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Bone health in teenagers and young adults · 'Bone Up'

0:00
Hello and welcome to Bone Up, the podcast all
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about bones, how we make them, why we break them
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and if we fully understand them. I'm David Armstrong.
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Hi and I'm Richie Abel and over this series we're
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going to be exploring osteoporosis, bones, what
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we know and what we're yet to discover and we
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hope you will join us on the journey. So for
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anyone keen to learn more about our infrastructure
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of calcified collagen, this is Bone up. Welcome,
0:55
listeners. We're back. How are you doing, David?
0:58
I'm doing very well. If you followed us on Twitter,
1:00
you will have heard we had just a slight delay
1:03
through life events. We have to do the things
1:06
that they actually pay us to do occasionally,
1:08
Richie, as well, don't we? Unfortunately, we
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do, yes. But we're back and we have several more
1:15
guests lined up for very exciting interviews.
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And today is one of those. So have you been busy
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the last month or two? Yeah, very busy. I went
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on a trip to visit MIT in Boston, meet some collaborators
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and try and get a project going, which was, I'm
1:34
excited about that. Had the start of term here
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at Imperial, getting everybody going again. All
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the students are back, which is nice because
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the place gets really lively. Had a couple of
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new PhD students starting in the lab, looking
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at the effect of air pollution on bone. And hopefully...
1:53
In the next few months, we'll have another PhD
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student starting in the lab looking at the health
1:56
of ballet dancers. So if you're out there and
2:00
you're interested in ballet and you want to do
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a PhD, get in touch. Yeah, that's something you
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talked about earlier in the year, which was very
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interesting. And yeah, I mean, we got over the
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Royal Osteoporosis Society conference as well,
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which was great to be back for a face -to -face
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conference. I've certainly been busy seeing a
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lot of osteoporosis patients. at my clinic and
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then I had the great privilege I was asked to
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give the annual Dairy Council of Northern Ireland
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scientific lecture at Ulster University and I
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had the chance to not only talk about bones which
2:33
is what you imagine I would talk about but also
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a bit about ancient history about archaeology
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about the development of dairy farming over the
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last sort of eight or nine thousand years We
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got to hear about what some ancient doctors and
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ancient historians had to say about bones. We
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got to look at some Renaissance art. We got to
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talk about 19th century politics and right up
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to the present day. So I really enjoyed myself
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immensely. Richie, I have to say, getting talking
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about history and bones, which are my two big
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areas, and I got good feedback. Everyone else
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seemed to enjoy it as well. And I got a lovely
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piece of fine china as a thank you. So, yeah,
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that was good fun. I saw the pictures on Twitter.
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It looked amazing. Well, it was fun to do, and
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it seemed to get good feedback. Was it recorded
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so we can all listen? I don't know if it was
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recorded. I think they had the slides, but to
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be honest, the slides bore very little resemblance
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to what I actually said, because as you know,
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I tend to just make things up as I go along.
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But yeah, maybe that was a wasted opportunity
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or maybe not. But yeah, other things going on
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as well. I mean, I suppose to keep people up
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to date, we had Stuart Ralston and Kirsty on
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talking about a year ago now about pregnancy
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associated osteoporosis. So that study is up
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and running and I've managed to recruit a number
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of patients to that. So that's exciting. In fact,
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I have someone else coming up just next week.
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So that's ongoing. And also, I mean, we had Jared
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Wong on earlier the year talking about Duchenne
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muscular dystrophy. And I've been very privileged
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to be asked to join a committee looking at that
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and looking at guidelines for adults with osteoporosis
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with Duchenne. So, yeah, keeping myself busy,
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as are you. But we find time to do this podcast,
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which is the most exciting and important thing.
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It is. To be honest with you, it's probably the
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most fun bit of my job right now. So listeners,
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we quite often put out messages on Twitter asking
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people what kind of topics you want to hear about.
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And since the day we started recording the podcast,
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one of the things that always comes up is bone
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health in young people and the relationship between
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bone health and eating disorders. So that's the
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topic we're going to discuss today because so
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many people have been asking us about it. David
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how does this come up in your clinic? Yeah I
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mean it's something we've talked about often
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the perception is that osteoporosis just affects
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older people but actually in a hospital setting
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as a specialist I get quite a high percentage
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of younger people referred to the clinic and
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I think that's important because osteoporosis
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in younger people is clearly a complex and you
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know more unusual area. I see a fair number of
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young people with eating disorders, predominantly
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young women, and I probably should see more young
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men because it's probably more common in young
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men than we recognize. I do see young people
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who take steroids, corticosteroids, and sometimes
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high doses for other conditions. And you do sometimes
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get young people referred up with fragility fractures
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and bone problems and investigations reveal other
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diagnoses. So sometimes you would pick up other
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conditions such as osteogenesis and perfecta.
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We've had one or two people diagnosed with celiac
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disease who presented with fractures and low
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bone density. But every now and again, we turn
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up other unusual conditions. So, I mean, I would
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say people probably don't perceive that an osteoporosis
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specialist or that most osteoporosis specialists
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see a lot of young people. But certainly at my
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clinic, I have sort of 16 year olds right up
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to about two weeks ago, a 99 year old at the
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clinic. So, you know, we cover a wide age group.
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I think the exciting thing about our guest today
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is that she... specializes mostly in that younger
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group of people and would be regarded certainly
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nationally here as the UK as someone who would
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be a leading voice in that younger group of people
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with osteoporosis. I'm really excited about today's
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interview so let's get started. Well listeners
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we have a really wonderful guest with us today,
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somebody we wanted to have on the podcast for
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a really long time, Dr Jenny Walsh. Dr. Walsh
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is a Senior Clinical Lecturer in the Metabolic
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Bone Centre at the School of Medicine and Population
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Health in the University of Sheffield, which
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is a really world -renowned bone research institute
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and bone training centre. Welcome, Jenny. Welcome,
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Jenny. We're really delighted to have you on
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the podcast. Thank you both. I'm really pleased
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to be asked and very excited to be doing this.
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That's great. I'll maybe sort of kick things
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off. People often think of osteoporosis as a
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condition that affects older people. But as you
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and I know, it does affect younger people as
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well. So could you give us some sort of general
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idea how common osteoporosis is in younger people?
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And probably a related question, how common fragility
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fractures are in younger people? Yeah, so I think
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the first thing is I'm going to be a bit awkward
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about the use of the word osteoporosis in young
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people. I generally prefer to talk about people
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with low bone density because the definition
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of osteoporosis includes deterioration in bone
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structure. And for me, deterioration kind of
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implies an aging process. to a bone which is
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already grown and developed whereas in younger
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people we're often talking about bones which
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are still in development or only just developed
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so i think trying not to think about the kind
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of processes of osteoporosis as we think about
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them in older adults is an important differentiation
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in this group and so i think that's sort of relates
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to your question about sort of how we think about
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osteoporosis in this group um then if Low bone
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density in young adults is reasonably common
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and it can be because of a range of causes really,
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either specific inherited disorders or because
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of concomitant illnesses which often affect.
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children and young people or the treatment of
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those illnesses so including things like steroids
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or cancer treatment but there are a group of
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young people who just have low bone density and
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we never really find an underlying cause and
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it's probably sort of a mixture of sort of the
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multifactorial genetics they've inherited from
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both parents. But there does seem to be a group
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of young people that do have something that looks
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a lot like osteoporosis in older people, and
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we can't really find a cause for it. There's
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a clearly defined and well -recognized peak of
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fractures in kind of teenagers. And this happens
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in the normal healthy population because as bones
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are growing in puberty, particularly around the
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time of peak height velocity. And, you know,
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you'll all recognize this from your own kids
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or kids that, you know, there's that age where
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kids just suddenly. shoot up in early puberty
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and when they're doing that their bones grow
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in length and size first and then secondarily
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fill in strengthen and build their structure
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so there's this kind of window when the bones
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have grown but aren't yet strong enough where
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bones are a little bit vulnerable And that age
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of kind of peak height velocity tends to correspond
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a little bit with peak stupid in teenage as well.
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You know, of the age of fighting with your siblings
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and falling off your bicycle and pushing each
10:54
other off stuff. So there's a sort of clear peak
10:57
of bone fragility in normal teenagers. But there
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are a number of things that can cause low bone
11:02
density and increased fracture risk in young
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adults for other reasons as well. For the benefit
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of the tape, David was giving that a big thumbs
11:13
up. So given then that we should be talking about
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low bone density in young people rather than
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a disease osteoporosis, how do the ways in which
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you assess fracture risk in young people compare
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to the way in which you would maybe assess a
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fracture risk in an older person? Yeah, that's
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a really good question. And the same principles
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apply. Bone density measured by DEXA does associate
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with fracture risk in young adults. But there
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are a few differences in how we use bone density
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and how we interpret it. And firstly, in younger
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adults, we shouldn't be thinking about... t -scores
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because t -scores are how we define osteoporosis
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in older adults and a t -score is comparing your
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bone density to an average young adult and so
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a t -score is really asking the question kind
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of how much bone do you think do we think you've
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lost since you were a young adult and so in a
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young adult that's not really an appropriate
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question to ask so we use the z score instead
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which compares you to somebody of the same age
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and same gender so it's asking you know is your
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bone density different than we would expect given
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your age and your gender. The bone mineral density
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by DEXA does associate with fracture risk in
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young people but the gradient is much much shallower
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than it is in older adults and so if you draw
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a graph of bone density and fracture risk for
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different ages In older people, as bone density
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decreases, fracture risk increases quite steeply.
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But in younger adults, the increase in fractures
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with decreasing bone density is much less. And
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so it's really important to understand that even
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with low bone density in young adults, their
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absolute fracture risk isn't as high as it would
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be in an older adult. And something else I'm
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going to say that's kind of really important
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is that FRAX hasn't been validated in people
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under the age of 40. So we shouldn't be using
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FRAX in under 40 year olds. So when we're thinking
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about the bone density and how that associates
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with fracture risk, it's really important to
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separate out the concepts of relative risk and
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absolute risk. So a 25 year old with low bone
13:48
density. might have 10 times the fracture risk
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of an average 25 -year -old with normal bone
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density, but that's still going to be 10 times
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nearly nothing. So although their relative risk
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is higher, their absolute risk is still really
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not that high. And I think that's a really important
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thing to try to understand and bearing in mind
14:10
when we're making judgments about fracture risk
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on bone density. And then in the same way we
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would of... A person of any age would think about
14:20
their bone density, but would also think about
14:22
the context of their clinical risk factors and
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the other underlying factors that increase their
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fracture risk, their risk of injury, their risk
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of falls. In the same way that we think of vertebral
14:36
fractures in older adults as being really, really
14:39
important predictors of future fracture risk,
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that holds true in young adults as well. And,
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you know, we'll talk a bit about sort of using
14:50
pharmacological treatment in younger adults.
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But vertebral fractures is one of the few things
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that might nudge me towards using pharmacological
14:59
treatments in young adults because it's such
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an important indicator of high risk. I'm very
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excited to get on to talking about using pharmacological
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treatment or perhaps not using pharmacological
15:11
treatment in young adults. um just to pick up
15:15
on your point about should we use the term osteoporosis
15:19
for an 85 year old and a 25 year old and i have
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to say yeah i agree with that a lot i think they're
15:26
they are quite sort of different conditions really
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or the way we should think about them are quite
15:31
different conditions um do you think using the
15:35
term osteoporosis because A 20 -year -old or
15:39
25 -year -old may have been told after their
15:41
DEXA scan or told by their GP that you have osteoporosis.
15:45
Do you find that's unhelpful? I think because
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osteoporosis is a word that a lot of people sort
15:54
of understand and recognise, that most people
15:56
would know that that means that your bones are
15:58
weaker and more likely to break. It's not a...
16:03
a bad word to try and explain things to people
16:06
but it's quite a frightening thing to say to
16:08
somebody at that sort of age because it is associated
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you know with older adults and very much that
16:15
kind of older adult bone fragility and it can
16:17
really terrify people that come to then see you
16:20
and say you know am I gonna end up with spine
16:23
fractures and hip fractures and is that what
16:25
we're talking about when I'm 25 or 30 and for
16:29
most people that's not really the case so I think
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it's It's a word that a lot of people understand,
16:34
and so I understand why it's used to try and
16:36
explain the results of bone density measurements
16:38
and bone fragility. But I think it is a word
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we need to use a little bit carefully. And as
16:43
a follow on from that, do you find yourself trying
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to explain to a lot of... younger people perhaps
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why they shouldn't be on pharmacological treatment
16:52
more than trying to persuade them to take pharmacological
16:55
treatment do you see young people have perhaps
16:58
been started on a bisphosphonate by the gp age
17:00
20 who you're you're stopping it again yeah that
17:06
does sometimes happen um and it's because low
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bone density in young people is often It's quite
17:14
individual because often there will be an underlying
17:16
cause or they're definitely sort of perhaps a
17:20
less uniform group than osteoporosis in older
17:23
adults. It's really individual between patients
17:26
as to kind of their perception of risk and how
17:29
keen they are to take treatment because they're
17:31
frightened of the risk or whether they're reluctant
17:33
to take treatment because they're variably sensibly
17:35
thinking, you know, I'm young and I don't really
17:38
want to be committing myself to. something that
17:40
could be years and years of treatment but certainly
17:44
if someone has been started on treatment perhaps
17:47
by somebody who sees the bone density result
17:49
and associates that with the risk of somebody
17:52
a bit older I think there is an important conversation
17:55
to be had about trying to explain that idea of
17:59
sort of the absolute risk in younger people and
18:02
if We don't think that they really need to be
18:06
on treatment, having an open conversation about,
18:09
you know, what the treatment, the fact that it
18:13
might not really be buying them any benefit right
18:15
here, right now, and there may not be such a
18:17
strong case for them to be on treatment. What
18:23
are the treatment guidelines for managing young
18:27
people with low bone mineral density? So there
18:33
aren't really any specific guidelines for young
18:38
people. And I think that's partly because of
18:41
the heterogeneity of the group. And so the circumstances
18:45
are very different for different groups. But
18:47
I think there are some really sensible general
18:50
principles that can be applied to all young adults.
18:54
And so that's look for underlying causes of low
18:58
bone density. Data to show that in younger adults,
19:05
it's more likely that there is an additional
19:07
underlying cause than in an older adult with
19:11
low bone density and fractures. And then give
19:14
the same lifestyle advice that we would give
19:16
to anybody around maintaining a good dietary
19:20
calcium intake, being physically active, smoking
19:23
cessation, alcohol moderation. And then. generally
19:30
reserving pharmacological treatment for the people
19:33
who are at really high risk right now. And that's
19:38
either because they're having ongoing fractures,
19:41
particularly vertebral fractures, or that you
19:43
can see that their bone density is decreasing
19:45
over time and you need to do something about
19:48
that. And what kind of treatments do you give
19:52
the patients? Is it the same treatments that
19:55
you might give an older person who has osteoporosis?
20:01
That's where things get quite difficult because
20:04
none of the treatments we use for osteoporosis
20:08
are really licensed for use in younger people.
20:11
There's a lack of evidence to guide treatment.
20:14
Most of what we have is studies in small numbers
20:17
of people. So if I do need to use treatment in
20:23
a younger adult, my first line generally would
20:26
be a bisphosphonate on the grounds that... We've
20:30
been using them for a really long time. We understand
20:32
them really well. We know what the risks and
20:35
benefits are. But it's always important to have
20:37
a conversation with the young person about the
20:40
fact that this is outwith the usual use of the
20:43
drug and that they understand that. And particularly
20:46
with young women, there's a really important
20:48
conversation to be had around the use of pharmacological
20:52
agents, including bisphosphonates in pregnancy.
20:55
and making sure that they understand that they
20:57
shouldn't be getting pregnant while they're using
21:00
a bone drug and that they're using reliable contraception.
21:05
I mean we focus understandably on that concept
21:08
that you have peak bone mineral density or peak
21:10
bone mass when you're 25 and we tell students
21:13
that and we often explain that to patients as
21:16
well. Can you actually improve your peak bone
21:20
mass then if you're 26 or 27 or 30? if you can
21:23
address the underlying problem or is 25 simply
21:27
a cut off and that's it, you can't do any better?
21:32
You definitely can make improvements beyond the
21:35
age of 25. And peak bone mass is not a single
21:42
entity. So different skeletal sites reach peak
21:45
bone mass at different ages. And so probably
21:48
your hip is actually at its peak bone mass. for
21:52
a woman actually by about age 19, 20, whereas
21:56
your vertebrae are still developing bone structure
22:00
and gaining bone density probably a bit later,
22:03
sort of 25. And we see that as well when we see
22:07
people that have had negative influences on their
22:10
bone during development. So kind of the age at
22:12
which something starts to affect your bones affects
22:15
kind of the pattern of where you'll have low
22:17
bone density. So although your bones are done
22:21
maturing, usually by the age of about 25 in men
22:25
and in women, there is evidence that those kind
22:27
of lifestyle interventions, physical activity,
22:31
calcium and vitamin D, smoking cessation, do
22:34
still cause small increases in bone density.
22:38
And there are increases in the sort of magnitude
22:40
of, you know, a couple of percent, but a bisphosphonate
22:43
only increases bone density in most people. by
22:46
about five percent and that's associated with
22:49
a really significant decrease in fracture risk
22:51
so even sort of small changes of a few percent
22:54
due to lifestyle changes are really meaningful
22:57
in terms of getting bone in the bank um and you
23:02
know we talk to young adults a lot about doing
23:04
what they can now to get their bones as healthy
23:08
as possible and do their future self a favor
23:10
and you know when you're you know 20 25 The prospect
23:16
that one day you will be 40 is utterly inconceivable.
23:22
But trying to kind of talk to people about the
23:25
idea of kind of, yeah, what you get in the bank
23:27
now is a reserve that you will have, your future
23:30
self will thank you for. That's interesting that
23:36
I think there's been a lot of talk lately about
23:39
how can we engage young people more in their
23:42
bone health. To try and encourage them to take
23:46
positive steps so that they're going to maintain
23:49
that health throughout their lives. And I suppose
23:53
with this group of patients, young people with
23:55
low bone mineral density, you're really at the
23:58
sharp end of those discussions. Speaking about
24:01
the lifestyle changes, do people take kind of
24:06
more drastic action? Do they change the way that
24:09
they live, like, you know, avoid adventure sports
24:11
or skiing or things like that? Oh, yeah, that's
24:17
a really good question. And this is a conversation
24:19
I often have with patients. And it's about finding
24:25
that balance of risk. And so generally, people
24:31
with very low bone density, particularly people
24:34
with vertebral fractures, I would discourage
24:37
from activities that really put their spine at
24:39
risk. So things like horse riding, trampolining.
24:45
bungee jumping um but there is a balance to be
24:50
struck between doing the things that make you
24:52
really happy and keep you fit and healthy and
24:55
accepting that you you're probably a bit more
24:57
at risk of fracturing if you have an injury than
24:59
someone with normal bone density um but it's
25:03
about striking the balance and so i would really
25:06
try not to make people fearful that they can't
25:09
go out and live their lives but taking a few
25:11
sensible precautions is kind of the route that
25:16
I would take. I do have patients who have low
25:21
bone density and are at quite high risk, but
25:24
they have things that are really, really important
25:26
to them that they really, really want to keep
25:28
doing. So my job is to advise and help them think
25:31
about the risk. A lot of people have been getting
25:37
in touch with us ever since we started the podcast
25:40
to ask about the effect of... eating disorders
25:43
on bone and whenever we put out a call on social
25:48
media has anybody got any things we would like
25:50
to discuss that is a topic that always always
25:53
comes up so we wanted to ask you a few questions
25:57
about that if we may what kind of effect do eating
26:00
disorders have on bone health and how can you
26:04
manage the health of people living with a eating
26:07
disorder Yeah, this is a really important question.
26:12
And similarly, you know, generally often when
26:15
I give talks, this is the question that people
26:17
really want to ask because it's complicated and
26:20
it's a real challenge for patients with eating
26:23
disorders. It is well documented that people
26:27
with eating disorders do have lower bone density
26:30
and that they do have a higher risk of fractures.
26:34
And there was a really nice paper in... jbmr
26:38
this year with quite a long duration of follow
26:41
-up to 40 years of people with eating disorders
26:44
demonstrating that they do have an increased
26:46
fracture risk and it's a complicated bone disease
26:52
because there are so many factors that are feeding
26:55
in so we tend to think about you know the effects
26:58
of low body weight and we know that you know
27:01
the amount of weight loading on your bones has
27:03
an effect on your bone density and your bone
27:05
strength And then there are the nutritional factors
27:07
around people eating quite restricted diets.
27:11
But they're not the only factors acting. We need
27:15
to think about all the, I'm an endocrinologist
27:17
by training, so obviously this is all going to
27:19
be about the endocrinology. But people with eating
27:22
disorders have low sex steroids, low estrogen
27:25
and low testosterone. And obviously we know that
27:27
that has negative effects on bone. But people
27:31
with eating disorders also have high levels of
27:33
cortisol because of the kind of chronic stress
27:35
reaction. And so that has effects on bone in
27:39
the same way, to a lesser magnitude, but at the
27:42
same way that taking steroids does, that it increases
27:45
bone resorption and decreases bone formation.
27:48
And people with eating disorders and low body
27:50
weight also have low levels of IGF -1. which
27:55
is an important factor for bone health, especially
27:57
in young adults. And so there are all of these
27:59
different factors feeding into the low bone density.
28:02
And that's why often when people have done studies
28:06
looking at interventions for bone health in eating
28:09
disorders, they're not very successful because
28:12
they only really tackle one aspect of this kind
28:16
of multifactorial bone disease. So, for example,
28:21
in trials of... combined oral contraceptives
28:26
taking the pill that's not very successful and
28:29
that's probably because it sort of resolves some
28:31
of the issues around the low oestrogen but it
28:33
makes the low IGF -1 worse so you're kind of
28:35
improving one of the factors but making another
28:38
one worse and so that's why some of the intervention
28:41
trials haven't really shown much benefit because
28:45
you need to think about sort of complexity of
28:47
the effects on bone rather than just one factor.
28:50
We've talked before in other episodes of this
28:53
about the importance of exercise for bone and
28:56
actually importance of exercising young people
28:59
for bone and building bone. Obviously with an
29:01
eating disorder there's a group of patients there
29:04
who will over exercise and will use that to control
29:07
their weight. Now if you get let's say the menstrual
29:11
cycle sorted out and there's an improvement maybe
29:14
in the relationship with food and some weight
29:16
gain and other things are going well How do you
29:19
fit exercise into that? Because, as I say, people
29:23
will sometimes have a bad relationship with exercise
29:25
in the sense that they will use it to gain weight
29:28
or to keep weight down, but we want people to
29:31
exercise because it's good for their bones. Yeah,
29:35
this is a really tricky issue, as you say. You
29:38
know, weight -bearing activity and resistance
29:41
activity is really important in maintaining your
29:44
bone health. But some people with restrictive
29:47
eating disorders do use exercise as a way of
29:50
managing their weight and keeping their weight
29:52
down. So I think this is something that needs
29:55
to be done really carefully in combination with
29:58
the person's eating disorder team. And so that
30:02
kind of you set some clear parameters and a clear
30:04
plan for what's an appropriate level of physical
30:06
activity for that person and do that in conversation
30:10
with the patient and with their wider team. It
30:14
is quite a multidisciplinary approach. You've
30:16
sort of touched on that on a number of occasions
30:19
there. Yeah, very much so. And I think that's
30:22
the key to looking after people with complex
30:26
multifactorial disease. You need a team of people
30:30
with the right expertise working together and
30:33
working with the patient. And this affects young
30:35
men as well as young women. I mean, I think we
30:37
automatically maybe think of young women with
30:39
eating disorders. But, you know, could you put
30:41
even a figure what percentage of eating disorders
30:44
or in terms of low bone mineral density, what
30:47
percentage of young men we're looking at here?
30:49
And are we missing young men, do you think, because
30:51
we're not thinking about it? Yeah, absolutely.
30:54
I think young men with eating disorders get missed.
30:57
I think, you know, probably. About 10 % of people
31:03
with eating disorders are men. And that's, I
31:07
would guess, probably a bit of an underestimate
31:09
because they tend to have different features
31:12
as part of their eating disorder, which might
31:15
go a bit unrecognised. And I think probably as
31:17
healthcare professionals, spotting the signs
31:20
of people who might have eating disorders and
31:22
asking them whether that might be something that
31:25
they recognise and need help with, we're probably
31:28
a bit blind. to eating disorders in men and so
31:32
I think probably we don't do a very good job
31:35
of spotting the things that might indicate an
31:38
eating disorder and having that conversation
31:40
with men so I think they are probably yeah an
31:42
under -recognized and underserved group and there
31:45
are some data showing that you know the effects
31:48
on bone density in men and the effects on fracture
31:52
risk are pretty similar to women with eating
31:54
disorders so their bone health does need to be
31:57
considered. Yeah, absolutely. You know, the key...
32:29
the key is addressing the underlying eating disorder
32:32
and if that can be improved and with improvements
32:38
in body weight and particularly restoration of
32:40
spontaneous menses then that's the key to improving
32:44
bone health um and that's really easy to say
32:47
as the bone doctor isn't it because you just
32:48
kind of say to the eating disorders team and
32:51
the patient kind of well you know just sort out
32:53
the eating disorder and the bones will get better
32:55
um but obviously In some people, eating disorders
33:00
are chronic and you need to think about what
33:05
you do to manage the bone health in patients
33:08
whose eating disorders aren't improving and aren't
33:12
resolving if they're at high risk. So certainly
33:16
calcium and vitamin D supplementation, making
33:20
sure that you can address that. And most patients
33:22
with eating disorders will accept calcium and
33:25
vitamin D supplementation. talking about the
33:29
other general lifestyle things around, you know,
33:31
smoking, alcohol, all of that stuff. And then,
33:35
yeah, very occasionally in people who are at
33:38
high risk, then I might consider using a bone
33:42
drug. In very young women with eating disorders,
33:47
so kind of women in their teens, there is quite
33:49
good evidence for the use of transdermal oestrogen.
33:53
to improve their bone density again you know
33:56
really small studies in these groups but because
33:59
using oestrogen patches transdermal oestrogen
34:02
it doesn't have the effect on to lower igf1 that
34:06
taking a pill does and in the the available evidence
34:10
young young women with eating disorders given
34:12
transdermal oestrogen and do actually improve
34:15
their bone density at the same sort of rate as
34:18
comparable women of the same age without an eating
34:20
disorder. So it does seem to be really effective
34:23
in that group. In women past the age of peak
34:29
bone mass, there is small study evidence that
34:33
resedronate can improve bone density. And when
34:37
I say small study, I mean studies of like 30
34:39
people. And there is a more recent study using
34:44
denosumab, which did show some improvement in
34:47
spine bone density. in women of average age of
34:50
about 29 but again you know small studies early
34:54
days and obviously you know using denosumab in
34:57
this group raises all sorts of other questions
34:59
about kind of how long you would use it for how
35:02
you would stop it and complexities around that
35:04
one of the things comes up again and again on
35:08
our podcast is this concept of bone quality as
35:11
well as bone quantity and certainly in terms
35:14
of eating disorder patients you know we've talked
35:17
just about bone mass and bone density i've seen
35:21
patients who have maybe do you ever recover entirely
35:25
from an eating disorder have done a lot better
35:27
and are maybe middle -aged and are doing better
35:29
with it they're still simply with quite a high
35:31
risk of fracture and i wonder about the quality
35:34
of the bone if you've had chronic malnutrition
35:37
and and you know poor exposure to important nutrients
35:41
at a crucial age for bone development. Do you
35:45
think quality is an issue as well even if you
35:47
sort out the quantity of bone and is that reversible
35:50
as you get older? Yeah I think that's what we
35:54
know a lot less about. There have been some studies
35:58
using high resolution PQCT in women with eating
36:04
disorders to describe kind of the change in the
36:07
bone microstructure and those studies have demonstrated
36:10
that there is poorer microstructure within the
36:14
bone. So the cortex is thinner, the cortex is
36:17
more porous, the trabecular density is lower
36:21
and the trabecular connectivity is less good.
36:23
So all of those things that kind of feed into
36:25
the mechanical strength of the bone, independent
36:27
of the bone density, are impaired in people with
36:31
anorexia nervosa. But I think what we don't know
36:34
really is, yeah, how recovery, how much of that
36:37
recovers. when the eating disorder is treated
36:40
and improved and I think you may well be right
36:44
that even though we see improvements in bone
36:46
density some of those kind of microstructural
36:48
factors and other bone quality factors might
36:51
continue to be impaired and contribute to an
36:53
increased fracture risk. Jenny the studies that
37:00
you've been talking about where people have tested
37:03
the bone medicines in people with an eating disorder
37:08
do sound very small. Why is that? Is it that
37:13
our community hasn't put enough emphasis on developing
37:16
studies like that? Or is it that it's such a
37:19
small number of people that are affected that
37:21
it's difficult to deliver the trials? Probably
37:29
a little bit of both. I think they're obviously...
37:37
People with eating disorders have got quite complex
37:40
health concerns. They've got a lot of interventions
37:45
going on, a lot of healthcare professionals,
37:48
and then kind of asking them to engage on top
37:51
of that with research and trials, particularly
37:56
drug trials, when people are a little bit wary
37:59
of anything that might interact with their eating
38:04
disorder. um their weight i so i think it's a
38:10
challenge to to do big number trials in people
38:14
with eating disorders because they have got a
38:16
lot going on and understandably are a bit reluctant
38:18
to sign up for research and then sort of maintaining
38:21
people within the trials and retention is difficult
38:23
um so i think yeah probably a little bit of both
38:28
probably a little bit of weariness that it's
38:32
difficult to do the trials and the trials are
38:34
a bit difficult to do in this patient group and
38:39
with younger patients there's always that low
38:41
risk of fracture in the background as well isn't
38:44
there that you know it's harder to prove reduced
38:47
fracture risk perhaps unless in this group you're
38:50
following up for 20 or 30 years but of course
38:52
that's clearly difficult to do as well yeah absolutely
38:58
so jenny One of the reasons I wanted to get you
39:07
on the podcast is because I've seen you speak
39:09
a lot of events around the bone community. I
39:12
remember the first time I ever saw you give a
39:15
talk, it was about using bone turnover markers.
39:19
And I got there early and sat down in the front
39:21
row. And I remember you gave an absolutely amazing
39:25
talk, crystal clear all the way through, talked
39:29
about bone markers and how they can be used in
39:31
clinical practice. And since then, I've seen
39:33
you many times recently, the ROS, where you gave
39:36
a really clear talk there. It's clear that you
39:39
devote a lot of time and a lot of effort to the
39:42
bone community, not just in your clinical practice,
39:46
but outside as well. Where do you find the drive
39:50
to put so much love and time into your work?
39:58
Oh, thank you. I think it's a combination of
40:03
the fact that I genuinely find these subjects
40:06
really interesting. You know, my medical students
40:10
will tell you that, you know, if anybody asks
40:13
me a question or anything to do with an aspect
40:16
of bone health, you know, they're in for a long
40:17
answer. I really remember when we were teaching
40:21
online a lot during the pandemic and I was teaching
40:24
my medical students and my partner was just passing
40:27
through the room behind me at the point one of
40:28
the medical students asked a question about bone
40:30
turnover markers and my partner just started
40:32
shaking his head in a kind of, oh, you're going
40:35
to get more of an answer than you bargained for
40:37
here. I think I find bones really interesting
40:41
to work with because of the kind of multidisciplinary
40:46
nature of the science that you need to understand.
40:49
the biology and the chemistry, but you also need
40:53
to understand bones as a physical object. So
40:56
you need to understand the physics and the material
40:59
science. And, you know, a few years ago, I was
41:03
working with the in silico engineers trying to
41:07
build experimental models of bones that could
41:11
be passed into the virtual physiological human
41:14
project. And so that kind of working with people
41:17
from so many disciplines, I find really exciting
41:20
because it means you spend all your time with
41:22
really interested, engaged people who fuel your
41:26
own enthusiasm. And then the other aspect is,
41:29
you know, I genuinely enjoy working with this
41:33
patient group of particularly, you know, young
41:38
adults and the young adults I see, whether they
41:41
are people with inherited bone disorders like
41:45
osteogenesis imperfecta. or whether they are
41:48
people who've had other health problems that
41:50
affect their bone or people that I see because
41:53
they've had bone problems because they're elite
41:56
sports people. And it's just a really interesting
42:00
group of people to spend time with. And being
42:03
a young adult is really difficult as well. You
42:06
know, there's a lot going on in people's lives
42:09
at that age. And then having health problems
42:14
layered on top of that, I think is... really
42:17
a lot to deal with so yeah i think it sort of
42:20
is twofold genuine nerd enthusiasm for the subject
42:25
and also a lot of empathy for these patients
42:29
and really wanting to do what i can to make things
42:35
work a bit better for them as individual patients
42:37
but sort of as as a group as well through kind
42:40
of research and um you know working with national
42:44
groups and things like that It really comes across
42:48
that you love what you do. What was the spark
42:52
that set you off down this route? When I was
42:57
a third year medical student, I did my very first
43:02
placement with endocrinology. And their enthusiasm
43:10
for the subject and... was so clear and I think
43:15
you know that has a big influence isn't it it's
43:17
the people that you see along the way and their
43:19
enthusiasm is infectious um and I enjoyed the
43:22
subject material as well and sort of through
43:25
that I started to get interested in sort of puberty
43:28
and young adult medicine and so I did um kind
43:32
of clinics with teenagers who presented with
43:34
problems of puberty and growth and from there
43:37
I kind of started doing kind of uh clinics for
43:41
cancer survivors who'd had sort of long -term
43:45
consequences of their cancer treatment and that
43:47
kind of got me more interested in bone and then
43:49
yeah from from there I did um yeah that's sort
43:55
of the route that got me here and kind of kept
43:57
me going ever since really that's amazing how
44:01
different things could have been if you had a
44:04
different placement yeah yeah if I'd worked with
44:07
yeah Yeah, if my first placement had been with
44:10
a really enthusiastic gastroenterologist, I could
44:12
have had a very different life. It's something
44:14
I'm always conscious of with medical students.
44:16
You know, no matter how grumpy you're feeling
44:18
and how bad a day you're having, you have to
44:21
let the actual basic enthusiasm for what we do
44:23
shine through, I think, because, you know, you
44:25
do remember that, don't you? People you've worked
44:27
with when you were younger, who, despite the
44:28
fact they seem terribly old and academic and
44:32
all the rest of it, they still seem to enjoy
44:33
what they were doing. And yeah, I think most
44:35
of us hopefully still do. enjoy enjoy what we're
44:38
doing yeah it's a really privileged thing that
44:42
we get to do isn't it you know if you're wondering
44:46
why we didn't ask you anything about Duchenne
44:48
muscular dystrophy and young people um young
44:51
people with that we had Jared Wong on a couple
44:53
of episodes ago talking all about that because
44:56
that's something that you and I very recently
44:57
have been on the committee talking about so You
45:00
know, there are obviously many other aspects
45:02
of osteoporosis in young people we just haven't
45:05
had time to touch on. But, you know, we'll maybe
45:07
get you on again and get you to talk about other
45:09
things as well. And Jared is doing really, really
45:14
good work to pull together some coherence of
45:18
practice and clinical guidelines for that group
45:20
of patients. He's doing great work with that.
45:24
I think it's nice for our listeners to know because
45:25
we've had lots of guests on over the last few
45:27
series, but we do actually all sort of meet up
45:30
in different environments and work and chat together
45:32
as well and sort of know each other outside the
45:35
podcast, which I think is nice. And important
45:39
for recruiting people onto the podcast as well.
45:43
Jenny, it's been an absolute delight talking
45:46
to you today. Thank you so much. Thank you so
45:50
much for having me. I'm always happy to have
45:53
the opportunity to go on about the subjects I'm
45:55
enthusiastic about. So thank you very much. It's
45:57
always lovely to talk to the two of you. It's
46:00
always such great fun talking about bones, isn't
46:03
it? David, I really enjoyed the interview today.
46:09
What were your takeaways? Yeah, you know, my
46:12
first takeaway from these things is always that
46:14
I'm sorry we can't go on for longer. I can't
46:16
believe the time runs so quickly. I mean, I think
46:21
one of the things Jenny said that has always
46:23
struck me is even using the term osteoporosis
46:26
for younger people and how she prefers to say
46:29
to a young person, you've got low bone mineral
46:31
density and then discuss the actual fracture
46:34
risk and how it can be managed. And I think that's
46:41
useful because sometimes using the term osteoporosis
46:44
doesn't. you know it it can be helpful but it
46:47
also can scare people and they can believe that
46:49
they must get strong drugs immediately so in
46:52
some ways that's given me some reassurance and
46:54
confirmation that that you know i should probably
46:57
be just talking about low bone mineral density
46:59
for younger people i think that's good i think
47:01
that's a good learning point in general um i
47:04
think the other thing just you can see how complex
47:07
an area this is when you see low bone mineral
47:10
density in the younger person you know one size
47:12
does not fit all there are many different potential
47:15
causes there are many potential different managements
47:19
and of course as jenny mentioned pretty much
47:23
all of the drugs we use if we do use them in
47:26
young people they're not licensed and we're using
47:28
them You know, we're using them sort of on first
47:32
principles or on the basis that they help others.
47:34
But there's really very few or no significant
47:37
large studies showing the benefits of these drugs.
47:40
So, again, emphasising the importance of talking
47:43
to the patients about what we're trying to achieve,
47:45
getting the patients on board, finding out about
47:48
what their values and concerns are and sort of
47:52
making a joint decision. And I think it's particularly
47:54
important that a younger person understands if
47:57
we are going for one of these stronger drugs.
47:59
what we're actually trying to achieve. You know,
48:02
that conversation can be a bit easier in a 75
48:04
-year -old who's fractured a hip. It can be more
48:07
complex in a 21 -year -old who maybe hasn't had
48:11
a fracture, but has a lot of other complex things
48:13
going on. So, and yeah, just to be generally
48:17
inspired by how enthusiastic and knowledgeable
48:19
Jenny is on the subject. And what about your
48:23
takeaways? I think mine were quite... So impressed
48:31
by the depth and breadth of Jenny's knowledge
48:35
about our subject area. For example, even the
48:40
little things like peak bone mass. I've always
48:43
understood peak bone mass to develop sometime
48:46
around about 25 to mid 30s. I never knew that
48:50
the peak bone mass would develop in different
48:52
parts of the body at different times. And I didn't
48:55
know that. At least in women, as Jenny said,
48:59
that peak bone mass develops in the hip before
49:02
it does in the vertebrae. I was very impressed
49:07
by the way Jenny talked about her patients and
49:11
the way that she talks and communicates with
49:13
the patients. I guess the same goes for you.
49:17
It must be very difficult to work with young
49:20
people who suddenly get this bolt out of the
49:23
blue that they have low bone mineral density
49:25
and they might have a fracture. As a young person,
49:28
that's probably the last thing that you would
49:30
think you're going to get told. It seems like
49:35
Jenny has a really great love for her patients
49:37
and a great love for the field, as we said in
49:39
the podcast. And I'm so impressed by that. It
49:41
makes me inspired and it makes me want to do
49:44
more, which I really like. And I think overall,
49:46
my takeaway from this whole podcast is that it
49:50
helps me to keep going because it always keeps
49:52
me inspired and motivated, you know. I hope the
49:56
podcast, I hope it inspires those other health
49:59
care professionals and scientists who are working
50:02
in the field to do what they do with more determination.
50:08
I hope it inspires patients as well who are listening
50:11
to know that there's a lot of work going on and
50:16
that those people who are involved, both seeing
50:18
them in the clinic and seeing them in the surgery
50:20
and seeing them in the gymnasium, but also those
50:23
of us who are involved. like you, you know, in
50:26
the laboratory doing work, that, you know, we're
50:30
continuing to work behind the scenes, that we
50:32
think about what we do, that we reflect on it,
50:34
and that, you know, we're all trying to do a
50:37
better job if we can. Yeah. Working together
50:41
to share best practice. Yeah, absolutely. Well,
50:44
listeners, we hope you enjoyed today's episode.
50:48
Thanks very much for listening, and hopefully
50:50
we'll have another episode up for you very soon.
50:54
Bye -bye. Bye now.