Latest / 'Bone Up' / Global Challenge of Osteoporosis

Transcript

Global Challenge of Osteoporosis · 'Bone Up'

0:00
Hello and welcome to Bone Up, the podcast all about bones.
0:06
How we make them, why we break them and if we fully understand them.
0:10
I'm David Armstrong.
0:11
Hi, and I'm Richie Abel and over this series we're going to be exploring osteoporosis,
0:17
bones, what we know and what we yet to discover and we hope you will join us on the journey.
0:24
So for anyone keen to learn more about our infrastructure of calcified collagen, this
0:29
is Bone Up.
0:56
Good afternoon David, how are you doing today?
0:59
I'm not doing too bad.
1:00
I'm a bit better this week.
1:02
I think you knew I had a bit of a dental emergency last week, I had a tooth abscess, but thankfully
1:10
I was able to get my friend Mark to do some drilling and I feel a lot better now.
1:15
Thanks.
1:16
Actually, I should point out my friend Mark is actually a qualified dentist.
1:19
He's not just a bloke I know who I asked to drill into my head, but no, I'm doing a lot
1:26
better thanks.
1:27
And as you know, dentists and osteoporosis specialists don't always get on.
1:32
So I try not to remind him I'm an osteoporosis specialist before he starts drilling.
1:37
But I was very thankful to see him and doing a lot better.
1:40
And how are you?
1:41
How are things in Imperial?
1:44
All good here at the minute, thanks.
1:46
New term is well underway.
1:48
Students are busy beavering away at their work and we're working on some grant applications
1:53
to put in before Christmas.
1:56
It's a very busy but also a very nice time of year.
1:59
It's interesting what you were saying about the dentist there.
2:01
We've had a lot of people getting in touch with us on Facebook and on Twitter to give
2:07
us some ideas for upcoming episodes.
2:09
And we've had some really good suggestions.
2:12
And one that we got from Sheffield was that we should do something about dentistry and
2:19
the interactions between treatments and dentistry.
2:22
We've had some other suggestions about looking at development of bone, maybe looking into
2:27
the relationship between anorexia and early osteoporosis.
2:31
So please everyone do keep your suggestions coming in and we'll try and fit as many in
2:37
as we can.
2:38
Yeah, we've had many, many suggestions and we really will try.
2:42
If not in this series then in the next series, we will try to get around them all.
2:50
And thank you to everybody who's been listening.
2:53
We've picked up quite a few new listeners in the last month or so since we put out the
2:57
episode with Dr. Javed.
3:00
And we've got new listeners recently in Sri Lanka and also in Taiwan.
3:06
So welcome to Bone Up.
3:09
We also had a listen in the Cayman Islands.
3:11
So if there's anybody out there who's interested in funding any bone research, drop us a line.
3:17
We can send you our sort code and account number.
3:20
Absolutely.
3:21
We'd be delighted to do that.
3:22
Let's just hope it wasn't one of your friends on holiday, Richie.
3:27
I don't think my mum's been to the Cayman Islands.
3:31
On with today's episode then.
3:33
And we've said quite a few times in the podcast before that osteoporosis is a global challenge
3:39
facing the whole world.
3:42
Today we have a guest on the show who's hopefully going to give us some wider perspective about
3:47
that.
3:48
So I'm really excited about today's episode.
3:51
David, I guess in your clinic you're probably going to treat people from all around the
3:57
world.
3:59
Do you see any differences in osteoporosis or risk of osteoporosis or fractures across
4:06
different populations or different ethnicities?
4:12
There certainly are differences in different parts of the world.
4:16
It's one of the first things I think you learn about osteoporosis is that there are certainly
4:24
ethnic differences in osteoporosis and in fractures.
4:28
There was some publicity I think about five years ago now, a study published from Nick
4:34
Harvey's group by our friend Beth Curtis that suggested there was a 50% higher fracture
4:41
incidence in Scotland as compared with London.
4:46
And there was a lot of speculation as to the causes of that, of course.
4:49
There were links with deprivation, for example.
4:52
But one of the issues that came out of that, even within a single country, even within
4:56
the UK, was the ethnic differences and the fact that older white women appear to have
5:03
a 4.7 times fracture risk as compared to older black women.
5:09
And that's something had been known about for a time in different parts of the world,
5:13
but I think it showed how it even can cause a difference within one country.
5:19
It's been known, for example, that black people in America have a higher fracture incidence
5:25
than black people living in Africa.
5:27
And people have often wondered, is that purely a genetic issue or is it related to other
5:34
things, to lifestyle, to diet, to vitamin D, or indeed to the occurrence of other diseases,
5:41
for example, like HIV or TB?
5:45
But it's a difficult area and it's a complex area and it's an area in which there's not
5:49
necessarily as much research as we would like.
5:54
So we know, for example, that it is quite possible to have low vitamin D levels despite
5:59
the fact you live near the equator.
6:02
We know that in some parts of the world, people naturally have a very low calcium intake in
6:06
their diet and yet appear to have quite good bone density.
6:11
There's all sorts of research ongoing and more research needed on the impact of HIV
6:16
and people who are living with HIV on bone health.
6:19
We know that is harmful to bones, but whether that's related to the chronic inflammation
6:25
of the disease or to the treatment of the disease remains, I think, an area still of
6:31
uncertainty.
6:33
And just as we look around the world and we see life expectancy increasing in a lot of
6:38
lower and middle income countries, so the longer people live, the greater number of
6:43
years there are postmenopausal for them to develop osteoporosis and fracture.
6:48
And therefore, some people have said as life expectancy and standard of living improves,
6:54
more osteoporosis is perhaps inevitable.
6:58
But these are complex areas and as I say, there's still huge gaps in research and huge
7:03
gaps in our understanding.
7:06
And today, we might be able to drill down into some of those gaps and at least look
7:12
into the research which is currently being delivered to try and fill in those gaps for
7:17
us and help us to tackle the global challenge of osteoporosis.
7:23
So without further ado, we better move on to our guest today and we're very excited
7:27
to announce that we have Professor Kate Ward from the University of Southampton.
7:32
And just to emphasize what a wonderful guest we have today, I'd just like to have a quick
7:35
run through of Professor Ward's job titles.
7:39
First up, Professor of Global Musculoskeletal Health, Co-Director of the Sub-Saharan Africa
7:46
Musculoskeletal Network, Honorary Senior Research Fellow at the MRC Gambia Unit in the School
7:53
of Hygiene and Tropical Medicine, Professor at the MRC Live Course Epidemiology Centre,
8:00
Director of the NIHR Southampton Global Nutrition Research Group and Honorary Associate Professor
8:05
at the University of Witterstrand, Johannesburg, South Africa.
8:13
Prof Ward, it's great to have you on the show today.
8:16
It's a pleasure to be here.
8:18
Thank you very much for coming.
8:19
It's a wonder you have time to do all those jobs, let alone find time to join the podcast.
8:24
So we really do appreciate it.
8:26
Pleasure.
8:27
Yeah, I think we're taking a lot of man hours out of the osteoporosis research community
8:32
doing this podcast.
8:36
So Prof Ward, we're really excited to have you today because we're constantly telling
8:40
our audience that osteoporosis is a global disease of global importance.
8:46
But so far on the show, we've mostly focused on the UK perspective and interviewing guests
8:53
from the UK.
8:54
So it's going to be really nice today to demonstrate that global perspective.
8:59
And I've wanted to talk to you about your work ever since I saw you speak at the Boards
9:03
BRS Conference in 2019, where you had a plenary lecture about your work in the Gambia.
9:10
And there's a lot for us to go through today, but I suppose the best place to begin is to
9:15
ask if you would just give us a quick outline of the work that you're doing studying fragility
9:20
and fracture prevention in sub-Saharan Africa.
9:24
Yeah, sure.
9:27
So briefly, well, as my job title suggests, I work at Life Course Epidemiology in South
9:33
Hampton as my predominant role.
9:36
And life course research is really where I've always focused my work, particularly during
9:42
adolescence and the later years.
9:45
And so in terms of global health, I've worked in the Gambia since 2008 when I was in Cambridge
9:51
in my previous role and focused very much on understanding how bones develop healthily,
9:57
how we develop peak bone mass in order to prevent fractures.
10:01
But then in the latter years, looking at fragility fractures and understanding the epidemiology
10:06
and risk factors for fractures in later life.
10:10
And that's really where I am today.
10:13
Fantastic.
10:14
I suppose when thinking about sub-Saharan Africa then, an important question is how
10:20
prevalent is the disease osteoporosis?
10:25
I think we know very little.
10:27
There are certain pockets of work such as the National Osteoporosis Foundation in South
10:34
Africa and the research groups in the Gambia of myself and Zimbabwe of Celia Gregson.
10:41
As an example, in the Gambia in the most recent work I've done in the Gambian Bone Aging
10:46
Study or GAMBAS as we like to call it, the prevalence of osteoporosis in women there
10:51
is about 20%.
10:53
So that's just to give you an idea.
10:56
There are many risk factors for osteoporosis that are similar to that that we see here,
11:01
such as aging and low BMI.
11:05
But what also occurs or co-occurs in sub-Saharan Africa are diseases such as HIV, which are
11:11
very highly prevalent and are probably changing the epidemiology and the occurrence of osteoporosis
11:21
and fragility as populations age.
11:25
And I think that's really the key thing about the whole continent is that it's really sub-Saharan
11:31
Africa is the only region in the world where population growth is predicted to keep rising
11:37
throughout this century.
11:39
And so the greatest proportion of older people in the world will live in sub-Saharan Africa,
11:44
which is why it's now a very relevant and timely time to take action in terms of fragility
11:53
fractures and aging healthily across the board.
11:57
So sarcopenia osteoporosis as well.
12:01
It's interesting that you mention that because often when I think of osteoporosis in sub-Saharan
12:06
Africa, I immediately think of things like HIV and treatment for HIV and different types
12:12
of nutrition and life experiences.
12:14
And I was just wondering how similar osteoporosis is.
12:18
So how much, for example, does HIV contribute and how much is it still the traditional risk
12:24
factors that we would appreciate such as family history and other things like that?
12:33
I think you make a really good point.
12:35
I think we don't know fully.
12:37
I think with the improving treatments for HIV, HIV is now considered a chronic disease
12:43
of aging.
12:44
And so we're only now starting to see populations who are living very successfully with HIV
12:51
and other comorbidities getting to the age where we'd normally see osteoporosis start
12:55
to occur.
12:57
So in terms of understanding fracture prevalence and the impact it has, we don't yet know that.
13:04
There is certain data from elsewhere across the globe that suggests that fracture prevalence
13:08
is higher in individuals with HIV.
13:12
But certainly as part of our new research, we will be looking at that in much more detail
13:18
in Zimbabwe and South Africa.
13:21
In terms of family history, we're talking about countries where life expectancy has
13:26
been relatively low compared to what we'd expect.
13:30
Of course, with the epidemiological transitions we're seeing, which differ across the continent
13:35
as well, we're now seeing life expectancy rising quite significantly.
13:42
And so I think over the next five to 10 years, we're going to get a much better idea about
13:47
those risk factors and what we might do to prevent the disease.
13:52
Yeah, it's interesting thinking of fracks, for example.
13:55
One of the strongest components of fracks is a parental history of hip fracture.
14:00
But obviously if life expectancy is quite limited, then the chances of having parental
14:04
hip fracture, I presume, are much less than if the life expectancy is maybe 70 or 80.
14:13
Do you find fracks useful in that sense?
14:16
Is it not as useful?
14:18
So until recently, fracks hasn't been calibrated to sub-Saharan Africa, but work with the fracks
14:24
team together, well, led by Sapna Della and Bilkish Kassim in South Africa.
14:30
There's now a model for fracks in South Africa.
14:33
And I believe the risk factors are still the same as in our fracks, as we would see here.
14:39
It's also been calibrated to Zimbabwe and I think Botswana and Kenya.
14:46
So the use of fracks is growing, or the availability.
14:50
And I think with that, again, it will give us a much better idea about those risk factors
14:56
and how, again, how prevention of the disease might occur.
15:04
With a HIV risk factor, is it the disease that is a risk factor or is it the antiretroviral
15:11
drugs that people take to treat HIV?
15:14
I think it's multifactorial.
15:17
We did some work quite a few years ago now in premenopausal women with and without HIV
15:24
and looked at people who had just initiated antiretroviral therapy.
15:29
And so at the beginning, the bone mineral density, which would use as our measure and
15:34
an outcome to understand what's happening to the bone, bone mineral density was similar
15:38
in those women with HIV and without HIV.
15:43
When they started the ART treatment, they had a significant loss of bone, which then
15:47
reached a sort of a steady state after 18 months to two years, which suggests that the
15:53
antiretroviral therapy might be one of the big drivers.
15:57
But of course, there's the chronic inflammation.
15:59
There are the comorbidities that are associated with the disease as well.
16:04
In children as well, I know we're not focusing on that right now, but in children, growth
16:08
is poorer in children living with HIV and antiretroviral treatment.
16:15
So I think it's multifactorial.
16:17
It's very difficult to pick out one factor, but it's certainly a significant factor that
16:25
we need to consider.
16:28
The follow on then from asking are the causes of osteoporosis similar in sub-Saharan Africa
16:36
is asking are the consequences similar?
16:39
So we're all used to the figures, let's say in the UK, if you suffer a hip fracture, there's
16:44
a 20% one year mortality.
16:47
If you have a hip fracture, I think it's less than 50% of people are independently mobile
16:51
out of doors.
16:54
What's the picture then in the areas in which you work, for example, in the Gambia, what
16:58
effect does having a fracture have on your ability to work your role in society?
17:03
What availability is there of orthopaedic care?
17:08
So formally, I can't give you any figures for the Gambia.
17:12
What I can say is that the orthopaedic care is growing.
17:16
There are, I think, currently between four to six orthopaedic surgeons in the Gambia.
17:22
It's a very small population, but the healthcare and resources, of course, are challenged across
17:30
the continent.
17:31
So that's not unique to the Gambia.
17:35
But the consequences are that it's very difficult and very expensive to access hip replacements,
17:41
materials for successful recovery.
17:46
There's often a long delay to operation, which of course we know here has a significant impact
17:54
on the outcomes.
17:56
People in the Gambia, there's a big cohort of traditional bone setters.
18:02
And so people often for any musculoskeletal condition would consult them first.
18:07
And so that may or may not impact outcomes.
18:12
And so I think all of your questions so far point to the Fractures E3 study, which is
18:18
a collaboration led by Celia Gregson from Bristol, together with myself and Bilkish
18:25
Kaseem in South Africa, Rashida Farand in Zimbabwe, and Landing Jarja in the Gambia.
18:31
And with that, we're going to study in much more detail the impact of hip fractures.
18:37
We're going to look at hip fracture incidents.
18:40
We're going to look at vertebral fracture prevalence in Gambia and Zimbabwe in South
18:45
Africa.
18:46
We're going to look at the health economics and look at the service availability and readiness
18:51
assessment.
18:53
And also, and I think very importantly, look at the individuals and the barriers and facilitators
18:59
to them accessing services and how those pathways actually work in our different contexts.
19:06
I think one of the things that my personal research has led to for me is understanding
19:13
that one size doesn't fit all and we can't assume that what we know here applies elsewhere.
19:20
And I think it's the same in the Gambia.
19:22
It's all sub-Saharan Africa.
19:25
The continent is so vast.
19:28
Gambia is one of the poorest countries in the world and one of the least transitioned,
19:32
whereas South Africa is a middle-income country.
19:36
Much more healthcare provision with different barriers, facilitators, and risk factors.
19:41
So that's really when we put the programme together, why we wanted to look at the different
19:46
countries to be able to take a broad approach to the context we're researching.
19:52
This sounds like the biggest audit I've ever heard of.
19:57
Trans-country continental level audit.
20:01
That's amazing.
20:03
It's exciting.
20:04
It's daunting, I must say, Ritchie.
20:07
It's daunting and very ambitious.
20:09
We're fortunate to have the platforms that we can, in the Gambia, I've got two Dexam
20:16
machines and I've got peripheral quantitative computer tomography.
20:20
So the techniques that we can use to really study bones and look at their shape and their
20:24
design in much more detail.
20:27
And that's what we'll do in the Vertible Fracture Study.
20:29
But I think the mixed methods that we'll be using and the teams that we've assembled
20:34
across the UK and across Africa just presents such an opportunity.
20:41
I'm not sure I'd describe it as an audit, but I think it just presents that opportunity
20:48
and platform for us to really try to make a difference to care across the countries
20:55
we're looking at and hopefully wider.
20:59
So how do the mechanics of the research work?
21:03
Is it easy to travel to Africa and then travel around Africa to get to the communities and
21:10
get people Dexascan'd?
21:13
I know in the UK, for example, a lot of patients here don't get Dexascan'd because it's difficult
21:18
to get to hospitals.
21:20
Car parking fees are expensive.
21:22
Public transport is very poor.
21:25
How do you cope with those kind of problems?
21:28
Well we have very good teams.
21:31
We have in-country teams.
21:34
So all of the research is led by them.
21:37
So there'd be no way you could do this.
21:39
You know, sat in a university in the UK trying to govern it all.
21:45
So we have very experienced teams who in the Gambia, my team are based in a rural site.
21:52
They're both Medical Research Council Gambia sites.
21:58
And so the teams engage communities.
22:00
There's a lot of sensitisation of communities about why we want to do the research, why
22:05
we think it's important.
22:08
And so we work up the research with them.
22:11
It's interesting, the Gambas study, which is a predecessor to Fractures E3, we never
22:18
did many studies in men.
22:20
We often, we look at mothers and children to understand quite rightly maternal and child
22:24
mortality.
22:25
And the men started to say, look, why don't you ever talk to us and why don't you ever
22:29
try and understand what's happening with our health?
22:33
And so that Gambas came along and we did, of course, because of male osteoporosis being
22:39
such a prevalent issue in the UK and elsewhere.
22:43
We added men into the mix, which was great.
22:47
That presented its own challenge.
22:49
There's many sort of cultural and social challenges to studying in these countries.
22:54
And that's why you just have to have the team that's committed and dedicated and able to
23:02
engage and work with the communities.
23:04
It's vital.
23:05
It sounds like this is a really wonderful project guided by the patients and the people
23:12
towards the health care they need.
23:14
Yeah, I think more and more so.
23:17
I mean, I could go completely off piste and talk about another hat that I wear in the
23:23
global nutrition group.
23:24
But I think engaging communities and understanding what they want and what they need and their
23:34
understanding or prioritisation of what you want is absolutely crucial.
23:38
I think it's across research now.
23:42
It's really important.
23:43
We see it at the Royal Osteoporosis Society and in the NIHR here.
23:48
The role of the patient in directing research and helping researchers understand what's
23:55
important to them is invaluable.
24:00
Which there greater potential do you feel for preventing osteoporosis and fracture in
24:05
lower and middle income countries than we'd maybe see here?
24:10
In the UK, so many of our patients have passed their peak bone mass.
24:14
We're trying to reverse decline.
24:16
It strikes me a lot of the work you're doing is still at the preventative end.
24:20
You're talking about adolescents and young people and mothers and babies.
24:25
Or do you maybe just face the same barriers as we would face in the UK, for example, in
24:32
preventing osteoporosis?
24:33
I think the barriers and challenges are the understanding, again, of the risk factors
24:39
or what we need to do.
24:42
Some of the research where I started in the Gambia, it was all based around very low calcium
24:49
intakes.
24:50
Well, if a population has a very low calcium intake, surely what you need to do is increase
24:54
their calcium intake and prevent fractures, which is what we do here.
24:59
The complete paradox in Africa is that there are very low calcium intakes, but the fracture
25:05
incidence is much lower.
25:07
And that's the same for children as it is for adults.
25:12
I think there are opportunities because we are trying to gain an understanding of growth
25:21
and a better understanding of adolescent growth and how you can, I guess, empower adolescents
25:28
to make choices of their own.
25:30
Again, that's happening in the UK, but also in Africa.
25:33
And so guiding around health in general, I don't think you can really just take bone
25:40
by itself in isolation or cognition.
25:43
I think it's taking that approach to health in general and optimizing growth, optimizing
25:54
child outcomes to be able to prevent osteoporosis through improvements in peak bone mass.
26:01
So I think it's complex.
26:05
And wonderful.
26:07
You mentioned that paradox.
26:11
You mentioned that paradox, which I think is reasonably well known that often in Sub-Saharan
26:14
Africa, there's quite low calcium intake, but you wouldn't see the severity of osteoporosis
26:19
and fractures you might expect.
26:21
Is there something else which is correcting for that?
26:25
So for example, is physical activity or more physically active lifestyles correcting for
26:31
that or is it genetic elements that are correcting for that or is it complex?
26:39
It's complex.
26:40
I think there's an adaptation to that low calcium intake.
26:48
It means a different thing because the population has evolved to survive on the nutrition that
26:56
it has.
26:57
And so a very low calcium intake in the Gambia means something very different to a teenager
27:04
or an adult here having 300 milligrams of calcium a day, which is about the average
27:09
in the Gambia across the population.
27:13
I think there are hints that there are adaptations in the parathyroid hormone axis and absorption
27:21
of calcium.
27:22
And we've recently seen differences in adaptations to pregnancy between UK and the Gambia as
27:29
well.
27:30
So I think the body is a remarkable thing to adapt to that situation.
27:36
I think one of the challenges that's presented as countries transition and availability of
27:43
food changes and variability of food or quality of food choices happens, I think that's the
27:52
challenge because the populations are adapted to what they have.
27:58
But then as things change or proportions change, then that might then become a risk factor
28:04
in later life.
28:06
So necessarily increasing calcium intake across the Gambia may not improve the outcome in
28:11
terms of osteoporosis or fractures.
28:14
In fact, it could potentially have negative consequences on other aspects of health.
28:19
Yeah, that is potentially.
28:22
Certainly in our work in children and the intervention studies, there wasn't that lasting
28:25
effect of calcium supplementation that you would expect.
28:30
It changed the timing of puberty, but it didn't really have a positive benefit on bone density.
28:39
It's amazing that you're studying developmental health as well as aging at the same time.
28:45
That must be an incredibly difficult project to pull off.
28:50
Is it possible, going back to David, what David was saying earlier on, that if you do
28:54
have a much better handle on development and the effects of development on bone disease,
28:59
that you would be able to set up a system for very early prevention of bone disease
29:05
in old age?
29:06
Well, yeah, I mean, there's been quite a lot of work from cohorts here in the UK, like
29:14
the Hertfordshire Cohort Study.
29:17
I've done some work with the National Survey of Health and Development, which is a 1946
29:22
birth cohort, and work that has also been done by Southampton in Helsinki shows that
29:28
that trajectory of growth and the way that you transition through puberty impacts peak
29:33
bone mass, and that peak bone mass then impacts later fracture risk.
29:38
Now, that's a study that now you don't have the opportunity to really get those birth
29:44
cohorts and follow them all the way through.
29:47
But for sure, the way people gain weight, gain height, and as I said, transition through
29:53
puberty, whatever is optimal for that population is probably going to have an impact on their
30:00
later life, together, of course, with environment and factors such as vitamin D status and nutrition,
30:09
physical activity as well.
30:12
Vitamin D status is obviously another interesting topic.
30:16
Some people imagine that vitamin D status is great in sub-Saharan Africa and that vitamin
30:20
D deficiency doesn't exist.
30:22
And have you any insights on that?
30:24
Yeah.
30:25
I mean, there was a really nice review last year.
30:30
I can't remember the name of it, which doesn't help you.
30:32
I mean, there's quite a paucity of data in sub-Saharan Africa, but there is prevalence
30:42
of rickets.
30:43
It's calcium deficiency or calcium and vitamin D deficiency rickets in younger children.
30:47
There's quite a lot of work in Nigeria on that from Tom Thatcher and John Pettyfore.
30:55
And the vitamin D status in the Gambia is pretty good.
30:59
Gambia, for the listeners, is just north of the equator.
31:03
So it's a tropical climate.
31:06
It's seasonal.
31:07
But vitamin D status is adequate.
31:10
You know, the levels are what we consider healthy here.
31:18
In the more seasonal climates in the more southern Africa, vitamin D deficiency does
31:24
occur.
31:26
I don't know.
31:27
There's quite a lack of data in adolescents and older people.
31:31
So I can't think off the top of my head of figures for them.
31:36
But certainly, I think also clothing choices and, of course, darker skins impact the absorption
31:43
of vitamin D as well.
31:46
So certainly, there are populations where, and populations within those populations where
31:52
vitamin D deficiency is an issue.
31:56
And certainly something we want to look at in terms of risk factors for older people's
32:00
musculoskeletal health.
32:02
So it sounds as though the risk factors in sub-Saharan Africa are much more complicated.
32:12
There might be a lot more variation within populations, especially between countries.
32:20
Possibly there'd be more of an impact of developmental health on health in old age in the sub-Saharan
32:27
populations than perhaps in the UK?
32:31
That's a very good question.
32:38
I suppose with osteoporosis research has been happening for so long here, I can remember
32:45
debates about risk factors when I first started in this field quite a long time ago.
32:52
And I think the complexity of risk factors and the evolution of risk factors is still
32:58
occurring here, for example, if you looked at people who were with obesity, the profile
33:06
for fractures is very different, but they might be at risk of lower trauma fractures
33:10
than we'd have previously thought they might be.
33:13
So in sub-Saharan Africa, I think there are a lot of unknowns.
33:17
Of course, as I said earlier, the ageing population is increasing rapidly.
33:25
And with that, there are changes in housing with the transition.
33:31
There's changes in roads, there's changes in traffic use.
33:34
The number of higher trauma fractures and road traffic accidents, I know in the Gambia
33:40
is a massive concern to the healthcare system because of that accessibility now to transportation.
33:48
So I think it's almost like there's more of a rapid change happening in the environment
33:57
that will need to be dealt with for older people to prevent fractures than maybe we've
34:03
seen as a more general evolution here over hundreds of years.
34:11
I think wherever you research or look at musculoskeletal health, I think there is often that thing
34:19
or the assumption that one size does fit all.
34:23
And it's something that I've probably annoyed people with many, many times talking about
34:29
it.
34:30
And I know Anne's group, who I worked with in Cambridge, often said it.
34:36
One size really doesn't fit all wherever you are.
34:40
And whether you're in the US on the West Coast, East Coast, Midwest or in the UK in Cornwall
34:48
or Aberdeen, I think there's always that range that needs to be considered when you're thinking
34:55
about environment and risk factors.
34:58
I'm absolutely in awe of the size and complexity of this project.
35:04
Osteoporosis on its own is a complicated problem.
35:08
It sounds like there's so much variation between countries, between populations, and the patterns
35:13
of those variations are going to be constantly changing, probably for generations.
35:20
It's mind boggling.
35:22
Absolutely mind boggling.
35:23
It is.
35:24
Do you have any ideas about how you might be able to bring this research to bear for
35:32
the people?
35:33
Any ideas about how you might be able to use the data and information that you're collecting
35:40
to develop or change clinical practice to improve outcomes?
35:45
The key thing for Fractures E3 will be engagement with policymakers, both nationally and internationally.
35:52
So we've already, within each of our countries, engaged with the Ministry of Health.
35:58
And depending on how the healthcare systems are organised, talk to regional directorates,
36:06
to individual healthcare centres in the Gambia.
36:09
Traditional bone setters are a very big part of the research that we'll do.
36:14
And so I think the primary thing will be to have some, have data that we can provide to
36:20
them about pathways of care that their patients have.
36:25
And what might be possible to improve care within the limits of what they're able to
36:37
do.
36:38
So I think that's probably one of the first things.
36:40
I think I would hope that we would be able to get some education or engagement activities
36:49
with communities for them to understand healthy ageing and what's happening with their relatives
36:57
and the importance or the possibilities that might present in terms of recovery and an
37:05
older person having a quality of life, helping them return to work.
37:11
I think David asked me about that earlier in terms of productivity.
37:14
And so giving options to people with osteoporosis or poor mobility that are achievable and will
37:23
support them and just give back that quality of life that we know is possible from all
37:29
of the work that's done here.
37:32
One of the great things about increasing life expectancy is I suppose people then need to
37:36
prepare for longer life and think about it.
37:39
It's something we've talked about a lot in that you put money in the bank when you're
37:44
younger so that it's there.
37:45
Well, you can do that literally for your pension, of course, to prepare for older age, but certainly
37:49
in terms of your bones as well.
37:52
But that's maybe just a mindset as life expectancy increases, then we need to plan for health
37:57
in older age as well.
38:00
And if things are complex or confusing, it's just because we don't have enough data yet.
38:05
And hopefully you're going a long way to resolving that problem.
38:11
Hopefully.
38:12
Hopefully.
38:13
How does it feel to be running such a large and important and potentially incredibly impactful
38:24
project in the world?
38:29
Well Fractures E3, Professor Celia Gregson from Bristol is the PI, so I guess the book
38:36
stops with that.
38:38
In terms of the Gambia project, and I know the Gambia projects I find intensely rewarding
38:50
in terms of, you know, I'm a researcher, I fell in love with research 30 years ago, and
38:57
I've been fortunate that I've been able to evolve questions and make them relevant as
39:02
times progressed.
39:06
It is daunting, it is daunting, but I think the greatest pleasure you get is in knowing
39:15
that you are building teams, you're helping to build capacity in an area that's under
39:22
resourced and that you see the growth in people and groups and that you can really hopefully
39:32
have an impact on communities.
39:33
I'm not there yet in terms of the community changing what's happening, but I think that
39:40
building and growing the research and recruiting and recruited a new PhD student three weeks
39:47
ago and just starting, you know, that time in a PhD's life where you're starting to
39:53
plan the questions and start to engage them and try and give them that enthusiasm for
39:58
research, it's very rewarding.
40:02
The most amazing thing is that by setting up the in-country teams, you're going to
40:08
build a legacy potentially of generations of researchers and scientists who are going
40:14
to be addressing osteoporosis.
40:16
It's amazing, just amazing.
40:19
Hopefully, hopefully.
40:23
At some point we're going to have to get you back on so you can give us an update on the
40:27
project and I think we're going to need to talk to some of the other members as well.
40:30
Yeah, that would be really good actually to hear because we know you're still at the early
40:34
stages of a lot of this work, so it'd be really exciting to see what comes from it and, you
40:41
know, even maybe hear some voices somewhere from the people who are actually taking part
40:47
in the research, you know, people from the Gambia, Zimbabwe or South Africa even to somehow
40:52
just hear what it's like from that side of the research.
40:58
That would be a really exciting thing to do as well.
41:01
I'm sure we could facilitate that and yeah, be delighted to help with that.
41:07
Every time we do a podcast, we come up with at least two more podcast ideas.
41:10
That's good.
41:11
It is, it's really great.
41:12
And most of them come from talking to our guests and just how interesting and exciting
41:19
it is to talk about bone health with people from different perspectives.
41:24
This research goes beyond interesting and exciting and into inspirational.
41:30
That's very kind, Richie.
41:34
It's unbelievable.
41:37
It's been such a pleasure to talk to you today, Kate.
41:40
Thank you so much for coming on the show.
41:42
Well thank you very much.
41:43
I've really enjoyed speaking to you both as well and looking forward to coming back.
41:49
It's been really, really great and thank you for making the time.
41:51
I know you've had even council a meeting this afternoon to speak to us, so we really do
41:55
appreciate that.
41:57
And the wifi stood up at the end.
42:01
That's great.
42:02
Thank you, Kate.
42:05
Bye bye.
42:07
Bye.
42:08
Bye.
42:10
Wow, that was awe inspiring.
42:13
The size and scope and the impact of that research is enormous.
42:21
It is.
42:22
It's what Professor Javed was saying to us just in the last podcast about how you can
42:27
treat one person in front of you and make a difference to that person.
42:32
He mentioned you can change a guideline or change a government policy and make a difference
42:36
to tens of thousands of people, but potentially the work that Kate and her colleagues is doing
42:42
here has the potential to change the health of hundreds of millions of people and have
42:49
a legacy that would go through generations right across Africa.
42:53
It's as you say, just the scope of it is really fantastic.
42:59
And the idea that because each country is different, the problems, the barriers and
43:07
the solutions might be slightly different in each country on top of that.
43:12
To think that they are engaging many governments at the same time in their research is incredible.
43:22
When we did the leadership training with the Royal Osteoporosis Society, we should tell
43:28
the listeners one of the programs that we did, we got taken to the Houses of Parliament
43:37
for a couple of days and we met lords and we met civil servants and we met MPs and we
43:42
practiced trying to engage with them, pitch ideas with them, try and get them interested
43:47
in osteoporosis and the problems.
43:50
And I remember thinking, wow, this is hard.
43:53
They have so many demands on them.
43:54
It's going to be hard for us to be heard.
43:58
To think that Kate and the wider team are doing that with many, many governments at
44:03
the same time is incredible.
44:05
The amount of communication is enormous.
44:09
Absolutely.
44:11
And it wasn't interesting to how she talked about it's so important to engage people
44:18
where they are.
44:19
So for example, she said people have a lot of trust in the traditional bone setters,
44:25
let's say in Gambia.
44:26
And therefore it was really important to have people involved in that sort of as part of
44:33
your project and to involve them and to reference them as part of it.
44:39
It was so many challenges and yet they're so positive and so optimistic about being
44:46
able to do this work.
44:48
Yeah, we touched a little bit in the interview on the patient involvement.
44:54
Yeah.
44:55
But really, this project goes way beyond that to engaging whole communities.
45:01
Whole communities, health healers, the clinical community, the local people and the in country
45:09
teams.
45:10
Wow.
45:11
Wow.
45:12
I mean, I think one of my big take home messages will be just what she said that one size doesn't
45:19
fit all.
45:20
And just because we think we understand bone health and osteoporosis in a higher income
45:27
setting, those things do not necessarily apply to countries with lower and middle incomes.
45:35
Even something simple like the fact that calcium in the diet tends to be quite low in sub-Saharan
45:41
Africa, but that is not associated with the rates of osteoporosis and fracture you might
45:47
expect to see, let's say in the UK or North America.
45:51
And therefore, by consequence of that, increasing the calcium in the diet does not necessarily
45:57
have the same effects as you would see in some of the research done, let's say, in Europe
46:03
and just how we need to really go back to square one.
46:06
And so much of the data they're getting at the moment is so exciting.
46:11
It's so interesting that they're really taking nothing for granted and they're starting really
46:17
at the bottom and looking at the prevalence of fractures, prevalence of osteoporosis and
46:22
looking at all these different risk factors, as I say, on the basis that one size doesn't
46:28
fit all.
46:30
And just also looking, she mentioned about educating people and particularly younger
46:35
people to have autonomy over their health and to realize that they can actually make
46:39
a difference to their health, not just now, but have an impact on their health in the
46:46
future and as the life expectancy increases and even impact upon their fracture risk as
46:51
they get older, which is something we're saying to people in the clinic that I work in, and
46:58
it's relevant, as you can say, all across the world.
47:03
I think as a scientist, my takeaway is that Kate and the wider team might rewrite our
47:11
understanding of bone and bone health and rewrite our understanding of how bone develops
47:18
and how bone ages, especially in terms of how much variation there might be across the
47:24
world.
47:25
That's amazing, really amazing.
47:29
And it's made me think about how I engage the people around me, how I engage with patients,
47:34
how I engage with clinicians, how I engage with my research teams.
47:39
And it's going to make me think about what I can do better and how I can improve.
47:44
Yeah.
47:46
Just that idea of having a legacy that could extend to over tens and hundreds of millions
47:52
of people for generations to come.
47:54
It's really wonderful work that's being done.
47:56
And certainly on behalf of the podcast, we wish them every success and we look forward
48:02
to hearing more about it in future.
48:06
Absolutely.
48:07
We definitely have to get some of the team members on for an update.
48:14
That would be really good.
48:16
Okay, we better say goodbye to everybody now.
48:20
Thank you for listening today.
48:21
Hope you enjoyed this episode and we'll speak to you all again soon.
48:25
Goodbye.
48:26
Bye now.