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Never too late: exercise and bone health in older people · 'Bone Up'

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Hello and welcome to Bone Up, the podcast all about bones, how we make them, why we
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break them and if we fully understand them.
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I'm David Armstrong.
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Hi, and I'm Richie Abel and over this series we're going to be exploring osteoporosis,
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bones, what we know and what we yet to discover and we hope you will join us on the journey.
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So for anyone keen to learn more about our infrastructure of calcified collagen, this
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is Bone Up.
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Hello again and welcome back to Bone Up, the podcast all about bones.
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It's nice to see you again Richie.
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We've had a very slight delay in getting this episode out for various reasons.
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We both have real jobs I suppose, but it's great to get back talking about bones.
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Oh, it's fantastic.
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It's really good to see you again.
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And for the benefit of the listeners, we have a little video display so we can look at each
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other while we're talking and we find it a bit easier.
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How are you this week, David?
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I'm not doing too badly.
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We're still working hard in the hospital here coping with the pandemic, but I do my best
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to get a little work done on bones as well and all things osteoporosis.
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So it's great to have the support.
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We've had lots of feedback from listeners as you know all around the world and that's
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very encouraging and that's very, very positive.
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My daughter was telling me she has been listening to the podcast.
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She tells me she listened to it when she was doing her shopping in Tesco's and that she
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finds it hilarious.
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So I don't know what's more concerning that she's not giving us 100% attention or that
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she seems to feel it's a comedy episode.
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But as I think you said in the previous podcast that the family are always your harshest critics.
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It's good that they're listening.
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The latest download figures are looking really good.
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We've had over 1300 downloads in 32 countries, which is great for three episodes.
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Although I wonder how many of the downloads are our families?
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Well people on Twitter have been very good supporting us as well and encouraging others
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to listen.
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So that's all that's all very positive.
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Yeah, a big thank you to everybody who's been contacting us on Twitter and sending us emails.
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It's really good to know that people are listening, we're getting some really wonderful feedback.
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So thank you very much.
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It'll help us keep going.
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It's wonderful and there has been some comment on Twitter this week.
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Osteoporosis has been, I wouldn't quite say in the news, but there is a popular BBC medical
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programme, medical drama called Casualty and one of the characters playing the doctor in
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Casualty gave it some advice about osteoporosis this week and certainly lots of people have
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been on Twitter raising their eyebrows about the advice that was given out because that
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advice was that if you had osteopenia or osteoporosis, if you had weak bones that you should avoid
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exercise and specifically avoid running.
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And really we couldn't be more on point then with our topic today, which is about exercise
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and bone health and exercise and osteoporosis.
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You're probably aware of that, Richie, you saw that on Twitter?
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I did, yeah, and it reminded me of last month's interview with Dr. Paskins.
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And Zoe said to us that when she was thinking about patient communication, she had the concept
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of one wrong word.
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And that's been ringing in my ear ever since last week.
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And I think this is a really good example of that, where a big media outlet has had
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one or two wrong words and misinformed the public.
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And it's really great, like you say, that this week we are going to be talking about
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exercise because it's a good connection between last month's episode and this month's episode.
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And it's obviously very timely.
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And I suppose the place to start is by asking you, David, about what you do in your clinical
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practice with your patients.
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How do you advise your patients?
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I mean, I think the first thing to say about exercise, even talking, before talking about
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any specific guidance, is just to get the message out there that exercise is good for
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bones.
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I mean, people understand that if they exercise, they expect their muscles to get stronger.
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If they go to the gym, they expect their muscles to get stronger.
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And that's something we've mentioned before.
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Muscles and bones, they exist together in the body.
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They develop from the same stem cell.
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And therefore, you expect your bones to get stronger as well.
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Exercise is good for bones as well as muscles.
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That may surprise you, and I hope you will be surprised, Richie, I qualified as a doctor
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26 years ago this year.
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Just yesterday.
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Just yesterday, absolutely.
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And certainly when I started working as a doctor, it wasn't unusual for people to be
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admitted to hospital for rest.
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If you're having problems with your muscles or your bones, you'll be brought in for a
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good rest.
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Which guidelines do you recommend to your patients and why?
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There are excellent guidelines from various bodies.
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The ones that I recommend to most people are those produced by the ROAS, Royal Osteoporosis
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Society.
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They have guidelines called strong, steady and straight.
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And those three different areas really sum up exercise in terms of bone health.
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The strong area is, I suppose, what people would consider training.
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And that is building up bones, building up muscles, doing resistance exercises, things
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that you need to put your sports clothes on for.
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Steady is based on balance.
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That's something which is often supervised by a physiotherapist, but involves improving
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your balance, improving your core strength.
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And finally, straight is based on the idea of caring for your spine and various exercises
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and stretches and advice you can do to prevent further spinal fracture and care for the spine.
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And they really highlight a number of points.
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Just even on the front page of that guidance, that people should be doing more exercise
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rather than less if they have osteoporosis.
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And again, that goes directly against what you saw on that television program.
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Someone was told they had osteoporosis.
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They were told to do less exercise.
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It's the opposite we should be telling people.
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If you've got weaker bones, you should be doing more.
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We should be encouraging people how to exercise, how to do the things they enjoy rather than
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telling them not to do specific things.
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And finally, we should be avoiding telling people to restrict exercise purely on the
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basis of an opidexia scan.
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In fact, if your bone density is low, you should be doing more.
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The ROS guidelines seem quite simple and straightforward.
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Is that why you recommend them to patients?
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Yeah, they're both comprehensive and yet they really fit on a couple of sides of paper.
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And, you know, they can be easily printed out and put on the wall of a surgery or put
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on the fridge door at home.
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I mean, as I say, they cover things you can do to actually build your bones and make them
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stronger.
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And that can be using resistance bands or using weights or even exercising using your
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own weight.
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They involve improving your balance.
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Simple things like standing on one leg, usually worthwhile having supervision from a physio
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if you are quite frail and your balance is poor.
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And then things about improving your spine, low intensity exercise, stretching, swimming,
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things like that.
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It's set out really for people who are keen to go to the gym and do exercise and perhaps
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for whom sport has been an important part of their life.
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There are also lots of examples there for people who don't really play sport, have never
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been to a gym, but who there are other things they can do.
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There's dancing, walking, all sorts of other ways to exercise.
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So they're very much aimed at patients.
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They're comprehensive.
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They're backed with a lot of science and people find them very helpful and very accessible.
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So without trying to reinvent the wheel, I would suggest to most people that they go
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and have a look at the ROS site and look at the strong, steady and straight advice that's
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there.
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So listeners, if you want to take a look, the website is theros.org.uk.
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We'd highly recommend taking a look.
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It's time for some wider perspective.
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So we had better get onto this month's interview.
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So I'm really excited today to say that we have Dr. Alex Mavroidi, Senior Lecturer in
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the Physical Activity for Health Group at the University of Strathclyde, Glasgow.
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Alex works in the fields of nutrition, exercise, sedentary behaviour and of course, bone health.
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Welcome Alex.
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Great to have you today.
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Lovely to see you, Alex.
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Welcome to the podcast.
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Thank you for having me guys.
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Alex, I suppose the big question that we all have, scientists, clinicians, patients, the
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listeners at home, what are the major determinants of bone health, especially in older people?
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Well, there are a number of influences of bone health.
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So there's an interdependence of factors that could determine someone's bone health.
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First of all, genetics.
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We know that about 85% of our bone mineral density is determined by genes.
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And therefore, there is a very, very strong influence on the way that our skeleton ends
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up.
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The other big influence comes from hormones.
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We know that as women get older and they go through the menopause, their estrogen levels
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goes down and that has a profound effect on their bones.
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But there's not much that someone can do about their genetics.
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You can't choose who your mum or your dad was.
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And there's not that much you can do either for the natural decline of hormones that come
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through aging.
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There is, however, something that you and I and everyone can do about lifestyle choices.
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They're also very important on determining how good our skeleton is going to end up being.
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So lifestyle choices like what we eat and drink and how much, how often and what type
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of physical activity we do.
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Interesting.
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So there's, I suppose, the non-modifiable risk factors and then the modifiable one.
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Absolutely.
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So non-modifiable things like genes and hormones that change through the normal aging process
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and the modifiable risk factors, nutrition and physical activity.
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For physical activity, there seems to be a lot of confusion about the effects and the
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importance of physical activity, especially in older people.
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In our intro today, we were talking about casualty on the BBC, giving out poor advice,
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recommending no exercise to people with osteopenia and osteoporosis.
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I guess the burning question that our listeners are going to have is can physical activity
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improve bone health in older people, even in people with osteoporosis?
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So the sort answer to that is definitely.
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And now let me give you a kind of longer answer to that.
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We know that physical activity is very important throughout the lifespan for a healthy skeleton.
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The most, if you want, the most impressive influences on the skeleton are during childhood
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and adolescence.
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That's when people build up their skeleton.
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And it's a very important time during your life to actually give your skeleton a good
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start.
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Up until you reach peak bone mass, which is in your kind of late 20s.
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Once you reach skeletal maturity, exercise also has a role to play in maintaining that
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good bone mass that you built while you were younger and also making small increases as
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well.
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So in younger age, in children and adolescents, you see randomized control trials that can
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achieve in a very small period of time impressive changes in bone marrow density.
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We're talking about five to six percent increases.
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In older years, when you're in the adult stage, those changes also occur.
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So there is improvements in bone marrow density, but they're slightly smaller, one to two percent.
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What happens when you get into the postmenopausal year and the older years of your life?
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Exercise also is very important for bone marrow density, but it's also important for other
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things that would make sure that you don't fall and fracture your bone.
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So exercise becomes very important for muscular strength and balance, which will prevent people
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from having fall and therefore prevent people from having a fractured hip or a fractured
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wrist.
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So the answer, the short answer is yes.
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Exercise throughout the lifespan is very important, very important in younger years, during your
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adolescence, during your adulthood for maintaining bone marrow density and in the older years,
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not only for maintaining bone marrow density and reducing how much bone mass you lose through
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the aging process, but also for maintaining muscle strength and balance that would reduce
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your chances of falling and fracturing.
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So exercise then seems like a really good way to prevent falls that cause fractures,
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as well as improving bone health as well to resist the fall.
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Correct, especially in older age, yes.
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Hi Alex, I always end up getting the very practical questions, maybe that's how my mind
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works.
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So if you had an older patient who's come to see you, who has osteoporosis, maybe they
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haven't been particularly active in the last five or 10 years and they were asking for
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just one way they could start or maybe just one or two things they could do, they could
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change their lifestyle in terms of exercise, what would you advise them?
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So the first thing that I would advise them is to minimize their sedentary time, the time
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that they spend doing what we're doing just now lads, sitting on a chair in front of a
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counter, sitting on a sofa, watching TV, any type of activity that it's on kind of a lying
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position or a sitting position.
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That is very important.
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We know that older adults spend an enormous amount of their daily routine sitting or spending
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it in sedentary positions.
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So about 80% of their waking days is spent on sedentary activities and that represents
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about eight to 12 hours per day that people could be sitting and not doing much.
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So reducing the amount is very important of how much we sit, but also breaking down the
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long periods of sitting or sitting balance effectively by simply just standing up every
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30 minutes.
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So that's the first thing that I would say to them.
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Reduce how much you spend sitting about and also if you are sitting because you're watching
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your program, make sure that you put your remote control on the other end of the sofa
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so that you have to stand up and break up your prolonged period of sitting and therefore
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becoming more active during your sitting time.
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So that's one.
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And the next thing that I would say for born health is that every older adult should incorporate
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in their weekly routine at least two days a week of doing strength and balance exercises.
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Now strength exercises are important to keep our muscles and our bones and our joints strong
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and balance exercises are important for older people to reduce their chance of frailty and
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falling.
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So I would suggest for things like building strength, things like, you know, obviously
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doing resistance exercise.
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So like the stuff that you were talking earlier on, David, from suggestions from the Royal
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Osteoporosis Society website.
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So whether you're using your own body weight or whether you're using light weights or whether
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you're using resistance bands or even whether you're doing yoga, for example, or even more
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simple things of everyday life like carrying your heavy bags with shopping around.
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That's the type of resistance exercise I'm talking about.
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You need to be doing that at least twice a week.
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And equally, we want to incorporate at least twice a week other exercises that improve
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people's balance.
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So things like Tai Chi, for example, has been shown to improve balance, especially in older
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people with osteoporosis.
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But other things like dancing, things like that could do the same thing.
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So challenging people's strength and balance is very important and reducing sedentary
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time.
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There's some very useful practical tips, particularly putting the remote control at the other end
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of the sofa.
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You know, some of us remember when you had to get up and walk over to the television
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and change the channel.
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This is all very, very good advice and we spend a lot of time giving this advice to
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people.
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In your experience, Alex, do you find older people living with osteoporosis do take steps
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to improve and if they don't, then what are the sort of main barriers to them engaging
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in this healthier lifestyle?
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So from my experience of kind of engaging with people with osteoporosis in a more educational,
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if you want, role and speaking to a lot of newly diagnosed people with osteoporosis,
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especially those who come through the Royal Osteoporosis Society support groups to come
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and listen to kind of my talks, people are very interested to know what they can do themselves
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to improve their chances of refactoring, for example.
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So especially newly diagnosed patients have got a weak fright.
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They now have got a new disease to deal with and they want to know, except from obviously
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taking the drugs that you guys prescribe, they also want to know what can they do themselves
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to improve their chances of, reduce their chances of refactoring and regaining some
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self-confidence as well, because that's the one thing that we see with people who might
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have had a fall and a fracture.
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The fact that people, there is an increased fear of falling in these people and sometimes
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that increased fear of falling and lack of confidence in their own balance could lead
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them to stop doing exercise and stop doing the things that they enjoyed doing before
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they had that osteoporotic fracture.
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So people want to know how can I get back to being able to dance with my partner and
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be able to play with my grandchildren again like I did before without being afraid of
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falling again and breaking my wrist again or breaking another bone in my body.
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So they are very willing to listen to the advice.
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The barriers that they put forward is that mainly that fear of falling.
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Quite often they will also say that, well, perhaps I don't have time to go to the gym
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or don't particularly enjoy going to the gym.
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But then that's when we talk about exercises that can be done at home without having to
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go to a group exercise activity.
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That's quite often a barrier for joining exercise groups in older adults, if I'm being honest.
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Perhaps it's a shame that you're not able to do as much as other people in that group,
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etc. etc.
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But the main motivator is I want to get back to what I was before.
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I want to have a good quality of life and I want to be able to play with my grandchildren.
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So thinking about the research that you have done or that you're aware of, Alex, I've read
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some stuff and there's a suggestion that men and women perhaps benefit differently from
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exercise or physical activity, particularly in the older age group.
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Do you have any insights into that for us or for our listeners?
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Well, how our body responds to any type of exercise is very individualized.
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In general terms, for both men and women, the lower your baseline level of physical
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activity, the greater the health benefit that is associated with an increase in physical
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activity.
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So your starting point is very important.
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If you start low, then anything you do will help you improve bone density and generally
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bone health.
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And the lower you are, the greater those increases that you're going to see.
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There are some changes, there are some differences between men and women and how they respond
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to kind of exercise.
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You also need to remember that in general terms, men exhibit about 20% higher bone mineral
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density compared to women.
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So not only is important the starting level of physical activity, but it's also your starting
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level of bone mineral density as well.
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So men generally speaking have got stronger bones than women in general, probably because
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they're bigger as well.
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So taking those two things into account and also some results that we have found in our
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systematic review about sedentary behavior in bone health, but also other people have
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found there seems to be a slight difference on how men behave compared to women as far
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as bone mineral density is concerned.
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So we looked at the evidence on sedentary behavior and bone mineral density and we found
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that in general terms, women seem to have, there seem to be some positive associations
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between sedentary behavior and bone mineral density, while the opposite was true for men.
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So basically women, those who had higher levels of sedentary behavior seem to have worse bones
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and vice versa for men.
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Why would that be the case?
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Well, there could be a lot of reasons.
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One of the reasons is what else do you do instead of sedentary behavior?
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So it appears that quite often in men, what we find is that yes, they might have high
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levels of sedentary behavior, but also they have higher levels of MVPA, so moderate vigorous
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physical activity.
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And therefore that moderate vigorous physical activity that they do could be the dominant
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part of physical activity that gives them the positive association with BND.
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And what is that moderate exercise?
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So moderate physical activity is any type of activity that increases your breathing while
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you're still able to talk.
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So a brisk walk would be a good example of moderate to vigorous physical activity or
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going for a cycle or going for a swim.
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More vigorous forms of that activity would be instead of going for a brisk walk, going
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for a run, playing sports, climbing stairs at a quick pace.
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So any type of activity that makes you be out of breath, but while you're still able
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to talk to your friends, if you were, for example, going out for a walk, that's moderate
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to vigorous intensity physical activity.
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So what we're finding is that men, yes, they're sedentary, but they seem to have bouts of
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these moderate to vigorous activity during the week.
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And because they do that, they seem to have kind of better bones.
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On the other hand, you've got women who might also have prolonged periods of sedentary
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behavior, but they don't engage in these moderate to vigorous physical activity.
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They tend to do more light type of activities, more activities, for example, like household
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work or doing lighter activities where they don't increase your breathing.
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That could be one of the reasons.
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And the other reason is obviously that sedentary behavior is not only important as an entity,
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but it's also important how often you break up sedentary behavior.
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So more frequent breaks during sitting time could explain the differences that we see
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between men and women.
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So they may be cultural or societal reasons rather than physiological ones almost.
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Yeah, it's complicated.
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That's what it is, lads, if I'm being honest.
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As a scientist, a non-clinician, I haven't really had that much experience talking to
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patients, but I have been to a few Royal Osteoporosis Society events and I've got to talk to patients
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there and they've told me their stories about how they've had a vertebral fracture because
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they've lost body height.
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They can't eat properly.
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There's not enough space for their stomach.
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People have told me about how they're not able to go out anymore.
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They're missing their friends.
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They're missing their family.
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People have told me about how vertebral fractures have led to them not being able to work anymore,
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losing their income, losing friends that way, the people that they work with.
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I get an overwhelming response from them, which is, what are you going to do for my
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grandchildren and for my children?
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I just wondered, what advice could you give to people who are suffering from osteoporosis
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who should be talking to their children and grandchildren about it?
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What should their children and grandchildren do so they don't have osteoporosis when they're
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older?
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I would say to tell them to go out and play outside as much as possible, go out and climb
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trees and run and play rounders and play football and do loads of different activities that
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have a lot of impact on the bones, a lot of weight bearing exercises, a lot of jumping.
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That would be the best type of activities you want to do for building strong bones during
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childhood.
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You also want to be out and about to get as much vitamin D as possible from the sun or
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during the summertime.
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And you also want to be having a fair amount of calcium in your diet, so do not replace
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your glass of milk with a glass of the juice.
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Drink your glass of milk, that's very important.
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And generally speaking, have a healthy, balanced diet that is very important, not only for
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your bones, but for your overall health during childhood and young adulthood.
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And that would set you up for how your body is going to respond later on in life.
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For bone health, for osteoporosis, it's very important to build a very strong skeleton
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while you're growing and a good diet and exercise will help you with that.
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But for other things as well, so for your cardiovascular risk as you get older, the
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foundations of a good cardiovascular health are built as well during childhood and young
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adulthood.
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So that would be my advice to them, go out and play, enjoy physical activity in general,
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because that enjoyment is very important.
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It means that physical activity will be more sustainable even in older years as well.
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And have fun and continue doing that throughout life.
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So there you have it listeners, go and spread the message to your families.
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Thank you, Alex, that was a really wonderful interview, fascinating answers.
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Delighted.
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Loved it.
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Thank you so much for having me.
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Yeah, it's really great to have you and thanks very much for your contributions and for the
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clarity and brevity of your contributions.
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I'm in awe of your brevity.
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There you go.
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Fabulous.
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Thank you so much for having me guys.
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And this is a great podcast, so for your listeners, keep on listening.
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I'm sure there's more to come in the future as well.
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I wish our listeners could see your hand movements and the passion and enthusiasm you put into
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all your answers, Alex.
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Thank you.
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Thank you.
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Thanks.
32:36
David, I thought that was a really fascinating interview with Alex.
32:43
What were your key takeaways?
32:45
I mean, I think the general takeaway is that exercise is something we should be very positive
32:50
about in terms of bone health.
32:54
In terms of what I advise patients, it's something that you should enjoy.
32:59
Your osteoporosis management, it's a lifestyle choice.
33:04
That's something we've come across before.
33:07
Going to the gym may be something that attracts you.
33:09
It may not.
33:10
If it's not, then there's dancing, there's hell walking, there's playing with the grandchildren.
33:17
Do something that you enjoy, because if you enjoy it, you're more likely to make it part
33:21
of your lifestyle in the long term.
33:23
And this is a long term commitment that we need.
33:28
Thinking of the patients that I see, there are some who haven't taken part in much physical
33:34
activity, who are quite frail, who are unsteady.
33:38
And for that group of people, I would probably urge them to look at the balance area first,
33:44
the sort of steady area from the Royal Osteoporosis Society Project, maybe before they go on to
33:51
the sort of stronger resistance type exercise.
33:55
Because as Alex mentioned, fear of falling can be a problem.
34:00
And so if you've been a long time since you've been physically active, start with the balance,
34:05
start with the steady, start with improving your core strength.
34:10
And then I suppose finally, we've talked in previous podcasts about empowerment, and people
34:17
will still come back to me at times and say, I went to the gym, I filled in the application
34:23
form, and when I ticked the box for osteoporosis, they said, I'm sorry, we don't want you here.
34:29
Or they may have said, I went to a trainer, and the trainer was very reluctant to advise
34:33
me to exercise because I had fractured.
34:36
Or perhaps even some physiotherapists would be very cautious.
34:40
So be empowered by this.
34:42
Take the information that you've heard on the podcast.
34:45
Take what Dr. Mavroidi discussed.
34:50
Take what you find in the Royal Osteoporosis website, and bring that with you, and use
34:56
that to get the information you need, get the advice you need, and to get the exercise
35:01
you need for your bones.
35:03
And as I say, be empowered by the information that was available today here.
35:10
So as a scientist then, listening to our interview today, Richie, what are your takeaway points
35:16
from it?
35:19
I was interested to hear that there was evidence supporting the two basic interventions that
35:25
Alex suggested, simply leaving the remote control for the TV at the other end of the
35:30
sofa, and getting exercise in daily life by carrying shopping home from work as a form
35:36
of resistance exercise.
35:38
It was really interesting to know that those kind of simple activities that we can all
35:42
do as part of our lives are beneficial and effective.
35:48
And it would be nice to get Alex back for another interview in the future, maybe to
35:51
drill down into that a little bit more.
35:55
And I was also really interested to hear about how building up bone health early in life
36:01
is important for preventing fractures in later life.
36:05
And I think it would be really great if our listeners who do have osteoporosis do go and
36:09
tell their children and grandchildren about that.
36:12
When I asked Alex the question about the advice that she would give, really I've been to lots
36:18
of events, and people have told me really horrible stories about the way osteoporosis
36:23
has affected their lives.
36:25
And they're so keen to do research.
36:28
They're so keen for me to do research that will help stave off the disease for their
36:33
children and grandchildren.
36:34
I think it's a really wonderful thing.
36:36
Yeah, as clinicians, we tend to see people later in life when they're getting the consequences
36:42
of osteoporosis and getting the consequences of not having achieved high peak bone mass.
36:48
And yet you often think if I could only have got hold of this person 30 or 40 years ago,
36:53
I probably could have done so much more then to prevent osteoporosis.
36:58
Now we're just seeing them when they've got the consequences of a lifetime maybe of not
37:06
being kind to their bones.
37:08
I suppose my job as a scientist researching bone health and fracture prevention is to
37:14
put you out of a job.
37:17
I'd be happy for you to do so, Richie.
37:21
Maybe we have a job in broadcasting.
37:25
Maybe that's what we'll fall back on.
37:27
Fingers crossed, eh?
37:30
Well.
37:31
I thought it was a really fun episode today.
37:33
It's been really great to see you again and see you and all the listeners at home next
37:38
month.
37:39
Bye bye.
37:40
Bye now.