize your extended benefits for this year, please keep in mind that October, November and December are my busiest months, so I recommend not waiting too long.

I am currently booking ~2-3 weeks ahead, but I do have a cancellation list.

Please check your with your plan provider or company benefits representative to find out what your specific extended benefit plan covers.  

To your good health,

Joy

 

You can follow me on:

Twitter: https://twitter.com/jyerdile
Facebook: https://www.facebook.com/BetterByDesignNutrition/

 

References

 

1. Coletto, David, Abacus Data, “Canadians and Health Care: Workplace and Group Insurance Plans”, April 6, 2023, https://abacusdata.ca/healthcare-canadians-clhia-workplace-and-group-insurance-plans/
2. Dietitians of Canada, “Dietitians are the Best Choice for Employee Benefit Plans”, https://www.dietitians.ca/Advocacy/Priority-Issues-(1)/Dietitian-coverage-on-employee-benefits-plans
3. Dietitians of Canada, “Providing access to nutrition services in employee health benefits plans”, https://www.dietitians.ca/Advocacy/Priority-Issues-(1)/Dietitian-coverage-on-employee-benefits-plans/Nutrition-Services-(Test)

 

Copyright ©2024 BetterByDesign Nutrition Ltd.

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the ”content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

 

Therapeutic Ketogenic Diets

Therapeutic ketogenic diets have been used for more than 100 years in the treatment of epilepsy and diabetes and more recently as adjunct treatment in some types of cancer and in mental health.

These are very high fat diets that range from 65-72% fat (2:1), to as high as 90% fat (4:1) [1], and since the amount of protein, fat and carbohydrate is tightly controlled, ingredients are weighed. Monitoring and tracking blood glucose and blood ketone levels is also required to ensure that the desired therapeutic level of ketones is achieved, and maintained.

Three Types of Therapeutic Ketogenic Diets 

A Keto Diet

There is no one “keto diet”, but rather a range of keto diets. What these diets have in common is that they limit carbohydrate intake to 10% or less of daily calories in order to promote the body’s production of ketones.

A Well-Formulated Ketogenic Diet

Final Thoughts…

References

 

Copyright ©2024 BetterByDesign Nutrition Ltd.

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the ”content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

 

 

International Diabetes Federation has just released a new Position Statement that indicates that an oral glucose tolerance test performed at 1-hour after a glucose load is more effective in screening at-risk individuals for prediabetes and type 2 diabetes than a 2-hour Oral Glucose Tolerance Test (OGTT). 

The International Diabetes Federation is a non-profit umbrella organization of more than 240 national diabetes associations from 161 countries including the United States (represented by the American Diabetes Association), Canada, Australia, as well as many countries in Europe, Asia and Africa. This global reach means that the IDF’s reports and recommendations have significant international implications.

This international Position Statement provides the evidence to support the practice of requisitioning a 1-hour post load glucose test in place of 2 hour Oral Glucose Tolerance Test to diagnose prediabetes and type 2 diabetes in at-risk individuals.

For physicians who prefer to choose to continue to order a 2-hour Oral Glucose Tolerance Test, this new Position Statement provides support for adding an additional extra assessor at 1-hour, something I have asked for over the last several years based on existing evidence. 

Prediction of Risk of Type 2 Diabetes

The new Position Statement highlights that a 1-hour post-load plasma glucose level of 8.6 mmol/L (155 mg/dL) or higher during in people with normal glucose tolerance strongly predicts the development of type 2 diabetes as well as various complications such as micro- and macrovascular issues, obstructive sleep apnea, metabolic dysfunction-associated fatty liver disease, and death in individuals with risk factors. The recommendations are for  individuals with 1-hour plasma glucose of 8.6 mmol/L (155 mg/dL) or higher to be prescribed lifestyle intervention and referred to a diabetes prevention program.

Diagnosis of Type 2 Diabetes

The Position Statement indicates that a  1-hour post-load plasma glucose level of 11.6 mmol/L (209 mg/dL) or higher confirms a diagnosis of type 2 diabetes and recommends that a repeat test be conducted to confirm the diagnosis of type 2 diabetes and once confirmed, to refer the individual for treatment.

Benefits of the 1-hour Post-Load Glucose Test

The Position Statement indicates that the 1-hour post glucose load test;

1. 1. shows glucose dysregulation earlier than the 2-hour post glucose load test
   2. provides an opportunity to avoid misclassification of glucose status if fasting blood glucose or HbA1c are used alone.
   3. predicts diabetes and associated complications including death in populations of different ethnicity, sex and age
   4. allows for early detection in high-risk individuals which enables the ability to provide intervention to prevent a progression to type 2 diabetes.

Conclusion

The conclusion of the International Diabetes Federation Position Statement is that there is strong evidence to support redefining current diagnostic criteria for prediabetes and type 2 diabetes to include testing at 1-hour post glucose during an Oral Glucose Tolerance Test.

Final Thoughts

There is strong evidence for the use of a 1-hour post glucose load test to diagnose or rule out prediabetes or type 2 diabetes in at-risk individuals.

Most significantly, use of the 1-hour post glucose load test allows for early detection and provision of dietary and lifestyle intervention support to prevent the progression to type 2 diabetes. 

To your good health,

Joy

 

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/

Reference

 

1. Bergman M,  Manco M., Satman I., et al, International Diabetes Federation Position Statement on the 1-hour post-load plasma glucose for the diagnosis of intermediate hyperglycaemia and type 2 diabetes, Diabetes Research and Clinical Practice, Vol. 209, 111589, March 6, 2024 https://doi.org/10.1016/j.diabres.2024.111589

 

Copyright ©2024 BetterByDesign Nutrition Ltd.

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the ”content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

 

 

If you are considering having a DEXA bone density scan to assess your risk of osteoporosis, where you have it done will significantly impact the accuracy of the results, and whether they will provide you with the information you want.

While dual-energy X-ray absorptiometry (DEXA) bone density scans are considered the gold standard for assessing bone mineral density (BMD), it is important to note that there is a large difference in the accuracy of DEXA scans obtained from non-accredited imaging centers offering bone density scans as a service, and facilities specializing in bone densitometry (the clinical assessment of bone density). An accurate scan enables doctors to rule out or establish a diagnosis and provides opportunity for timely treatment recommendations, including dietary and lifestyle modifications.

To illustrate the difference, the first part of the article will explain the standards for accredited facilities, and then contrast them to non-accredited imaging centers. This comparison will underscore the differences between the two.

Accredited Facilities for DEXA Bone Density Scans

For bone density scan data to be reliable in ruling out or diagnosing osteopenia or osteoporosis, it’s important that the scans are conducted by a trained bone densitometry technologist, in a facility that adheres to accreditation standards established by the International Society for Clinical Densitometry (ISCD), and in Canada, by the local College of Physicians and Surgeons of the province. Finally, the scans must be reviewed by a Radiologist, a doctor who specializes in medical imaging before a report is generated.

In British Columbia, the accreditation of bone densitometry facilities as well ensuring that bone densitometry technologists have the appropriate training is overseen by the College of Physicians and Surgeons of British Columbia (CPSBC). They operate the Diagnostic Accreditation Program (DAP), which ensures the quality and safety of a range of diagnostic services, including DEXA bone density scans. The DAP not only verifies that a facility meets the necessary quality standards but ensures that they consistently maintain those standards.

Accredited facilities must adhere to the Accreditation Standards for Diagnostic Imaging from the College of Physicians and Surgeons(1). This comprehensive 312 page document contains imaging standards for x-rays, mammograms, ultrasounds, MRIs , with the standards for bone densitometry beginning on page 274. These standards ensure the quality and safety of bone density scanning procedures.

These standards also outline that bone densitometry facilities must have a Medical Director overseeing operations, and that bone densitometry technologists performing scans must either be certified with the International Society for Clinical Densitometry (ISCD), or have obtained 12 Continuing Medical Education (CME) credits in bone densitometry. Additionally, technologists in accredited facilities are mandated to regularly update their knowledge by acquiring 24 CME credits in bone densitometry every three years.

Summary of the Accreditation Standards for Diagnostic Imaging for Bone Densitometry

The bone densitometry section of the Accreditation Standards for Diagnostic Imaging (1) consists of ten pages of standards, including;

• • patient preparation for the exam
  • standard imaging procedure protocols to ensure that the examination is appropriate for its intended use in clinical decision making
  • ensuring that current and accurate medical records are kept for each person
  • that diagnostic reports are in a standardized format and provide comprehensive and necessary information for clinical decision making / interpretation 
  • safe operation and maintenance of equipment
  • acceptance testing for equipment to ensure it is tested prior to use, and  quality assurance programs to ensure that the required quality is attained

These standards provide additional mandatory requirements and best practices that supplement the accreditation standards established by the International Society for Clinical Densitometry (ISCD) (2).

Below is the first of the ten pages of standards (this page is on patient preparation).

These standards require that the following information be collected before a bone density scan takes place.

(1) taking clinically relevant medical history, including family history, prior fractures, bone trauma, surgery, chronic illness, and any relevant medication that may affect bone density (such as corticosteroids, or thyroid medication),

(2) ensuring that the person has not had any procedures such as a barium x-ray or radionucleotide study that can affect the results,

(3) assessing whether the person has arthritis, deformity or other degenerative changes that can affect measurement,

(4) ensuring the person hasn’t had any implants in the area being assessed, such as a hip replacement,

(5) that a qualified physician is involved in assessing any interference or contraindications,

(6) review of previous bone density scans to determine if a specific site should be excluded from the current scan,

(7) patient height and weight are accurately measured at the time of examination.

None of this, or any of the other 9 pages of standards are required to be followed in an imaging center that provides bone density scans as a service. 

Imaging Center Providing DEXA bone density scans

Imaging centers that provide DEXA bone density scans as a service are business, and are not clinically regulated.  There are no physicians or radiologists involved. These business are not required to meet the international standards of the International Society for Clinical Densitometry (ISCD), or local clinical standards outlined above.

While these centers need to assess height, a construction tape measure attached to the wall with tape may be used, instead of a stadiometer.

Weight may not be asked but rather calculated from the results of a whole body composition scan performed at the same time.

Questions about personal medical history, family medical history, risk factors, medications or procedures that could affect results will be limited.

Image Quality

In accredited facilities, rigorous standards are in place to ensure high image quality, as all scans undergo review by a radiologist prior to report generation.

Images are required to be clear and well defined, such as the top pair of images from HealthLink BC (3). 

Images from imaging centers, such as the pair of images on the bottom often lack the contrast and definition which limits their usefulness.

 

Measurement Accuracy – hips

For hip scans to be useful in diagnosing osteoporosis, it is essential that the neck of the femur (hip bone) is measured at the narrowest part (4), such as the image on the far right (4).

The image on the left from an imaging center does not measure the neck of the femur at the narrowest part, and as illustrated in the middle image, the narrowest part is to the right of where it was measured.

Measurement Accuracy – spine

Spinal images from accredited facilities (left photo from (4)) are clear, and show equal amounts of soft tissue on either side of the spine. In addition, the height of each vertebrae is roughly the same height, with markers in the disk space (4).

   

The image on the right from an imaging center is not clear and has little contrast. It does not show equal amounts of soft tissue on either side of the spine, and the height of each vertebrae varies considerably.

Finding an Accredited Facility

In British Columbia, a full list of accredited diagnostic imaging facilities in the province is available on the College of Physicians and Surgeons web site (5).

The International Society for Clinical Densitometry (ISCD) has a searchable list of accredited facilities by country, as well as US states and Canadian provinces.

The College of Physicians and Surgeons in your province or state may also have a list.

Final Thoughts…

For data from a DEXA bone density scan to be reliable and useful for ruling out or diagnosing osteopenia or osteoporosis, it needs to be performed at an accredited facility.

This can be compared to the difference between home lab test testing and lab tests. While at-home blood testing kits are available to screen for different conditions, diagnoses of a medical condition requires blood tests from an accredited laboratory that are reviewed and assessed by a physician.

If you want to have a DEXA bone density scan to assess your risk of osteoporosis, then speak with your doctor to get a referral to an accredited facility.

How I Can Help

If you have been diagnosed as being at risk for osteoporosis, or have been diagnosed with osteopenia or osteoporosis, implementing appropriate dietary and lifestyle changes can be beneficial.  Please let me know if you would like some support.

DEXA Bone Density Scans are the gold standard for assessing the quality of the inside of bone, and determining whether a person has osteopenia or osteoporosis. More on those scans, soon.

A DEXA Body Composition Scan is designed for assessing the amount of body fat and the distribution of that fat, yet often come with a report that includes “bone mineral density” information. It is essential to understand that “bone mineral density” on a DEXA Body Composition Scan is estimated, not measured. 

This article is about the DEXA Body Composition Scan and what information it reliably provides.

NOTE: (February 14, 2024) If you are thinking of having a DEXA Body Composition Scan, be sure the facility you choose is accredited by the College of Physicians and Surgeons in your area.  More on this in the next article!

DEXA Body Composition Scan

The DEXA Body Composition Scan measures

(a) total amount of fat mass in grams, and

(2) total amount of Lean Body Mass plus bone, in grams.

It does not measure bone mass, but adds both lean body mass and bone mass together. This is important because reports that often accompanying DEXA Body Composition Scans include information about “bone mineral density”, but this information is estimated, rather than assessed. 

The DEXA Body Composition Scan reliably indicates how much total fat someone has, and the distribution of that fat over the body. It does not differentiate between sub-cutaneous fat (the fat under the skin) and visceral fat (the fat around the organs) which is associated with increased health risk.

Since fat mass is what is being directly evaluated in a DEXA Body Composition Scan, the total amount of body fat determined by this method is accurate.

DEXA Body Composition Scan Data of Fat and Lean 

Below are two pages from a DEXA Body Composition Scan report. 

This above page from a DEXA Body Composition Scan report is mostly related to what it assesses directly, which is Total Fat Mass in grams, and Lean Body Mass plus bone in grams, and evaluates the distribution of that fat.

While a DEXA Body Composition Scan does not differentiate between subcutaneous fat and visceral fat, the report indicates “Estimated Visceral Adipose Tissue (fat)” in the table of adipose (fat) indices. It is important to note that visceral fat is not assessed, but estimated. 

DEXA scanners (both GE and Hologic brands) have the National Health and Nutrition Examination Survey (NHANES) data integrated into their software, this which enables them to generate Z-scores for total amount of fat in grams, as well as localized Z-scores for fat in arms, legs, and trunk (1).

Z-scores compare the an individual subject’s results to those of an aged-matched population, and since a DEXA Body Composition Scan measures total fat directly, the z-score in this report for adiposity (fat) is valid.

T-scores compare an individual’s results to how many standard deviations it is from the results of a 30-year old young adult, and since a DEXA Body Composition Scan measures total fat directly, the t-score for adiposity (fat) is also valid.

DEXA Body Composition Scan Data on Bone Mineral Density and Bone Mineral Composition

This is where reports that may be provided with a DEXA Body Composition Scan can get really crazy.

A DEXA Body Composition Scan does not differentiate between Lean Body Mass as muscle and bone, so any information about “bone mineral density” and “bone mineral composition” is based on estimations!  

Since there is no measurement of bone mass in grams separate from Lean Body Mass (muscle),  z-scores for “Bone Mass Density” from a Whole Body Composition Scan make no sense.  This is a comparison of estimated bone data to actual data from an aged-matched population! 

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Have a look at the table below from a 55 year old woman whose DEXA Body Composition Scan report indicates that she had osteoporosis based on estimated bone density numbers. Without having a DEXA Bone Density Scan, of both hips and lower spine she really doesn’t know if she has osteopenia or osteoporosis or not. A DEXA Body Composition Scan is designed to assess fat mass and the distribution of that fat, not bone.

Final Thoughts…

If you have had a DEXA Body Composition Scan and been told that you have osteopenia or osteoporosis remember that this is based on estimates of total amount of bone, and not actual measurement of bone. In such a case, I would recommend discussing with your doctor having a DEXA Bone Density Scan of both hips and lower spine.

If the DEXA Bone Density Scan indicates that you meet the criteria for osteopenia or osteoporosis, then meet with you doctor to discuss the results and their recommendations. In some cases, a doctor may recommend medication to keep bone from breaking down too quickly, and/or a program designed by a Physical Therapist to enable you to safely exercise and retain as much of bone mass you still have, while minimizing the risk of fractures. 

Take Away Message

Remember, that estimated data of “bone mineral density” from a DEXA Body Composition Scan is not the same as data from a DEXA Bone Mineral Density scan which is based on direct assessments.

Getting accurate information using the right diagnostic tool is essential.

How I Can Help

If you are an older adult who wants to optimize your diet and lifestyle to retain as much bone mass as possible as you age, I can help.

To your good health,

Joy

 

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Reference

1. Shepherd JA, Ng BK, Sommer MJ, Heymsfield SB. Body composition by DXA. Bone. 2017 Nov;104:101-105. doi: 10.1016/j.bone.2017.06.010. Epub 2017 Jun 16. PMID: 28625918; PMCID: PMC5659281.

 

 

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