Recognising and reversing osteoporosis with Dr Taher Mahmud
Dr Taher Mahmud is a rheumatologist from London who has the ambitious plan of eradicating the bone weakening disease osteoporosis by 2040. Osteoporosis is a common disease, particularly for women around the time of the menopause, but with the right nutrition, exercise and hormone supplementation it is possible to prevent loss of bone tissue and even reverse osteoporosis if it has developed.
The experts discuss this worldwide preventable problem and some common misconceptions about bones. The discussion covers the challenges of current healthcare systems in getting accurate information about your bone health and the importance of raising awareness of how preventable osteoporosis is to all individuals.
Dr Mahmud’s tips:
- Take time for yourself, think about your body and your health and value it
- It is easy to diagnose osteoporosis and treat it, however…
- It is far better to learn about your bone health and do what you can to prevent osteoporosis
To learn more about your own risk of osteoporosis, visit www.sticksandstones.org.uk
Dr Mahmud is based at the London Osteoporosis Clinic, for more information visit www.londonosteoporosisclinic.com
Dr Louise Newson [00:00:09] Hello. I’m Dr. Louise Newson and welcome to my podcast. I’m a GP and menopause specialist and I run the Newson Health Menopause and Wellbeing Centre here in Stratford upon Avon. I’m also the founder of The Menopause Charity and the menopause support app called balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based information and advice about both the perimenopause and the menopause.
Dr Louise Newson [00:00:46] So today on the podcast, I’ve got with me Taher Mahmud, who I’ve recently met and I love talking to him because he’s very respectful about the work I do, so it’s always nice to get praise. But he’s actually on a mission. I’m on a mission to improve the global health and wellbeing of all women. And he’s actually bigger than me because he wants to improve the health of everybody by improving their bone health, which is incredibly important, yet very, very, neglected. So welcome to the podcast today.
Dr Taher Mahmud [00:01:15] Thank you. Thank you very much. It’s a privilege to be with you and understand all the stuff that you’re doing as well.
Dr Louise Newson [00:01:21] Yeah. So as many of you know who’s listening, I didn’t set out my career to do menopause. In fact, I wanted to do cancer medicine, oncology, and I did my hospital exams. And when I was in hospital was probably one of the first times I had ordered a DEXA scan, a bone density scan, and thought about osteoporosis because it was glossed over a bit when I was at medical school. And I did a pathology degree and we learnt more about bone structure and pathophysiology then, and then I got a DEXA scan report and it was really quite hard to read. There were lots of numbers and there were minuses and there were different scores and I honestly felt really embarrassed. I was just looking for the summary at the end to tell me what to do. And over the years as a GP, I have ordered a lot of DEXA scans and I’ve been really interested in it, but also very interested in evidence behind it, but guidelines as well. Because a lot of resources are very limited in the NHS obviously and understandably, but a lot of times we can’t order an investigation until someone’s had a fracture and I’m very keen on preventative medicine. So there’s lots and lots and lots to unpick and osteoporosis is incredibly common. So let me just hear, if you don’t mind, just telling us a bit about why you’re doing what you’re doing and a bit about your past medical history, if that’s okay, with your career.
Dr Taher Mahmud [00:02:40] Yeah, well, thank you. So, yeah, I’m a clinician, general medicine, trained at King’s, Guys and Thomas’s and I’ve been doing rheumatology for 20 plus years and I sort of got into rheumatology a long time ago and had some interest while I was a medical student, but it wasn’t completely planned, it’s just how I ended up being interested in how the drugs work. And those drugs were rheumatology drugs. But I’ve been doing osteoporosis for approximately 20 years now, and it’s a subject that I feel very privileged to be able to do something in, in that osteoporosis can be diagnosed at a relatively early stage. It’s entirely preventable, in our opinion. So we can’t understand why anybody would go on to have an osteoporotic fracture, because we can make a diagnosis at any stage of somebody’s life. We can do a bunch of different interventions which would… we’d establish the diagnosis very easily, clinically and imaging such as DEXA, and then there are a bunch of interventions that allow us to stop the osteoporosis and in fact reverse it in many cases. So our aspiration is to have a point in the future, 2040, where there will not be any osteoporosis on the planet. So yeah, we’re sort of looking to collaborate and work with incredibly capable people like yourselves to help reach more people with information about the kind of things that might impact your bones, how you might try and establish a diagnosis, get the right help from your clinicians and look to, you know, deal with it if there is a problem. And hopefully there isn’t and then you’re all good. And yes, you’re right in terms of, you know, getting a DEXA scan. DEXA scan can be very useful for, you know, establishing a diagnosis, but also tracking response to treatment.
Dr Taher Mahmud [00:04:28] So I suppose stepping back a bit there’s a couple of things just to keep in mind for your listeners. One is that osteoporosis is affecting our bones and sometimes they may get the impression that, you know, once that happens or your bones are very fixed and solid and unchanging, they’re far from that. So our bones are very dynamic. They’re changing rapidly. If there is any period of immobility, you lose bone quickly. If you have a bunch of other positive effects on the bone, then they get stronger very quickly. So the bones are super dynamic and they’re changing throughout our life. Just that balance changes after a certain period of time. So in women, particularly around the menopause, obviously this is an area that you’re very devoted to and do incredible work. So around the menopause, about 5% per year bone loss can take place for about 4 to 5 years. And then it’s about a steady decline at 1 to 2%. But these figures can be adjusted drastically by lifestyle things, by other stuff that would minimise bone loss. And the main thing with all of this stuff is that it’s… these are measurable and then we can do different interventions to help improve stuff. So bones are dynamic, osteoporosis is actually common and we can touch on that, maybe affect one in ten of us at least. But more importantly, something can be done about it and we can reverse osteoporosis. So the idea of not making a diagnosis, not having any intervention, not having a plan to reverse is something that we find quite disturbing. But we have this aspiration that in the future there won’t be any osteoporosis, that we won’t need people like me as far as the osteoporosis part is concerned. And people would just be, you know, way better for their bones are concerned and hopefully that other health issues will be better too. So yeah, we feel very blessed in osteoporosis in that we’ve got a lot of interventions that can help, but the message is still not appreciated that we should make assessments of bone throughout and regularly and assess things in detail and then put in place set of steps that help us reverse if there is any osteoporosis.
Dr Louise Newson [00:06:29] Yeah, and that’s so important because I think osteoporosis just doesn’t get the attention that it deserves does it? You’ve already said it’s very common. We know it’s more common in women than men. The figures really vary. And there are some people that have a higher risk of osteoporosis as well, don’t they? So it can run in families or certain lifestyles that make osteoporosis more common: if people drink moderate or large amounts of alcohol, if they smoke, they’re sedentary. But what are the rough figures then for osteoporosis? What’s the prevalence?
Dr Taher Mahmud [00:06:59] Yeah, so it is very common and it’s sort of just in terms of age. So there’s gender – more women than men. But in the UK maybe about 2.8 million women and about 0.6, 0.8 million men. So actually it’s like one in four, you know, men are…
Dr Louise Newson [00:07:14] It’s a lot, isn’t it?
Dr Taher Mahmud [00:07:15] It is a lot, but that’s just osteoporosis. There’s a similar amount that are osteopenic, maybe more. So osteoporosis, The World Health Organisation definition is about a DEXA scan reading, but a clinical indication of osteoporosis, is just somebody falls from a sitting position or a standing height and they break something. They have osteoporosis and we get transitory osteoporosis at a bunch of different times in our life. So you deal with women and postmenopausal women. So during pregnancy, people can get osteoporosis and sometimes it can be significant. I have many patients who have had fractures in their spine during pregnancy. If you’re ill for any reason, you touched on some of those conditions, for any period where we’re immobile, that leads to osteoporosis. If we put an arm in a sling and don’t move it, we get regional osteoporosis. So the main thing to take away from all of that is that bones are really incredibly dynamic, super capable, because they’re very strong. They do many, many different functions. You know, all the bone marrow is in the bone. So all our immune system is contained within the bone. So bones are very critical to our health. The numbers are roughly three and a half million in the UK. Worldwide there’s probably about 700 million. But there’s another proportion of patients who just don’t have that definition, if you like, but yet still have osteopenia. And it’s worth keeping in mind the most fractures that people will get, this is the fragility of fracture, so sitting and falling or standing and falling, you can also get a spontaneous fracture. So I’ve got patients where they just take something out of the closet and they fracture their rib or they’re leaning back and they fracture something. So it affects very many people. One in five men and one in two women over the age of 50. So a lifetime risk of osteoporosis is very high and that the consequences are very significant. And because it’s diagnosable, treatable and preventable, we think all of that is wanton. The little old lady that you and I might see walking down or the little chap, somebody walking hunched over, a lot of those may be osteoporotic and I feel responsible for that. So even though I’m maybe inarticulate or maybe, you know, don’t have a reach or an audience necessarily, this is why I want to make the case. We want to say those people should not exist, not on our watch. If we’re the adults or we are the people with able to make a plea or request to do things for ourselves and people around us, we want a world where there isn’t this wanton stuff happening that is easily preventable. And if there is an issue, we can do a whole bunch of things to minimise. So the numbers are basically one in ten for the whole population and there’s higher proportions in different conditions.
Dr Louise Newson [00:09:59] Which is really high, you know, one in two menopausal women. And I read somewhere that, you know, one in three menopausal women experience osteoporotic hip fracture at some stage. And looking at the cost of that actually an orthopaedic surgeon told me about five years ago now, so these figures are a bit out of date, that it was £3 billion a year that was spent on osteoporotic hip fractures and orthopaedic surgeons are sometimes, not always, a bit arrogant and over exaggerate. So I thought it were million, not billion. And I went and did some research myself and it really is £3 billion a year on osteoporotic hip fractures. But a lot of people fall because they trip over a carpet like you say, it’s a very low impact fracture. But for a lot of these people, it’s stopping their independence once they have a fracture or if they’re immobile for a long period of time, they might be more likely to have a urine infection or a chest infection. So the mortality actually, is about 20% a year after a hip fracture. So that’s more serious than a lot of cancers. You know, if I was diagnosed with breast cancer tomorrow, most types of breast cancer are actually very treatable and the mortality figures are quite low. 20% then in a year after a hip fracture from a preventable condition as osteoporosis is huge. And we know a lot of people are walking around with osteoporosis. They haven’t had their fracture yet. They haven’t had a DEXA scan because they might not fulfil the criteria or it’s very difficult often to get a DEXA scan so they won’t know. And a lot of people think well a fracture, that’s something I can treat. But you and me have seen a lot of people, I’m sure, who have osteoporosis of the spine, which can be very, very painful. These little fractures in the spine, as you say, people become stooped and that can affect their breathing because you can’t inflate your lungs as well when you’re stooped over, but also digestion as well. A lot of people have digestive problems and their mobility problems as well. And, you know, it’s this sort of gradual nail in the coffin. You know, none of us really, I don’t want to live for us to be a certain age, but I want my quality of life to be as good as possible until very soon before I die really. And I’ve seen so many women especially, but men as well, with osteoporosis now given quite strong painkillers to as well, because these people are in pain, then they get constipation from their painkillers or they get nausea or they… it’s just this polypharmacy that occurs as well. So you’re not just treating the osteoporosis, you’re treating everything else. And so having anything to prevent is really important. But if we don’t know what we are preventing, then that’s really difficult as well, isn’t it? Because it’s not just an old age condition. One of my patients is quite young, she’s 34, and she’s had an eating disorder for many, many years. And her periods have stopped because of her eating disorders, she’s very thin, which is very common. But if your periods stop, it means you’ve not got hormones. And she’s also an exercise fanatic. Like a lot of these people are, very obsessive. They exercise all the time. She’s had multiple fractures in both her feet. So she’s in so much pain, but she can’t exercise and that’s making her eating disorder worse. And it’s just this one thing after another. And she’s been back and forth to many doctors over the years with her no periods. And they’ve all said, ‘Oh, no, don’t worry about that, let’s focus on your eating disorder’. But actually, if she has some replacement hormones, then it’s likely that her bones would have stayed stronger. So I do worry about young people as well, who have a risk of osteoporosis and some of the drugs that can switch off hormones. So we know some of the antidepressants can switch off hormones and even some of the progestogen only contraceptive pills, the implants and the injections actually can stop ovulation. A lot of people think, well, people are young and mobile. It doesn’t really matter. But I do worry for some of these people. I don’t know what you think.
Dr Taher Mahmud [00:13:43] Yeah, no, I think those are really important observations. And osteoporosis sadly affects people of every age. You know, I have patients in their teens even, and obviously people who are older. In fact, the original osteoporosis was looked after by gynaecologists. As you know, they saw people with amenorrhoea who were having fractures and they were athletes or, you know, doing athletics and so on. So it definitely can be any age. And so in terms of making that diagnosis, the clinical history is helpful and you identify some of those factors and so people can search for these things themselves. So if anyone’s had a fracture in their family or they’re worried about it, they can do questionnaires. We set up this foundation it’s called Sticks and Stones.org.uk. There’s a bunch of other sort of URLs but that’ll give you some risk factors. People can do a questionnaire and get an idea of what their risk is and then they can return to do that questionnaire, which would give them a bit of an adjusted score depending on, you know, how the risk factors might change. And a DEXA scan’s very important. I know you’re a great advocate of DEXA scans. There is some question about ‘there’s a lot of radiation’, ‘it’s too complicated’, ‘too costly to do’. All of those things are really not a concern. And the radiation is less than sort of being in a car for 10 minutes or something. The operator sits with the patient in the same room. So it’s not that somebody has to be shielded and so on. The DEXA scan is very low radiation. It gives us actionable information about the state of the bones. And then we can do interventions and then see what the change of bone is over that period of time. So bones take a while to change in terms of when they’re getting stronger, when they’re getting weaker. So any intervention can be tracked over time. And really it is helpful to get a scan because we can get a number and then we can make some adjustments and then repeat that number. We also have to do a whole series of other things and I think the service that you provide, which helps people have information about the state of their bones before any issues develop, before any complications develop, before they have a fracture, is obviously very valuable.
Dr Louise Newson [00:15:46] Yeah. I mean, I think there’s a lot now, isn’t there, even with the NHS, the screening and screening for people in their forties and I, I don’t know about you, but I certainly feel that everybody, man and woman, should have a baseline DEXA scan. And I had one done when I was 45, just starting to be perimenopausal. And actually it was very reassuring to know that I was in the green and good to go. And I know, like you say, my bone density will reduce when I’m menopausal, or hopefully it won’t reduce as much because I take HRT, but actually I could then – I mean, I do a lot of ashtanga yoga – but if I needed to do more weight bearing exercise or different exercise, that’s the time that I should be looking. And, you know, to see that rate of decline is really important as well, or rate of improvement as well with, you know, lifestyle, but also calcium, vitamin D is really important, isn’t it?
Dr Taher Mahmud [00:16:36] Absolutely. Yeah. And I think with all of these things, you know, it’s like if there’s a value or a interpretable information, then you want to track it over time because you know, that can be really useful. So in terms of ‘is there a lot of radiation with DEXA?’, that’s not really a consideration. Is it a lot of time consumption? No, it’s not. There’s no complications from doing DEXA. So it’s not that you have to do some intervention and there’s like 1% complication, which may be very… So in terms of time, the reliability of the result, actionability of the result, the effort to do it, you know, it’s non-invasive and the cost is negligible. So it’s definitely a worthwhile thing to do over time. And also nutrition and vitamin D and it’s worth checking your vitamin D. I personally check my vitamin D three times a year and it does fluctuate. And even though I mean, I think we all vary a bit in terms of what we do, and if we have a number, then we can use that number to adjust what we are, you know, eating or otherwise. And obviously there’s nobody more valuable on the planet than each one of us for ourselves. So we know it’s important that we invest a little bit of time and effort and sort of get whatever support that we need to, you know, continually, gently improve ourselves, optimise ourselves. So yeah, anything that people can do to really get some numbers, get some details and understand exactly what’s going on, I think would really help them.
Dr Louise Newson [00:17:51] Which is really important. But actually on the NHS we’re told we can’t do vitamin D levels, so that’s very difficult. And actually I was doing a presentation for the British Society of Rheumatologists not long ago and I was looking at the number of DEXA scans we have in the UK and I compared it to other European countries and we’re really low actually, really bad. And I know that just locally our services are very limited for DEXA scans in the NHS. And when I set up my clinic I, as you know, bought a DEXA scanner, my finance director went mad because I had already taken a big bank loan and she said, ‘What are you doing?’ And I said, ‘No, this is really important for holistic care having a DEXA scan’, because also it’s very difficult for people to access DEXA scans in the NHS. So I did stick my neck out, as you know, and got one, but it can be very difficult for people to access DEXA. And so then that was very hard and we know all women who have early menopause, so under the age of 40, they should all have a DEXA scan. And we see a lot of women, we’ve got about a thousand women with POI and most of those have not had a DEXA scan on the NHS and certainly they should have it regularly as well to make sure because there’s no other way. I mean there’s a lot of marketing out there for ultrasounds of heels or even a wrist one and they’re not accurate are they?
Dr Taher Mahmud [00:19:09] No exactly. I think you make some really valuable points there. I think the thing in any sort of big system, you know, there’s sort of inconsistencies or sort of stuff that’s not quite optimal. So for me, I would put people on anabolic treatment if they have osteoporosis, get them all back to normal and, you know, let them live happily ever after type of thing. How the system is organised at the minute is that you have to have multiple fractures sometime before anything is done. You get the diagnosis, then you get the least effective treatment maybe, which may have lots of tolerability issues and so on, and then you end up having a whole series of additional events. So you touched upon hip fractures. It’s incredibly impactful. In fact, my father-in-law had one hip, then he had another hip and then sadly, he passed away. It is very impactful. You know, you lose your mobility, the pain, we’ll send you a link which would just give you some graphic information of what the impact is. But you lose your independence. There’s a whole series of effects. You have complications of different kinds, you have that 20% mortality in the first year. So it’s all serious and consequential. I think with osteoporosis, as you know, there are no symptoms. It’s a bit like blood pressure, you have blood pressure and you don’t know anything, very little. And then you have a stroke or a heart attack and then you know you’ve got a blood pressure. With osteoporosis is, you have a fracture, you’re at one fracture, risk of future fracture goes up, your mortality goes up, your disabilities increase, you go into an institution. So hip fracture, quarter of patients don’t survive the first year or so, and a quarter have to go into an institution and half of them have a whole bunch of other disabilities. So this is why we think – and it’s probably the most urgent problem in healthcare in that if we did a bit of prevention, do some simple things and prevent the whole sort of multi-decade sequence, which then ends up with all of that suffering and all of that cost. And yeah, the cost for osteoporosis, you know touched on the figures earlier, it’s at least 4 billion in the UK, sort of hip and others. And obviously these figures are always out of date because it takes a while to collate them. But globally, there’s at least 100 billion spent on osteoporosis. But it’s like putting a plaster on somebody who’s already got multiple… it’s wanton. If we took that money, we took a bit of people’s thinking and applied it to prevention, we would have a different world and a whole bunch of other things would flow from that. So that’s why we’re making the case of having people think more about osteoporosis for themselves, about bone health, and then sooner to feel a bit more resourced and able to understand and navigate a few of the issues and then share it with some of the networks and so on. And if we do that network effect then, you know, we can reach this message to every part of the globe. But, you know, I mean, if your listeners are able to help in any way, you’re able to take some action. The only thing that I would ask is that they just look at this for themselves and improve their own appreciation of themselves and what incredible job their bones are doing for them. And once they have that sort of sense of awe almost about themselves, then they can explore things around this and then maybe, you know, become a bit of an advocate for the subject to others. But it always starts with us as individuals. And then once we have a bit more capability, we can then spread it to others and so on.
Dr Louise Newson [00:22:20] Yeah, and that’s so important. So I think looking up we’ve got the FRAX score haven’t we, to see what our risk is. So like you say, everyone’s different. It depends on your family, on your ethnicity, on your family history and also your lifestyle as well. And if you’ve had some diseases as well. So it’s always worth putting in and even doing it on a regular basis. And then looking at ways, like you say, you can improve yourself, but then if you do fulfil certain criteria, then you can request a DEXA scan and it would be worth really sticking your neck out for a DEXA scan and not going and having another suboptimal test like the heel or wrist scans because they’re not going to show you where… the DEXA scan looks at your spine and your hips, doesn’t it? And it’s really important that it’s done properly as well. The position of the patient is important. The type of machine, but also the way it’s reported is really important, isn’t it?
Dr Taher Mahmud [00:23:16] Absolutely. Yeah. So just to emphasise, the imaging diagnosis or the diagnostics for DEXA, the only thing that’s been validated and used in clinical trials and so on is the DEXA scan so and it’s done relatively quickly and safely and cheaply. Other tests such as the ultrasound and so on, they’ve not been validated. And because you can have regional variations, you may have a number here and a number there, but they may not be really correlating with a number in your spine or your hip. And because those fractures are the most consequential, it’s important to get that number. But another sort of thing that might alert you to do something is that if you’ve ever had a fracture, such as a wrist fracture, wrist fractures happen about seven, ten years before you get your hip fracture. If you had a bit of back pain, you were lost a bit of height, please go and speak to somebody. And then if you need anything like, you know, somebody needs to help me, guide me, support me, then you can go to either the London Osteoporosis Clinic website or the Sticks and Stones, and you’ll get some stuff and you get some material that you can take to the clinician to say ‘Well look, they’re saying worry about or think about this issue because of these fractures, I’ve got these factors. Can you help?’ So obviously everyone’s maxed out everywhere in terms of the NHS and otherwise, but for each one of the people listening, there’s only one of them and they’re the most important person for them. And really, please invest whatever, you know, training and thinking and stuff that you can do to really appreciate your own capabilities and build on those things. And then from our point of view, you know, anybody comes to us, they’re like the most important person in the universe when they’re in front of us and we do our utmost to support them and get them whatever assistance they need. So I think the NHS is challenging all the rest of it, but if you ask and you know, share some information or take some of the material that we have and discuss that with your teams, I’m sure they’ll do their best to support you. And if you do have to have these things done privately, well, you can get them done privately. But as I said, there’s only one of any one of us. And if you have a hip fracture, it’s going to take you out of your situation. I mean, my mum had vertebral fractures in fact, and she was in hospital. There was a particular situation so she was in and out of hospital so an hour after work I was driving to get to St George’s to see her because a spinal unit then I was there for a bit and then I was getting home, it took me another hour. So about 3 hours a day I was spending over a period of some weeks. So if you look at the cost of all of that, the stuff happens to you, the people around you, the systems around you, and so on. It is entirely preventable. So if something is entirely preventable and it costs a bit of time, bit of thinking, bit of sort of tooling up in terms of your thinking about the subject, you know, I think it’s a good investment. Yeah, I am biased.
Dr Louise Newson [00:25:58] Yeah. No, you’re absolutely right. But I think that’s everything in medicine, isn’t it. Is about prevention is better than anything else. You know, we know how much strain the NHS is on and the NHS is treating disease, but we really want to prevent it because it’s short term pain really, financial pain as well, for longer term gain. And certainly the synergy between menopause and osteoporosis is really, really important. It’s very well established that HRT can reduce osteoporosis and even prevent it as well, again with lifestyle too. So I’m really grateful for your time and I hope those of you listening go to some of your resources that we’ll link to in the notes and obviously we’ve got information on our website and The Royal Osteoporosis Society. I’ve been working with them to improve some of their information, especially with female health and menopause and hormones and osteoporosis. So before we finish just to put you on the spot, I always ask for three take home tips. So three things really just to increase awareness of osteoporosis. What are the three things that everyone should be saying to themselves to increase awareness of osteoporosis?
Dr Taher Mahmud [00:27:05] Yeah, I mean, my sort of biggest thing, I suppose, is always just for people to appreciate themselves. So if I could suggest they might take a couple of seconds or 10 seconds and just have a thought about themselves. They are like, they’re awesome. Every body is like incredible, their biology and so on. Your bones are incredibly dynamic. They’re changing all the time. They’re the source of, you know, a whole bunch of your sort of health and your longevity. So anything people can do to invest a bit of reading and thinking on the subject. So, so your bones are very dynamic. The diagnosis of osteoporosis is easily established, it is common, easily established, and treatments that can reverse it. But it’s obviously better to prevent it.
Dr Louise Newson [00:27:43] Absolutely. So great advice, really useful. And I look forward to seeing what we can do together. And we’re also going to start to do some research as well. So hopefully you’ll be able to come back in a year or so and report what we’ve been doing behind the scenes. So thanks again for your time today, it’s been great.
Dr Taher Mahmud [00:27:59] Thank you. It’s a privilege to spend some time with you too. Thank you.
Dr Louise Newson [00:28:05] For more information about the perimenopause and menopause, please visit my website balance-menopause.com. Or you can download the free balance app which is available to download from the App Store or from Google Play.