What to eat to avoid osteoporosis | Prof. Cyrus Cooper & Tim Spector

What to eat to avoid osteoporosis | Prof. Cyrus Cooper & Tim Spector



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Did you know that every 12 years, our skeletons undergo a complete transformation?

Osteoporosis, a condition where bones become fragile, significantly increases the risk of fractures from minor incidents, often without any noticeable symptoms. Worldwide, it affects one in three women and one in five men over fifty, leading to pain, potential disability and loss of independence.

In today’s episode, Jonathan, Tim and Cyrus ask the question: How can understanding osteoporosis and implementing targeted lifestyle changes enhance bone health and reduce the risk of fractures?

Cyrus Cooper is a Professor of Rheumatology at the University of Southampton, where he is also the Director of the MRC Lifecourse Epidemiology Unit and Vice-Dean of Medicine. In addition, he’s a Professor of Musculoskeletal Science at the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences at the University of Oxford.

Tim Spector is one of the world’s top 100 most-cited scientists, a professor of epidemiology, and scientific Co-Founder at ZOE. Tim trained originally in rheumatology and epidemiology.

If you want to uncover the right foods for your body, head to joinzoe.com/podcast, and get 10% off your personalised nutrition program.

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Follow @tim.spector on Instagram: https://www.instagram.com/tim.spector/?hl=en

Timecodes:
00:00 Introduction
01:10 Quickfire questions
03:44 What is osteoporosis?
06:57 Why might our bones become more fragile as we age?
08:56 Your skeleton renews itself all the time
11:29 Does menopause cause osteoporosis?
13:40 What is life like living with osteoporosis?
16:13 How common is osteoporosis in males?
17:06 What are the symptoms of osteoporosis and at what age should you get checked?
22:43 Some chilling statistics about osteoporosis
24:16 Common myths about the effects of Calcium and Vitamin D on osteoporosis
29:03 What is the latest science on Vitamin D supplementation?
36:54 Can Vitamin D and calcium ensure children’s bone density is healthy?
37:43 Osteoporosis treatment options, including new drugs
40:03 The impacts of HRT on bone density
42:13 What are the downsides to some of these treatments?
45:41 Does physical activity help to prevent fractures?
47:15 Lifestyle impacts: diet and nutrition
52:31 Can exercise make your bones stronger?
58:04 Ideal exercises to prevent osteoporosis
1:00 Cyrus and Tim’s top 3 actions to improve bone health
1:01:54 Summary

Mentioned in today's episode:
Accumulation of risk factors associated with poor bone health in older adults, published in Archives of Osteoporosis.
Link: https://link.springer.com/article/10.1007/s11657-015-0250-3

Relevant studies:
Influence of vitamin D supplementation on bone mineral content, bone turnover markers and fracture risk, published in Journal of Bone and Mineral Research
Link: https://www.medrxiv.org/content/10.1101/2023.05.18.23290153v1

Pregnancy Vitamin D Supplementation and Childhood Bone Mass at Age 4 Years, published in JBMR Plus.
Link: https://onlinelibrary.wiley.com/doi/10.1002/jbm4.10651

The role of calcium supplementation in healthy musculoskeletal ageing, published in Osteoporosis International
Link: https://link.springer.com/article/10.1007/s00198-016-3773-6

Books:
Osteoporosis: A Lifecourse Epidemiology Approach to Skeletal Health, Prof Cyrus Cooper: https://amzn.to/4dDIL1r
– Every Body Should Know This by Dr Federica Amati: https://amzn.to/4blJsLg
– Food For Life by Prof. Tim Spector: https://amzn.to/4amZinu

Episode transcripts are available: https://zoe.com/learn/category/podcasts

osteoporosis is the commonest bone disorder worldwide and it's associated with reduced bone density and an increased risk of fracture Cyrus Cooper is president of the international osteoporosis foundation and a professor of Rheumatology at the University of Southampton in the UK he recently received the best scientist award from research.com ranking him as one of the top 50 scientists globally osteoporosis often called The Silent epidemic people actually getting fractures without knowing about it and not realizing what the cause is and not realizing that it's preventable that's fascinating the skeleton that you walked in with is going to be different to the skeleton that you walk out of this room with it's around 10 to 12 years you completely replace your skeleton with new bat it's amazing one in three women in their lifetime are going to get a fracture and one in five men one in three is enormous but the good news is there are lifestyle interventions that dramatically reduce the risk such as welcome to Zoe science and nutrition where World leading scientists explain how their research can improve your [Music] health Cyrus and Tim thank you for joining me today nice to meet you great to be back so we have a tradition here at Zoe Cyrus where we always start with a quick fire round of questions from our listeners and we have these very strict rules you can say yes or no or if you absolutely have to you can give us a one- sentence answer is it's intentionally very difficult for professors are you willing to give it a go certainly brilliant will as many as one women in three have a fracture in later life due to weaker bones yes is osteoporosis mainly genetic no does menopause cause osteoporosis it doesn't cause it it's a point at which um bone density declines more sharply than it was before okay is it possible to reverse osteoporosis without doubt can I improve my symptoms through diet alone you can do something with diet alone but you won't be doing as much as you could uh if you used other things too are there new treatments we have today that are much better than in the past absolutely and last question and you're allowed a whole sentence what's the biggest myth about osteoporosis that you hear that it is an inevitable consequence of Aging it amazes me that so many of you watch and subscribe to this show we now get more than 2 million views a month on YouTube a number that I find very hard to comprehend two years ago when we started this podcast I guessed it would be a few thousand of you tuning in at most and in fact that the show would serve mainly to keep our Zoe coaches informed about the very latest science you can imagine I felt pretty great when so many chose to tune in from the very start and that so many of you continue to view US each week so we'll continue making Zoe science in nutrition and do everything we can to keep making it better if you appreciate this there's a simple free favor that you can do for us in return hit the Subscribe button below that's it thank you and on with the show so I think that's fascinating that in fact um something that maybe I just grew up with thinking was inevitable isn't and on the other hand I was completely shocked by how many people will end up um living with osteoporosis and also this huge number of people particularly women who are going to have a fracture later in life like one in three is enormous and I struck also quite a lot of men I understood from our research again it's not only women so just I'm surrounded by myths so I'm really excited to get into this can you start by explaining like what osteoporosis is and I suspect you're going to have to start by helping us to understand actually really what bones are osteoporosis is uh the commonest bone disorder worldwide and it's associated with reduced bone density A disruption of the microarchitectural um content of bone and an increased risk of fracture the fractures that typically arise from osteoporosis are fractures of the hip the spine and the distal forearm or wrist those three fracture sites account for about half of all fractures in older people and the other half are from all the other sites um combined around the skeleton the places you're talking about feel to me like not the most common places that people tend to break their bones when they children or in their 20s or 30s is that so that's exactly correct in their 20s and 30s it trauma plays a much bigger role than bone density this is like falling out of a tree or falling off your bike fall having a traffic accident breaking your nose yeah whereas as you get to later life particularly for women above the age of 50 the average age of menopause and um men more so after age 70 low trauma or in fact absent trauma is associated with many of the fractures and those truly are ones due to Bone fragility so what does it mean to break a bone without trauma I think of it always been like you no It it means just rolling over in bed for example you can actually trigger a a vertebral fracture wow uh just by doing that or twisting in a certain way most of our vertebral fractures present on an incidental finding on a radio graph and a vert just help me out vertial fracture where is my where are my ver spine and typically the bones that break in your spine the spine contains small vertebral bodies all the way down the mid thoracic which is the middle part of the back and the lower lumbar which is down towards the pelvis those are the main sites at which osteoporotic vertebral fractures occur that's got a wedge so you have these sort of square looking vertebrae lots of them all on the spine which act as these sort of shock absorbers and when you get a fracture it sort of crunches in on itself and so and if it does it in a certain direction you can end up with a a bent spine back example of us thinking about you know in the past like old ladies s have been bent over and some of these old ladies don't feel any pain it just gradually comes on they don't notice it happens at night or whenever you can have you know five or six of these uh without any pain at all and that's why it's often called The Silent epidemic which for this reason that people are actually getting fractures without knowing about it and not realizing what the cause is and not realizing that it's preventable so it's slightly terrifying idea that you might just roll over and you know things break in your bones could you help me S understand what's going on why does this start to happen now but you know nobody in their 20s is worried about this happening so all of us gain bone density through our childhood and Adolescence what does bone density mean so if we were to look inside a bone we'd find that there are layers of collagen and those collagen protein layers have gaps in them within which the calcium sits in osteoporosis there's a reduced amount of collagen and there's also a reduced amount of mineral and that's what makes the bone weak why are you talking about these fractures in these particular bones right like I've got bones all over why why these ones well these fractures are particularly um rich in what is called ular bone which is a honeycomb end of the long bones which uh loses bone fastest and which when it gets subjected to trauma fractures earlier so I'm thinking about my very simple you know almost cartoon picture of a skeleton with like long bones and little round bits at the end and you're describing sort of those round bits at the end of the things just beneath the round bit at the end that part of the bone so the fracture neck of femur the area just underneath the head of the femur which is what gives way and breaks so it's a combination of actually the mechanical weak point so that's where the hip you know is got a long bone but obviously the longer the bone the more likely pressure is going to be able to break it plus it's also what's going on inside the bone where it's at its weakest so that you going it's less dense less thick and we have this this idea that your skeleton is renewing all the time so I think it's around 10 to 12 years you completely replace your skeleton with new bone that's amazing all our body is renewing all its proteins all the time but it's slower with bone and this happens at different rates at different people and so and and also slightly in within your bone it can happen at different points so we often think that the weakness in bone is also because it might be a point that's renewing even more rapidly what's remarkable is is that we developed this bone turnover cycle or bone remodeling cycle in order to get rid of bad bone bone that's accumulated microcracks um in it uh and replace that with good bone if you'd ask me 20 minutes ago I'd be like oh no I just have my bones for the rest of my life like my teeth it's completely not like that it's actually that your the skeleton that you walked in with is going to be different to the skeleton that you walk out of this room with and the reason we can do that is we have cycles of bone cells that are two different cells one cell that makes bone and one cell that resorbs bone and throughout all our bones uh there are these little microscopic fosi where a a a cell takes out a piece of bone and then rests for a bit and then fills it with new bone and and that's the basis that has allowed us to develop interruptions to that remodeling cycle that eventually can become treatments for osteoporosis another analogy is you have a you know our bones are Remodeling and throughout all our bones you got these little teams of workmen one digging a hole Yeah and the other one coming along and filling it in I love this so it's a bit like somebody repaving the road outside my house exactly so it's continuously being dug up and renewed but you know but it takes 12 years to actually finish the job a bit like the local Council but sarus is saying the the drugs we've got interfere with the speed of which those things happen so that if you can do that properly you end up with more the workmen who are filling in the holes working faster than the ones who are digging digging the holes out why does anyone get else to perosis just you know showed me this picture which sounds brilliant which is like I'm in my late 40s I really like the idea I might have done bits of damage to my bone your micro fractures how you said and I'm going to get them all fixed but it sounds like in fact for a lot of people this fixing is no longer working properly yeah so two good examples of that um relating back to the cycle of bone formation and and resorption are of the menopause in women where there's a step change in the ability of the cells to turn over because of the deficiency of estrogen and the other would be um inadequacy of calcium absorption by vitamin D in the gut which happens with advancing age and which leads to um again people being unable to maintain calcium balance and be at increased risk of of fracture so tell me about the menopause for a minute I feel like there's a lot of listeners who are saying this catalog of things that happen it just sort of gets more and more depressing so this is not one we've talked about before we had this little metaphor that Tim had about digging up the road and replacing the road what is going on is as someone is going through per menopause and men when you have low estrogen you the cells that are digging the road carry on being active if anything they're a little bit more active whereas the cell that are filling the holes in become less active and the whole cycle slows down so it accentuates the loss of burn and do we have any idea why that might be the case given that obviously menopause is like a normal part of um well one of the earliest observations about estrogen and bones in the laboratory uh showed that they're covered particularly in estrogen receptors and the use of estrogen and estrogen like products has been attested to in clinical trials that show retardation of bone loss can you just help us to imagine what life is like for someone who is living with osteoporosis the different three common fractures uh manifest really in different ways so a hip fracture typically would occur at age 81 that's the average age in Western countries the US um asenia and Europe typically the person has a fall and bangs the outside of the right hip or the left hip and that fall is typically backwards or to the side and indeed The Falls have been studied well enough that some people suggest that say institutionalized or nursing home uh residents might benefit from using hip protectors which Shield the greater tranta from from damage so um whether or not that's taken up as a large scale Public Health measure it show shows that the hip fracture requires the traumatic episode to its outside that then takes the weakened bone and it breaks a vertebral fracture as we've discussed uh before or actually manifests for most people on an x-ray they have no symptoms they might have had some pain on use of their spine but typically there's no trauma if there is trauma it's the sort that you're in the hotel lobby lift your suitcase strongly and find that there's sudden back pain in the lower part of the spine and then the wrist fracture typically occurs when you're walking outdoors in on icy Pavements have a slip fall backwards because you just put your wrist out to to support yourself and it just doesn't have the strength to take you and I think that's really interesting because so if you did that you fell over you tripped over a Paving Stone in you're 30 you put your hand out yeah it you might sprain it or bruise it but it doesn't usually break as you get to over 50 or over 60 you know men or women then that doesn't happen what's really interesting is when you get to 70 or 80 and same thing happens your your reflexes generally don't allow you stick your hand out and so you fall onto your hip fractur your hip so it's it's really interesting how these uh you know the same fall at different times of Life can lead to a different outcome so yes different outcome we talked quite a lot about women can men get osteoporosis as well absolutely uh so for example men of the age of 70 um there'll be a significant proportion let's say 7 to 10% who will have low bone density and one in 10 men from the age of 50 will sustain an osteoporosis related fracture in the remainder of their lifetime so they definitely will just not at the levels at which women because you're saying like one in 10 of men but one in three of women corre will have a fracture caused by this weeken bone which is so still a lot of men but it's not almost half as you're describing with women a lot of them get missed because doctors don't expect men to get it and they don't and patients often don't think about osteoporosis if they're male as well and so many of them are much more a Mist than in in women if you're listening to this and you're worrying about yourself or maybe you're worrying about a loved one is there a way to find out if you have this um osteoporosis because you're saying it's like hidden away inside the bones inside my body absolutely so that the assessment of future fracture risk has become a very topical area in the last uh 15 years before we understood that age and a previous fracture were definite markers of a future risk of fracture and those people um particularly those with a past fracture um uh needed to be evaluated even before 15 years ago in 2008 we developed a global tool that mixed risk factors for osteoprosis just from a questionnaire height and weight and a dexa scan to derive for an individual patient the um 10year risk of a hip or any osteoporotic fracture and that 10-year risk is now Incorporated in multiple rules which are often dependent on different Health Care Systems in different countries but the principle of which is to Target treatments according to people's fracture risk and if you were a woman listening to this at what point would you start to because I think I'm hearing nobody almost no one in their 30s would this make sense a person who had a 20% chance of having a major osteoporotic fracture or a 3% chance of having a hip fracture meet the criteria for the cost effectiveness of drugs that their future risk of fracture so it's bit like the Statin story so in a way what the osteoporosis world have done has come up with a a sort of table of risks yeah proportional to your age and sex to say at this point it's worth worrying about it and each country's got its own levels but it really varies a lot with age so the exactly the same risk factors but just 10 years older you much more like to have a fracture it's much more important to get some intervention and so if you're a man or a woman listening to I guess my question is what at what age would you say I think I should have a conversation with my doctor to to discuss this because it sounds like this is something that is changing a lot with age absolutely ever since the development of dexa scanning dxa scanning um there has been discussion about when we should use that bone density measurement and on the most discussion was directed to at the time of the menopause at age 50 say in women of course that's actually an inappropriate time to undertake Mass screening it's much better when age has caught up the fracture rates to around 70 to 80 years for individuals on a large scale to benefit from knowing what their bone density is what's interesting is just before covid I was still doing osteoporosis clinics and I was actually UND diagnosing more people than I was diagnosing undiagnosed meaning saying you don't have osteoporosis did a EXA scan and the t- score was high they were they were at low risk of osteoporosis so just make sure saying you did a scan and it said you looked into their little honeycomb bones and you're like actually they're all looking good but it's rather strange because there's many people out there who are undiagnosed with a osis particularly in their 70s or 80s who aren't thinking about it but there's many people in there between 40 and 60 who are told they've got osteoporosis because their bones are slightly lower than average and their risk is really low in the next 10 years of getting a fracture so as far as I'm concerned they don't have clinical osteoporosis anything to worry about at the moment you know these are the people that are coming to their their their doctors and uh using all these resources that are actually slightly inappropriate because they're not at the high risk group and so that's why I ended up saying you know what you're average for your age don't worry about it come back and see me in 10 or 15 years time so I think it's really important how important age is in this whole factor and I think it's not emphasized nearly enough and the use of the new technology the bone dead stomry um in this way has been shown in large scale trials in the Netherlands in uh Denmark and in the UK that showed that over a 5year period after such a GP screening approach for primary prevention of hip fracture there was a reduction of hip fracture by 28% so a really meaningful impact of treatment in the older age group when bone density was found to be and just before I talk about treatment because I think you've talked a lot about the hip fracture but haven't really talked about what that means and I know that in in the research of the team was showing to me actually having a hip fracture was a pretty terrible thing to happen could you just again the story of what this means and therefore why you're saying this is so important yeah so first of all almost 90% of hip and vertebral fracture patients report their symptoms as the most severe on any of the uh scales of impact of of quality of life so these are major events for people who sustain them and in some one or two of the studies people even describe osteoporotic fractures after they've had them as being worse than death itself so this is something that the the patients take seriously themselves they can't to judge that it's hard to judge that agree I agree but but that paper was in the bmj and it was it caused a ripple isn't it more like the the other important fact is that uh you know 25% mortality yeah related to the fracture which people don't think about fractures you think oh well you get patched up in hospital but actually about a quarter die of it and about half never go home yeah I think that they're they're the frightening St and and 50% never walk again that were walking before so for a hip fracture it's a catastrophic effect on on mobility and quality of life for vertebral fractures it's really the the the the height loss and back pain that are the two main um consequences of osteoporosis and Fracture some people have none back pains you know it's only in a percentage of them and it usually disappears so they forget about it and then don't get treatment what are the most common myths that you hear about um how you can you know treat this risk of osteoporosis and I I still have a feeling that you're going to talk to me about calcium CU that's how I was brought up which is just as long as you drink a glass of milk every day and like maybe two of them if you're going through menopause then you'll be fine and I know from Tim um which is there's also been a lot of conversation about you know popping vitamin D um pills as a way to solve this yeah so I think with regard to calcium my own view is that we have developed ways of absorbing calcium which even at really quite low intakes of calcium we can maintain adequacy so it's only when you get to very low levels of calcium in the in say a strict vegan diet where you might wish to think about calcium uh supplementation for vitamin D sunlight is the major determinant of vitamin D in in the skin which then gets converted in the liver and kidney to the active form of vitamin D and um other than absence of sunlight it's only for group group of institutionalized elderly immigrant groups that have suddenly encountered much less Sunshine than they were exposed to before those are the groups where we think about giving widespread vitamin D supplementations cont a to government advice yeah and B what goes on in every osteoporosis clinic in the country as you and I both know so so where's it all gone wrong why do people not listen to the research data have we got into this mess that as Jonathan says calcium and vitamin D are the you know oh that's the first thing everyone should take to to make sure they're healthy and that keeps these companies really rich and Powerful yeah I feel like there are a lot of people listening to this particularly I think menopause is a great example because you've just said no there really is this increased risk of menopause that your little workers are no longer laying down the bone so you need to eat lots of things with calcium and if not pop um you know some sort of calcium pill every day 30 years ago that's what and I believed I think we would we' be on saying yes calcium and vitamin D bound to work give it to everybody can't be anything wrong with it it's going to work and the trials cus haven't shown that they don't they don't show that and if anything one or two of the observational studies suggest that there might be um problems associated with giving calcium supplementation to do with cardiovascular disease and the heart you know so what would you be saying to somebody thinking about taking calcium had a pint of milk the day or the equivalent in terms of yogurts cheese um puddings cakes and biscuits which are the main sources of calcium I wouldn't go for um calcium supplementation because you think it might actually be harmful yeah I know yeah I'd go even further I'd say I used to say that and I was worried about vegetarians and vegans but looking at the data you know you get plenty of calcium from vegetables and other sources as well and leafy vegetables green leafy the ones Zoe is trying to promote and if you have a good diverse plant diet there's no evidence you're going to be calcium deficient and absolutely no evidence from the trials that giving extra calcium in the form of these artificial tablets is going to help your your fracture risk and is that true even for people who would be eating a vegan diet so like no calcium from you know the yogurts or things like that that a lot of people listening into this would probably be having some of even if they're not having any milk I think if they have a diverse plant diet I I they're thinking about their diet consciously and they are getting a variety I mean you can get calcium from just having many italian mineral Waters it's in many things that you don't you don't think about and we don't actually need that much our body is pretty good at absorbing what little there is and most of the world doesn't have dairy products and they don't get fractures the only caveat I i' would add to that discussion which we are in agreement with with is that when people are taking the drugs particularly the against resorption drugs the trials have shown that calcium and vitamin D at relatively low amounts uh should be given with the drugs that are that are used so but but you would agree with Tim that actually for most people L they're not obviously treatment with routine calcium supplementation is not something that I would want to promote Public Health as a as one of our colleagues as you reminded me said what does the latest science say because again I think many of us who live in more Northerly climates um are used to the government saying we're all low on vitamin D we all need to be taking supplementation um what ises the and the recommendation the recommendations again are sometimes out of step with the evidence so the evidence from what are called observational studies that vitamin D is deficiency is linked to a whole host of outcomes including uh even early death uh Frailty and Fracture so that sounds pretty bad Cyrus that has me straight for the Vitamin D supplementation yes that's not good for it um when you to take the trials into account because the trials don't don't Echo the observational data they actually suggest that if there is any beneficial effect it's a really rather small one perhaps a 5 to 7% reduction in the risk of all fractures and even that is quite a discrepant evidence base didn't you do some trials that actually showed it made it worse s we did and and and uh explanations were forthcoming from our colleagues in the industry that uh produce Vitamin D supplements to explain that worsening can I just make sure I've understood that right because you're smiling but it's really shocking you're saying the were quite old people so they were at quite a lot of risk of fractures you split them into two groups you only gave vitamin D to one of those groups you presumably thought it was going to make them healthier and reduce the number of fractures actually they were worse off and that on its own would enter the realm of oh bad luck you know the one that went the other way except that an Australian study echoed pretty much the same findings let me tell you a quick story so Wednesday last week I went for dinner with my wife Justine now this would have been a source of anxiety for me in the past because some foods would leave me feeling really tired and sick for hours afterwards and as a result I actually followed quite a restrictive diet then I did Zoe and discovered that I'm prone to blood sugar spikes from my Zoe digital coach I learned that this doesn't mean I have to restrict what I eat I just just have to be smarter about my food choices so back to last week at the restaurant we were eating Italian which before Zoe would never have happened but my Zoe coach helped me make choices that consider my blood sugar I started the meal with a delicious Italian salad and then enjoyed some pasta afterwards drenched in olive oil of course and after dinner I felt great energized by my food and by the fact that now I don't have to limit the foods I eat and choose between a healthy and a happy happy life whether I'm eating out or cooking my Zoe digital coach helps me make smarter choices every day honestly it's transformed how I feel and according to the scientists who continue to develop the digital coach making these choices now could give me many more healthy years why not join more than a 100,000 other people giving Zoe membership a shot and tell me what you think to take the first step towards the possibility of more energy less hunger and more healthy years take our quick is to help identify changes to your food choices that you can make right now simply go to zoe.com podcast where as a podcast listener you can also get 10% off take it all together the trials are really either negative or detrimental only a few are pointing in the right direction but if you discount some of those early trials in the 1980s which were a bit dodgy there's no good evidence that vitamin D supplementation for the vast majority of people is beneficial it doesn't mean that no people will benefit and is there anything because we're obviously talking about osteoporosis would there be anybody listening to this saying oh well that's true for osteoporosis but it's got these other really important benefits or is this just basically across the board that you think people do not need this vitamin D unless they got very very low I think because of those other trials and mortality being evaluated now in large vitamin D trials all over the Western world one would have to hold judgment on a mass program of VD supplementation um to older people sarus is arguing against this but we actually have government guidelines from what used to be Public Health England saying everybody over UK you're saying in the UK in the UK and I think other countries also have some of these uh guides I'm not quite sure what the US guidelines are on vitamin vitamin D but I think they're similar 400 to 800 units daily given to older people you know and that seems blun a blund bus Approach at best and possibly uh when when the aggregate is all looked at in the round uh something that might have a negative um impact we did a podcast on um vitamins a little while ago which only listeners were interested could take a look at one of the things that shocked me was his feedback that sometimes vitamins can actually be harmful because you know you we are used to seeing in our stores like super doses you know 10 times the recommended dose and I think we all assume from this well you know if one is good 10 must be better and I think what you're saying is here when you talk about both calcium and vitamin D actually even within the recommended dose might might be harmful um with the latest evidence so we need to be really thoughtful about supplementation rather than just assuming that there's no possible downside and we should just take them is that I just want to make sure that that's what you're saying the latest data on vitamin D and and calcium is saying yeah and I think it's also because it's in a different form to the way our Evolution has has allowed us to absorb these these vitamins vitamin D which isn't actually a vitamin uh you know is produced in our skin from sunlight for a reason we're able to absorb it that way and that's where calcium we get it from plants and you know dairy products we don't get it from a not designed to get it from a giant chunk of a gram capsule that suddenly dropped like an atomic bomb into our gut and overwhelms our system so it's the way these vitamins are sold or processed that may be the problem uh because by definition a vitamin is something you need a minute amount of in order to service the body and keep it functioning normally the other thing I would I would add is that it's this whole area of vitamin D metabolism throughout the life course is sub a subject for research rather than translation to policy so our studies over a period of 15 or 20 years have shown that the mother at the time of before and during pregnancy is susceptible to The Offspring having an enhanced trajectory of bone mass uh during childhood if the mother is supplemented before and during pregnancy with vitamin D at relatively low dose you know 1,000 units daily just want to make sure I understood that I think you were saying that if you're pregnant and taking Vitamin D supplements that might be a good thing because that might actually mean that you're child ends up having better bones over time absolutely and and and raises the possibility that there might be some enhancement of the peak bone mass something that we never thought of as an outcome from uh from vitamin D supplementation and Cyrus um I have a few children but my my youngest is four is it too late for me to do anything for her in terms of ensuring that her bone density is going to be great when she goes through actually for that for that sadly the studies that have been done in childhood vitamin D supplementation so long as you get an ad adequate Dairy intake you know or and vitamin D nutrition are not so good for giving all school kids vitamin D so again and I shouldn't be pushing it sounds like I don't have to particularly be pushing a glass of milk um to her either from what I'm hearing well I think that becomes a more complicated issue because it's the protein that is provides the benefit in the GL in the glass there's not the calcium not the calcium back again there will be a lot of people listening to this who saying oh maybe I want to go and speak to my physician my doctor um get checked they will have this scan and maybe they'll say actually you are seeing these signs of osteoporosis you mentioned the fact that there are some real treatments could you help at the highest level to understand what you can do sure so the first line of treatment would be a drug class called the bisphosphonates and uh examples of bisphosphonates are alendronate or risedronate those are taken in tablet form um once per week with um adjunctive as I'd mentioned before calcium and vitamin D uh as part of the trial regimen and and the those drugs will reduce over a 3 to 5e period and indeed longer uh with follow-ups of the trials uh by 50% the number of fractures oh wow so you can just take a tablet once a a week and you could actually half the number of but only while you're taking it that's the caveat we used to think oh if you treat people for five years you know you've you've got everything you've pushed everything five years away it doesn't seem to be true it's only while you're taking it are you protected and that's sort of the problem because you're actually slowing the bone down while you're on it so that's why we have these drug holidays you go on and so every uh five years you have a little break for a year let your bone recover and then you go back on it inde indeed that's the regimen that would be the first line then you can use intravenus of the same type of drug zonic acid it's called but it's a bisphosphonate given once a year and and that allows the uh bone resorption to be reduced uh in a much more marked manner than the um oral bisphosphonates then the next line would be the last of the anti- resorptive agents which is called denosumab and that is given once every six months with a subcutaneous injection those will reduce by 50 or 60% so I I feel like if if you're listening to this and you're concerned you would you definitely want to know your state perhaps I should also mention HRT which we mustn't forget about which was the first one before the hormone replacement therapy or estrogen replacement therapy in the US what what does that do above the age of 6065 there's been a um a a sort of discussion that perhaps the risks of heart disease become prohibitive on the on on General use of HRT but in someone who's had a fracture uh they are going to be benefiting from their bone density's point of view and from age 50 to 60 is the current controversy which is perhaps we should be looking at HRT as a whole in those ages in women because of the risk benefit balance being and it has a significant reduction in the risk of fracture it's nearly as good as the bis phosph and for many people going through menopausal symptoms it provides Extra Protection as well and and might actually reduce heart problems as well so I think a lot of the data and the worry in this field was that all the data we had was based on the old regimens of HRT which used different combinations of the progesterone and the estrogen rather than than estrad rather than having estrad patch and then new types of proest new ones which are much safer for the heart so I think the jury is still out on the exact risk benefit but for most people if they are taking HRT they should still be getting the benefit they will be getting the benefit on the bones and generally they're getting a fair bit of protection for their scalet at the same time I would just add very quickly that the new class of bone forming agents have an even more profound effect on rapid changes in bone density they're more recently developed and used much less widely today but are likely to become part of this armentarium the bottom line is that we have a whole variety of therapeutic interventions for people at different levels of severe ostosis so it's really encouraging that there are these effective treatments on offer cus can ask are there any downsides or side effects to these treatments absolutely the major side effect uh from oral bisphosphonates are problems with the esophagus they induce they can induce an esophagitis an inflammation of the of the gullet uh which can lead to the drugs having to be withdrawn that's an indication to move to the intravenous um or subcutaneous um agents for both of the um anti-resorptive drugs as a whole there has been a lot of uh activity particularly legal activity about rarer side effects of long-term suppression of the bone cells that that that eat away bone the first uh problem is called osteonecrosis of the jaw and although it's got an incredibly low frequency it has been sensitized uh by uh the the legal cases in the United States which have led to dentists not wanting to treat patients uh with the bis phosphinates and uh guidelines have now been drawn up that are adhered to about information regarding bisphosphonates and what is called omj the other is second and subsequent atypical fractures which happen when again the skeleton has been exposed to long duration of bisphosphonates and denosumab and there we had take those drug holiday uh that we talked about earlier that enable us to continue with bisphosphonate therapy if the patient needs it um after a period of time in which it leeches out of the of the bone yeah so there are these side effects and like like this frozen bone is the other sort of colloquial term for it where you know the drugs are doing such a good job that they're just slowing everything down which means it doesn't repair and therefore you can get these consequences as Sarah said the this rare necrosis of the jaw where you you bone in the jaw gets sort of eaten away or you get these really rare fractures that come out of nowhere uh that look really odd on x-ray but they're incredibly rare I so one atypical fracture and no jaw problems in about 25 years years so I think the lawyers have exaggerated this problem and and caused problems but this is one reason we don't just give everybody age 30 these drugs for life because there are side effects and even if rare you wouldn't therefore want to give them to yeah everyone because then you're giving it to hundreds of millions of people and there's also the idea if you give all these drugs too early they might not work when you need them to so that's the other thing if you just give it 20 years too early then it's not going to be really effective at the time when you're in your 70s and you really need that protection so they're the they're the sort of subtleties about this so the drugs really work but it's all about timing that's the crucial thing when do you give it to that person to maximize benefit and minimize risk and it sounds like um you haven't really said this but it sounds like this is another example where if we were living the sort of Highly active lifestyle that our ancestors um had it sounds like in fact it's it's quite likely that you know far fewer people would have this osteoporosis at 70 or 80 because of all that impact of excise would probably have meant that they had significantly stronger bones s and I wrote a paper together in the 1980s we did it was show tracking in the US activity levels and Fracture levels and they sort of ABS mirror each other as people from the 1960s onwards did less and less and fractures just sort of just went up through the roof I think what's so interesting is this is the exact opposite of how I was brought up as a child which is that when someone becomes older they're supposed to take it easy like you should take all the luggage away from them they should just sit down and I think what's fascinating is you know this is done with love and caring right um and actually it's terrible advice and we're actually hurting the people that we love because actually they shouldn't be going around carrying things and walking up the stairs and you're saying like bouncing and all these things that we were scared of get your granny to carry the suitcases that's the rule yeah and they should be out dancing it sounds like and generally yes and carrying the suitcases and all the things that we thought made you old are actually the things that were probably keeping you young I think that's absolutely right this would not be like a Zoe podcast if we didn't want to talk about the lifestyle factors that people can use could we maybe start with diet and nutrition and and maybe just at this point maybe Tim start with you so diet has a big role to play in osteoporosis and if you looked at some metaanalyses where you combining lots of these studies together from all these cohorts around the world you find that once you've accounted lots of other factors the quality of the diet has a big impact on the risk of fracture and it's not things like the amount of calcium in the diet it's not things you know amount of zinc or any one item it's the sort of things we talk about in this podcast all the time you know having plenty of vegetables being protective it's about having small amounts of processed food it's not having lots of junk food not having lots of fizzy drinks so it's that Health Quality aspect which has come out globally when you look at the metaanalyses as being really important and it's significant is it this difference between a high quality diet and an average diet not sort of like 2% that only scientists can see talking sort of 30 40% differences between these extremes these These are really big ones but it it's of highlighting that the same things that are good for many other diseases are also good for osteoporosis and Bone but it's also telling us that it's not you know as we used to think all about calcium or all about protein it's actually the quality of the diet the combination of foods rather than these individual ingredients which people use to sell supplements completely that's right and this is true at all ages as far as I know so I mean you've done some this work children uh adolescents older adults uh the the the move towards dietary quality as compared with uh micronutrients that are specific for bone health has definitely been the direction I think that's really interesting because I think you know one of the things that was most surprising to me in my journey from Zoe over the last seven years is you know seven years ago I assumed that there are these very specific vitamins cuz they're the things that are on the you know the back of the pack and that you see being sold in the stores and that those were really mattered everywhere and I think I've subsquently discovered that you know there's a 100,000 chemicals in food and and all these other sorts of things even before they hit your microbiome and they make all these other things but I had at least until this morning thought well at least calcium is really important for bones you know I'm sure I learned that when I was 11 and what you're saying I think is even there your total diet may be really important but it's not not because there's calcium in that diet it's something to do with all the different just because the calcium is in the bone does not mean that modifying it by increasing its level in through in in your stomach will actually have any impact on on your bones and sorry we've been brought up on this myth that calcium was all important and we just assumed it was a fact and it's only really in the last 10 years with all these massive analyses and people starting to look at diet differently a more Global holistic way of looking at food that we start to see that actually calcium doesn't even make the list of contenders so doesn't matter whether you actually drink milk or not it's about the quality of your diet it's really interesting what you're saying is the calcium does really matter in my bones like I need to have the calcium is what you're saying but in order to get more calcium on Bones like eating or drinking more calcium doesn't help you were saying like if the road's dug up outside I can't just give you a bunch of asphalt that doesn't make it happen like I need someone to come with that fancy machine that lays it and so I sort of need to pay the person who's going to lay it rather than just say oh I'll eat some asphalt this will solve the more gra that's fascinating now I think one question a lot of people will be saying is is there anything specifically however that I should be thinking about adjusting so imagine that maybe I'm going through pen menopause I'm going through I've been through menopause is there anything that we know about sort of way that I might want to think about changing my diet or is this just like overall I need to have care more about the quality of my diet perhaps than when I was I think the number one message is care more about the quality of your diet try and get more plants in there because they are all these sources of other minerals you know as you said there are 100,000 different chemicals in food so the more diversity we get the more we are going to get a balance of these things and so that's why a rich balance of particularly plants is going to give you all these whether it's zinc or magnesium or phosphate in exactly the right amount that your body needs because we're evolved to you know take it up and absorb it in those ways that's more important than any saying okay I'm going to forget all that I'm just going to take some vitamin D capsules and drink a pint of milk so I think in a way that's where we've got it wrong in the past we've said well there's one quick fix here where actually it's going back to you know there isn't a quick fix it's this holistic idea again it comes back to food quality and but I think get the food quality right and then Asus will tell us there's some really good exercise tips now that at all stages of life that are really important right so could you talk about that cuz actually we haven't mentioned exercise yet one of the reasons we have a skeleton and Bones is for the muscles to work of and for Locomotion for walking around running evading um Hunters uh in in in the olden days that role of exercise is very close to the starting function of the skeleton itself we already know that when we start in the earliest stages of life weightbearing we can start to see an acceleration in the uh mineralization of the skeleton at at those very early stag toddler's First Steps absolutely you're saying once the toddler starts walk suddenly their bones get stronger they've been weightless in utro they come out and they start to to ambulate and you can see a discernable change in their mineral ACR from the blood if you like into the skeletal um tissue thereafter there's a rapid gain up to age 25 examples the serving arm of a tennis player is 15 to 20% higher bone density than the non-serving arm a stroke or reason for or paralysis of a limb leads to massive demonization of the bones in I just want to make sure because everyone everyone sort of is familiar with the idea that their muscles shrink if they're not using them but what you're saying is that if I use my arm for example your tennis example is like I'm using that arm more and hitting something with it my bone is actually going to get bigger and stronger or like denser stronger absolutely that's exactly what happens that's crazy if you send someone into space they'll their skeleton will dissolve you know with calcium leaving the bone and being passed out in the urine because they're weightless because they're with weightless and therefore no action of the muscles on the bone weightbearing exercise is crucial really at all stages of life and I think that's the sort of number one lesson people need to learn and what we also learned from another experiments is it doesn't have to be huge amounts of time you don't have to run marathons that's the point you of course you'll do well if you run marathons but if you just walk an Hour 3 days a week as an older person you'll still have an improvement in both your bone density and your Falls risk your muscle function and Falls risk such that you'll have an impact on fracture and what about actually weightbearing exercise this has come up on a lot of podcasts here often talking a lot about sort of the muscle benefits but it seems here you're talking about impact weight bearing or weightlifting I'm talking about weight lifting here where you're actually doing exercise that involves like resistance and something this was always controversial weightlifting and there was in the early days a lot of information suggested that things like swimming and weightlifting didn't give you as much benefit as jumping up and down skipping you know I used to tell my patients to skip for two minutes a day yeah and there are some studies to show that just that is as effective as doing an hour's sort of weight lift for sure it's the it's the operationalization of realistic activity schedules for someone who's um interested and uses um swimming as a hobby for example you wouldn't want to discourage them from going swimming but just point out to them that the evidence would suggest rather more that weightbearing rather than non-weightbearing is better for the skeleton I want to clarify because it's not really clear to me so you know I do go to the gym a few times a week because I'm told it's really good for my health and a lot of that is resistance I'm you know um doing stuff with weight because I'm also told that's really good for my health what will the impact of that be on my skeleton from the research that's been done it would have a a measurable effect on your bone density but we have no idea what it would do to your risk of fracture okay so the bone density will improve but it's not there isn't the studies out there to show what that will do in terms of fra risk and it probably wouldn't improve as much as if you were playing tennis every day right I agree that's right could you help to understand because the weight bearing could you explain I think it's CU I don't understand what weight bearing is I think about it's jumping up and down so putting extra pressure on your uh limbs really for for bone the sensitive part of the bone cycle is the change the delta in the Force being applied to the Bone so jumping up and down is um giving lots of stimulus to the Bone forming cell swimming is giving very little stimulus to the Bone forming cell so it's like that's why two minutes of skipping may be as good as an hour of walking gently if you walk briskly you're going to be putting more load therefore it it's better so what would IDE deal let's say somebody's listening to this you know they're motivated to improve their health worried about osteoporosis maybe because they've been told that there's some risk or there's some risk in their family what would be the exercise that you would be saying is ideal so the first thing I'd say to a patient is do not be sedentary some exercise is going to be better than being s sitting sitting in the armchair and watching the TV once you've decided to take exercise even walking half an hour a day for 5 days a week is going to do some good to your balance and bone density and risk of fracture and then if you want as tailor made exercise regime for osteoporosis you go and consult a physiotherapist which we have as part of our team and they provide you with the specific exercise regimen that uh is is appropriate for you I was told my patients do some of you enjoy because you're more lik to do that for long periods of time and if it's weightbearing you if you can do it brisker if you can do it with a bit more bounce if you hate exercise or you you for example can't do it for very long my example of skipping um is actually quite a good one or some people who are even you know have arthritic problems can't do that there was something called heel raising which was really big about 20 years ago where basically you just go up and down on your toes swinging your arms and you put heels down on the ground so you're not moving far at all there's no risk of falling really just swinging up and down and as your heels go down on the ground uh you just do that for five minutes a day and that has been shown to have some benefit on it so in a way what we're saying is there's some exercise for everybody whether it's running whether it's walking slow or brisk skipping heel strikes or any other activity uh or sport they like doing brilliant final question for you both having sort of pulling all of this together if you going to advise our listener on the top three actions that they could take today to improve their bone health what would you say maybe starting with you Cyrus I certainly feel they should uh have a healthy lifestyle and in parentheses for that I would have a a prudent diet an appropriate level of exercise and avoidance of Lifestyle um aspects which are poor for sceletal health uh including smoking and very heavy alcohol uh the second thing I would do would be um uh assess your risk and number three would be to um treat that risk appropriately because there are so many um agencies now available to us to reduce it significantly Tim what would your three be as SAR says work out what your likely risk is which will depend on your age and what you need to do you know people in their 20s are going very different advice than in their 60s the two key things are eating well and avoiding Ultra processed food having a rich variety of vegetables that according to the epidemiology studies could reduce your risk by 30% just really following Zoe advice and having an exercise regime that you do that's good for bone health and even if you are a swimmer you just add in something that's also going to be good for your bones and if you do those three things then you're maximizing your chance of reducing a fracture and you know you're setting yourself up to have the least amount problems in your life amazing I would like to try and do a little summary there's been lots of fun and um correct me if I got any of this wrong so we started by saying osteoporosis is incredibly common and you describe the fact that one in three women and one in 10 men will have a fracture caused by weak bone so there's a huge number of people who are listening to this you said there are a number of fractures you could have but particularly if you have a hip fracture this is a really major event that half of people after this hip fracture will never go home again they'll never walk again and a quarter of people will die within 12 months of having a hip fracture so that's really serious what we're talking about so it starts off quite scary and then I think the good news is for a lot of things we talked about is there's a lot you can do we talked a bit about bones and I discovered to my amazement that all my bones have been replaced every 12 years and I've got this beautiful image of like the Workman taking them away and then the Workman putting it back that they for taking out this calcium and collagen and you need to put that calcium and collagen back and then if we don't do that that's where you start to have this osteoporosis that explains all of these um risks and one of the things that happens at menopause is suddenly you keep taking it out but you're not putting it back as well and hence this real shift for women after menopause the good news is you really can diagnose it you said particularly there you can now use this dexa scan which you know I know is quite common it's something I did when I did the um the first zo studies with with Tim um so you can diagnose that and really understand what your risks are and then we said almost everything that the listener knows about how to deal with osteoporosis is wrong and actually downright harmful so calcium you don't need to take lots of calcium supplements and in fact you both said that you wouldn't take calcium supplements um there's a good really good evidence that if you're eating a decent diet there is no value from uh adding um calcium supplements and I think Tim you said actually even if you're vegan then if you're having a good diverse diet there's you know no evidence and I think you said there are all these people elsewhere in the world who don't really eat any um um dairy products and they're not all having higher fractures so that that's one thing that's out and then you said on vitamin D Cyrus even more amazingly you did a three-year study where you separated people into two groups and the group that you gave vitamin D to actually had more fractures than the group without and that has been repeated elsewhere so from your perspective you know the evidence suggests that um vitamin D could even be harmful um if you're taking it as a supplement in terms of Bones is that am I saying that fairly which I find extraordinary because at the same time you also said oh by the way lots of governments in the US and the UK tell everybody to take these Vitamin D supplements and this feels like another example as we see with a lot of our food where there's a real mismatch between government advice and um the latest science and of course you know this show we can't give official advice but we can share what is the the latest science having said all of that Cyrus you did say that vitamin D supplementation during pregnancy might actually be great for your children and could actually reduce their risks um long term so um I guess another example where the situation in pregnancy can be quite different from from everywhere else the good news is there's a lot of Medical Treatments that are out there um and that actually there was you know quite nice you could pop a pill or maybe even have an injection once a year could half your risk um and they also take in estrogen supplementation HRT as well as all the other benefits that we've talked about on other podcasts could have a significant um reduction in risk of Osio brosis as well and then I think we talked about diet and lifestyle and I think the really good news here is that diet can have a really big effect Tim I think you said maybe a 30 to 40% reduction in in Risk but it's not about taking calcium or zinc or protein is actually about an overall high quality diet lots of vegetables limiting Ultra process essed Foods trying to have more more plants and your key message was it's an example of why you might want to care more about this during per menopause and menopause for example because suddenly like this is a r a higher risk and you can deal with it and I think we wrapped up talking about exercise where I think for me the really interesting thing is you were really focusing on this idea that you need to put pressure on your limbs and that's quite different maybe from putting pressure on your muscles so swimming puts quite a lot of pressure on your muscles right you're pushing but you're saying well it doesn't do anything for your bones cuz they're not banging and so you need to think about exercise where you know you were describing skipping or jumping or any of these things which you described as weightbearing and so that activity that's giving these sort of shocks is really important for your bones which again I guess says there's not always one exercise that solves everything and you need to to get this advice here well done brilliant I thought that was really interesting thank you so much I think it's it's one of those things where it's a little scary what you're describing but on the other hand there is a lot that you can do which is really exciting and I guess one of the key measures is this is something you'd really like to understand about your risk yourself or your loved ones early because there's really a lot you can do it's not something where it's uh you find out this information but there's nothing you can do about it that's right and it's at different times of life so you might want to find out you know at age 50 and then revisit at age 70 I think the decisions you take will be different amazing thank you both very much thank you pleasure I really enjoyed my conversation with SAR him today I learned an enormous amount and I hope that you did too and that you heard plenty of valuable tips for preventing or managing osteoporosis I certainly did now you also heard from cus and Tim how important nutrition is to our health and if you'd like personalized advice and support on how you can eat the best food for your body then why not try a Zoe membership Zoe can help you feel better now and live healthier in the years to come backed by real clinical studies to find out more about what Zoe membership entails and get 10% off your membership head to zoe.com podcast right now I'm your host Jonathan wolf Zoe science and nutrition is produced by yellow huin Martin Richard willin and Sam Durham as always the Zoe science and nutrition podcast is not medical advice it's for General informational purposes only if you have any medical concerns please consult your doctor and see you next time he [Music]

#eat #avoid #osteoporosis #Prof #Cyrus #Cooper #Tim #Spector

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