The Dr Louise Newson Podcast - 033 - Bone Health, Osteoporosis & the Menopause - Professor David Reid & Dr Louise Newson

Episode Date: February 4, 2020

In this week's podcast, Dr Newson is joined by Professor David Reid, Consultant Rheumatologist and Osteoporosis Specialist at the University of Aberdeen. Professor Reid is also the Senior Medical Adviser and Fundraising Ambassador for the Royal Osteoporosis Bone Research Academy. Bone density reduces as our hormone levels lower, as a result of the perimenopause and menopause. Around one in three menopausal women will have a osteoporotic hip fracture so it is essential we are all thinking about ways of improving bone density and reducing future risk of developing osteoporosis. In this episode, Dr Newson and Professor Reid talk about what osteoporosis is, how to diagnose it and also ways of increasing our bone density.  Professor David Reid's Three Top Tips for Bone Health: For people in their 20s and 30s, don't worry too much about your bone health - take plenty of exercise and eat well, this is the best way to prevent any future problems. For women going through the menopause, now is the time to start thinking about your bones. Take preventative measures such as reducing your alcohol intake and stop smoking. Consider a DEXA scan to measure your bone density. For elderly people, try regular weight bearing exercise and get the required amount of Vitamin D and Calcium, be careful to ensure your home is safe from trip hazards that can result in fractures.   

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsome, a GP and menopause specialist, and I run the Newston Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. So today I'm very delighted to introduce to you Professor David Reed, who's a professor of rheumatology, who I've become acquainted with over the last few months, because some of you might know that I'm very interested. in disease prevention, including osteoporosis. So welcome, David. Thanks for coming. Thank you very much for these. Nice to be here.

So before we start talking about osteoporosis, I just thought it be really interesting to hear more about you and your work. And I know you've had all sorts of jobs and over the years, but what got you interested in osteoporosis and rheumatology from the start? Okay, well, for osteoporosis, it was because when I was training as a rheumatologist, I went many, many, many years ago. I went to Edinburgh. to do part of my training. And there was a machine there for scanning bones. It was actually a very old-fashioned technique,

which is not used again now because it was actually gave a very high dose of radiation. And nobody was exploiting or researching this machine. And my then professor in Edinburgh said, perhaps you would work with these physicists to work at the technique and look at the bones of people with arthritis, various sorts and steroid users and so on.

We did a lot of work on that. And that became a great interest of mine. And at the same, more or less the same time, I started becoming involved with the Osteoporosis Society, which was then called the National Osteoferozo Society, now the Royal Osteoporososia Society, and did a lot of work with them in an advisory capacity and eventually rose up and chair of the board of trustees at the charity.

So it became a kind of passion. of mine and an obsession and I started the first bone unit, bone research and clinical unit in Scotland actually, well, probably the second one if I'm honest, but in Scotland in Aberdeen and we did a big

a lot of research in the field a bit of an obsession, too much of an obsession really but because I realised I've developed that in session by very very small children which was right. Always hard as I know to balance family yes you think oh dear

Yeah. Yeah. And now you mainly, I know you work in London, don't you? Yeah, so, I mean, I was basically a university, well, NHS and university employee all my life and work. And now I'm ostensibly called a meritist professor, which supposed to mean, I suppose I have some merit somewhere, but I'm not sure what it is. But so I am not ready to give up, hang up my stethoscope or my Xer scanner yet. So I basically work most of the time. London and mostly in the private sector. Following my obsession with osteoporosis and prevention and treatment there. Yeah, which is so important and we're delighted that you're working as part of our team to report our scans for our dexas scan here, which is brilliant.

So just our bones, when people think about bones and certainly my children who, my older two who are teenagers, think about bones as a solid structure that is just a supporting structure for our bodies. It's a bit more complicated than that, isn't it? The bones are very dynamic. So talk us through what bones. Well, it is, but basically they're the coat hanger in which we hang our clothes and our muscles and all the other tissues. So they are very solid pieces of kit, if you like, which are there for a purpose of giving us support. But you're right in a way, they're living organs. So they turn over all the time.

A small piece of bone turns over and takes about three to nine months to turn over completely and renew itself. and it's that turning over and renewal of bone which becomes the problem later in life and it becomes a particular problem or can become a particular problem for ladies at the menopause because the estrogen hormones which your listeners will be well aware of are very protective to bone and when they fall in concentration in the system

as happens in all ladies as they go through the menopause unless they take HRT of course then the bone starts. turning over more rapidly. And basically the forming of new bone, I can't keep up with the breakdown of bone, and they lose bone. And they lose it particularly in areas where the bone is kind of aery-fairy in the inside, so in the spine, for example. It's where the bone looks a bit like an old-fashioned, what do you call these chocolate bars with bits of them, crudgy or arrows or whatever. So I used to say when I went to speak to lay people that osteoporosis bone looks like an arrow that

you bought from bobas, which is an old shop where it's very cheap. So lots of holes and not much chocolate. And that's the problem. And that's why bones crumble because the structure, the internal structure's lost of it. And they therefore give way in those most severely affected. And so estrogen is very good at building the bone, isn't it, when it's there? It's very important. But it's really main function is actually preventing the bone, the cells that break down bone

from being overactive, called osteoclasts, as you know, and the osteoclasts become overactive at the menopause. Without the estrogen there. And it's quite a rapid decline, isn't it? Yeah, I mean, it falls by, on average, about 2 or 3% per annum in the spine, for example, in the immediate post-menopause, and actually slightly before the menopause period.

Yes. And then it kind of slows down after the age, if people don't do anything about it, slows down by the age of 60 or... So maybe for about 10 years or so. For those 10 years, it's more active, it's breaking down a bit more rapidly, for the average person. Of course, some people...

Some people... Some people are very variable. Some people, it doesn't happen. And some people, it happens more rapidly than that. Yes. And I suppose also it depends where you're coming from. We don't know often what our bone density is. And so if we're coming from a high level and reduced 2%,

we won't miss it. Absolutely. Whereas if we're just on the edge and lose 2%, every year, 20% over 10 years, that's a lot, isn't it? It is, it is a lot. And those are the people who get the ladies particularly. Of course, it happens in men as well, but men, as you know, just gradually fade away

rather than suddenly becoming menopausal, if you like. So in women, that period between around the menopause and just after is very critical for their bone health. And I've read somewhere, well, actually I've read on the Royal Osteoporosis Society website that around one in two women over the age of the menopause, develop osteoporosis, one in five men. It's very carefully crafted statistic that. It's one in two women over the age of 50

will have a fracture which could relate to osteoporosis within the remaining part of their lifetime and the figure for men is one in five. That means that one in two people will get a fracture and that they're more likely to be one of those one and two if they have osteoporosis. But it doesn't mean that everybody who has one of those fractures has osteoporosis.

No, okay. So it's hard to know. the figures, isn't it? It is very hard. I think a lot of people think about osteoporosis and hip fractures, but it's not just hip fractures, is it? No, I mean, the spine fractures are the ones that I worry about a lot

because they can and frequently are silent or relatively silent and it's interesting how many people you meet or we do dexas scans and where, as you know, we do here and in other sites a picture from the side and you say, oh, you've got a fracture

there, when did you have the pain in your back? and they don't know. Never had any pain, but I have noticed that I'm having a little trouble getting up to higher shells in my kitchen or whatever. So they've lost a bit of height. They've got a little bit more. Good for the radio. That's my demonstrations. I've bent and become stooped.

And that's the cause for most older women of older women looking stooped and having to bend forward in the walking. And that can cause quite a lot of problems, can't I mean, certainly I've seen lots of people when I've done visits. as a GP to nursing homes, people who are very stoop, can affect their breathing, can affect their digestion. Definitely. It's a big disability, isn't it? It is. And of course, by the time it becomes critically obvious or very obvious, it's not too late to do something about it.

It's harder. But prevention would be much better than cure. Early treatment is much better than trying to late treatment. Yes. And certainly when you read the figures about osteopotic hip fractures, the cost to the NHS It's about, I don't know whether it's two or three billion pounds a year, depending on what you read. It's astronomical. It is huge.

And of course, part of the cost is the rehabilitation costs for people that have had a hip fracture because I think the figures are one in two women and men who have a hip. In fact, men are slightly worse, actually, in terms of hip fractures, who have a hip fracture are less able to look after themselves after the hip fracture than they were before. Of course, they're usually pretty elderly and they're pretty frail. other ways, but it can often be the trigger comes. I'm going to say the straw that breaks the cameras back, but it's not

perhaps very good analogy. But it's the sort of thing that makes people go from just coping. Yes, it's not. Yes. And then they're less mobile, they're more likely to pick up a chest infection or a urine infection. Yes, and certainly we see a lot of people who, like you say,

they're just about managing independently at home, and then they either have to have carers at home or they're going into care, which is costing. a lot of money for the NHS, but also for them, it's doing their independence. It is. And we did many years ago a big study to screen women at the menopause for their bones to see whether screening them and treating them at that stage with, at that point, HRT,

would potentially prevent those. The problem with screening at the menopause is that you have to take the treatment, whatever it is for many, many years before you get the benefits. So the costs of the screening then becomes quite high for the NHS relative to the benefits. And so more recently we've been trying to work up ways as a scientific community, of ways in which you can start screening rather later in life in people's 60s or 70s to try and introduce treatments then. But then, of course, for the majority of who don't come to your clinic,

it won't be with HRT and have treatments. Yeah. So it's very hard osteoporosis. a blood test for osteoporosis, is there? And even just doing a normal x-ray, you can't diagnose osteoporosis. No, you said you have to lose about 30% of your bone before you can see it. Yes. And that's probably about right, actually.

So if someone comments on an x-ray... If they comment, they probably have. It's probably quite significant. Probably significant. It is one of the recognised reasons. In the NHS you're restricted sometimes to have a dexas scan because you've got to have a certain number of risk factors. But one of the recognised risk factors

which would allow people to have it is they have a radiological, that is x-ray osteopenia. And then what other risk factors? We've talked about the menopause in general. People, women have a reduced bone density, but early menopause is a risk factor. So women who are under the age of 45

or P.O.I. Premature and Ovarian Insufficiency under age of 40s. One in 100 women, really common. Yeah. That's a risk factor, isn't it? Sure. Yeah. I mean, it's just they start the bone.

start aging, if you like, earlier. So the bones are basically whatever number of years before the menopause should have occurred, that already starting to bones of 55 or whatever if they go through the menopause at 40. So it's, I'll be start at that sort of level. So it's not too surprising in early menopause is a risk factor. And the early menopause is entirely, the effect of the early menopause is entirely driven by the bone density. Some of the risk factors, for example, smoking or excess alcohol are only partly driven by bone density being

lower, also perhaps more likely to induce falls and structural changes in the bone. So calculating risk, we should wear a simple blood test, but there isn't. And we started many years ago just using a dexascan. Now we always calculate risk based on a dexascan plus the clinical risk factors. So people have a questionnaire, don't they? This frax score that we usually do. And that's asking, isn't it, questions such as age of the menopause, whether they smoke, drinking. Also steroids, can't they?

Steroids treatment. And there are things frax is being continuously updated. For example, one of the things that we were talking about earlier is the ladies who have breast cancer who require to take specific drugs for their breast cancer. That block the estrogen. Yeah. oocygene's and their bone is lost very, very quickly when they start that. Quite often they have not bad bones to start with, which is good and they can get away with it, but the bone density does fall very quickly and it would be nice to see everybody who is going to start one of those

drugs making sure they've had their bone density measured before they start or at the time of starting, and then you can monitor it, see what happens. But bone density, so this is the dexascan, isn't it? Talk us through, what's the difference between a dexascan and an x-ray then? Well, the Dexiscan has the word x-ray in it, so it's a dual energy x-ray of optometry. But instead of an x-ray produces a picture directly by throwing x-rays onto a photo plate, basically. There's all sorts of modern ways of doing it digitally rather than by putting an x-ray plate. But it shows the image directly. Dexascan measures the x-ray beam as it passes through the patient,

and it counts how much of the beam is absorbed by the patient or their tissues. And then by doing two energies, you get a picture of the bone and a picture of the soft tissue. Now, the pictures are not great. They're not supposed to be there for pictures. And all of them say image not for diagnosis. You can tell some things. So it's a different way. But we can use it, the image, to look at the spine.

And we do this here in Newsome Health. For ladies over the age of 50, we look at the... spine from the side to see if there's a fracture, you can see them. You can see them quite clearly and it's almost as good as an x-ray, but at a fraction of the radiation. Yes, so it's how much radiation does having a dexoscan? It's not much. No, about a tenth.

Well, it's overall, by the whole thing, about the day, the same as you get, it's a day of exposure in a moderate radiation area. Yes. It's outside. Much less than flying over the Atlantic, for example. Yes, it's very low, so it's very safe, isn't it? And it's, if any of you haven't seen the machine, It's an open machine.

It's not going in a tunnel. No, no, there's no tunnel. I've got to sleep when I had one, I think. It's quite relaxing. Live quite comfortably. Some people do fall asleep, but not many. How long does it take to do... Each site, the ones from the side take maybe four or five minutes, four minutes maybe.

The ones for the hips and the spine, the hip and spine, takes about two minutes maximum. So overall, you can do the whole thing. It depends how hard you're pushing people through, but you can do it in about. 25 minutes without the whole procedure. And then you get the result looking at the bone density in the spine and also the hip. Exactly. Why choose in those areas? What if someone had a fracture of the wrist?

You know, lots of women say to me, well, I've had a fracture of the wrist. You would think. You would think. So the reason the spine and the hip are used is that those are the sites where the prediction of future damage is best. The forearm's not too bad from that perspective, but the forearm is not too bad. but the forearm is much more variable about how much people lose over time, first of all. And secondly, because there are lots of conditions where, for example, rheumatide arthritis,

which people get very low forearm density, but it doesn't mean their density and their other sites is low at all. So it's not a recognised site by international definition of osteoprosis, the forearm. Sometimes used when other sites are not. not available if you've got both your hips taken out of for example but generally but generally speaking you don't use the forearm just occasional situations that you measure the forearm but mostly spine and hip and they're predictive of that's why they're used the fracks score puts the bone density of the hip into it which means that it's not as good

as the total package in predicting those who will have a spine fracture yes but you know it's best we've got at the moment. And again, the fracts is being amended and adjusted at the moment to try and take in some factors which will more clearly predict spine fractures as well. Because that's the important thing, is trying to prevent fractures. It is. Absolutely. It's really important. But not everyone can guess a dexas scan on the NHS. No, exactly not. It's quite, really quite strict guidelines as to who can and who can't have a dexas scan. Yeah. Most health authorities have their own. So it does vary.

So it is a bit variable about who gets them done. And there's often quite a long waiting time despite that. So, I mean, we probably have enough dexas scanners, really, in the NHS, just about. Most places have it. But they tend to hone in now many of the services in people who've actually had a fracture. Fracture liaison services, people think men and women, having had a fracture over the age of 50, are often and should always, I think. be sent for an XA scan to determine whether they have the condition or whether they're at really significant risk of having further fractures. So it's kind of secondary prevention that's being

concentrated on in the NHS and before thinking about primary prevention. Which is good, which is important, but it would be lovely. And I know the Royal Osteoporosis Society is working very hard, isn't it, to think about preventative measures. And the whole of the NHS, as you know, is struggling. So the more we can do preventative, we want to prevent disease, not treat disease. So I think the more work we can do to prevent osteoporosis as well as other conditions, whether it's with our lifestyle or with medication or with hormones, you know, everyone's different. But it's trying to look at our risk factors early, isn't it? So we obviously know that hormones can both prevent and treat osteoporosis. But what else can we do? What's good for

eating and exercise that we should be. Sure. So, I mean, the evidence that you can actually prevent osteoporosis completely or prevent bone loss with intensive lifestyle changes, if you like, is very limited. Now, that's not to say it's not that you can't, but the problem is that apart from anything else, that people generally, it's not women alone, in fact, men are probably worse, are not very good at saying, yes, I know I should change my lifestyle, but they don't do it. It's not easy. It's not easy. You're used to living and enjoying life as a smoker or whatever. But obviously stopping smoking is one thing.

Smoking is really bad for our bones, isn't it? Very high alcohol intake is bad. A small amount is okay. But, you know, people are well advised to keep within the Sally Davis limits of 14 units. I would, of course, say that could be a little higher. I would say that. So those are the negative things. Positive things is weight-bearing exercise.

And it doesn't need to be intensive aerobic exercise. It's just basically walking or gentle jogging or whatever. Cycling? I know you're always good. Cycling isn't that helpful because it doesn't weight bear really. Swimming similarly. Wonderful exercise for cardiovascular fitness and so on. Exercise biking probably also.

But it's probably not so great for osteoporosis. And the problem is what do we do about putting pressure and weight bearing through the spine. That's hard, isn't it? It is very hard. I used to say it until I got into trouble for it, that in Scotland there's a song called You shouldn't shove your granny off a bus, which is, I keep saying, you know,

it actually might be quite good for your granny just to get a few bumps on our bottom by being pushed off a bus, but I think I got into a bit of trouble. I think that's ideal to recommend. But we are really wanting to know how you stress the spine. and it may be bouncing up and down on a ball or something but we just don't have the evidence base exactly how you can keep that spine bone.

But being active. It won't do any harm and it may help you. And so, you know, I do advise my osteoporosis patients to go to Pilates and body balance and so on and at least keep the muscle strength there. Muscle strength and muscle build does work in cahoots with bone. And that's very important. Not to forget the muscles, isn't it?

It is. As we age, men and women, we develop something called sarcopenia, which is loss of muscle mass, isn't it? So without the muscles holding our bones, also we're more likely to fall if we've got weaker muscles. Absolutely. Any exercise is good, isn't it? But weight bearing.

And then what about vitamin D? The recommendations for vitamin D? So vitamin D, you know, vitamin D is almost the universal vitamin now, and everybody, not technically takes it, but an awful lot of people. There is a good evidence. that you need a bit more vitamin D than generally we get just from the sunlight and from our diet in the UK.

And it's particularly the case in my part of the UK in the northern part of Scotland and the northern part of the UK as opposed to the southern part where we just don't get enough sunlight exposure in the winter months doesn't do anything in the winter months because the wavelength's the wrong wavelength.

So you need to build your stores. And that means that we do need to need, probably to take a little bit of extra vitamin D. Personally, I don't. I probably should, but I don't. But recent coma advice, the nutrition advice, was that people would need a supplement for, or should be taking 400 international units per day.

Well, actually, I didn't say that's really quite difficult to get from your diet, so you're probably going to have to take a supplement, and probably most of it should take 400 a day in the winter month. And if you've got low bone density, if the bone density is low, I advise. 800 to 1,000 internationally a day. Totally.

I mean, I think it's really important because in the past we used to be able to prescribe vitamin D and certainly a lot of health authorities are saying we can't prescribe it anymore because of costs. So it's really important that people buy a bit of... It's cheap. It is cheap. And you don't, of course you don't know exactly.

You know, if you buy a capsule says it's got 800 and it might have 600 or a thousand. It's not like a pharmaceutical grade product because the quality of testing as to how much is actually in it. It will be the right thing, but how much is maybe viable. But, you know, 800 to 1,000, that's why I say thousands.

You can't overdose on vitamin D. Well, you can. That's part of the problem. So, you know, there's lots of things about people with multiple scleroses or whatever. And people hear these stories and start taking what we might be called the industrial doses of vitamin D. And actually there's a little bit of evidence that too much vitamin D, especially if you used in big busts all at once

actually make people more prone to falls and it's only just coming and we need to prove it yet but my argument is well what's the point in taking the risk because you don't need that amount for a majority of people but most people taking 800

800,000 years find it's these mega doses some people are taking 20,000 national units a day so you should not be doing that unless it's under medical advice And there might be some medical advice. And sometimes there are the odd person who, one of the causes for osteoporosis,

which is not uncommon when we've, is people who have gluten sensitivity of celiac disease. And quite often they don't realize and until they've had a bone density measurement, they suddenly, oh, my bone's very low, I'm surprised. And then they maybe have a vitamin D measured and it's extraordinarily low. Yeah.

And I thought, oh, right, maybe I'd had that for quite some time. Yes. I just didn't realize and we just thought but the tummy upset and nothing. And vitamin D deficiency is something we see more and more because we're using so much more sun cream, we're covering ourselves off

in the 70s. When I said when I was growing up we would just go out in the sun and I couldn't even wear any sun cream. Well exactly. If we did it, it was factor two or four not... Exactly. So I mean it's obviously your exposure from the sun has to be measured

if you like or has to be limited in some ways but 20 minutes outside in the summer months with a reasonable amount of skin exposed is probably going to be okay to keep your levels up. But skin cancers are a major issue and you shouldn't be over exposed to vitamin D. It's difficult, isn't it? Trying to balance. It's certainly vitamin D and then what about calcium in our diets? Is that your problem? I mean again, yes, but again it's a question of how much, how much is enough and how much do you really need more? and our guidelines now say between 700 and 1,000 milligrams a day,

which if you were taking it only in milk would be a pint and a half of milk a day. Not suggesting anybody would want to take a pint and a half of milk. But that gives you how much. So 700 milligrams are a pint of milk, roughly speaking. People that are taking no dairy product or dairy alternatives because all of the dairy alternatives, oat and milk, all these sort of things are supplemented with calcium up to the same. sort of level is milk, sawyer milk and all that sort of stuff.

So it doesn't matter if they're not taking their dairy in dairy form because they're supplemented. Yeah. But anybody's not taking any dairy, no milk, no cheese, no fish. The oily fish has got a good source, or fish has got a good source of calcium, particularly the bones and small fish. Anybody who's not taking any of that stuff, total vegans have low calcium intake. So they should then take a calcium supplement.

Yeah. And there's actually a very good. good, very simple, well, relatively simple calculator on the, such you on the University of Edinburgh website. If you put an online calcium calculator into Google, you'll find this thing in the Edinburgh website, and you can calculate how much you're taking in your diet. Which is really useful, because I think people do sometimes overestimate what they're having.

Yes, they do. It has to be regular. It's quite straightforward to fill it in. And I get, even the patients I'm trying to see quite quickly, I'll just send it to them, and they send me back the result, and they'll tell you how much to take. it's better than just take a stab at it. And I think that it's better just to take it than the diet.

And if you need a bit of a supplement, you can get a... Yeah, I think so. And I think that's the same with a lot of supplements, isn't it? If we can eat healthily, it's better for so many other things, not just our bones, but totally that's really key. And again, the reason for not over, you know, doing it and taking too much calcium is, again, a bit subtle. But again, there's a little bit of evidence that those older people

who are taking high doses, really high doses of calcium, either in their diet or mostly supplemented, may have a little bit higher risk of heart problems. Yes. As the calcium perhaps gets deposited in their vessels around their heart, which is not... Yes, I think the evidence is limited, but it's still there and suggests there might be something. It's just, you know, when you don't need it, there's no point. Absolutely. So if someone wants to take a supplement for their bones, it's better to take vitamin D and eat

calcium but take a supplement if they need it if their dietary habits don't allow them or they don't want to yeah so great advice so we've gone through quite a lot there's still more I'm sure that we can talk about so I might have to lure you back in to talk again but it's been really useful and I think hopefully that's given people a chance to reflect about their bone health and their bone density osteoporosis risk factors so before we finish David do you mind just giving three take-home tips. So for people who are thinking now about their bones, what should they be doing? I think there's no point in thinking about them too much when you're in your 20s, but when you're in your 20s, you should be doing the right lifestyle things,

taking plenty of weight bathing outside, get outside and enjoy the sun in the summer months when you can without overexposing. So that's for younger people. For women and around the menopause, it would be wise if they all thought about their bones and start to think about it because they're going to lose some. They're going to lose some. And to have it measured and to have their risk measured at that time

makes sense. They won't be able to get that on the NHS unless they've got significant risk factors. And that's unfortunate. But for me it makes good sense. And then for the older person who either has it or is very concerned that they might have it,

it again, it goes back to lifestyle advice, but also being careful and making sure that they're not doing things that make them more prone to falls and trips and so on. And that is a very straightforward thing to avoid, but it's not something we do. And so for carers, if you like, we're looking after all the people, we should be sure there's not loose cables as you've got right in front of you lying across the floor.

Because you do, I know myself. You kind of fall over things more easily. and you're not paying attention. So it's making sure that the carpets are not loose and you're not likely to fall and just avoiding them. So the key from all of this is prevention. Prevention, whether it's preventing your bone loss or preventing a fracture is really key.

So thank you. That's been really interesting. So thank you ever so much for coming up from London today. Thank you very much. Nice to see you again. For more information about the menopause, Please visit our website www.menopausedoctor.com.uk.