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Programme no. 3 - Osteoporosis
RADIO 4
THURSDAY 15/03/07 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
NICOLA PEEL
PRODUCER:
PAMELA RUTHERFORD
NOT CHECKED AS BROADCAST
MYERS
Hello. We all lose some degree of bone density as we get older, it's part of the natural ageing process but it becomes a problem when you lose so much that your bones just can't stand up to the physical stresses of everyday life; they quite literally snap. The medical term for crumbling brittle bones, leading to fractures, is osteoporosis and it's very common. Half of all women will experience a broken bone due to osteoporosis and although it's often thought to be a female problem as many as one in five men will also suffer the same fractures of hip, wrist and spine. Osteoporosis is a chronic condition but there are ways of treating it to minimise the risk of fractures and the pain and disability that may follow.
If you are losing height or if you've had a broken bone or if any of your immediate family has and you want to know more about your risks of osteoporosis and how to treat it call us now - 08700 100 444 - and put your questions to our expert today, she's Dr Nicola Peel, consultant in bone medicine at the Northern General Hospital in Sheffield.
We've got our first caller on the line: Diana is in Devon, has broken a couple of bones, not skiing or doing anything dramatic Diana?
DIANA
No that's right, I really just put my foot in a pothole and it just sort of went over and both bones snapped at the same time.
MYERS
Are you worried then about osteoporosis?
DIANA
Well I do wonder about it because I'm in my 50s and I know that my mother has got osteoporosis, so what I was wondering is the consultant didn't seem to think that I needed a bone density scan but I'm wondering if I should ask my GP for one and if so really what benefit there is in knowing about it in terms of what I might be able to do to make matters better?
MYERS
Well let's put that question to Nicola Peel: Is Diana right to be worried?
PEEL
I think she is. Although we tend to think about osteoporosis as causing broken hips and bones in the spine any fracture that happens as a result of a minimal amount of trauma, as yours did, can be indicative of osteoporosis, so I think you should certainly ask your doctor to refer you up for a bone density scan. And if that were to show osteoporosis then we have very effective treatments which can reduce your risk of having further fractures in future.
MYERS
And you mentioned your mother having osteoporosis.
DIANA
Yes, yes she has.
MYERS
So is there a known inherited risk?
PEEL
Absolutely, we believe that a large contributor to the amount of bone that we lay down in early adult life is down to inheritance and our heredity probably also affects the rate at which bone is lost later on in life. So a family history is really important.
MYERS
So press for a scan and if necessary for treatment. Diana, thank you very much for starting us off, we'll go to Hertfordshire, where Caroline's waiting to speak to us. Bit of a problem with your bone density Caroline, which you know about?
CAROLINE
Well yes I'm a 40 year old and I went through the early menopause and first starting when I was 35 and I started running then as a preventative measure against osteoporosis and I recently had a bone density scan through my doctor, fully expecting that everything would be fine, and my hips were above average density, which is great, for my age group, however, my spine is below average and it's still within normal but it's only just above what's deemed osteopenia. And my question is what can I do to help maintain bone density in my spine?
MYERS
So Nicola, the early menopause is a known risk, is it not, for osteoporosis?
PEEL
It certainly is, yes, yes. And although we recommend very little hormone replacement therapy these days for post-menopausal women with osteoporosis, we still would recommend that somebody who experiences an early menopause does consider taking HRT as a preventative measure and continues to take that up until about the age of 50, which is the age of the natural menopause. So my recommendation would be that unless you have any reasons not to take HRT that that's something which you discuss with your doctor.
MYERS
What about lifestyle measures? A birdy tells me that you're a bit of a runner Caroline, is that right, you enjoy running?
CAROLINE
That's right yes and I've been running for about the past five years and training for a marathon at the moment.
MYERS
Right, is that a good thing to do then if you've got low bone density, I mean could that not in itself lead to fractures?
PEEL
Well weight bearing exercise is an excellent preventative measure which helps to maintain bone density but like most things it should be done in moderation and we do know that people who train very intensively do actually put themselves at greater risk of bone loss if they're exercising so hard that it suppresses the normal hormone production. And in women that would be - would show itself as the periods becoming irregular or even stopping, which obviously might not be apparent in your case because you've already gone through the menopause. But there are other lifestyle factors which we should always consider to try and keep bones healthy - it's important to maintain a good intake of calcium in the diet and to have a good balanced diet; sunshine exposure to have adequate vitamin D from the sunshine is important, obviously again without overdoing it and we always advise people that they shouldn't smoke and that they shouldn't drink too much alcohol because all of these things can have an effect on the bone.
MYERS
Okay thanks very much for that, good luck with the marathon Caroline, if you go ahead with that. And let's move to another caller in London - Jane, who says that she has been anorexic for 30 years and I guess you do know that that is a bit of a risk factor. So you're concerned about what damage that might have been doing to your bones?
JANE
Obviously yes I know that I am at very high risk of osteoporosis but I don't really know whether there's any point in me finding out just how bad it is because I don't know if anything - if I can do anything within the limitations that anorexia puts on me to minimise the risk of fracture.
MYERS
So the anorexia is ongoing is it Jane?
JANE
Yes.
MYERS
Okay could you advise Jane on this?
PEEL
I think it probably would be helpful to quantify your risk and to find out what your bone density is and certainly ...
JANE
And basically I - sorry to interrupt you - I basically didn't - I haven't had periods since I was 18 and I'm 47 this year.
PEEL
And we know that women who become amenorrheic as a result of anorexia and other eating disorders are certainly at high risk of developing osteoporosis. There is some thought that giving hormone replacement therapy can have some benefit on the bone in that situation but unfortunately the most effective treatment for the bone in your situation is to overcome the eating disorder and regain weight ...
JANE
After 30 years I think I have to come to the conclusion that that's just not going to happen.
PEEL
But it's certainly important to think about the other lifestyle factors which you can look at and there are other treatments which may also be appropriate, particularly as you're getting to the age where osteoporosis treatment is often considered.
MYERS
Jane, thanks for sharing that problem with us. And just thinking about other women who may not be anorexic or have eating disorders that leave them with no periods, which is obviously the problem, thinking about girls - women - who are very slim, does that necessarily put them at risk?
PEEL
It is a risk factor and the more risk factors an individual has then the more likely it is that they will have low bone density and be at risk of osteoporosis.
MYERS
It's not just women who are at risk though, we've got David Mee on the line, he's in Saltburn, with osteoporosis David?
MEE
Oh good afternoon to you. Yes I was recently diagnosed with the very early stages of osteoporosis through a bone densitometry scan. The reason being that I had been diagnosed with very low testosterone levels. I also take medication for epilepsy which - the particular medication concerned is - there has been some research to suggest that long term use of it may lead to a predisposition to osteoporosis ...
MYERS
David, before I hand you over to the expert, just to let us understand this a little bit more, so how is the condition affecting your life as quite a young man?
MEE
I'm still - I'm just coming up to my 41st birthday. It's just recent, so emotionally it's quite a shock. I mean I've always been a very active person but I feel like - I've got to take medication now plus the calcium for the osteoporosis plus the calcium and vitamin D supplements which I don't mind doing but - as long as it works.
MYERS
Well let's see from Nicola, I mean for a start is that the kind - of the right treatment and will that help in future, can bone be rebuilt, for example, if you know you have osteoporosis and are taking treatment or is it a matter of slowing any further degeneration?
PEEL
The main aim of treatment with osteoporosis is to prevent further bone loss and with the majority of treatments that we use we do see an initial small increase in the bone density. But the treatments have a very marked effect on the bone turnover, which is the way that the bone is repairing itself on a regular basis and by slowing that process down - which is the way which most treatments work - it actually reduces the risk of having further fractures by as much as 50%. And as David's pointed out we generally give osteoporosis treatment together with supplements of calcium and Vitamin D because we believe that that helps to make the treatment as effective as possible. And I don't know David - have you had fractures up until now or not?
MEE
No remarkably I've never actually yet, as yet, broken anything.
PEEL
Good, well in that case I think treatment at this stage will hopefully help to prevent you from running into problems and hopefully won't need to curtail your lifestyle.
MYERS
David did mention in the first instance that he has been diagnosed with low testosterone, so that's if you like the cause of this in his case is it?
PEEL
It certainly sounds like it although, as he also points out, the anticonvulsant therapy he's taken may also have contributed to some extent. But we know that having a low testosterone is a very common cause of osteoporosis in men and it's not always readily apparent, particularly in the older men that we see with osteoporosis so it's something which we always look for very carefully if we diagnose osteoporosis in men.
MYERS
And is there something you can do about treating that underlying condition and would that make any difference to the progress of the osteoporosis?
PEEL
Absolutely, as in any other situation if we find an underlying cause then by treating that that often helps the bones as well. And providing there's no reason to not give testosterone then that would be the first choice treatment in a man who presents in this way. If on the other hand testosterone is not appropriate for any reason, because sometimes there's a concern about the risk of cardiovascular disease and so on, then other osteoporosis treatments can also be used in men.
MYERS
David thanks for joining us with that question and you're not the only man on the programme today because John Hayes is with us now from County Antrim, also with osteoporosis John?
HAYES
Yes you could say that. Two thousand and one - I'm only 45 now, be 46 in August - and the difference between myself and David is I've managed to fracture and break and do everything else. I work in the bar, catering, entertainment trade since I was left school, one minute I could be holding a kegful keg of beer, the next minute I could be holding a speaker, lifting and carrying them all about the place, load bearing exercises of course - done that all my life. Two thousand and one I had a fit in the back of the car when we were about to bury my mother and I ended up with two crush fractures in my spine. Got diagnosed, got bone scanned, got diagnosed - have osteoporosis, that was back in 2001, as I say I'm 46 in August and for instance there just at the end of September I managed to do a fracture in my wrist that went down into the joint, osteoarthritis now of course and another fracture or another crush fracture in my spine, plus another damaged one.
MYERS
Well John, I'm very sorry to hear that, it's a real catalogue, isn't it, of bad news. I don't know how we might be able to help you, was there a particular question or would you just like some general advice from our expert?
HAYES
I would love to know how the heck did I get it - was it the so-called bad living with the entertainment side of it and the bar side of it and the catering side or was it - well my grandmum probably had it, my grandmum did have it - it used to be called the stoop in the late 1890s, 1900s, my mum was 40 odd when she had me, my mum had it, so was I just the unlucky one out of myself and my sister?
MYERS
So two possible risk factors in other words, you weren't just carrying those kegs of beer, I guess you were enjoying the occasional tipple and alcohol in excess certainly is known to be a risk factor. But the other question is about hereditary, could it be something that's just there in the genes Nicola?
PEEL
It certainly could, as we said before, there is a strong inherited component to the amount of bone that we lay down in early adult life and then other factors which come along - such as, for instance, heavy alcohol intake - we're making some presumptions here - but if that's the case then that again may have contributed to your risk of osteoporosis.
MYERS
And in terms of treatment for John, you didn't quite say what if any treatment you're having but let's at least here what Nicola would give you if indeed you came as a patient to her osteoporosis clinic, is there something straightforward that John should be looking for?
PEEL
Well I think unless an underlying treatable cause were found then we would probably recommend treatment with one of the bisphosphonate group of drugs and the one which is licensed for treatment in men is a treatment called Alendronate. So that would probably be what I would recommend as a first line treatment, together again with calcium and vitamin D supplements.
MYERS
Are you having treatment in fact, is that something you're familiar with John, that particular prescription that Nicola's just mentioned?
HAYES
Yes, that's what I have. Also I have [drug name], 3500s and I end up having to actually go to the elderly care unit every two years in the Belfast City Hospital.
MYERS
So what's the outlook really, I suppose is the question, I mean should John be able to look forward to a reasonable future without risking fractures every time he turns around, as it were?
PEEL
Have you had fractures since you started off on treatment or have things improved?
HAYES
Yes I have actually, mainly ribs - ribs - I could even turn over in bed at one stage and was actually fracturing ribs but that's stopped now but at the end of September there, as I said, I actually had a wrist fracture, I just slipped on a kerb, I have a wrist fracture which went down into the joint, I had a plaster on for nine weeks and I had crushed - one more crushed vertebrae and another damaged vertebrae.
PEEL
Certainly it sounds as though you've had a lot of problems and it may well be that you need to move on to another treatment at some stage but hopefully the treatment you're currently taking will be reducing the risk of further damage.
MYERS
We will have to move on, thanks for that call John. Tina's waiting to speak to us and Tina is worried about steroids and whether they are causing osteoporosis, is that because you're on steroids Tina?
TINA
Yes I've been on for about two and a half years. They've - I started with 12.5 milligrams and they've sort of slowly reduced them but they could only do that after about six months because I was still getting a lot of pain. But I'm down to one day and two the next day alternatively at the moment.
MYERS
And are you showing any signs of osteoporosis?
TINA
I don't know really. I've got a bad shoulder and the other night I'm noticing that the back - like the hip, I don't know if it's the hip or not because I'm not up to this sort of thing, and down the leg I was still getting a lot of pain and they didn't put me on calcium for about six months and that sort of - the pharmacist kept saying you have to go on calcium, you have to go on calcium because the steroids strip the calcium off of the bone. And my doctor wouldn't give me them at first, he was reluctant, I had to more or less fight to get them.
MYERS
Okay, well let's see what Nicola has to say, that's quite a nasty prospect that the steroids strip the calcium off the bone.
TINA
Well that's what I understand.
PEEL
Well we do know that steroids are an important risk factor for osteoporosis and the first thing to say is don't stop taking your steroids, you've clearly been given them for an important reason and it's important that you continue them, particularly because we know that steroid induced bone loss can be prevented and halted. But it is really important to think about the risk of the effect on bone at the time when somebody starts on steroids because one of things we know about this treatment is that it does affect the bone very quickly and so we would generally recommend thinking about whether either a scan is needed or what preventative treatment to prevent the effects of steroid on the bones within the first two or three months of starting treatment.
TINA
They never did that and I was on 12.5 which is quite a high dosage and I had - they tried to cut it down but I had to stay on it - the same quantity of steroids - for about six months. And then I fought about for - it must have been about four or five months later, they gave me Calcijex D3 (phon.), which I'm taking now, which I took after about five months but it was only the pharmacist that kept pushing me to get it.
PEEL
I would suggest that even with the calcium and vitamin D it still is worth asking your doctor whether you in fact do need to have additional treatment, bearing in mind the fact that you're still taking the steroids two and a half years down the line.
MYERS
And can I throw in an e-mail from Liz who is a 42-year-old woman and she's been on steroids, in her case for psoriatic arthritis? And of course she too is wondering if there is a risk of developing osteoporosis, should she have a bone density scan? Now she's a little bit younger, would that make any difference to her risk of osteoporosis?
PEEL
It would make a great difference because we know that the effect of steroids is much more of a problem in older individuals but even so, since she's been taking them for a long time, again I would strongly recommend that she talks to her doctor about having a scan to assess her risk and fractures as a result of steroids and osteoporosis in young people, and by that I mean women up to the time of the menopause and men of a similar age, fractures in that age group are very uncommon. But the steroids can still have an effect and it is sometimes still necessary to give treatment to prevent that from happening.
MYERS
We have to go to another call - Cirencester now, where Rachel Hudson's waiting to speak to us, Rachel has celiac disease, again a question about the connection, is it, between this and osteoporosis Rachel?
HUDSON
Yes, well I was diagnosed about three years ago and lost an awful lot of weight and I had two bone scans, the first one indicated I had low bone density and the second one I had about a month ago said that I've got osteopenia and I'm trying everything I can - I'm - I've put the weight on, I'm eating loads of calcium and I just wondered was it's a foregone conclusion I'm going to develop osteoporosis or are there things I can do now?
MYERS
And just to be clear for those who may not - celiac is where you have a sensitivity...
HUDSON
A gluten intolerance.
MYERS
... to glucose - gluten not glucose - gluten in wheat and other cereals. Okay, so Nicola what thoughts for Rachel?
PEEL
Well I think that this is very interesting, we know there are a lot of conditions which predispose to osteoporosis and celiac disease is certainly one of those, particularly when it's undiagnosed and still active and you're not absorbing calcium and other nutrients effectively. We often do see an improvement in the bone density once the celiac has been diagnosed and people become established on a gluten free diet ...
HUDSON
Well that's what I was hoping but ...
PEEL
Was there any improvement in your scan or not?
HUDSON
No, if anything it - well it had, it had dropped again and this was two years after initial diagnosis and I'd put the weight on but I'm still not having periods because those stopped.
PEEL
Right and was that felt to be connected with the celiac disease?
HUDSON
Yes, with the weight loss.
PEEL
And is your - when did you get back to what you'd say was your normal weight?
HUDSON
Probably about six months ago I would imagine.
PEEL
So it may well be that there's a bit of a lag time before the periods come back and hopefully once that happens then there will be an improvement in the bone density as well. And in the meantime it sounds as though you're doing all the right things by maintaining a good calcium intake and so on.
MYERS
And can you just comment on osteopenia - I think was the word Rachel used and we've had Georgina - she's trying to contact us to ask what osteopenia is?
PEEL
Yes osteopenia is one of the classifications that we use and when we measure bone density using a DEXA scan we compare the individual's bone density to what we would expect to see in a healthy young person. And depending on how the bone density compares, if there's a small decrease then we would call that osteopenia, which indicates a small increase in the risk of fracture. And if the bone density is decreased further then we would classify somebody as having osteoporosis.
MYERS
And can we get a very quick answer to a question from Marguerite who's asking: Is losing height normal? She's concerned because she's always disliked milk and she doesn't eat much dairy, could this be the problem?
PEEL
Losing height is very common but it doesn't necessarily mean osteoporosis, it's very common to lose height with ageing, as a result of arthritic problems in the spine. And if that's the predominant problem then probably the first thing to be thinking about is whether she might need a spine x-ray. And in terms of the calcium then ...
MYERS
Calcium's always a good idea.
PEEL
... calcium's good.
MYERS
Calcium is good in whatever form. Thank you very much and we will have to stop there. Thanks to everyone who's phoned and e-mailed. If you want more information you can go to our website at bbc.co.uk and you can also, if you wish, speak to us by phone. But join us if you will at the same time next week when we're inviting your questions about dizziness.
Ends
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