Bone Health: A Matter Of Life & Death

Episode 100

The title of this podcast sounds like an exaggeration and a marketing ploy to get you to listen to this episode. I assure you it is not. Let’s say you are a 65-year-old standard American female or male with three medical conditions and had a hip fracture. You have a 30 to 40% chance of being dead one year from that fracture. Astronomical; how come nobody is talking about this? Luckily, we have your back and will break down everything you need to know about your bones and how to optimize bone health for healthy aging.

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Episode Transcript

Dr. Richard Harris MD  00:00

Today we’re gonna dive into something that really should be talked about a whole lot more. And it’s something that you really never hear about. And that is bone health. Our skeleton is essential to our overall function, it does more than actually provide support. It is endocrine in nature as well, which means hormones that our skeleton make impacts our overall physiology. That’s what we’re going to talk about today. We’re gonna talk about our bones, what they do, how they’re made, what can go wrong with the bones? And then how can we ensure good bone health as we age spoiler alert, if you’re elderly 65 and above and you fall, your 12 month mortality after that is between 30 to 40%. Huge. We’re going to talk about it. Are you ready to boost your health, EQ and IQ? Cue the music?

Dr. Richard Harris MD  01:04

Join me Dr. Richard Harris as we strive to unlock the secret to the human body. Strive for Wellness strive for great health. Follow the show on iTunes, Spotify, Google and Android.

Dr. Richard Harris MD  01:30

And now a word from our sponsors. Our first sponsor is Nimbus healthcare, the company that I co founded personalized medicine personalized results. At Nimbus. We don’t believe that there’s a one size fits all when it comes to treatment. And the data is starting to show that there’s a large variety of how people respond to certain things. And we’re in the Age of Science where we can use things like genetic testing and biomarkers to truly customize a plan just for you. And that’s what we do at Nimbus healthcare. We are in the hair loss and the hormone space. And what we do is we use lifestyle medicine, supplements and compounded prescription medication to tailor and individualize a plan just for you. If that sounds like something that you’re looking for, you can check out Nimbus healthcare.com or click the link in the show notes. Our other sponsor is CBD health collection. CBD health collection is the CBD that we use in the house. We use it. Our dog uses it love CBD health collection, it meets all of the requirements that we set forth in our CBD episode, organic us grown. They do a lot of third party testing so you know exactly what you’re getting in the product. And it works. My ordering data is wonderful when I take the product for sleep, and then I also use it for inflammation and recovery. If you’re looking for a high quality CBD that is third party independently tested and who does research they work with universities to do research on their products to push the edge on CBD and make sure they’re staying current and CBD health collection is the CBD for you. You can check the link in the show notes more head to our website, the GH wellness.com and click CBD at the top. And now to this week’s episode. Welcome to the strive for great health podcast with your host Dr. Richard Harris.

Dr. Richard Harris MD  03:17

I know it’s been a while since I’ve podcasted things have gotten super crazy in business and life. I have episodes coming up for you guys. I have an episode coming up about BDNF brain derived neurotrophic factor. I have an episode coming up another Mythbusters. We’re going to talk about fat loss myths and actually got some stuff wrong and said some stuff wrong on this podcast. And that leads us to the next episode I got coming up. We’re going to talk about artificial sugars. And this is something that I have gotten wrong. And I’m not afraid to admit that I’ve been wrong about stuff. We’re going to talk about. Are they safe? Spoiler alert. Yes, data shows are they’re pretty safe and I got it wrong. So what we’re going to talk about today is bones and I think this is so important. We’re gonna start off with the function of our bones bones gives the body our shape. It allows for movement it stores and minerals, and unfortunately toxins. And we talked about that in the toxin podcast episode provides protection makes red blood cells and white blood cells are made inside our bones and bones are not dead tissue. They are very much living tissue. And because they’re living tissue, they depend on nutrients and blood flow and everything else just like all the rest of our living tissue. We have 206 bones in the human body. The smallest are the bones in the ear, which help us here. And the largest and strongest is the femur, the thigh bone. bones have an endocrine function and what we mean when we say endocrine function is they secrete different hormones and mediators that go throughout the body and impact the function of other organs. For instance, osteo calcium we’re gonna talk about that more in a minute, can act on the pancreas to increase insulin sensitivity and actually make more of the cells beta cells that release insulin. It can have adiponectin stimulation in fat cells and the testes osteocalcin can enhance Leydig cell function improve testosterone function in the brain, it increases neurotransmitters in the hippocampus involved with learning and memory osteocytes we’re going to talk about osteocytes here in a minute, their cells in the bones regulate phosphate metabolism and it can influence the development of immune cells in lymph tissue. So bones have a wide variety of function and endocrine function. And so our bone health really is a microcosm of our overall health. And our overall health depends on healthy bones. What are the structure of the bones bones exist as a matrix that contain spongy bone, compact bone, bone marrow, and then the outer portion, the peri Ostium. the periosteum is a tough fibrous outer cover that protects the outside surface of the bone. Then you have compact bone, it’s dense outer layer bone, this is bone that is hard and strong. Then you have the spongy bone. It’s called spongy because it’s porous. It has holes in it. This is a layer that is lighter and it’s less dense than the compact bone. And then you have bone marrow, this is soft connective tissue or blood cells are made it resides in the pores of the spongy bone. And then bone can be classified as different types depending on the shape you have long bones like the femur, short bones like your wrist, flat bones like your breastplate. Citral bones, which are the certain bones in the skull sesamoid bones like the patella and then you have irregular bones because they don’t fit a nice neat little pattern, like your vertebrae, how do our bones form, there’s three different types of bone cells that we’re going to talk about the first one, and for overall health purposes, the one that it’s usually impacted the most are osteoblast osteoblasts, make collagen and mineralized bone they take in nutrients from the blood to do this, and this is a two step process. The first step is a secrete collagen mainly type one collagen, in other proteins like osteo nektan, osteopontin, osteocalcin and proteoglycans. proteoglycans are basically protein sugars, and this forms the organic matrix of the bone. Next, the bone needs to be mineralized. And this is a two phase process. This is phase two or step two that I mentioned earlier. Calcium ions are secreted from the osteoblast, and little vesicles. These are basically containers that hold different things. In this case, the containers are holding calcium, and this is trapped by those proteins sugars to proteoglycans. I mentioned earlier, when the proteoglycans are degraded by enzymes released by the osteoblasts the calcium is released. The second phase of this occurs when phosphate containing compounds are degraded releasing phosphate ions in the calcium and phosphate bind together, creating hydroxy apatite crystals to calcium hydroxy. apatite is the mineral structure of our bones. supersaturation occurs leading to rupture of the structures containing the hydroxy apatite crystals, and they spread to the surrounding matrix. And that is, in a rudimentary form, how our bones are made. Now there’s a supporting cell called osteo sites osteocytes direct uptake of minerals from the bloodstream, they produce components essential for maintaining the bone matrix. They also function as mechanical sensors to help detect bone loads and adapt bone to daily stressors. We’re going to talk about this more in a minute. But basically, our body will increase our bone density based upon structural load. If you’re working out spoiler that’s one of the great ways to increase bone density, these osteocytes they are derived from mature osteoblasts. So when the osteoblasts reached their later phase of life, they turned to osteo sites and osteocytes are actually the most abundant cells in the bones. They make up 90 to 95% of the bone cells. And these things have a long life they can live for up to 25 years. osteo class are the final of the three types. We’re going to talk about osteo class dissolve minerals in bone and release them back into the blood. It’s pretty cool how they do this. They basically form a seal around the area secrete a bunch of enzymes to dissolve the bone. Basically, the ostial Blast mineralized and hardened collagen using a form of calcium called calcium hydroxy apatite in the osteo class, dissolve the bones and then take those materials and release them back into blood stream mainly calcium in this regard, and then the osteocytes are there to support the osteoblast. How are these things activated osteo class are activated by something called rank L. This was actually something that was newly discovered right around the time that I was in pharmacy school, we had just started developing things related to rank L, which is primarily activated by parathyroid hormone. parathyroid hormone is secreted by the parathyroid. There are four little sticky glands that are on the back of your thyroid, and parathyroid hormone is very important for calcium balance in the body. The funny thing is, is that the rank L is made by osteoblast and osteoclast precursors rank is the receptor that rank l The L stands for login login is a molecule that binds to something and it’s found on osteo class osteoclast precursors in dendritic cells, part of the immune system osteoblasts make something called osteo protection, which binds to rank L and serves as a decoy, thus allowing for bone formations to interaction between this rank l rank and osteo protection in the varying levels of these things determine if we’re going to have more bone formation, or more bone degradation, what stimulates bone for mation in general, upregulation of rank l downregulates, OPG, or osteo. Protecting things that are going to stimulate bone formation are going to increase osteo protection, things that are going to stimulate bone reabsorption or bone degradation are going to stimulate rank L. Factors like IGF one, TGF B FDF, stimulate bone formation that’s transforming growth factor B, or fibroblast growth factor. If you want to look these things up, we reach peak bone mass by about age 30. This is one of the reasons why if you’ve heard me talk on the podcast, I say, by the time you hit 30, you really want to have a good exercise program that is at least 6040 strength training to cardio. I prefer about 7030. But if you’re someone who doesn’t like weight training, then 6040 If you’re someone who doesn’t like cardio than 7030

Dr. Richard Harris MD  12:23

There is some variability and what our peak is. However, the higher the peak, the more you have in your bone bank as bone starts to degrade over time. Now things like our sex, our race, our family history, our body frame size, these can all affect peak bone mass, African Americans tend to have higher peak mass and generally higher bone density. I am one of them who has super high bone density. I believe I was in like the 99.9 percentile on my bone mineral density testing, I cannot float at all. I sink like a rock bone contains type one collagen we talked about that earlier is mostly 90%. Type one collagen type three, and five collagen are also abundant in bones. And these acts as a scaffold for bone cells and provide support. It’s the major determinant of bone strength. Now let’s talk about osteoporosis. That’s what we’re going to focus on. When we talk about what goes wrong with the bone. Of course you can have fractures. But Osteoporosis is a disease that takes decades to form. In general, we see these in people who are above the age of 50. But there are genetic conditions where you can see these happen at younger age. There’s also a condition where your bones can be too hard, where you get too much osteoblast activation, but that’s super rare. Now the unfortunate thing about osteoporosis, just like many of these other metabolic type diseases that we see, osteoporosis is silent until a fracture happens. The hallmark of the disease is weakened bone tissue, bone structure and bone strength. And osteoporosis is largely preventable. Another case of a largely preventable condition based upon lifestyle. According to the CDC in 2017, and 2018. The prevalence of osteoporosis at the femur, neck or lumbar spine overall was about 12.6% of the population. That’s millions of people that have another preventable metabolic condition. I say it’s metabolic because it deals with the ratio of breakdown and formation of bone. That’s metabolism turning one thing into another. If you break it down by men and women, 19.6% of women and then 4.4% of men, so it’s mostly women here that have osteoporosis. osteopenia is the precursor. This is when bone mass is low, and it’s found in 43% of adults 51.5 percent of women and 33.5% of men, and unfortunately the prevalence of osteoporosis is increasing among women, but doesn’t seem to be increasing among men when you compared rates in 2007 and 2008 to 2017 and 2018. The prevalence of low bone mass however, has not changed when we compare those years. So the rates of osteoporosis are but not low bone mass. And the rates in women of osteoporosis are increasing, but not men. The US population in 2017 was 325 million. These conditions are literally affecting hundreds of millions of people get you never hear anything about it, we’re gonna dive more into some shocking statistics right now. On average, in the USA, the direct costs of a hip fracture is about $30,000 per patient. The total cost in osteoporosis related fractures is estimated to be around $25 billion per year. And then we spend another 5.2 billion on osteoporosis treatment $30 billion on something that is largely preventable. One report from 2015 suggested that a five to 20% reduction in secondary fractures. So after someone has already had osteoporosis had a fracture, their high risk for another fracture. So reducing those secondary fractures could have saved Medicare between $310,000,001.2 billion over a two to three year period. These are massive sums of money, again, for something that is largely preventable. The problem is, is it takes decades, and it’s often silent. And we are very, very poor. Here in America at preventing things that are silent and take decades the form, see Alzheimer’s, see heart disease, all of these things. We’ve talked about all that before on the podcast, let’s dive into some morbidity and mortality information. The main problem with brittle bones is the increased risk of fracture, which can occur with even low impact trauma or without trauma at all. If you’ve ever worked in the ER, or internal medicine in the hospital, you see these cases all the time when I first started, it was always in women. Now you see it in men as well, where there’s a fracture, and there wasn’t even a fall, the non traumatic fracture due to osteoporosis, it’s estimated that 50% of women and 22% of men will have an osteoporosis fracture after age 50 in their lifetime. Again, I’m gonna repeat that because that bears repeating 50% of women and 22% of men will have a bone fracture related to osteoporosis after 50 in their lifetime. The main fracture sites we see are the hip, the spine, the wrist, morbidity, this is really really important loss of ability to walk. One study showed 50% of elderly women with hip fracture lost the ability to walk independently afterwards, talk about something that has a profound mental health impact, something that we’ve been doing since longer than we can remember and all of a sudden, you can’t even move without help. Another study found that 50% lose their independence and require long term care or help with daily activities. Another study 1/3 of hip fracture patients became totally dependent on family members. For me, a lot of the reasons why I do what I do is because I never want someone to be having to take care of me all the time. I never want to be a burden to someone because of something I did or something I could have prevented. That would be the worst to me. And again, this is a largely preventable condition. With vertebral fractures, that affects about 25% of postmenopausal women. And then 40% of women aged 80 or higher. There’s a lifetime risk of about 15% for women and 8.6% for men after age 45. The major morbidity is back pain, but can also come with height loss, curvature in the spine and functional limitations. The interference and activities of daily living for vertebral fractures was comparable to hip fractures in one study. So both of these can cause very significant impairments and quality of life and function of life.

Dr. Richard Harris MD  19:38

Risk fractures, risk fractures can lead to being completely disabled. Many have interference with the ability to perform daily activities like cooking and cleaning. One study about half 50% reported fair or poor functional outcomes six months post fracture study self reported lower self esteem, impaired body image and mooching. changes after fracture, there’s an increased risk of future fracture. And then even after the fracture, there’s a significant amount of time before you can get back, even out of the healthcare system. Patients who need hospital care and rehab need an average of 30.5 days for a hip fracture 20.4 days for a vertebral fracture. So that’s hospital care and rehab. Now, here’s the crazy thing. The 30 day mortality rate, after a hip fracture is seven to 10%. That’s a significant amount of people that die very quickly after this happens. The one year mortality rate is 37.1%. In men 26.4% In women, and this is according to data pulled from multiple studies. Another study had a cumulative mortality rate of 33%, one year after hip fracture that was 43% for men, 30% for women. Now all of the studies I looked at, had higher rates of mortality after fractures, for men and for women. This is something significant, literally, if I said that you had a 30 to 40% chance of dying one year after doing something that was that revelant. You would be like, what is it? Why is nobody talking about this? And in my head, I’m going through this information I’m like, seriously, why is nobody talking about this? This is life and death, literally life and death depends on bone health. Let’s talk about the risk of developing osteoporosis in women. Studies show the major risk factors age, as we age, we tend to get more osteo class the breakdown activity than osteoblast. The building activity, menopause age, menopause, duration, BMI, and that’s low BMI, low BMI is associated with worse outcomes. Educational level alcohol consumption. Now I’m not saying obesity is protective No, because the factors that lead to obesity are factors that worsen your chance of developing osteoporosis. And then of course, we’re seeing the morbidity and mortality data for like everything. For men. The major risk factors identified were BMI, smoking, alcohol consumption, physical activity, and sun exposure. In general, parental history of hip fracture Caucasian are higher risk, previous fracture of long term use of steroids a higher risk at risk factors of dying after a fracture. Those are increased where people above the age of 75 people with severe liver disease and heart failure were the most at risk in one study. Other risk factors included being male being institutionalized kidney disease, COPD, dementia, diabetes, visual or hearing disorders, that is for the risk of dying after a fracture. multiple medications contribute to the risk of developing osteoporosis, anti androgen therapies, these are things that you’ll see people on with prostate cancer on anti estrogen therapies, which sometimes we use for breast cancer. steroid use Coumadin Warfarin use because of its antagonism of vitamin hay, which Vitamin K is very important for bone health. We’re gonna talk about that in a minute. And then protein pump inhibitors, the acid reflux drugs, which we’ve talked about a lot on the podcasts, how they can do a lot of bad things. Well, these can impact calcium absorption, they can impact magnesium absorption. We’re gonna talk about those things and why they’re important for bone health here soon. Thyroid hormones. Hypothyroidism can cause bone loss by increasing osteo class activity. And then the sex hormones lack of estrogen, mostly estrogen, but also testosterone. These hormones worked by decreasing the making of the osteo class, they prevent osteoblasts from dying and the process we call apoptosis or regulated cell death. They stimulate osteo class apoptosis, they increase production of osteo protection, they inhibit the synthesis of rank L, they decrease some inflammatory cytokines associated with osteoclast formation. It appears that testosterone main effect here is by conversion to estrogen by aromatase in the bones. However, the androgens do have a direct effect in stimulating bone formation.

Dr. Richard Harris MD  24:39

If you have an overactive parathyroid, and it releases too much PTAs This is a hormone that increases osteo class activity and calcium released from the bones. You need to find balance here because the initial process when we’re remodeling bone, it’s the osteo class come in, degrade the bone that needs to be broken down. In the blasts come in and then make bones. It’s like if you wanted to build a new house over your old house, what would you do? First, you would tear the old house down and then build your brand new house. Increase cortisol. We’ve talked about cortisol a lot here on the podcast. Increased cortisol levels stimulate osteo class activity, inflammation, multiple inflammatory mediators can also stimulate bone loss through stimulating osteo class. Again, our bone health is systemic health. We talked about how our bones can impact other organs. But also you can see our general health overall impacts our bone health. And this is why holistic medicine is so essential, looking at the body in totality, because everything can impact everything else. Let’s move on to some key minerals and vitamins for bone formation. A lot of these we’ve already talked about before, magnesium, magnesium is necessary to activate vitamin D we covered vitamin D very well, and our vitamin D podcast is directly involved with bone structure as part of the hydroxy apatite crystal depletion of magnesium leads to larger crystals, which makes bones stiffer. Depletion is also associated with low osteoblast and osteoclast activity, osteopenia and bone fragility. low magnesium decreases PTCH, which causes hypocalcemia, which decreases vitamin D and also decreases bone formation. Again, osteo class are not inherently bad, they have a job to do. They’re essential in the bone formation process and the first part of the process. So if the cycle is dysregulated, like we have too little PTA or too much bth it dysregulates the cycle. low magnesium is associated with oxidative stress, which increases bone resorption. That’s the fancy term for bone breakdown. in postmenopausal women, low magnesium intake is associated with more rapid bone loss or lower bone mineral density. magnesium levels are very important. Vitamin D, the active form of vitamin d3 increases calcium and phosphate absorption in the gut. It increases calcium reabsorption from the urine. Without adequate calcium, there is a effect to stimulate osteoclast activity, because you’re going to try to hold the calcium from the bone. So without adequate calcium, your body needs calcium is calcium is very important for metabolism. A lot of things in our body don’t happen until a certain level of calcium is involved in the cell. So you’re going to stimulate osteo class activity to get more calcium in your body to the other cells, less calcium in your bones, less bone mineral density. serum vitamin D levels are associated with fracture. One study found for every standard deviation decreased there was a 26 to 27% increased risk of fracture. Vitamin K to vitamin K to in the MK four form helped pull calcium into the bones. And there’s an MK seven form it’s just most of the data that I found was on the MK four form. And that’s actually what other countries use, I believe is Japan has a medication that’s a high dose vitamin K to in the MK four form, but helps pull calcium into the bones. It also helps activate osteocalcin to bind hydroxyapatite to the bone form of calcium. It increases osteoblast activity reduces osteoclast activity in increases osteocalcin. The main effect here is to stimulate and help regulate the processes that are important for bone formation. Vitamin C, we’ve covered vitamin C before on the podcast it’s important for collagen formation also has antioxidant properties. BV vitamins elevated homocysteine levels are associated with osteoporosis and decreased bone mineral density and B vitamins are so important for numerous aspects of our metabolism.

Dr. Richard Harris MD  29:07

Calcium, food sources of calcium are preferred over supplement sources. And studies calcium in excess of one gram to 1.2 grams per day are associated with increased cardiovascular disease risk in developing kidney stones, but that’s from supplements and actually not from food. And we’re going to talk about a little bit later but there’s actually a form of calcium that I prefer and that is bone calcium because that’s the calcium that most of our body. Calcium is in that hydroxyapatite form because most of the calcium in our bodies in our bones boron. Boron is a trace mineral that plays a role in the metabolism of calcium, phosphorus, vitamin D. It has a role in the metabolism of other hormones like testosterone and estrogen, and it may act to directly stimulate osteoblast cells. What else phosphorus. Phosphorus is a mess major component of hydroxy apatite. The RDA for phosphorus is about 700 milligrams per day. The average phosphorus intake is about 1400 milligrams per day. phosphorus deficiency results in stunted growth. rickets is a disease that you used to see all the time where people kind of had the Bode bones and they would walk with the assistive devices that the you know would test their arms and that was Ricketts.

Dr. Richard Harris MD  30:27

This is rare nowadays. Now 85% of the body’s phosphorus is in the bones. Dietary deficiencies and phosphorus are also extremely rare. Phosphorus is naturally present in meats, nuts, seeds, lagoons, dairy grains, it’s added to food for various reasons during processing grains account for nearly 30% of the intake milk 21% and meats 25%. Soft drinks is about 3.3% of total phosphorus intake. Now, the thing here is even though it’s only a small amount, frequent cola consumption, not the clear is the cola have higher phosphorus content than the clears, is associated with altered bone metabolism, lower bone density, and fractures in human and animal studies, about a 20 ounce cola contains about 55 milligrams of phosphorus, not that much. But it’s a highly bioavailable type of phosphorus, so you absorb it very easily. Plant phosphorus is not very bioavailable, it’s not absorbed very well, then meats, and then the food additive phosphorus, even though it’s a low amount, it’s just very bioavailable. And then also probably what we know is people who drink the most like diet soda or even regular soda tend to be more unhealthy, they tend to have more unhealthy behaviors, it might just be that it’s not the soda itself. It’s just that the intake of soda in the highest amounts is a hallmark signal for people who have other issues related to metabolism, other lifestyle issues that are causing metabolism issues. But the main problem here is combining high dietary phosphorus intake. With low calcium most people don’t get enough calcium, this combination leads to an increase in p th, which increases bone resorption in response to the high phosphorus diet, because calcium and phosphorus will bind together. So if you start removing calcium, bioavailable, unbound calcium, your body will increase p th to try to increase your calcium levels. This does not seem to happen when calcium is increased with phosphorus from milk sources. And milk has more phosphorus than Cola, but it contains calcium as well. And then the ideal ratio, no one really knows some people proposal one to one, or 1.3 to one intake for calcium and phosphorus and diet for optimal health. But if you look at like the RDA is they’re actually pretty similar, you know, about 1000 of calcium 700 of phosphorus. So they’re pretty similar, but the problem is more people because of their eating highly processed food Ultra processed foods, they’re getting too much phosphorus, not enough calcium. That’s a recipe for bone mineralization problems. How do we measure these things DEXA scan, low bone mass is defined, and it’s defined by standard deviation. So if you’re between one and 2.5 standard deviations below the mean of a young adult male or female, then then this is assessed at the the femur neck or the lumbar spine. Osteoporosis is defined as a bone mineral density that’s 2.5 standard deviations below that of a young adult mean value. Now the problem here is that the values were based on Caucasian women in their 20s and 30s. There is some problems extrapolating that to other groups of people, but it’s still the gold standard for testing your bone mineral density, a 10% drop in bone density more than doubles the risk of fractures. There’s some bloodwork that we can do to look at this, this isn’t done very often. But there are bone turnover markers, like CT x, which is C terminal crosslinked tele peptides of type one collagen, or in TX, which is in telopeptide version of this, that is osteocalcin you can use as a marker of bone formation. This is mostly done in studies. But some physicians will do these when they’re treating osteopenia or osteoporosis to see if we’re getting a response. And they don’t want to do more frequent like DEXA scans.

Dr. Richard Harris MD  34:36

There’s also something called fracks fra x. This is the 10 year probability of developing a hip fracture or major osteoporosis fracture for women. Now the effectiveness of screening and recommendation for subsequent treatment and postmenopausal women using DEXA. There was a study that was done here for screening and one of my main issues was screening. I don’t have a problem with screening I think we need to scream But screening without prevention is not very effective. And what I mean by that, well, this study showed there was a reduction in fractures from 11.7% to 11.2%. Major fractures from 8.4% to 7.8%. In hip fractures from 2.7% to 2.2%, there was no difference in all cause mortality for all fractures. And about 11 to 18% initiated medication after screening, the number needed to screen to prevent one fracture was 247 for osteoporosis fracture, and specifically for hip, it was 272. These are not very impressive numbers. At scale, when you’re talking about 100 million people, you know, a point 6% or 1% difference makes a big difference. But it’s not. If you’re talking about a physician’s practice who’s got 1200 patients. And that’s why just screening by itself is only half the story, get screened, but take preventative measures, if you don’t teach people how to prevent these things. And just rely on screening. While most people are going to get these things. Eventually, we’ve just looked at the data on the numbers of people who get brittle bones, osteoporosis and osteopenia. Let’s look at prescription treatment. And I always ask myself some questions about prescription medication and we’re gonna look at three questions here. We’re gonna look at does it prevent mortality? Because that’s important. Does it keep me from dying? Does it lessen the severity associated with fractures? So if I get a fracture, am I better off because I was on the medication? And then does it prevent fractures? Those are really the things that you care about if you’re told you have osteoporosis and okay if I get a fracture, am I gonna die? If I do get a fracture is the severity lesson and am I going to prevent fractures from taking his medication? Let’s look at this. There’s multiple classes of medications to treat this. The most popular one the most well used one are something called bisphosphonates. bisphosphonates are absorbed by osteo class and they slow down resorption so they don’t actually help you. Stimulate osteoblasts they actually just work to stop or slow down the osteo class breaking down bone. One main analysis looked at bisphosphonates. They also looked at a medication called denosumab which targets the rank L. They also looked at teriparatide was this a synthetic p th, and they found a number needed to treat of 60 to 89 to prevent one vertebral fracture. So you have to treat 89 people, or 60 people somewhere in between there to prevent one fracture. That’s an absolute risk reduction of 1.1 to 1.6%. And then for a hip fracture, you have to treat 50 to 67 people to prevent one hip fracture. That’s an absolute risk reduction of 1.4 to 2%. And that’s with one to three years of treatment. I’m not impressed by those numbers. So you’re telling me my best shot is a 160 shot. And I got to take this medication for three years to get there, or a one in 67 shot and I gotta take that medication for three years from a hip. Not impressive to me. These absolute risk reductions are so small, one study found in men with zoledronic acid, which is another bisphosphonate IV, once a year for two years, but an absolute risk reduction of 3.3%. And that was for fractures found on radiology. So sometimes you can find these fractures and people don’t have symptoms, you just incidentally find them especially in the vertebral area. And then for clinical diagnosis, their reduction was down from 1.8% to 1%. Again, population level hundreds of millions of people, yes, you can make an argument for this. But again, you have 100 people, in this case 3.3 of them are going to prevent a fracture. That’s not good enough for me.

Dr. Richard Harris MD  39:05

One problem with bisphosphonates is that longer use can lead to a typical femur fractures. Now it’s about 30 to 100 fold less risk than for untreated persons of osteoporosis. But still, using this medication can actually cause what you’re trying to prevent the medication from causing another drug with a new antibody that was approved in 2019 called Roma Susan Mab and this works by inhibiting a protein called Gore Ossington, which prevents ostial Blast inhibition. It does increase bone mineral density more than the bisphosphonate Alendronate or teriparatide. But then again, let’s look at absolute risk reduction because that’s, to me, absolute risk reduction and number needed to treat are the most important thing. Next I’m gonna look at number needed to harm an adverse effects because the benefit has to outweigh the risk First of all, a medicine do no harm. If the risks outweigh the benefits. Why am I giving it to you? With this new medication fracture reduction showed a 1.3% absolute risk reduction at 12 months and a 1.9% reduction at 24 months. This was for vertebral fracture, but no significant reduction in non vertebral fracture. And the main problem here is cost as doses are limited to 12 or more patients had serious cardiovascular events when treated with the drug as well as about half a percentage more cardiovascular events. Here’s the other problem with these medications. The effect seems to peter out somewhere between five to 10 years as stopping the medications and certain studies showed no difference in fracture rates after that you get about five to 10 years of a very marginal benefit in preventing fracture. Okay, what about mortality? Right? So you’re telling me okay, it may help a small amount of people prevent a fracture? What about death? You said 30 to 40% of people will die within a year of having a fracture related to osteoporosis. So does the medication prevent that from happening? There’s not a whole lot of data on this there was two studies with the zoledronic acid, which is the bisphosphonate. The two studies when he pulled the data, there was no mortality benefit, there was 5.4% versus 4.9%. That difference wasn’t statistically or clinically significant. bisphosphonate use in pooled analysis total of 48 trials showed a reduction in all cause mortality by about 10% that is showing a four bisphosphonate use in this pooled analysis 48 trials you were able to show a reduction of all cause mortality by 10%. And another meta analysis of 38 trials found no mortality benefit from bisphosphonates or zoledronic acid. So what this means is, there’s somewhere between no and 10% mortality benefit, we don’t really know if that actually impacts mortality.

Dr. Richard Harris MD  42:14

If you look at overall, two of the studies of pooled data found no benefit one found a 10% benefit. So if there is a benefit to mortality, it’s likely small. What about quality of life? All right, we’re basically over to here. Now, Richard, please tell me that these medications have some improvement in quality of life? Well, there’s not much data. One study out of France with the teriparatide did not show improvement in quality of life and women with severe osteoporosis. It did show some improvement in people who had back pain because of osteoporosis. Other studies, there were three studies that are small with single agents. Two of them not available in the US strontium, and alkatone. And teriparatide only showed quality of life improvement for those with pre existing vertebral fractures and pain or severe osteoporosis. Okay, so what does this mean overall morbidity for preventing fractures, that data to me was not impressive, mortality benefit, that data to me was not impressive. Quality of life improvement seems to only happen when you have very severe disease, the best medicine can offer you is some improvement in your symptoms when you have severe disease right now. And that’s my interpretation of the research. So again, this goes along with what we talked about with cholesterol. This goes along with what we talked about with high blood pressure, you cannot just depend on medications. For metabolic disorders, the efficacy is to me poor at best, it is best to prevent these things from happening. Now let’s look at holistic therapies for bone health. Let’s start with what we alluded to earlier. And that is resistance training. Resistance training is associated with a 51% decrease in the occurrence of fractures in older adults. From one study, it was 10.9% to 4.8%. Exercise increases bone mineral density. The most effective form of exercise for the femur neck is resistance training, while a combined resistance and cardio program is more effective for the lumbar spine in one meta analysis. And again, these effects are all additive. If you look at one single thing, the effect might be small to moderate at best. But then you start layering these behaviors together and you start getting a larger effect. Because, again, there’s multiple inputs that regulate these systems. So you want to make sure they all have these inputs that regulate the system, that you have a plan for each one of them and that you’re optimizing every input because that’s going to give you the best outcome. Smoking cessation one twin study show Smoking during adult life reduced bone density by five to 10%. Smoking may also negate the positive effects of HRT and postmenopausal women. So once again so often is one of the worst things that we can do for our health, and chiropractic care. I’m a big fan of chiropractic care. I couldn’t find any human studies on this, but animal models show chiropractic care increases osteoblast activity. Nutrition, so important. What can we do from a nutritional standpoint, protein intake, higher protein intake was associated with lower risk of hip fracture and bone loss in several studies. After fracture, higher intake of protein was associated with decreased bone loss and shorter rehab stay low protein intake associated with higher bone loss, most Americans do not consume enough protein. I’m a fan of for getting 20 to 30% of our calories from protein, I tend to like to be on that 30% I usually try to get 1.6 grams per kilogram of protein, and that may go up to 2.2 or 3.4. Depending on my goals. If I’m trying to build muscle, I’ll go to that higher range. I’m trying to maintain my muscle while cutting like I’m doing now. I’m getting about three grams of protein per kilogram right now higher fruit and veggie intake is associated with higher bone mineral density. This is not surprising, because higher intake of flavonoids, we’ve talked about flavonoids are a really potent class of antioxidants. And one twin cohort study showed higher bone marrow density at the spine. Another study found higher dietary intake of flavonoids was positively associated with bone marrow density at the spine and neck and postmenopausal women. We talked about how inflammation and inflammatory markers can create bone loss by stimulating osteo class. Well, if you deal with that inflammation, it’s going to balance the system. And we know that higher intake of fruits, vegetables, flavonoids, antioxidants, anthocyanins, all of these types of compounds are very beneficial for antioxidant purposes, and just our overall health, higher intake of omega threes associated with improvement in bone mineral density in young and the elderly. While higher intake of omega six fatty acids are associated with lower bone mineral density in children in older adults. Omega threes are thought to provide benefit by reducing inflammation and by increasing absorption of calcium from the gut. We’ve talked about omega threes and how to get those before fatty fish, walnuts, chia seeds, flax seeds, pasture raised eggs, all of these are great examples of omega threes and then of course you can supplement omega threes if you need to. I personally take one to two grams of fish oil a day.

Dr. Richard Harris MD  47:39

higher intake of carotenoids foods found in things like carrots sweet potatoes, spinach, kale, collard greens, bell peppers, these are usually your yellow green orange veggies are associated with increased bone mineral density. And the Framingham study, the highest first lowest group of carotenoid and lycopene intake how to reduce 15 year fracture incidence by 46% of women and 34% and men.

Dr. Richard Harris MD  48:04

significant reduction here by what you eat, again, what you eat determines what you’re made of, like our body does doesn’t make things out of nothing. It has to have resources, and those resources are what you eat. So what do you eat? What do you put into your body, you putting in stuff that’s going to help your bone minerals, you put it in stuff that’s going to cause inflammation and decrease your bone mineralization. Epidemiological studies show positive associations between vitamin C intake and bone mass, higher dietary intake of vitamin B six. These are things like beans soy beans, liver whole grains are associated with higher bone mineral density. Boron most people get less than one milligram of boron per day via food. Three milligrams of boron per day may have positive effects on bone. There is no RDI for boron. Boron is found in fruits, veggies like potatoes, avocado, lagoons, nuts and eggs. A small study did show that born of three milligrams per day decreased urinary calcium loss and postmenopausal women. We talked about how boron works through calcium and vitamin D earlier vitamins. The data on vitamin K two is mixed, you’d likely need higher doses to be beneficial for osteoporosis, lower amounts for just general maintenance. Overall, it’s recommended the 90 micrograms a day for women for vitamin K 220 For men, but that’s based on k one levels needed to prevent bleeding. There is some evidence that shows that our vitamin K to intake should be around 10 to 45 micrograms per day. But most of the cake that we get is k one in western diets. It’s found in things like natto eel cheese, mostly hard cheese, liver, chicken butter, ghee, sauerkraut, pasteurized eggs. There were clinical studies done in Japan with vitamin K to that NK four that talked about earlier, at 45 milligrams per day. This dose maintain bone mineral density when combined with calcium and reduce vertebral fractures similar to a bisphosphonate in one study out of Japan, calcium and vitamin D. We talked about this earlier, I prefer to use whole bone calcium, and I have a form of whole bone calcium in my East door. That’s what I recommend to people. The total between supplements and intake of calcium should be around 1000 to 1200 milligrams of calcium daily, vitamin D depends, and we discussed that on the vitamin D podcast however, for fractures a pooled analysis showed no benefit for vitamin D supplementation less than about 800 international units daily. Large prospective studies however, have consistently shown improvement in bone mineral density, with calcium and vitamin D. Some studies do show reduction in fracture risk others do not. One of the largest trials though, showed that compliance was a big factor in reducing risk. We know that people are very bad at remembering to take their vitamins and even their medications. How you take these things actually does matter. From is here, the baseline vitamin D levels were not assessed and most studies made an analysis showed benefit for calcium and calcium plus vitamin D but not vitamin D alone. This makes sense. The main purpose of the vitamin D is to make sure that you’re getting adequate calcium to your bones. So if you don’t have adequate calcium, the vitamin D is not going to be able to do his job without adequate calcium. And this is what we talked about on the podcast before that these vitamins don’t exist in a vacuum. They’re not a smart bomb like medication, they need other cofactors to work for your bones. Vitamin D needs magnesium to be activated needs calcium to be present needs vitamin K to to pull that calcium into the bone. It’s like construction. You can’t have one construction worker and expect him to put your house together. No he needs other people with other jobs to help him build your house or her risk reduction for hip fractures were approximately 13 to 19% for calcium plus vitamin D. Magnesium. One observational study found hip bone mineral density 3% higher and whole body bone mineral density 2% higher for women who consume more than 423 milligrams of magnesium daily versus those who consume less than 206 milligrams. human trials are mixed with some studies showing improvement in bone mineral density and bone turnover markers. It’s likely only beneficial in people who have low magnesium levels. Now the good news here is most people have low magnesium levels. 60% have inadequate intake about 45% have low magnesium. So I personally take between 100 to 200 milligrams of magnesium glycinate every day isoflavonoid. isoflavones are antioxidants they’re thought to inhibit inflammation, enhance antioxidant pathways, increased calcium absorption and promote osteoblasts while inhibiting osteo class and help modulate a growth factor called IGF one in postmenopausal women. So flavonoids derived from soy to phyto. Estrogen have shown improvement in bone mineral density and some studies. In particular, there’s one called genestein in one trial showed modest improvements in bone mineral density and markers of bone resorption. Justin can be seen in some health products. ipriflavone isn’t one that you’ll see a lot in products. This has mixed results as well. 600 milligrams per day for use of longer than six months can cause adverse effects the white blood cell count so if you’re taking it, it’s something you want to be aware of. in postmenopausal women in China, those with high dietary soy intake had a 36% reduction in fracture risk. And that was 13.26 grams daily verse about five grams per day.

Dr. Richard Harris MD  54:01

hormone replacement therapy, therapy with estrogen and testosterone is associated with improvements in bone mineral density DHEA that’s another androgen. Some studies show benefit and bone mineral density, and resorption markers however others do not. It’s likely only beneficial when DHEA levels are low. But these are just giving you tips and things that you can check with your doctor to see which one of these things you may need. B vitamins some small studies show improvement in bone markers and patients without osteoporosis and they have low folate and then PEMF PEMF can increase bone mineral density and human trials and postmenopausal and elderly women. So we’re giving you a lot of tools, a lot of tips, a lot of tricks to treat and prevent these things from a holistic perspective things to look at how to evaluate your bone health. And I hope the key takeaway you got from this podcast was that your bone own health is important as a marker of your overall health is essential to your overall health and well being. Especially as we get into our I don’t want to say twilight years maybe our awesome years. I don’t know, I need to come up with a term for that as we age because, you know, I’ll be 40 next year, so. Yay. Alright guys, thanks for listening to me ramble once again, longer episode, but there’s a lot to cover. We’ve got those other episodes I talked about coming out soon. Y’all have a blessed day. Thank you for listening to strive for great health podcast with your host Dr. Richard Harris. It’s our mission and goal at the podcast to impact as many lives as possible to empower individuals to take control of their health, and live a life full of joy and purpose. You may help us achieve this mission by leaving a five star rating and review on your preferred podcast platform. And by sharing this podcast with anyone you think it may help. You can also support the podcast by making a donation to your favorite charity. If you do so, and send us an email. We’ll give you a shout out on the podcast. Because here’s the strive for great health podcasts. We’re all about charitable giving and making the world a better place. Thank you for listening and God bless


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