Welcome, my name is Dr Warrick Bishop. I'm a cardiologist, an author and a keynote speaker. I'm 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, 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, I'm Warrick Bishop and thank you for joining my podcast and videocastation. Today I've got the chance to speak with Dr. Helen Cooley, a Hobart-based rheumatologist. And this is the second time we've had a chance to speak and we're talking about osteoporosis. Hi, Helen. Thanks for joining me. Thanks for having me. Look, in the first episode or the first interview that we were able to record, we really spoke about osteoporosis, what it means, how many people are affected, many of the conditions that can feed into it, and how we evaluate it using particular scans. What I'd really like to speak with, you about today, Helen, is some of the things that we can put in place when we start to identify people who are osteoporotic. So when you identify an individual, let's say a peri or postmenopausal woman who's referred to you with suspicion of osteoporosis, walk me through how you would approach that individual. Okay. So if I'm seeing a perimenopausal woman um i would ask her a pretty extensive medical history about what conditions she's had illnesses as a child that might impact on her bone density, medication use, in particular medications such as glucocorticoids or steroids. Has she been treated for epilepsy? Has she been treated for breast cancer, for example, and maybe on drugs such as anastrozole or letrozole, which are associated with impacting on bone density. Lifestyle factors are incredibly important. Does she smoke cigarettes? Does she drink a lot of alcohol? What is her exercise pattern like? Is she doing any weight bearing exercise, for example? And probably most importantly, has she had a fracture? When we're talking about managing low bone density, it's not just about what the number is on the test. It is what your actual fracture risk is so that your age, have you had previous fractures and also how many falls have you had in the last 12 months play a large role in determining what your actual fracture risk is. And there are some guidelines that can help you decide whether a younger woman or certainly an older postmenopausal woman. when they should start, you know, medication for the treatment of their low bone density. So that if your hip fracture risk is around 4% or so over the next 5 to 10 years, or if your overall... fracture risk such as say a wrist or a spine is somewhere around 12 to 16 sorry 16 to 20 percent in the next five to ten years you might want to have a discussion then with that particular patient about medication for osteoporosis but i cannot over-emphasize how important the lifestyle things are. If you're continuing to smoke, if you do no exercise, then that's really detrimental to your bones as well as all your other potential health issues. So a couple of things there which I'm finding interesting, obviously I'm learning as well because this is out of my normal realm. When you talk about risk of fracture, are you talking about risk calculators that have been put together that you put different factors into? Yes, that's right. There's an international one or there's a local one here called the Garvin Risk Factor from the Garvin Institute in New South Wales, which I use on a regular basis. Okay. And is that online? Yes. Yep. Okay. And it's free. The other thing that's really interesting is you've mentioned smoking several times and alcohol several times. I would guess that there'd be lots of people who didn't realise how significant the impact of smoking and alcohol are on your bones. To be honest, it's a little bit of a surprise to me, but it's obviously very significant. Yeah, yeah. And it can relate to perhaps in other lifestyle factors as well as a direct effect on your bones as well. Yeah, okay. So when we're talking about lifestyle, obviously, alcohol, cigarettes, as you described, exercise is really important. Is there any sort of exercise you recommend people do? Are you just happy for them to be moving and doing something? I really like them to do something. Walking is a great exercise that most of us can do quite easily. Bones do like a bit of stress on them. So even things like taking out your skipping rope and putting a bit of stress through your bones is good, but I am a bit reluctant recommending that to some of my 85-year-old patients because the other thing is you can have osteoporosis and it is silent until you break something, so a fall is a good way to do that. But basically any exercise is good, but we do like weight-bearing exercise. So a lot of people might like cycling or swimming, and they're certainly great exercises for lots of other things. But if you're concerned about building and maintaining your bone density, adding in some weight-bearing exercise to that would be good. Okay. Also under that, if you like, under that umbrella of lifestyle is diet and possibly supplements. One of the things that we talked about was patients with calcium identified in their arteries of their heart, but they've also been told they've got osteoporosis and they're being told to take calcium and they're worried about calcium in their heart. What's some of the advice you give about that, Helen? Yeah, diet is also incredibly important. And generally we advise people to try and get their calcium from their diet as opposed to taking calcium supplements for probably that reason. There has been some conflicting data in the literature that... taking calcium supplementation may increase your risk of heart disease. So that if you can get your calcium from your diet, that that's the best way to do it. Many years ago, there was an ad where you had, you know, cup of milk and a piece of cheese and a tub of yogurt. So dairy is certainly, you know, your best source of calcium. But there are other ways to get it as well. You can get it from some green leafy vegetables, even things like strawberries, some nuts like almonds, walnuts, Brazil nuts, soy based products, you know, they can be. calcium enriched. So there's lots of ways to get it. So if people really do dairy avoid and they struggle, I would suggest a supplement to them then. Of course, vitamin D is very important as well. There's always a confliction between. I'll jump in on that supplement. Okay. I found this on the web for he's very important as well. And there is always a confliction between. Check it out. Is that at your end, Helen? Yeah. Yeah. I think Siri just started speaking to me. Okay. We're not going to work that out for everyone listening. So we're going to. Ellen's going to turn that off, but I'll jump in and just make a comment about the supplements. I think one of the things that is concerning with taking a supplement is you get this enormous peak in the bloodstream and it makes little sense. It's not physiological. And so those very people you talk about, you were just alluding to who may need to take a calcium supplement because their diet. just doesn't allow them to get enough calcium in there, I often tell them to grind up their calcium and spread it with their meals over their three meals in the day. Yeah, it is important. It depends which calcium you use. Most people would use calcium carbonate, the big horse pills. And they actually need a bit of acid for optimal absorption. So having them with your meals is important. And a lot of people take proton pump inhibitors for their esophageal reflux disease. So they can actually have really low acid in their stomach that can make it difficult to absorb these products. So they may want to use something like calcium citrate. Okay. A bit better absorbed. Okay. Well, that's good to know. Sorry, I interrupted your flow on vitamin D. No, that's all right. Look, vitamin D is another, like, huge, huge subject. Vitamin D deficiency is certainly blamed for, you know, a lot of diseases, but supplementation doesn't always fix them. So vitamin D is important. You want to be replete in vitamin D. And there is obviously some conflict between the sunsafe messages, which are also very important, but also getting enough sunlight to get some vitamin D. A lot of Tasmanians here in our winter months, the levels will drop just simply because of our shorter days and it's freezing. You probably don't really want to run around in your bikini when it's about eight degrees. And why is vitamin D important for your bones? Because it enhances your intestinal absorption of calcium and phosphate that you need for your bones. The actual optimal amounts. They're not exactly sure how much we need of both calcium and vitamin D, but you want to keep probably your vitamin D level around 55, 60. So some people may benefit from supplementation during the winter, certainly. Probably the benefit's not there, maybe for you and me who get out inside and move around. But if you're living in a nursing home, then certainly that group would benefit more from vitamin D supplementation than the general population. Look, while we're on supplements, Helen, one that I get asked about from time to time is vitamin K2. Do you have any... Look, I've got a little bit of information. And if you go to the pharmacy and see all the supplements, K2 is often in there. K2 is actually made, you need vitamin K for the bones as it's co-factor in some proteins that are needed to mineralize your bones and make them strong. There have been trials done in K1 and K2. K2 is actually made by your gut flora. But the data for the treatment or its benefit in osteoporosis is a bit conflicting. K2 menitrinone is used in Japan to treat osteoporosis. But when it's been applied to other populations, it doesn't look to be that useful. And again, vitamin K is so easy to get from leafy green vegetables. I'd much rather see people eat those. Yeah, I think it's a really difficult story. And I think you talked about stuff being done in Japan. My understanding was some of the initial research was done. by a particular highly regarded Japanese researcher on K2. But it turned out none of those experiments, which were very positive when he did them, were able to be repeated by anyone else. So there's that uncertainty there. Certainly we would see when we block vitamin K using warfarin for thinning the blood, blocking vitamin K seems to affect calcium metabolism because we often see people with a lot of calcium in their arteries not necessarily a huge increase in risk of heart attack but certainly calcium in their arteries so there must be some interplay but maybe it's a watch this space thing and eat healthy leafy greens in the meantime yeah no i think i think that's right and certainly because you can see some physiological role you can't necessarily extrapolate into treating disease. Yeah, yeah, exactly. Associated with the pathophysiology, yeah. Look, we've just covered about 10 to 15 minutes with a really nice dive into lifestyle, diet, for osteoporosis. I'd be pretty happy to wrap it up there if it's all right with you. I want to invite you back for a bit of a talk about some of the drugs that people might end up needing. So I'll finish it up there. Thank you so much. For sure. For those listening, I hope you found this as informative and educational as I have. It's a real delight getting this great information, and I hope you're enjoying it too. For now, I'm going to wish you the very best. Thank you so much for tuning in. Until next time, please live as well as possible for as long as possible. Take care. Did you know that coronary artery disease kills one in four people? carry some risk or know someone who does. If you're interested in finding out more about how to evaluate that risk, check out www.virtualheartcheck.com.au. It'll give you information about risk and what else can be done to be even more precise.
