**EP331: Who Is At Risk of Thin Bones?**
**Dr. Auric Bishop:** Welcome, my name's Dr. Auric Bishop. I'm a cardiologist, an author, and a keynote speaker. I'm the CEO of the Healthy Heart Network. I'm all about trying to help people live as well as possible for as long as possible. Heart disease is huge in Australia. Every 20 minutes, someone suffers a heart attack. Most of these could probably have been avoided if only we knew what to do. This podcast is all about helping you understand blood pressure, weight, and cholesterol for better health. If you enjoy this podcast, I would be honoured for a five-star review. You can share it with your family and friends. It may well save someone you love.
Hi, my name is Dr. Eric Bishop, and welcome to my podcast and videocast station. As always, I'm super grateful you've taken the time to tune in. If you enjoy my podcasts, please share them with someone who you think will benefit. And please subscribe. You can do that through Spotify, Apple, or any of the platforms. I'm on just about every one of them.
Well, with that aside, what would I like to talk about today? You may be aware from other podcasts that I've touched on the importance of bone health. Now, part of the reason I've touched on that is because, with my partner, Shell, here in Hobart, we've opened a franchise business called OsteoStrong. If it's in your part of the world, I suggest you check it out. OsteoStrong is all about improving bones, balance, and strength for individuals. Now, that can be any comer because we can improve athletes, we can improve run-of-the-mill people, so the average Joe Blow off the street. And really importantly, we can improve people who are deconditioned, who are moving towards frailty, who maybe have osteoporosis or osteopenia—two different extremes of thinning bones.
So my interest is about making sure I can give the best information to the people who come through our centre in regard to their bone health because we might be able to help them. What I'm going to do is share a little bit of information from the Australian Family Physician. These are the sort of guidelines and some of the concepts that GPs will have in regard to osteoporosis. So who do they consider should be considered for bone mineral densitometry?
Bone mineral densitometry, or bone mineral density (BMD), is done using what we call a DEXA scan. That's a dual x-ray absorption scan, and that scan is used broadly. It's reproducible; it's what we've used in studies, and it gives us a really nice idea of how dense and healthy your bones are, mainly in the hip and spine, compared to an average 30-year-old of the same sex.
So who should we be doing bone mineral density checks on? This is where the Australian Family Physician and general practice recommendations sort of sit. They recommend that anyone over 70 years of age is a reasonable candidate for a bone mineral density test. I'm not going to speak to the Medicare rebate on this; that's a conversation for you to have with your GP and for you to think about in your own context. I'm not talking about the rebateable scans—that's a different story, and you can obviously flag that with your GP. I'm talking about where the current sort of practice suggestions are in general practice.
So, people over 70 years of age are considered reasonable candidates for bone mineral density testing. Then we look at men over 60 or women over 50. If there are any of the following risk factors, or if you like, potentiators—a potential for osteoporosis—this includes a family history. So if there are bad bones in the family, then if you're a woman over 50 or a man over 60, it might be a really good opportunity to be thinking about scanning.
Remember that the difference of 10 years is exactly what we see in cardiovascular disease, except it's the other way around. In cardiovascular disease, men hit the problem about a decade earlier than women, and that's really because of that protective role of the estrogens for women in cardiovascular disease. In bone health, it's reversed. Men hit problems after women; women hit it first, often because of hormonal-related issues. Their loss of sex hormones or reductions of sex hormones during menopause is implicated. But also, women tend to be lighter and have a lesser bone mineral density to start with. So if they're losing from a lower level, they're going to be in a high-risk scenario earlier than men.
So just think about that: men and women are different in their risk. For cardiovascular disease, men first, women second. For bone health, women first, men follow. So, men over 60, women over 50—if there's a family history of bad bones, think about getting a bone mineral density test done.
If there's a smoking history, believe it or not, cigarette smoking reduces bone mineral density. As far as I understand, this is due to the compounds within cigarettes interacting with the cells that lay down and absorb bone—osteoblasts and osteoclasts—and throwing that out of balance. Importantly, alcohol will do it too. Two to four standard drinks per day can come back and cause problems with the bones, so keep a close eye on that.
If there's a lack of calcium in the diet, it's hard to know who would be at risk of that. Perhaps people who are strict vegans, or those who just have poor nutrition. We also know that people of low body weight, particularly those with eating disorders, can run the risk of osteoporosis because they just don't have the nutritional component. People who are at risk of increased falls may well benefit from bone mineral density testing just to make sure that those falls aren't going to put them at significant increased risk.
A sedentary lifestyle is really important. We know that maintaining activity once you're 25 or 30 years of age and ongoing slows the rate of bone mineral density loss. So those are the sort of risk factors that, if they're occurring within your life or within the life of someone you care for, you may wish to flag that they have that conversation about bone mineral density with their general practitioner.
It's also really important that we think about medical conditions that could be associated with an increased risk of thinning bones. Now, importantly, things like endocrine problems come into play. For women, early menopause could be a problem. Males who have, for various reasons, loss of testicular function—perhaps through surgery for prostate-related issues—may also be at risk. People with thyroid issues and hyperparathyroid issues are also significant.
Now, what does that mean? The thyroid is a sort of regulator of how the body idles, if you like. It's a metabolic guide. If your metabolism is increased, then you turn over all sorts of things, and you can weaken those bones. Parathyroid glands, which sit right next to the thyroid gland, are super important for the regulation of calcium within the bloodstream and the body. If they're not functioning properly, increased amounts of calcium can be reabsorbed into the bloodstream and can weaken the bones.
Inflammatory conditions in the long term, such as rheumatoid arthritis, ankylosing spondylitis, and gut-related problems—particularly malabsorption—can also impact bone health. If you've got a problem with absorption in the top part of your gut, you may not be absorbing the calcium and magnesium that you need. We also know that people with inflammatory bowel disease can have an inflammatory process affecting the whole body, and these inflammatory processes can also impact bone health.
Of course, people who go through major procedures like organ transplants or bone marrow transplants end up on significant medications that can dampen down the immune system and impact bone health. As you might imagine, chronic kidney disease can drive bone health problems as well and can often lead to secondary hyperparathyroidism. That's actually a topic for another occasion, but there's a lot of complex interplay. Just be aware that chronic kidney disease can be a marker or a real flag for people who could be at risk of osteopenia (a little bit of bone loss) or osteoporosis (significant bone loss).
As you might imagine, alkaline phosphatase, which is central to bone health, is also important in liver function. Therefore, chronic liver disease or any problems with the liver can be a really big issue.
Beyond that, one of the most important things that I saw in this document from the Australian Family Physician are the drugs that can be involved. Now, I'm going to read those out so I don't miss any of them, but most importantly are things like corticosteroids. Corticosteroids, without question, are a major risk when it comes to reducing bone mineral density.
So who gets corticosteroids? People with bad lung disease, particularly asthma, may receive multiple doses of corticosteroids over a lifetime. That's a real red flag and should drive us to ask the question: could this person be at risk of low bone mineral density, and therefore should we be getting a scan?
Increased thyroxin—over-treatment with thyroxine for someone with a thyroid issue—can also be a concern. Anti-androgens, which are used for someone with a sex hormone-sensitive tumor like prostate cancer, can lower bone mineral density. Anti-estrogens for the same reason—someone with a tumor that could be sex hormone-sensitive, like breast cancer, may be put on an anti-estrogen.
You may not have guessed this, but anti-epileptic medications can also alter bone mineral density. They do this by accelerating the turnover of some of the components that are really important in bone mineral maintenance.
But here's the one that really caught my eye: if you've heard of the more recent line of antidepressant agents, which many people are on, they're called SSRIs—selective serotonin reuptake inhibitors. These keep high levels of serotonin within the gaps between our neurons, resulting in improved mood therapy for depressive illnesses.
Now, why is that important? Well, so many people are on SSRIs, and we really need to be asking the question for this large number of people: should we be looking at their bone mineral density sooner rather than later? I think the answer to that question is pretty straightforward.
One of the other agents, which isn't even listed on this GP list, is the proton pump inhibitors that we take to treat acid reflux and peptic symptoms. Medications like omeprazole or pantoprazole—long-term therapy for these can alter the absorption of calcium and therefore impact bone mineral density health in the long term.
If I've not touched on just about everyone in the community, I'd be surprised because there are so many people impacted by these different factors that can feed into bone health. The last one I'm going to mention, because it's on this list, is a condition called multiple myeloma. Now, that's a bone cell cancer of its own. Again, it almost needs a whole podcast of its own to describe it. But we know that multiple myeloma, a form of blood or bone marrow cancer, can lead to thin bones and reduced mineral density. Super, super important.
Well, I think I'm going to wrap that up there. What I would like to do is come back on another occasion and talk about the blood tests that you might speak with your GP about getting if you've been diagnosed with osteoporosis or osteopenia and you want to ensure you're covering as many bases as possible.
Now, my disclosure here, and I've said it before, is that I'm a cardiologist. That's where my absolute expertise sits, and where I'm able to be fairly clear about exactly what information I offer in this space. I'm a doctor; I've got lots of experience. I have done basic physician training, but this area is not my absolute box and dice. I'm happy to give people information that they can think about and talk with their own personal physician, whether that's their GP, their bone doctor, their endocrinologist, or their rheumatologist, and cover those conversations or help support those conversations so that you get the very best health care for yourself.
So I'm all about trying to make sure you're as educated as possible so that you can take that information with you, and it can be contributory to your best health journey. For now, though, I am going to wish you the very best. I do hope you live as well as possible for as long as possible. I really, again, appreciate you tuning in and having a listen. It really means a lot to me when people come up and let me know that they've been enjoying these podcasts.
If you do think of someone who these podcasts could help, and I try to be broad and sensible and pragmatic and all those things, please share it with those people. If you subscribe, that's absolutely fantastic. If you want to try subscribing, I'd love that too. For now, I wish you the very best. I hope you live as well as possible for as long as possible. Take care and bye for now.
**Dr. Auric Bishop:** Hi. Ever wondered what your risk of heart attack is? You should. It's the single biggest killer in the Western world. We're talking one death less than every 30 minutes in Australia and one death less than every 60 seconds in the United States—1 million deaths globally per annum.
Well, how do you check your risk? You can go to www.virtualheartcheck.com.au. You'll find out about your risk and what can be done beyond that to be even more precise.
