Living longer, living healthier

A 2004 report by the surgeon general warned that by 2020 half of all American citizens older than 50 could be at risk for fractures from osteoporosis and low bone mass.

As an endocrinologist who conducts research on bone health, Reina Armamento-Villareal, M.D., has seen the devastating impact of osteoporosis on patients — a hip fracture can result in death or disability 60 percent of the time.

“People used to just accept weakening of the bones as a normal part of aging, and in the past it didn’t affect so many people because we didn’t live as long,” she says. “But with our longer life spans now, unless we find better ways to treat and prevent osteoporosis many more people will face significant disability in old age. I’m really interested in what I can do to help.”

Armamento-Villareal is assistant professor of medicine in the Division of Bone and Mineral Diseases and a bone specialist at Barnes-Jewish Hospital. She treats patients with a variety of disorders that affect the bones.

Not surprisingly, many of her patients are women past menopause. Postmenopausal women face an increased risk of osteoporosis because their estrogen levels have dropped. Armamento-Villareal has a special interest in the role of estrogen in bone health and women’s health in general.

She also sees patients with Paget’s disease of bone, hyperparathyroidism and vitamin D deficiency. In addition, she sees a significant number of transplant patients, whose bones are affected by the steroids they take to prevent rejection. She says she enjoys the challenge posed by her bone cases.

A love for challenges seems to have served Armamento-Villareal well — it allowed her to gracefully manage the transition from life in a tropical village in the Philippines, where she was born and raised, to a successful medical career in a Midwestern American city.

Armamento-Villareal grew up in Tuburan, the Philippines, population of about 1,500, on the eastern coast of Cebu, an island near the center of the Philippine archipelago. She graduated high school at 15. With no experience of city life and little exposure to the outside world, she headed to college in the Philippines’ second largest city, Cebu. She earned her undergraduate degree at Cebu Velez College.

“I never saw television until I was in college,” says Armamento-Villareal with a tone of amazement. “We didn’t even have a telephone at home. It was a huge change for me.”

Armamento-Villareal earned a medical degree from Cebu Institute of Medicine and completed training in endocrinology and diabetes in the Philippines before accepting a fellowship in endocrinology, diabetes and metabolism at the School of Medicine in 1990.

Arriving in February from tropical Cebu, where daily high temperatures were in the 80s or 90s, Armamento-Villareal found St. Louis a blast of cold air. “The temperature was negative something,” she says. “It was the first time I had ever been in cold weather.”

St. Louis also was where Armamento-Villareal drove a car for the first time. She laughingly describes her driving lessons: Her teacher was an Indian woman who gave her just enough information to pass the driving test and then told her, “You’re not young anymore. I know you’re not going to do stupid things. Just use common sense and you’ll be fine.” And she was — although she prudently stuck to the side streets on the way to her rotation at Shriners Hospitals for Children-St. Louis.

After her rotation ended and she had completed an internship and residency, Armamento-Villareal went into private practice at Collingsworth General Hospital and Collingsworth Family Clinic in Wellington, Texas, and then later at Overland Medical Center in Overland, Mo.

In 1999, she returned to the School of Medicine where Roberto Civitelli, M.D., the Sydney M. and Stella H. Schoenberg Professor of Medicine, introduced her to research that focused on how estrogen production and breakdown, or estrogen metabolism, affects bone health.

“When I came back, Dr. Civitelli asked me to revise a paper he was working on,” Armamento-Villareal says. “That started my interest in estrogen metabolism, and I wanted to see how I could explore this topic further.”

She has contributed significantly to the development of the Division of Bone and Mineral Diseases, according to Civitelli. “She’s a hard worker and has been very successful in developing her own projects,” says Civitelli, also professor of orthopedic surgery and of cell biology and physiology. “She represents just what we are striving for — younger investigators who can achieve independence and originality.”

Armamento-Villareal studies how variations in estrogen metabolism affect bone health in both men and women. Most people think of estrogen as a single hormone and often assume that only women have it, but actually several estrogenic compounds exist in both males and females. Each has a different “strength” or estrogenic activity. The particular cocktail of estrogens found in different individuals depends on their genetic makeup, diet and environment.

Armamento-Villareal’s work has helped show that not just women’s but also men’s estrogen metabolism affects their bone density. She also has demonstrated that women from families with a history of osteoporosis tend to metabolize estrogen to inactive forms. This highlights the influence of a person’s genetics, and Armamento-Villareal also has shown that differences in bone density may be related to genetic variations of a liver enzyme that breaks down estrogen.

One of her most recent projects delved into the relationship between estrogen metabolism, calcium intake and bone health. The study suggested that calcium from dietary sources was associated with an increase in the metabolism of estrogen to active byproducts. In addition, this study showed that calcium from dietary sources is better able to protect bone health than calcium from supplements. Armamento-Villareal is continuing her work in this area.

Other current projects look at the relationship between estrogen metabolism and cognitive function and study the genetic and dietary factors affecting bone density in those taking aromatase inhibitors, commonly prescribed to stop estrogen production in breast cancer patients.

Cynthia Ma, M.D., Ph.D., assistant professor of medicine in the Division of Oncology, collaborates with Armamento-Villareal on two research projects. Ma treats patients with breast cancer and often refers them to Armamento-Villareal because of her expertise in the effect of aromatase inhibitors on bone density.

“She cares so much about the welfare of the patients and follows their bone health closely,” Ma says. “I think of her as one of my mentors, and I admire that she has dedicated herself to her research not just because it’s interesting, but also because she wants to make a difference in patients’ lives.”

Armamento-Villareal’s husband, Dennis T. Villareal, M.D., is also on the faculty at the School of Medicine. Villareal, associate professor of medicine in the Division of Geriatrics and Nutritional Science, is doing research on frailty and obesity in older patients. Both conditions are related to bone health, so the couple’s specialties and research interests complement each other well.

“It’s good because if I have a tough case and need more input, I can ask him,” Armamento-Villareal says. “And if he needs more input about things like genetics, he can ask me.”

The two graduated from the same college and met during medical training in the Philippines. They have a son, Kenneth, who is starting his junior year of high school and says he’s interested in pursuing medicine — on some days.

“He flip-flops,” Armamento-Villareal says. “That’s OK, we aren’t pushing him into medicine. Something I like about America is you can do whatever interests you and still be a success. In the Philippines, there isn’t so much opportunity. Every day we are thankful our parents were able to send us to college.”