Midlife bone health is a topic often overlooked. We don't feel our bones ageing, but just like the rest of us, they absolutely are.
We talk a lot in The Latte Lounge about conditions like osteoporosis, but why is bone health so important, particularly as we age?
Katie spoke to Dr Kate Bunyan, medical director at Vira Health, on the podcast to find out more about the link between perimenopause, menopause and bone health and what we can do in terms of lifestyle changes to keep our bones strong in midlife and beyond.
Kate tells us what osteoporosis is, how it occurs and what part our hormones play in the process. She also talks about other risk factors and treatment options, including lifestyle changes and exercise.
Listen to the full conversation in The Latte Lounge podcast episode above.
Our bones are made up of a very solid outer cortex and an outer shell, and inside, the bone is weaved into more of a honeycomb structure.
It's all based on proteins, and our calcium then reinforces that honeycomb structure.
As we get older, that honeycomb structure starts to break down because of the way our bones work; they are constantly breaking down and making up. We call that resorption and then formation, and that's bone remodelling.
That's happening from the moment we are born, pretty much until the day we die, this constant cycle of breaking down and reforming.
Osteoporosis happens when the breaking down isn't matched by the making up, and we have more bone loss than we do bone growth and development.
Osteoporosis basically means our bones are getting to be more holy on the inside and thinner on the outer shell.
It's like a crunchy bar where, if you took away the delicious chocolate, then you'd have that tight shell on the outside and then the crunchy bit in the middle.
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Even the experts don't fully understand how oestrogen is involved in this dance between the cells that break down bone and the cells that make up bone.
But what we do see is that once oestrogen levels start to fall, the balance gets all out of kilter, so we have more bone breakdown than we do bone formation.
It is important to say this happens to everybody as they age, so men do get osteoporosis as well, but with oestrogen dropping off in the way it does at menopause, we see a sudden decline in a way that men only see a more gentle decline.
Women also seem to be at a little bit more of a disadvantage because we have physically smaller skeletons. That doesn't necessarily mean that we're just shorter than men on average, but it means that our bones themselves tend to be lighter and tend to be smaller. So (statistically speaking), we start off with comparatively less bone structure than men do.
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There are some medications that will impact whether or not you develop osteoporosis, particularly steroids.
We also see a connection with other sorts of medical problems, such as rheumatoid arthritis, hypothyroidism and hyperthyroidism, parathyroid disease, Crohn's disease, celiac disease, and strokes.
All of these things affect either the way we absorb the nutrients we need to help make our bones grow (calcium and vitamin D particularly), or they affect the way our bone cells work, or they impact the way we use our skeleton, and that impacts how strong our bones are.
We don't have any feeling of bone loss so often; the first time we know anything is wrong is because we fracture something through something fairly minor, and the clinicians will describe that as being a fragility fracture.
You may have fallen just from your own height, which is why we so commonly associate this with fractures of the wrist or fractures of the hip when people haven't been horse riding or on motorbikes or anything like that, they've just tripped over and managed to break quite a significant bone.
The only real symptom of osteoporosis is the pain related to actual fractures. There are ways other than just fractures of being able to diagnose that you have this problem with your bones.
Osteopenia is something else that we talk about, meaning thinner bones. It's not actually a medical problem, it's just a state that describes the fact that our bones are somewhere in between healthy and osteoporotic, and this can be identified with certain types of scans.
But a scan on its own isn't enough. We also factor in different lifestyle factors because we all have and have always had a different strengths to our skeletons. So a number on a scan by itself isn't the whole answer.
We then put that together with your other risk factors. And then look to see whether you are at risk of fractures because of your bone strength. And that's really what we then look at in terms of treating anything.
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Smoking isn't great for us in lots of ways, but we also know it affects the relationship between these building and breaking down cells. So stopping smoking is a great starting point.
We also know that alcohol can affect bone strength. We don't quite know the mechanism for that, but again, it's some form of interaction between this bone growth and bone loss. So reducing the amount of alcohol that you're drinking also helps to reduce your risk of bone loss.
Eat healthily. Having the rainbow on your plate and making sure you're eating a mixture of vitamins and minerals and a variety of different colours of fruits and vegetables is a great way of ensuring that you get enough of what you need.
Menopausal women need about 1,200 milligrams of calcium per day. We get most of our calcium from things like dairy, green leafy vegetables and things like almonds and sesame seeds. Sardines are also great.
So many foods are now fortified and enriched with calcium as well. So there's lots of ways that you can get that into your diet.
Vitamin D, you need about 10 micrograms per day, and you can get some of that in your food, but not all of it. A good amount of safe sunlight actually only looks like 10 minutes, twice a day, without sunscreen and being very careful not to burn.
The government advice now is that everybody in the UK should be taking vitamin D supplementation, at least in those later autumn and winter months, to make up for the fact that the strength of the sun just isn't enough for us to produce enough vitamin D, and because we don't tend to get enough vitamin D out of our food in a way that we can process and absorb.
Some people who do use regular sunblock and are very good at covering up in the sun are recommended to take vitamin D all year round, as are those with darker skin who find it more difficult to produce enough vitamin D in the UK.
There are two different sorts of exercise that are both important for bone strength. We've got muscle strengthening. And we've got weight bearing.
Weight-bearing is where you are literally putting weight through your entire skeleton, which is constantly stressing all the bones in your body. That's where we are getting the impact on the strength of our bones.
Low-impact exercise would be things like walking; even if that's quick, it's still quite a low impact.
Moderate impact might be things like jogging, running, or racket sports where you are launching yourself and dropping heavily onto your skeleton, onto your feet.
High impact is where there's even more of that. Things like star jumps, tuck jumps, volleyball or netball, things like that. Things that have you jumping quite high a lot – and landing and impacting.
That constant action on your skeleton is what really starts to reinforce the bone development and stimulate more growth than the loss phase.
Muscle strengthening is important because in order to strengthen your muscles, they have to pull on the bones. That's what stops them from just flapping around in the breeze and makes our joints work. So if you are improving your muscle strength, you will be pulling on the bones, and that stimulates more of the build phase.
That's the sort of thing where you are using weights, resistance bands or your body weight but on a particular group of muscles. So you are encouraging not your whole body weight but particular muscle groups to really strengthen.
This will make an impact on the particular bones attached to the ends of the muscles that you're strengthening; you can't just do upper body work and hope that that'll fix your hips.
The Royal Osteoporosis Society guidance would be that if you've already got osteoporosis, you should be looking at doing about 50 moderate impacts on most days. If you have more progressive osteoporosis, that reduces just because of the fracture risk.
50 impacts could literally be 50 jumps up and down. That could be really energetic dancing that you're doing up and down, 50 actual impacts, not 50 minutes, just 50 impacts.
That sorts out your weight-bearing element, then your muscle strength training; we're talking about two or three days of the week, about 20 to 30 minutes of some form of muscle resistance exercise work.
If you've never done any muscle resistance work before, you might want to think about finding a class, joining a gym, or getting a trainer that can help guide you through how to do that safely.
There is a risk if you just start without really knowing what you're doing that could do your joints and your muscles more harm than you're hoping to benefit from in terms of your stronger bones. So just making sure you're doing those movements safely and effectively can be a real benefit.
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HRT has been demonstrated to probably be as effective as some of the other main medications that you might see used in the management of osteoporosis.
What the oestrogen that you're replacing through HRT is doing is helping to keep the dance of breakdown and remodelling in tune as it has done up till your menopause.
There are a whole range of different medications that are now used in the management of osteoporosis, and there are the standard treatments that people will use.
Different medications tackle the problem in different ways, and that's where working with your doctor on what's the best type of medication for your particular situation and your particular risk factors is so important.
We can't change our genes; what you can do is optimize what you've got.
Probably by the time we've hit about 25, we've done the majority of our bone strength development.
We are growing more than we are losing at that point, and then somewhere between 35 and 45 for most people, men and women, we start to lose more than we grow.
The more you can do to help prevent that loss by doing all the exercise, keeping your diet good, reducing your alcohol, and reducing smoking, the bigger impact you can have.
For some with very specific risk factors, there may be worth starting medications earlier for those individuals before they've had any fractures.
But most of what we look at is really about preventing getting to that first fracture. And the way to do that is absolutely through those lifestyle measures.
The great thing about working with the Latte Lounge and having the ability to speak to women from the group is that in the appointments, we have longer to talk to you, which means we have longer for you to think through and start to articulate the challenges that you are having and the concerns that you've got without needing to have got it all perfectly straight in your mind before you come into the appointment.
We won't manage the medication for osteoporosis through Stella Plus, but what we can absolutely do is talk about the pros and cons. Look at whether HRT is something that is or isn't suitable for you and help you construct that conversation to take to your doctor about the risk factors.
The key thing with any of this is to go and see somebody. If you are worried, talk it out. Make sure that you find what is right for you. And I'd love it to be to come and talk to one of our team. But if that's not right for you, I'd rather you are seeing somebody than nobody.
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