Selasa, 19 September 2017

what is the cause of osteoporosis

what is the cause of osteoporosis

the skeleton is made up of bones, which provide support and shape to the body. they protect soft internal organs, such as the brain, and heart, from injury. together with muscles, strong bones enable the body to move freely. bones have a solid outer surface, called compact bone. the inner bone is called spongy bone, because it is less dense than compact bone, and has many small holes like a sponge. bones contain cells called osteoclasts that break down bone tissue. other cells, called osteoblasts, make new bone tissue using minerals, such as calcium and phosphate, from the blood. hormones, such as estrogen, growth hormone, and testosterone,

help keep the number and activity of osteoblasts higher than osteoclasts so that more bone is made than removed. physical forces and pressure during exercise also help bones to grow stronger and denser. these processes allow bones to grow strong in children and young adults. people have their strongest, most dense bones, called peak bone mass, in their thirties. after this age, osteoclasts gradually remove more bone than the osteoblasts make. osteoporosis is a condition that leads to weakened bones, causing them to break more easily. healthy bone is dense enough to support and protect the body, and to handle the stresses of movement and minor injuries. however, people with osteoporosis have abnormally thin bones with larger holes in the spongy bone. there are two types of osteoporosis.

primary osteoporosis is usually related to older age, as well as a reduced amount of estrogen in women. secondary osteoporosis affects both children and adults. it is related to other diseases or conditions, such as cancer, hormone problems, or use of certain medications. a person has a greater risk for either type of osteoporosis if they don’t develop enough bone mass when they are growing from childhood to adulthood. risk factors that can lead to low peak bone mass include: a family history of osteoporosis, being white or asian, being female,

a poor diet, certain medications, such as steroids or certain seizure medicines, lack of physical activity and weight-bearing exercise, and lifestyle behaviors, such as smoking and drinking too much alcohol. a person also has a greater risk for either type of osteoporosis if they have an abnormal amount of bone loss after age thirty. some bone loss is normal after this age. however, a person with the same risk factors for low peak bone mass can be more likely to get osteoporosis as they age. increased bone loss is also common in women after the time of a woman’s last period, called menopause. after menopause, a woman’s ovaries stop making the hormone estrogen.

with the drop in hormones, bone-removing cells, called osteoclasts, are more active than the bone-making cells, called osteoblasts. bones may break, or fracture, easily because they are unable to withstand the physical strain and pressure from even normal activities. common fracture locations in people with osteoporosis include the wrists, spine, and hips. building strong, healthy bones through a diet rich in calcium and vitamins, and getting regular exercise, can help prevent as well as treat osteoporosis. common medications for osteoporosis include: biophosphonates,

a medication called denosumab, selective estrogen receptor modulators, or serms, and calcitonin. in general, these medications act on bone-removing cells, called osteoclasts. parathyroid hormone acts on bone-making cells, called osteoblasts. food or supplements containing calcium and vitamin d are also recommended for osteoporosis. for more information, talk to a health care professional.

what is the best treatment for osteoporosis

what is the best treatment for osteoporosis

welcome to health care at home in the previous episode we were talking about the pain of osteoporosis. as i said that i'll share some tips, if you follow them from the beginning then chances of osteoporosis will be low. the first thing which i'll name here is apple apple contains flavonoids, polyphenols & such anti-oxidants which are very helpful to fight with osteoporosis according to an researcher of france apple contains a flavonoids called phloridzin which reduces inflammation & is very much helpful in growth of bone-density. in result you have strong bones & muscles.

apple also contains much quantity of borrone it increases the capacity of holding calcium in the body. thus you have strong bones and muscles. to cure with osteoporosis you have consume an apple daily, so start from today itself. so that there will be least possibilities of osteoporosis. second thing what you can do from today itself to prevent from osteoporosis. that's consumption of vitamin d means sunbath. our body is only able to absorb calcium when our body have good & ample amount of supply of vitamin d.

vitamin d is very rarely found in food items. non-vegetarian can get it in chicken or chicken liver but for vegetarians vitamin d is very low in food items. but we have very natural source of vitamin d i.e. sunlight. so what you have to do, take sunbath early in the morning. without clothes lay down under the sunlight for 10-15 mins. your body will absorb vitamin d in the enough quantity. with this absorption of calcium will increase. in result your bones will be strong and there will be least chances of osteoporosis.

thirdly what you can start from today itself i.e. consumption of pineapple. pineapple contains manganese, due to its deficiency too bones become fragile. due to this problem of osteoporosis can happen. take a bowl full of chopped pineapple and have it before your meal. or anytime in day if you'll consume a glass of pineapple juice this way deficiency of manganese will be suffice, you're bones won't become fragile. also there will be least chances of osteoporosis. so these were few tips which you can follow on regular basis. further i'll share some remedies, if you'll follow them you'll be able to fight with osteoporosis.

all that i will share in my next episode. rest our wish is only that you stay healthy, busy, carefree and be with us. to meet us you have to subscribe this channel. tell to your friends & relatives to subscribe this channel. get the health benefits by sitting at home. and do support us in our motive. our motive is that maximum number of people should get the health benefits by sitting at home only so, don't forget to share & like our videos as much as you can. thank you…

what is osteoporosis how can it be prevented

what is osteoporosis how can it be prevented

hello, if you're watching this video, you may be concerned about your back health and safety. well, don't worry we are here to keep you informed and give you some tips to help keep your spine safe and strong. you could say we're here to watch your back. certain exercises and movements can be beneficial for individuals living with osteoporosis. however, incorrectly doing these exercises, choosing the wrong exercises or doing too much too fast can do more harm than good. it is important to be mindful about posture, loads and other factors

to spare the spine of injuries during exercise or leisure activities. with these activites there are many spine sparing strategies that can be implemented to keep your back safe. osteoporosis is a degenerative disease that causes decrease in bone strength, and increases the risk of fractures or breaks. this disease effects both men and women and can strike at any age. over eighty percent of all fractures in canada after age fifty are caused by osteoporosis. the common sites of fracture due to osteoporosis are the wrist, hip, shoulder and spine. however, fractures of the spine are almost twice as common as every other fracture type.

exercise can reduce your risk of fall, and by increasing muscle mass and strength, while improving coordination and balance. strength training exercises should be modified to individual ability to ensure enough of a challenge. it is important to avoid over loading of bone and muscle to the extent that it would cause injury. back pain and injury due to exercise and leisure can be avoided by following some of these simple tips. to begin, let's look at proper posture and form. posture and technique are important. improper posture can lead to different kinds of back injuries, such as muscle stiffness, sprains, vertebral disc herniations, and even fracture.

here are some examples on how to effectively perform movements necessary for exercise and leisure. when lifting be sure to bend at the knees and not at the waist. if needed use a hip hinge strategy. to perform a hip hinge, the first step is to find the hip. place your hands at the crease of your hips and bend forward at the hands while keeping your back straight. for lifting smaller items off the floor, a golfer's lift is a great technique that is recommended to spare the spine of high loads. one leg comes off the floor behind you, and acts as a counter balance. the hip bends, and the body becomes almost parallel to the floor.

one arm reaches to pick up the object while the other can hold a counter or wall for support. another tip is to try to keep whatever you are lifting close to your body, and to not lift weights to high or low areas. for example, if you are grabbing a bag of flour when baking, make sure you hold it close to your body, and do not grab it from overhead. carry loads in two hands when possible, rather than just one, like when you are grocery shopping, carry your bags with both hands instead of holding everything in one hand. when wanting to turn your whole body to face where you are going, change directions with your feet. don't try twisting, or pivoting, as it puts unnecessary strain on the spine.

do not sit for long periods of time, to prevent spinal loading. for example, when knitting avoid doing so for prolonged hours at a time. instead, every half hour stand up and take a short walk. and finally, avoid high impact movements or exercise whenever possible. a simple strategy to help spare the spine is using abdominal muscles to help strengthen and stabilize. this involves activating and stiffening the abdominal muscles in preparation for an exercise or activity. in doing so, you greatly increase the level of stability in the spine. to activate or stiffen the abdominal muscles, pretend you are about to take a punch to the stomach. this is known as super stiffness, and can be key in maintaining back health during exercise and leisure.

stabilization exercises are a simple way to reach low back health objectives. it is important to challenge the muscles, spare the spine of high loads, and ensure sufficient stability. variations of these exercises are to be chosen with the patient's status and goals in mind. the bird dog exercise is excellent for spine sparing, applies very little compressive load on the spine, and is great for stabilizing back extensors. there are many different progressions for patients of different fitness and ability levels. begin on your hands and knees on a yoga mat. the wrists should be under the shoulders, and the knees should be under the hips. one arm or leg at a time, extend and put it straight out for a hold of three seconds.

repeat this with all four limbs. when this is perfected, one arm and the opposite leg can be lifted at the same time, repeated on both sides. it is important to remember not to go into end range flexion. in other words, do not push past your limits. in addition to making sure your back is safe for everyday activities, strength training is a great way to stay mobile, and healthy, and to keep your spine safe. resistance exercises can be done at home either lifting your own body weight, or using things like a can of soup or a bag of flour. exercises like wall squats, bridging, and calf raises, are low impact and will improve core strength. for wall squats, stand with your back against the wall and your feet slightly in front of you, hip width apart.

hold for twenty seconds at a time, and begin to progressively hold longer. work towards having your feet about two feet in front of you and your knees at ninety degrees. when performing a bridge begin by lying on your back with your knees bent and your feet close to your bum. press down through your heels and lift your bum, so your shoulders, hips and knees are in a straight line. hold for about twenty seconds, and then start to progressively increase. to do calf raises, stand on a stair with the front of your foot on the step, and your heels hanging off. alternate between flexing and pointing your foot, using your calf muscles to push you up. resistance training should be done for about thirty minutes, three times a week, at a moderate to vigorous intensity.

aerobic exercises, such as walking, biking, or swimming, should be done for about twenty minutes every day at a moderate to vigorous intensity. a good way to judge how hard you are working is the talk test. at the point where you can no longer keep up the conversation because you are out of breath, you are working at a moderate to a vigorous intensity. overall, we recommend speaking to your doctor before performing any exercise to make sure what your doing is right for you. we hope you keep these simple tips in mind to help spare the spine, and reduce further injury when participating in exercise or when you're enjoying your leisure time.

what helps osteoporosis

what helps osteoporosis

tips to prevent & reverse osteoporosis how to reverse osteoporosis

what does osteoporosis mean

what does osteoporosis mean

harvard’s school of public health explainsvery nicely the mechanism by which protein can cause problems for bone health. it says,“as your body digests protein, it releases acids into the bloodstream, which the bodyneutralizes by drawing calcium from the bones. following a high-protein diet for a few weeksprobably won’t have much effect on bone strength. doing it for a long time, though,could weaken bone.” now we’ve known for a very long time thatmeats, including fish, are acid forming in our body. scientists from columbia university,back in 1912, analyzed acid and base forming elements in food, and noted that, “all themeats (including fish) a decided excess of acid-forming elements”; all the “meats(including fish) show [a] decided predominance

of acid-forming elements." back in 1920, columbia’s department of chemistryalso reported that adding meat to one’s diet results in increase of calcium loss inurine, thought to be because “the added meat gave to the diet as a whole an excess ofacid-forming [over base-forming mineral] elements[.]" and what have we seen from the results ofthe consumption of animal protein with regards to bones? researchers from yale university’sschool of medicine looked back across a broad array of 34 prior published studiesacross 16 countries, and they found these studies over time showed “a strong, positiveassociation” between dietary animal protein and female bone fracture rates.

so, we’ve known for some time that thisassociation exists. we know eating a diet high in animal protein results in acidity,and that our body leaches calcium from our bones to buffer the acid. one of the mechanismsbehind this phenomenon is that animal protein has a higher amount of sulfur-containing aminoacids, and the “sulfur-containing amino acids from animal protein lower blood ph”. so animal proteins — including meat, fish,dairy, poultry or eggs — have higher amounts of sulfur-containing amino acids than plantfoods. as a result, when we eat diets high in animal proteins, our body produces sulfuricacid, which increases the acidity in our bodies. one of the body’s mechanisms to neutralizethis acidity is to draw calcium from our bones

(similar, for example, to when we take antacidsthat are made with calcium to neutralize the acidity in our stomach associated with heartburn).the problem is that constantly leaching calcium from our bones can reduce bone mass, makingour bones weak and more prone to fractures and osteoporosis. moreover, the chronicallyhigher calcium excreted in our urine can also lead to the development of kidney stones. this harvard study published in the americanjournal of epidemiology followed over 80,000 women over 12 years, and found that animalprotein was associated with increased risk of forearm fracture, but no increase in riskwas observed with higher intakes of vegetable protein. it found that women who consumedthe largest amount of animal protein in the

study had a 22% higher risk of fracture. evidencesuggests that “higher protein intakes in young...women have a negative impact on radialbone measurements”, meaning that women who consumed higher protein diets have been foundto lose bone mineral content and bone density. so we know that our body uses base stores(including calcium from our bones) to neutralize the acidity we get from our diet. this articlefrom the journal of nutrition explains the same thing. it says, “diets that are netacid producing...induce and sustain increased acidity of [our] body fluid. with increasingage, the kidney’s ability to excrete daily net acid loads declines, invoking...increasedutilization of base stores ([from our] bone [and] skeletal muscle) on a daily basis tomitigate the otherwise increasing baseline

metabolic acidosis, which results in increasedcalciuria and net losses of body calcium. those effects of net acid production and itsattendant increased body fluid acidity may contribute to...osteoporosis[.]” what thisis saying is the neutralizing mechanism in our bodies of taking calcium from our bonesto deal with the higher acidity caused by our diet can contribute to osteoporosis. this journal review in the european societyfor clinical nutrition and metabolism further discusses the issue, noting how problems associatedwith acidity become even worse with age. “the modern western-type diet...contains excessiveanimal products, generating a state of metabolic acidosis, whose magnitude increases progressivelywith aging due to the physiological decline

in kidney function.” as explained in this peer-reviewed study fromthe journal of nutrition, “the average american diet, which is high in protein and low infruits and vegetables, generates a large amount of acid, mainly as sulfates and phosphates.the kidneys respond to this dietary acid challenge with net acid excretion, [and] the skeletonsupplies buffer by active resorption of bone.” the study concludes, that, “overall, theevidence leaves little doubt that excess acidity will create a reduction in total bone acid-ash diet [means] a diet that creates acid in the process of its metabolism[,]”and this article concludes, “[m]odern peoples are now eating high protein, acid-ash dietsand [are] losing their bones.”

this study, published in the official journalof the council on renal nutrition of the national kidney foundation and the international societyof renal nutrition and metabolism, compared the net acid secretions among vegans (whoeat no animal products), lacto-ovo vegetarians (who eat no meat, but do eat dairy and eggs)and omnivores (who eat a traditional western diet of meat, dairy and eggs). the study foundthat net acid secretion was higher in both lacto-ovo vegetarians and omnivores than invegans, suggesting “that higher protein intake results in more renal net acid excretionand more acidic urine.” in addition to increased incidents of kidney stone development, higherprotein intake was also found to be associated with "increased urinary calcium excretion."it noted, “higher protein intake, especially

animal protein, was linked to an increasedrate of bone loss and increased risk of hip and forearm fractures in women.” the studyconcludes, “because acid-base balance has significant implications for renal and bonehealth, it is introduce appropriate dietary modifications to prevent or treatthe conditions, including kidney stones, bone loss and/or [bone] fractures, and possiblyosteoporosis." so to recap, eating animal proteins increasesbody acidity, and one of the body’s mechanisms to neutralize this acidity is to leach calciumfrom the bones. doing this for a long time can lead to loss of bone mass and weakenedbone, increased risk of fractures and osteoporosis, as well as kidney (or renal) stones. and,an easy way to avoid the increased risk of

these problems is avoiding animal protein.

Senin, 18 September 2017

what doctors treat osteoporosis

what doctors treat osteoporosis

hey guys. dr. axe here. doctor of functionalmedicine and founder of in this video, i'm going to share with you the toptips on how to heal broken bones naturally. and if you want to repair broken bones naturally,you want to follow a very specific diet, supplement regimen, lifestyle regimen, as well as usecertain essential oils and natural treatments to help your body heal much, much faster.and i'll tell you, i've seen broken bones heal two to three times faster by followingthe tips i'm sharing with you in this video. so number one, let's start with diet, andthe key nutrients you've got to be getting in your diet in order to heal broken bones.number one, you need a lot of minerals, especially calcium and magnesium. the best calcium richfoods are going to be green, leafy vegetables

and raw, fermented dairy products. so gettinga lot of kale, and spinach, and arugula, and chard and those green leafies, even broccoli.getting those in your diet is number one. they're packed with calcium, and calcium isthe main mineral that helps make up strong bones. but in order for your body to even use calcium,you also have to have magnesium. and so, some magnesium rich foods are going to be verysimilar. green leafy vegetables, raw, fermented dairy products like goat's milk, kefir orraw goat cheese. also though, magnesium rich foods may include certain seeds, like flaxseeds, chia, pumpkin seeds, grass fed beef are also good. so again, you want to get alot of calcium rich foods, magnesium rich

foods. also, you want to get foods that arerich in zinc. zinc foods again, are going to be grass fed beef, pumpkin seeds, chiaand flax seeds. very similar to the magnesium rich foods. and then, also you want to begetting loads of vitamin c, and even things like fresh vegetable juices. vitamin c richfoods can include orange juice, true oranges, lemons, bell peppers, kiwis, broccoli, asparagus.those are foods that are packed with vitamin c. so make sure you're getting plenty of vitaminc. so really your diet should consist of a lotof veggies, some fruit, some organic meat, some nuts and seeds. and that should reallybe the bulk of your diet as you're trying to heal, and get all of those nutrients forbuilding strong bones.

now the foods you want to stay away from arefoods that tend to be overly acidic, conventional meat and dairy products and alcohol. you alsowant to stay away from excess sodium and excess sugar. those will acidify your body. they'llactually leach those minerals out of your body and really cause your bone growth andhealing to slow down. now, the top natural supplements for the treatmentof broken bones are going to be, number one, taking a vitamin d supplement. if you havea broken bone, getting out in the sun is ideal. getting direct sunlight, vitamin d is reallyimportant for bone growth. but if not, then taking 5,000 ius twice a day for three monthsof vitamin d is crucial to healing broken bones fast.

the other supplements you're going to takealong with magnesium and calcium supplements, ideally is a magnesium chelate supplement,so it would go to whole food form of magnesium. also, things that can help is a fish oil supplement.those omega three fats can reduce inflammation, speed the healing process, as well as doinga green super food powder. getting a green super food that has spirulina and chlorellaand other alkalizing fruits and vegetables. very, very beneficial at actually healingbroken bones. the next step in healing broken bones fastnaturally, is going to be natural therapy, such as standing on a vibrational platform.there are studies that show a vibrational platform increases bone density, so you canfind vibrational platforms on line. stand

on those for 20 minutes, three times a dayand it naturally helps increase your bone density. and it's doing that without majorimpact, so again, vibrational platform. don't forget that. some gyms also have them in thegym. i know a lot of chiropractic offices that have those as well. so again, gettingon a vibrational platform. now, here are two other key things you cando to heal broken bones fast. the next one is use essential oils. three powerful essentialoils for healing broken bones, cypress oil, fur oil as well as helichrysum oil. and youwant to make a blend, and put this on your body, five to six times daily, is you're goingto put directly on the broken bone area. you're going to go ahead and put cypress oil, furoil and helichrysum oil.

cypress oil really improves circulation inthe area, speeding the healing process. fur oil really works in helping the bone, andyou have helichrysum which actually helps in communication repairing damaged nerve those three oils are the best oils for helping heal broken bones using that in allof those areas, five to six times a day. and then, last but not least, getting acupuncturetreatment. we know acupuncture really works with your body's meridians and different healingnetworks. and really transforming where sort of your body energy is utilized and reallysupporting your organs and repairing those damaged bones. so again, i would recommendseeing an acupuncturist. oftentimes, somebody that does a five elements acupuncture is veryeffective at the treatment of healing broken

bones. i promise you, if you do these tips,you're going to see your broken bones heal faster than ever. hey, i hope you've enjoyed this video, andif you want more tips, i've got another great article on my website, to checkout. hey, guys, i hope you've enjoyed this video on how to naturally heal broken bones.

what doctor treats osteoporosis

what doctor treats osteoporosis

[ silence ] >> hello and welcome to thespinal cord injury forum. i'm chuck bombardier. i'm a rehabilitationpsychologist here at the university ofwashington and the director of the northwest regionalspinal cord injury model system. we're grateful to the nationalinstitute on disability and rehabilitation researchfor sponsoring our forums. they make all the contentand videotaping possible

by a generous grant wehave received from them. tonight, we're very pleasedto welcome dr. jelena svircev as our speaker talking aboutosteoporosis and fractures in persons with spinalcord injury. dr. svircev is an assistantprofessor at the university of washington in the departmentof rehabilitation medicine and she's one ofthe staff physicians at the spinal cord injuryservice at the department of veterans affairs at thepuget sound health care system.

dr. svircev. >> thank you. thank you sci for inviting mehere to speak with you and share with you some of the things thati learned about osteoporosis and spinal cord injuryand fracture management. i have a few disclosures. one is that i have nofinancial disclosures. the second one, as manyof you who are consumers of spinal cord injuryknow that there are--

there's oftentimes verylittle evidence that we have to support many ofour practices. so when i talk about someof the management principles with osteoporosis andwith fracture management, if you find yourselfthinking, "hey, i had a fracture a while back"or "hey, i had a conversation with my provider aboutosteoporosis that's different than what i'm saying," recognizethe fact that there isn't a lot of literature and that eachrecommendation that's made is

based on the literature thati've gathered, the practices that i've learnedfrom my colleagues and how the individualsthat i work with have chosen to interpret the information. so take with you the informationthat i'm sharing with you and when you go talk withyour provider, you can bring up these different issues thatwe've discussed today but know that each treatment is goingto be customized to you. the last disclosure that i haveis, as dr. bombardier mentioned,

all my clinical time, excuseme, is done at the va. so throughout the talk,if i refer to my guys, it's because most of theindividuals that i work with are guys and that it'snot just showing you disrespect to my guys. we have wonderfulrelationships with the veterans. we do service smallfemale population and i don't mean no disrespectto the females in the audience and certainly thefemale veterans.

but i found myselfsometimes using that language. in the next courseof our discussion, i'm hoping we're going to learnsomething about osteoporosis in the spinal cord-injuredpopulation. we're going to talk abouthow one evaluates, treats, and prevents osteoporosis. are these even possibilities? if an individual fractures, whatare the fracture characteristics and how does one then managea fracture in the setting

of spinal cord injury. mr. k is going tobe joining us today. he is one of my guys. he is a young gentlemanwith a paraplegia. he's in his early 40s and hecame into clinic and said, "all right, doc,i've been injured for a couple of years now. i've heard about thisosteoporosis and bony weakening. i've got two little kids.

my two little kids like toride my leg as they show in this picture sometimes. i'm very active. i work full time. i like to ski. i also have a grandma whojust fell and broke her hip and i'm worried withmy occasional falls, with my transferswhat's going to happen to me 'cause she is goingdownhill quickly and doc,

i need your help tosee if there's a way that i can help managethis a little bit better." i said, "all right, mr. k, we're going to have along conversation now. we're going to startwith the basics." so if we think aboutosteoporosis, we think about bones and wethink about a typical long bone which is the long skinny ones, we think of a coupledifferent parts of the bones.

so we have the ends of thebone, the top, and the bottom, those are the epiphyses. we have the diaphysis andthat's the shaft of the bone and we have the metaphyseswhich is the part where the shaft kindof meets the end. and the area that we wantto focus on when we think about spinal cordinjury is the epiphyses, the ends of the bones. bone itself has acouple different parts.

we have the cortical bone,that's the compact bone. it's the outside of the bone. it makes up about 80percent of the bone. and then we have thetrabecular bone and that's kind of the inner, verymeshy layer of the bone. when we think of abone, you usually think of a solid hard object kindof like a rock and i want to emphasize the fact that boneis not a solid nonliving object. it is a very dynamic structure.

you have a coupledifferent parts of bones. bone is part of an organ so itis made up of different cells. we have the osteoidwhich is the bony matrix. it is a noncellular substance,but then we've got a couple of different cells, theosteoblasts, osteocytes and osteoclasts and theseare all living dynamic, tiny components thathelp support the bone, so it's a living, breathingorgan albeit it operates at a much slower pace thanmany of our other organs.

when we think about osteoporosisnow, osteoporosis is a disease where the mass of the bone, thesubstance of the bone is reduced so that fine bony architecturestarts breaking down, which is characterized by animbalance of the bony formation and the bony resorption,the breaking down of bone. and when we start losingthat fine bony architecture, we find that the bonesbecome more fragile and when the bonesbecome more fragile, an item that's more fragileis more bound to break.

in the next couple pictures, wehave just a schematic of what that breakdown looks like. so on the one side, we'vegot the healthy cortical, the outside of the bone and thetrabecular bone where you see that thickened cortex, thethickened outside layer of the bone and thetrabecular bone on the one side, you got lots more fine mesh. and as one goes to the processof developing osteopenia, first weakening ofbone, and osteoporosis

and severe osteoporosis, yousee that that cortical bone, that outside layer ofbones starts shrinking down and you see that youstart losing some of those fine connectionsin the trabecular bone so it is breaking down. those structures are losingconnections, hence leading to increased risk of fractures. this is another example ofthat-- of the top of the femur. so this is the upper leg boneand we see that the cortex,

the outer layer of the boneinitially is very thick and as one developsosteoporosis, it becomes much thinner, same thing with thatintertrabecular layer. it's nice, finely meshed. and as one developsosteoporosis, those connections arebroken down so you're left with a weaker structure. in order to think about howosteoporosis presents itself

in the spinal cordinjury population, i always find it helpful totake a step back and say, "well, why are we so worriedabout osteoporosis anyway? what about the able-bodiedpopulation." and we hear about it quite oftenin the able-bodied population. why do we hear about it and in what settingdo we hear about it. so many people areaffected by fractures, so 300,000 peopleper year in the us.

hip fractures usuallyhappen in adults who are over the age of 65. about 30 percent of individualswill die within the first year of fracture and there's ahuge amount of functional loss in those individuals whoare living the first year to two years after fracture. so only 40 percent of individuals will regain theirprefracture mobility level, so if they were ambulatingbefore fracture,

they may not be ambulatingafter fracture. only 25 percent of individualswill regain their formal functional status, so ableto take care of themselves and perform their activitiesof daily living to the degree that they were beforetheir fracture. and 71 percent ofindividuals aren't able to live in their prefractureenvironment. so we see that in theable-bodied population, not only is therea huge mortality

after one sustains a fracture, but there's a hugefunctional decline and this is where the big concern lies. we have to ask ourselves though, can we immediatelyextrapolate this and apply it to the sci population andi'm going to keep coming back to this idea throughoutthe talk. so how do we diagnoseosteoporosis? like we said, bone strength isrelated to bone mineral density,

so how much substance is thereand osteoporosis is that break down of the substance. one of the ways that we candiagnose osteoporosis is by doing dual-energyx-ray absorptiometry, which is sometimes forshort called dxa scanning for obvious reasons,they're mouthful otherwise. it's the most common methodto diagnose osteoporosis. it's a measurement ofthe bone mineral density. and the areas that oneusually examines when looking

for osteoporosis is thespine, hip, and forearm and this is another ideathat we're going to come back to when thinking aboutdiagnosing osteoporosis in the sci population. so with a dxa scanner, it's apaddy table with an x-ray tube. there are a couple x-raybeams that are performed and the difference betweenthose two beams are used to calculate a score. and then the scorethat one receives

after having a dxa scanis compared to that of a healthy personin their 20s. so when we think about how doesthe definition of osteoporosis, how does one get that diagnosis? we go to the worldhealth organization. osteopenia, which is theweakening of the bones, is given to an individual whohas a bone mineral density that is-- who has a bonemineral density score, as measured by dxascanning, that is lower

than someone in their 20s. someone has osteoporosis ifthe bone mineral density score that is much lower thansomeone in their 20s. so there are precise numbers. i won't go into those but knowthat it's a significant decrease in bone mineral density compared to an able-bodiedperson in their 20s. so what about osteoporosis in the spinal-cordinjured population?

when do we see it? well, we see it pretty soonafter spinal cord injury so it can be seen on x-rayas early as six weeks after spinal cord injury. most people think that anew steady state is reached about two years after spinalcord injury and in fact, about 80 percent of individuals with chronic spinalcord are going to have either osteopeniaor osteoporosis.

so it's a very common occurrencepost spinal cord injury. this is a simple graph thatdemonstrates what we expect to see in the able-bodied. so the top line, the bluesquares represent what we anticipate to see withbone mineral density in males as they age. the pink line demonstrateswhat we anticipate to see with bone mineral densityin the female population. these are both able-bodied sowe see that there's a high level

of bone mineral density whenan individual is in their 20s and it slowly decreasesover time. women have a lower bone mineraldensity than men and it goes down a little bit more abruptlycome about the age of between 50 and 60 with the onsetof menopause. well, what do we see with thespinal cord-injured population? we're going to compare this--we're going to use our example of the spinal cord injuryindividual as a male who is age 45 atthe time of injury

so they are plugging alongwith the bone mineral density on an able-bodied personuntil their injury, age 45. and within two years, that individual's bone mineraldensity is going to be dropping to a level of abouta 70-year-old woman, so there's that profound drop and it's very significant verysoon after and it leaves us with many questions when wethink about the prevention of osteoporosis andthe treatment

because that treatmentperiod for someone with a spinal cord injuryis going to be much longer than it is for someonewho is 70 or 80 years old. let's take a step back andsay, "ok, well, you know, we kind of have an ideaof why osteoporosis occurs in an able-bodied population,aging, weakening bones, alterations in hormonal levelswith the female population. what about spinal cord injury?" and with the sci population,

everyone always leaves theirhands and says, "it's you, it's because youdon't use your legs." well, yes it is. but as we're learningin spinal cord injury, it's never just one thing. there're always multiple factorsthat play a role in any sort of regulation and maintenanceof balance within the body so we see that disuse is one ofthe causes and we're going to go into that a little bitmore in depth in a moment.

we know that disorderedregulation in the delivery of nutrients through theveins and the arteries of the body can play a role. autonomic dysregulation, so thenervous system and the balance of input and output from thenervous system plays a role, how much? we really don't understand. we're just startingto learn this area. hormonal alterations,metabolic disturbances,

poor nutritional status can allplay a role and we don't know to what degree, that's thepoint where we're just starting to do research on hormonalalterations in sci, let alone hormonal alterationsin sci with osteoporosis so we're just starting togather this information. but the point is, isthat as with everything with spinal cord injury, it'snever just one issue which means that if you find a way to treatone component, it's just going to be a componentof the treatment,

that there are many otherfactors that are going to come into play in the developmentof that one condition. i'd said we're goingto talk about disuse. well, this is disuse. and we know that disuse playsa role in the development of osteoporosis and whydoes it play a role? well, we have this idea thatmechanical loading of the bone, so weight being placedon the bones or activity on the bones is communicatedfrom cell to cell.

so we had said that bonesare a living dynamic organism and when one puts pressureon the bones, that pressure, that sensation of pressureis somehow communicated through little connectionscalled gap junctions and with the use of transmitters and those transmitters will tellthe different types of cells, osteoclast, the bone buildingcells, the osteoblast-- i'm sorry, the osteoclast,the bone-breakdown cells. the osteoblast,

the bone-building cellswill tell the blast to act the clast to break down. if you don't have thatmechanical loading, if there isn't weightbeing put on the bones and muscles actively pulling onthe bones on a consistent basis, that communication and thattrigger of bone building and bone breakingdown is altered, so you don't have thesignals that are going to the bone building cellssaying, keep on building.

and if for whatever reason,you aren't getting that turnoff of the bone breakdown cellsof start breaking down. so one ends up withan imbalance. why this occurs? we just don't know. we're just starting to learn about how those transmittersoperate and the regulation of it. what about neurofactors and whatabout this idea of circulation

and nervous system playinga role on osteoporosis. well, we can think about,we know that individuals with spinal cord injury havealtered circulation at times. we know that the nervoussystem somehow plays a role in nutrient exchangethroughout the body. so if one is not gettingadequate nutrients or altered levels ofnutrients, or altered level of oxygenation throughout thebody, throughout the system, we can expect that this may alsobe happening at the bony level,

that there's some sort ofaltered nutrient exchange at the bony level and thatin addition may be causing-- contributing to theosteoporosis. so all right, we've gotan understanding now of osteoporosis,how it developed, how does it look like,how is it manifested in that spinal cordinjury population. when we see osteoporosisand spinal cord injury, we see it happening belowthe level of injury,

so this is the idea ofthe level of injury, how does that come in. well, osteoporosis alwayshappens below the level of injury. we see an average bonemineral density loss of about 30 to 40 percent. we see trabecular bonebeing more effective than cortical boneso that inside area of the bone is more effective

than the outsidelayer of the bone. and we see a greater losshappening at epiphyses, at the ends of the bone,rather than the diaphysis, the shaft of the bones. so if you think about it, ok,if more of my loss is happening at the epiphyses,that's probably where the fracturesare going to happen and that's in fact what we see. so classically, we seebone loss happening

in the lower extremities, thelower one third of the femur, the top upper bone ofthe leg is affected more than the other parts ofthe femur and the top part of the tibia so the top of the bone just below the kneeis most affected by bone loss. other things thancan affect bone loss in spinal cord injuryis level of injury. so we see that there's increasedbone loss in individuals who have tetraplegias orquadriplegias versus paraplegia,

and that kind of makes sense. so if you've got more boneloss occurring below the level of injury, if youhave a tetraplegia, you've got more bones that canbe affected below the level of injury than compared tosomeone with a paraplegia. we also know that the extentof injury, so the completeness of injury can attribute to morebone loss than an individual with incomplete injury. and when we think about this,

this may also intuitivelymake sense, that someone with an incomplete injurywho has some movement of their legs is going to havesome loading, some movement of the muscle pulling ontheir bones to maintain that bone mineral density thansomeone who has a complete level of injury who may not be doingany weight bearing throughout their lower extremity andmay not have that movement to help facilitate themaintenance of some of that bone mineral density.

all the things that mightaffect bone mineral density but we really don'tknow, we talked about-- i just talked about thatidea of incomplete injury and i suggested that tibiaor muscle pulling on bone may in fact maintain some degreeof bone mineral density. but when you thinkabout spasticity, spasticity is muscle pulling onbone, albeit not voluntary most of the time but isbearable for spasticity. the spasticity actually helpedmaintain bone mineral density

when compared to someonewithout spasticity. we don't know. this is kind of the theoreticalpart and the theorized when it comes to osteoporosisand spinal cord injury. how about duration of injury? so someone who's been injuredfor much longer than someone who is just injured, is theirbone mineral density going to be altered. and there are somesuspicion that it is.

we do believe that thereis some stabilization of bone mineral densityabout two or three years out after injury, but isthere a gradual decline that may happen with years. very well maybe, it kindof seems to make sense. we don't have thesestudies to support that but intuitively,it seems logical. well, that's all fineand good but what about the reallyimportant stuff.

so at the beginning,we have said, "well, why are we gettinghot and bothered about osteoporosis anyway." in able-bodied population,we saw increased mortality, we saw increasedfunctional loss. what about the sci population? is that the same thing we'reseeing with the sci population and these are some questionsthat we're just starting to ask. so that's mr. k. mr. kwas like, "all right doc,

you gave me a good lecturethere, what about questions. i asked about prevention,i asked about treatment. is there something i can do? am i going to diefrom fracture?" i said, "all right, mr. k,we're going to get there." so first question, should webe screening for osteoporosis in the sci population? so why do we screen for thingsanyways, why do we screen for things in theable-bodied population.

we screen for things if we thinkabout breast cancer screening, colon cancer screening,prostate cancer screening. we're trying to identifysilent disease or risk factors and the goal is to sortout those individuals who have the disease but don'tknow it from those individuals who don't have the disease andwe've got to keep in our heads that you should be screening forsomething only if care is going to be changed as aresult of the screening. it doesn't make a whole lot ofsense to screen for something if

and then you're going tosay, "yeah, we got it, but i ain't going to doanything for you differently than i would if i didn't know." so let's think about thelocation of scanning. i had referred to thisa little bit earlier. we usually look at the radius,so that's the end of the arm in the able-bodied population,the lumbar spine, the lower area of the spine or the hip. on the spinal cord injuredpopulation, what did we say?

where does spine-- wheredoes osteoporosis occur? it occurs below thelevel of injury. so does it make senseto diagnose osteoporosis by screening for the radiusin the sci population? probably not. i mean, in fact, insome sci population, the radius may actually havea higher bone mineral density than a little old lady becauseyou guys use your arms to walk, so you do a lot of transfers.

you're always propelling,you're maintaining that bone mineral density. what about the lumbar spine? there is some thoughtthat individuals with spinal cord injury may havemaintained bone mineral density in the lumbar spine 'causeyou are constantly loading it. you're always in uprightposition and putting pressure on it, so that's probably nota great place to screen either. and then we think about the hip.

well, measuring up the hipis pretty hard for a lot of individuals withspinal cord injury. not only is the hip not an area that we classicallysee the biggest loss of bone mineral densityin the sci population, but a lot of factorslimit the ability for us to get a good study ofthe hip, so spasticity, if someone transferson to a table and that constantlyjerking up, you're going

to have a hard timegetting good image. what about contractures, whatabout heterotopic ossification. so we had talked about how adxa scan is measuring the bone mineral density. it's measuring thequantity of bone, the quality of bonein that area. heterotopic ossification, extrabone formation, that's going to mess up your reading. it's going to read a wholebunch of extra bone in that area

that you're trying todiagnose osteoporosis. what if someone hashardware in there? what if they had ahip replacement prior to their spinal cord injury? well, you can't reallyuse that area to measure. and then what about just thepracticalities that someone with a spinal cord injury thati'm sure many of you encounter on a daily basis of you're goingto the doctors, you're now going to go over to radiology.

they are totallynot set up for you to transfer over to the scanner. you may not be able to getinto the room and you have to take a step backand say, "ok, well, why am i doing thisagain in the first place? does this make sense for me? is my care going to be changed? is it going to be improvedwith this bit of information?" but when we got the study,shouldn't we just use it.

this is an issue that'scome up relatively recently in the medical community. so radiation exposureaccount-- from medical imaging, accounts for about half of the radiation exposurein the united states. radiation buildsup within the body and it increases therisk of certain cancers. so whenever an individual isplanning on having a study, they should be able to justifythe study, optimize the number

of images that they'regoing to have and limit. so, individuals whoare getting imaging on a more regularbasis should be aware of that cumulative effectand always take ownership of their own health andwhen they're provider says, we're going to get these filedstudies, you should realize, if i'm age 30 rightnow and i'm going to be getting these studies forevery year, every two years, that's going to be cumulative.

so ask you provider, isthis really necessary because i'm going to end up overmy lifespan having a lot more radiation exposure than someonewho is able-bodied most likely. so should we screenfor osteoporosis at all and mr. k is asking, "all rightdoc, you're giving me a lot of information there, shouldi get my screening done?" many people say no. eighty percent of individuals with spinal cord injury had saidhave osteopenia or osteoporosis

if we know that 80percent of individuals do, is it almost safer to assume that one will haveosteoporosis rather than doing a screening studyjust to confirm something that we had alreadysuspected occurs. there are instanceswhere perhaps doing that imaging would provide somevaluable information but that's where you need to sit downand discuss what are the-- why is one gettingthe imaging done

and with the informationprovided by the imaging, what is one going to dowith that information. so there are instances whereone should have screening done, but as a universalrecommendation, we are at the point where weuniversally recommend screening for osteoporosisin sci population. so that mr. k again, he's like,"all right, i got osteoporosis. what can i do to treat them?" so, we can talk aboutdifferent medication options

or vitamin options. we think about calcium. we can think about vitamin d. wecan talk about bisphosphonates, that's one of the prescriptionmedications that's often time used for the treatmentof osteoporosis in the able-bodiedpopulation and teriparatide which is another medicationused in osteoporosis. so, if you think aboutcalcium in spinal cord injury. we know that immediatelyafter spinal cord injury,

there's a giant boost ofcalcium within the body. the bones are no longer beingused as they were in the past. calcium is excretedfrom the bony system. but after a short periodof spinal cord injury, a new balance is established inthe calcium levels in the body. so, just supplementing withcalcium alone is not going to be able to maintainthat bone mineral density. if one is going to usecalcium supplementations, you can usually useabout a thousand

or 1500 milligrams perday, calcium carbonate or calcium citrate are options. calcium carbonate which is liketums is cheaper, but it needs to be taken with meals. it can interfere with how somemeds are absorbed in the body and there are sideeffects of calcium. so, renal stones, we think about spinal cord injurypopulation oftentimes stone formation, kidney stoneformation can be a challenge.

unsettled stomach,indigestion can be a challenge. constipation. constipation with scipopulation certainly common. and once again theabsorption of some meds. so, even what a seeminglybenign medication can cause some challenges and the use of the medication is once againsomething you should discuss with your provider particularlywhen it comes to dosing. what about vitamin d?

this is certainly somethingthat we hear about a lot in the seattle areaand the [inaudible]. there are small studiesthat have been done in the sci populationlooking at vitamin d and vitamin d deficiency. so we know anywherefrom one third to nearly a hundred percent, 96 percent of individuals haveeither vitamin d deficiency or insufficiency, sodefinitely low or pretty low.

why is this? well, sometimes thatplays a role. there's just inadequate intakeand limited sun exposure. so, not only livingin seattle is going to challenge your sun exposure. but individuals with spinal cordinjury perhaps are not accessing and getting out of theirhomes and exposing themselves to the sunlight as much. so some do recommendsupplementation

with vitamin d on a daily basis. one of the forms of vitamind that's recommended is cholecalciferol and it'sjust generally preferred over another form of vitamind called ergocalciferol. safe limits are usuallyabout 400 to 800 internationalunits per day. there's one study,that's the one that i said with the 2000 internationalunits of oral vitamin d and that just suggest thata higher supplementation

of vitamin d may besafe in individuals with spinal cord injurywho are very deficient in vitamin d levels to get themto a normal level and then come down with the moretypical levels of vitamin d supplementation. but we have to remember that vitamin d supplementation,again, is not benign. it is not without its problems. there's a potential toxiceffect of vitamin d consumption

and once again, discussany supplementation with your provider tomake sure that the doses that you're takingare safe for you. what about bisphosphonates. these are the -onate medication,so alendronate, risedronate, ibandronate, zoledronic acid,some of the more common names, fosamax, actonel, boniva. so these are the sally fieldmedications she's always too [inaudible] about herimproved life on boniva.

what we know aboutthese medications is that they stronglyinhibit bone resorption. so they stop the bonefrom breaking down. but we don't have great studiesagain in the sci population to support their use overa long period of time. so we see that onestudy suggested that taking etidronate,one of the oral forms of these medications in the acute spinal cordinjury didn't show much effect

on bone loss. another study suggested thatanother medication, alendronate, in this population dailyincrease bone mineral bone density. some showed-- while it decreasebone mineral density a little bit, some showed it increasesit a little bit over 24 months. who knows what happened after24 months when the study ended. but we got to remember one otherthing is that very recently, we have published literaturein the able-bodied population

that demonstrated thatatypical femur fracture, so not the usual femurfractures that are seen in the able-bodiedpopulation, have been reported to occur more oftenin individuals who are on bisphosphonates. so they were gettingthese odd fractures that were occurring whilebeing on a treatment medication for osteoporosis toprevent fractures. when we think about thismedication being used

for the able-bodiedpopulation, the conclusion was, in that population, we don'tknow how long an individual should be using bisphosphonates. well, what aboutspinal cord injury? so, we said thatfractures very often happen in the able-bodiedpopulation and individuals who are 65 years or older. what if i'm working with someonelike mr. k, he's in his 40s, how long should ibe recommending him

to use bisphosphonates. how long is he going to beat risk for osteoporosis? well, here's theanticipated life span. it's good in 20, 30 years,maybe 40 years we're getting with the spinal cordinjury population. and i can't tell himif this medication in the long run is safe. another medication,teriparatide. so, this is a synthetic hormone.

no studies in the spinalcord injury population. we know that in thepostmenopausal population, able-bodied population,it increases spine and hip bone mineral density and it decreasesfractures in these areas. what are these areas ofconcern in the sci population? so, once again, we can't alwaystake the information that's offered in the able-bodiedpopulation and directly apply it to the sci population andsay they're all the same

and we should betreating them the same. so we have mr. k,again, "it's fine. i don't even liketaking medications. i'm going to minimize them. what else can i do?" so what are the othertreatment options? what about standing? so, many individuals seek outthe use of standing frames. with the standingframe, are we providing

that mechanical loading that mayhelp decrease the bone mineral density loss thatoccurs in individuals with spinal cord injuries? got a number of small studies. unfortunately, theyaren't always consistent. some look at them in the acutepopulation, some look at them in the chronic population. some have complete injuries,some have incomplete injuries. one study suggested that doingstanding or using a treadmill

for walking for five weeksmaintain one's bone mineral density in the acute spinalcord injury population. another study lookedat individuals with chronic spinal cord injuryanywhere from 1 to 26 years and they showed thatthere was no difference in the dxa scanning intheir bone mineral density when compared withtheir ambulatory status. and this isn't to say thatwe're crossing out use of standing frame completely.

there are other benefitsof using a standing frame, so some people feel thatit helps with spasticity, it helps maintainrange of motion. there's certainly apsychological benefit for many individuals ofusing a standing frame, but can we justify the useof a standing frame solely for the idea that itmaintains bone mineral density, not really. what about fes?

so, fes is functionalelectrical stimulation. it's applying electrodesto the legs to produce muscle contractionand we have this idea of bone loading or pullingof the muscle to the bone and that helping to maintainbone mineral density? in this area, there's a lot of research that'scurrently occurring, but many small studies. so, the studies areanywhere from 2 to 38 people.

once again, they're notconsistent in the population of individuals withspinal cord injury that they've chosen to select. so they are varyingdegrees of injuries. they are varyinglevels of injury and various timeframesafter injury. and what they're findingis that perhaps the effect of functional electricalstimulation on bone is site specific.

so, is the end of the femur,actually the area that we want to stop those fracturesfrom occurring, does it maintain thebone mineral density in that location betterthan the top of the tibia, the area just below the kneecap? perhaps? some studies suggest that there is somemaintained bone mineral density with this equipment. but when we say ok, we'vemaintained bone mineral density,

what does that really mean? is a 7 percent increase in bonemineral density significant? so, if i'm going fromreally, really weak bones to just really weak bones,have i really made a difference if i fall from mychair and fracture. one has got to weighthose things out. so, as i said, we don'thave consistent evidence to support the use of functionalelectrical stimulation. some studies suggest that thebone mineral density is kind

of maintained afteryou stop functional electrical stimulation. other studies say thateverything is fine and good while you're doing it, but once you discontinueits use, bone mineral density will goright back to where it's at. we don't know what the frequency of maintenance functionalelectrical stimulation is if there is such a thing.

and we don't know if thatincreased bone mineral density really translates todecrease fractures and that's what we're tryingto prevent in the end. the last technique thatwe'll briefly discuss is low intensity vibration. so, this is the transmission oflow magnitude mechanical signals which are delivered byan oscillating platform. it's a thing that kind oflooks like a big scale, a big bathroom scale that[inaudible] and why this helps?

not quite clear. but we do know that it doesmaintain bone mineral density in animals and somehuman studies. no studies have been publishedyet in the sci population but a number of centers areactively looking at this. some of the challengesare though is that one needs specificadaptation to stand. so, using this oscillatingplatform, the shaking platform, one needs to put theirfull body weight on it.

so, now you've got this platformand you got a standing frame and for someone who hasn'tstood, are you going to run into challenges withorthostatic hypotension, or the drops of blood pressure. how are you going to dothis on a daily basis? ok. so, standing frame, riskof fracture and bearing weight, haven't done that in 30 years. lots of little pieces thatwe saw that will figure out. is it going to besufficient to just sit

and have a platformbelow your feet and do that for a coupleof hours a day? just looking at that right now. so preliminary studiesin progress, more to come in a couple of yearswhen i come back again. so, we have to take a step backand say, ok, what about cost? it's something that wedon't like talking about but we're all talkingabout healthcare cost. so, we think of some ofthe treatment options

that we've come up with. so medications, expensivemedications, many, many years because that risk of developing a diseaseis not going to go away, we think about a standingframe, where we think about functionalelectrical stimulation. so, therapy or caregivertime couldn't put a price on that but generally high. what about a standing frame?

it's about 2,000 dollars. functional electricalstimulation 20,000 dollars. i use the calculationwith our va discount. we could say about 6,000 dollarsper year for medications, about 2,000 dollarsfor a standing frame, 30 years of treatment if we saythe individual was between 40 or 45 years at thetime of their injury. so 200,000 plus dollarsto prevent osteoporosis, our goal is to preventone fracture,

is that worth our investment? and we're going to take a back--a step back and think about one of our-- what wereour first questions, mortality, functional abilities? have we answered that yet? and we haven't yetanswered that. so, do we have a wayto prevent osteoporosis right now, we don't haveany therapeutic intervention that prevents osteoporosis inindividuals who don't ambulate

and we have to ask ourselves. if or when we findtreatments that slow bone loss, are they cost effective? so, is it worth the riskand worth the inconvenience, worth the price of multipleexpensive medications for life? hours of standing frame, hoursof electrical stimulation, how does that affectthe quality of life? so we need to define what isour optimal fracture treatment if one then sustainsthe fracture?

what are the expectedoutcomes after fracture and think about cost as well. so, what can we do toprevent osteoporosis right now and this is kind ofbasic information that we'd give to anyone. consume a healthy diet,quit smoking, limit alcohol, limit caffeine, stayphysically active, stay mentally active,and avoid falls. so, if someone is anambulator, are you ambulating

with the safest device? if someone uses a wheelchair, is the chair properlypositioned for you? are you performing yourtransfers in a safe manner? are you using proper techniques? are the assistivedevices that you're using for the transfers safeand well maintained? are you in an environmentthat allows you to be as safe as possible to minimizeyour falls?

and that's all finding good,but life happens, people fall. and when you do fall, attimes you can fracture. so, how do we nowmanage a fracture in an individual whohas osteoporosis? so, we do know thatfractures happen. so they happen in about a 2to 4 percent annual incidence. an individual who is fracturedat one site is at risk for fracturing atthat site again. so, a broken bone, even whenit's healed will never be

as strong as that intact bone. we talked about those areasthat are at greatest risk for fracture so that end of thefemur, the end of the upper bone of the leg and the top of thetibia, that bone right above-- right below the kneecap are atgreatest risk for fracturing. and we know that very littleforce very often is required to fracture. so, someone who falls from theirwheelchair during a fracture or falls from theirshower commode chair

in the process of bathing. some individuals turn in bedor do range of motion in bed and hear a snap, crack, or popand know that they fractured. we've had individualscome into clinic and say, "doc, my leg is swollen. i have no clue why." and you take a look andyou're like, "oh, my. that leg is in afunny position." and sure enough, theperson is fractured

and they can't give you a goodstory for why they fractured. so, why do we care? individual doesn't walk. why is this important? we know that deformityin a limb can lead to medical complications. so, if an individualhas a fracture, how is that fracturealtered the way they sit, are they placingthemselves at risk

for pressure ulcer development? if that individualhas a fracture that hasn't been well addressed,is that fracture going to heal in an altered position? is that altered position somehowgoing to contribute to how that limb interfaceswith their equipment? are they going to develop wounds and unfortunately endup with bone loss? or is there neuropathic going tobe increased such to the part--

such to the degreethat their quality of life is going to be limited? additionally, if a limb, despitethe fact that it may not be used in the traditionalable-bodied sense, if that individual has a limbthat is in an altered position, is it going to affectthe way they operate in their environment. so, are they going to havefunctional consequences as a result of thataltered healing of the bone?

is it going to change theway their body interfaces with their environmentor with their equipment? and is that change then going tolimit their ability to do some of the things thatthey want to do. so, here's an example of a guythat we worked with at the va who has a higherlevel tetraplegia. he uses a power wheelchairfor his mobility. he fractured the end ofhis legs, so his ankle, and the leg healed inthis pointed toe position.

when you think about whilehe doesn't use his legs, why does this the matter? well, this matters hugely. so, in this individual's case, you can see that his heelis hitting the bottom of his footplate placing himat risk for skin breakdown. additionally, his foot is nowsticking out about 6 inches in front of his footplate which now gives him a 6-inchlonger turning radius.

is he going to be ableto access his environment with his foot stickingout as well? so, this made a hugedifference in how he-- not only his medicalstatus, but he moves about in his environment. so, when you think about fracture management,what are your goals? well, we've got short-termgoals, we've got long-term goals.

short-term goals isthat we want to maximize that individual's functionalabilities while the fracture is healing. we're going to try tominimize the complications. we're going to make surethat any sort of adjustments in equipment that need to bedone are done and we'll try to minimize caregiver cost. the long-term goal, wewant to minimize deformity, maintain prefracture functionalabilities, and once again,

modify any equipmentif necessary. so when you think about howcan we manage fractures? we got surgery, wegot not surgery. so, basic surgical principle. you want to achieveunion of the bone, have the bone come together inthe most anatomic way possible and maintain functionof that limb. we've got reasons forwhy surgeons do surgery. they'll do surgery in abone that's displaced,

so one that is greatlyseparated. they'll do one-- isthey'll perform surgery in an unstable fracture. if it-- they willoften do surgery if it's a femoral neckfracture so that's an upper part of the upper-- it's anarea of the hip bone. and they'll do surgery in abone that has healed incorrectly in the past where othertreatments have failed. in cases where the surgeonsmay be a bit more hesitant

to do surgery. so, osteoporotic bone,that's too fragile to allow for a good surgical fixation, active infectionor osteomyelitis. when you think about, ok, someone with a spinal cordinjury comes in with a fracture, you're going to haveosteoporosis, well, yeah, contraindication for surgery. individuals with spinalcord injury oftentimes have

active infection. so do they have a bony infectionsuch as a bad pressure ulcer and have now fractured? you'll be doing surgery in aninstance of active infection, well, a lot of surgeonswill say no. so individuals with spinalcord injury at a setup of-- will be challenging to managefor the surgeons as well and these are ideas thatyou need to oftentimes bring up when a surgeonapproaches you and says, "yes,

automatically surgeryis the way to go." so, when we think about different conservativeways of healing fractures. we can heal it withdifferent types of splints so something very simplelike a pillow splint. we have casts, we haveoff-the-shelf support so ones that are used in the able-bodiedpopulation sometimes are applied to individuals withspinal cord injury and sometimes you havebig custom-fit devices

that can be fabricated. but the thing that we haveto remember when trying to manage these fracturesconservatively is that folks with spinal cord injury, thebodies sometimes don't fit some of those conservativeoptions very well. so you got to think about yourrange of motion in that limb, you got to think abouthow spasticity is going to play a role if you're tryingto put a limb and maintain it to be stable in order toallow for some healing.

and we got to think about howthe muscle is patterned along the bone and does thatdevice fit for the muscle? and we got a couple ofpictures of that coming up. so, here's an example. what's wrong with this brace? this is one of thoseoff-the-shelf ones. it's a long skinny tube. if we look at the top, wesee the guy's knee popping out of the top of it because hehas a knee flexion contracture.

so, if we're trying to stabilizethis leg, try to avoid it from moving, this cylindricalthing is not providing any support for thisleg that is flexed. so, this is perhaps abetter option for him, something that accommodates that individual'sbaseline range of motion. what about this one? well, it looks ok. you know, it got a lot of straps

and it can accommodatethis person's leg. well, oftentimes, individuals with spinal cordinjury have atrophy, so shrinking of the muscle. if your leg is thatskinny and you put it into a device that'svery big, are you going to be providing muchsupport for it? so, these are things thatindividuals need to bring up with if they do encountera provider who says, "oh,

we're just going toput this brace on." you're going to say,"you know what, my body don't bodyfit that brace. it's not going to work for me." another thing you got to think about when you're managingfractures is how is that individual going toget around with that type of treatment in place? so, is there a leg now ina fully extended position,

supposedly for eight weeks andyou use a manual wheelchair, you usually flex down and youdon't have an elevating leg rest, well how are you going tokeep your leg up for eight weeks and try to get around andlive during this entire time? what about skin andimpaired skin sensation? so, is that device going toallow one to check their skin to make sure that they don'thave those further complications of skin breakdown? how easy is it toget on and off,

once again to do skin checks,once again for those individuals who have impaired hand function? are they going tobe able to remove that brace in an easy way? how's that brace going tointeract with their equipment? what about caregiveravailability and what about their ability tocontinue with their life in the setting offracture healing? we have an individual at theva who fractured his leg,

worked full time, very oftendrove from location to location. he was put in a splintthat put his leg out in a completelyextended position so he can get nowhere near hisdriving-- his steering wheel. things that you got to think about when providingtreatment to an individual. so we have mr. k again. [inaudible], that'sthe way he decided to go with my information.

so, my goal with thisis not to overwhelm one with the different types ofinterventions that can be done which is a pattern of howdifferent considerations-- how we consider differentcomponents of his care when choosing the devicethat was best for him. so, his leg was kind ofrotated out a little bit as we've see in thefirst picture. we were able to make a customdevice that brought it in more in alignment and allowed himto maintain his regular chair,

but we put an elevatingleg rest on it. he healed in a good position and even during thefracture healing period, he was able to continueto maintain care of his toddlers at the time. so we can think about what arethat pros and cons of surgery versus conservative care. well, we know thatsurgery is fast. we go in, get itstabilized, be done with in,

you can start rangeof motion quite early. oftentimes, there'sless shortening or deformity 'cause you'rekind of forcing it in to that one position, but itdoes have its disadvantages. standard surgical risks, there'salways a risk of surgery. there's always a risk ofgoing under anesthesia. individuals with spinal cordinjuries have neurogenic skin, that idea that skin doesn't healas well or heals differently that it does in theable-bodied population

so you're now putting anincision into the skin, is that incisiongoing to heal as well? we are putting at timeshardware into bone that isn't the bestquality, so that means that that hardware hasthe potential of loosening and one has the risk of havingto undergo additional surgeries because of hardware failureor infections that can occur. what about conservative? we like to think,"oh, it's the best."

well, it's not invasivewhich is good and the direct cost is less. certainly, treating witha splint or treating with a brace is lessexpensive than surgery, but it certainly a lot slower and one can have skin breakdowneven in the best of braces. so, there are pros and cons ofboth and one needs to weigh them when discussing withtheir provider. so, we got to take a stepback again and say, well,

why are we doing this again? you know, what was thebig picture things, what were the reallyimportant things? it was the mortality andthe functional questions that we are most worried about. we saw once again,able-bodied population fracture. if you're older, highrisk of mortality, functional changeswere very significant. well, one of theareas of my interest

and of my research isthese questions exactly. so when thinking aboutmanagement of fractures and individuals with spinalcord injury, should we be going with surgery, should we be goingwith conservative treatment? and how do those optionsweigh in to this idea of increased mortality,complications like wounds, blood clots, whether or notthe bone decides to heal, so malunion, connectionof the bone, length of hospital stay,discharge location.

discharge locationoften is a reflection of functional abilities andhealthcare cost in general. so i'm currently ina collaborative study with a colleague of mine atthe va as well as providers in illinois, tennessee,and north carolina, looking at the vadatabase that we have so we are studyingmale veterans. we have just over a thousandfracture cases and we match them to individuals without fracturesand we looked at mortality

in the five years outfollowing fracture and we saw that there was nodifference in survival time for those individuals whohad fractures compared to those individuals whodidn't have fractures. so this idea of, ok, we'vegot to prevent osteoporosis because if we get osteoporosisand then we fracture, we're going to die sooner,well, it's not looking like this might be the casefor the sci population. i'm going to say, ok, so perhapsthere isn't this increased risk

of mortality in sci population. what about functional status? if i fracture aftermy spinal cord injury, am i going to be able totake care of myself as well as i was able to and participatein the things that i wanted to as well as i didbefore my fracture. so we've looked at this aswell both on a larger scale in this study as on a smallerscale of just are population of veterans here atthe va in seattle.

so we saw that manyindividuals, nearly 70 percent of individuals, required somesort of equipment changes, certainly in the short term. we saw that in the short term, so on the first yearfollowing fracture, short-- there was about a 50 percentchance of functional changes. so individuals who fracture thefirst year oftentimes needed increased resistancewith mobility or activities of daily living.

they've got a longbrace on their leg and they've got a tetraplegia. are they able to donand doff that brace? are they going to be ableto dress themselves as well as they did during thatperiod of fracture healing, very often, not as well. but we saw that thisdecreased functional ability, this decreased-- excuse me, functional decline wasreally sustained over the--

beyond one year of injury. so that first year, veryoften people weren't able to maintain their activities ofdaily living, but beyond a year, they were now able to and thisanswers our second question. we've got mortality,well, we don't think that mortality is different with the spinal cord-injuredpopulation, but what about functionalabilities? well, a year out from fracture,individuals are doing pretty ok.

â  so what can we say? well, we know that ourgoal with management of lower limb fracturesin the sci population is to feel the fracture ideally with minimal riskof complications. we know that shortening,angulation, rotational deformitiesare not acceptable because they very oftenplace an individual at risk

for medical complication andfunctional complications. got to consider the reality ofthe brace, does it work for you in your lifestyle and we'vealso got to remember to take that next step andassess all equipment. so knowing that not only isthe brace going to interface with the body, but the bodyis then going to interface with the chair, with the otherequipment that's available in the environment andabove and beyond everything, we want to maintain thatprefracture functional status

and this is whereyou come along. you should always realizethat you know the best about your body and howyour body interfaces with the different equipmentand look to your environment. so if you are choosingto discuss osteoporosis with your providers, ifyou sustain a fracture and you find yourself in theemergency room or talking with an orthopedic surgeon, ortalking with your rehab doc, you have to realize that youhave to advocate for yourself.

you're often willing to beteaching those providers about the different intricaciesof spinal cord injury and remember that your providersare always a team of providers. so the relationshipthat you have with the orthopedic surgeon,you have to maintain that and sometimes remind him, "oh, we've got to get thept involved" or, "oh, we've got the ot involved" or"please send to me my rehab doc so we can work with thespasticity after my fracture."

so we know that osteoporosisis very often expected we see the patternof injury is unique, but it oftentimes happens, usually happens belowthe level of injury. we know that there are manyfactors, not just as used that plays a role in thedevelopment of osteoporosis and decrease of bone marrowdensity in the sci population. we don't quite know howeffective the medications are in treating osteoporosisand we know

that there isn't one singlething that's going to help in treating osteoporosisin this population. when we think about theconsequences of osteoporosis, we know that lower extremityfractures are not infrequent. historically, we favoredconservative management over surgical management,but things might be changing and there certainly aremany avenues for research when looking into this. so i want to acknowledge dr.susan ott for this presentation.

she has contributed to a wealthof knowledge in this community. she is a geriatrician hereat the university who focuses on osteoporosis research. i also want to acknowledge mymentor, my colleague, my boss, dr. stephen burns at the vawho's also been my partner and crime for research in thisarea and our collaborators at the different vacenters across the us. [ applause ] and so the question iswhy is the mortality

in the able-bodied population sohigh after they break their hip? multifactorial. so lots of differentreasons for it. there're-- some individualsspeculate that the individuals that fall and fracture are anyways in unhealthier population. so if one is at riskfor falling, do you-- are there other medicalcomplications or other medical diseases thatyou're experiencing that led to that fracturein the first place.

so heart disease, lungdisease, general disability that contributed to the fall andthen contributed to the fracture and constellation of thosethings lead to the death. the other thing interestinglythat may also contribute that applies to the spinal cordinjury population is we talked about in the able-bodiedpopulation how oftentimes the discharge home locationor their-- where they're going to beliving postfracture is different than where they're livingprefracture and sometimes what

that comes down tois very simply bowel and bladder management. so someone who didn't,for example, use a foley catheter beforetheir fracture suddenly has a foley catheter in place, areanyway of lower health status than they were priorto injury, are they now at increased risk of infection. so it's kind of anindirect, wasn't doing great, i fall and fractured, i nowhave a number of other things

that are being done to methat are increasing my risk for infection and then i endup dying because of that. is the functional abilitiesand functional status altered because i was really active, ifell and fractured, i can't move as much because i'mnot moving as much. i'm not breathing as well. i'm setting myself upat risk for pneumonia, do i actually get a pneumonia? is it direct causefrom the fracture?

well no, but constellationof conditions. so the question is,what is the-- what are the top threereasons for fractures. i'm assuming the spinalcord injury population. falls, falls, falls. most of the falls arerelated to transverse. oftentimes, there isn'tgreat information on it but from why we've collected,we see that most of the times, the falls are related totransverse, very often related

to bathroom transverse,someone [inaudible] in the wet slippery skin factor. i would say thoseare the top two and then the others are justkind of a conglomeration of running in offractures as the result of altered equipment interfaceand that's a fancy term of saying i was in my chairand i caught my toe in the door and twisted my ankle andfractured and in some instances, the fall-- or the fractures areresult of high impact injury.

so just because you havea spinal cord injury, it doesn't mean you can't getinto a car accident or be hit by a car while crossingthe street. but i would say, falls,falls, falls, ramming the leg into a door or the sideof a wall and then some of the more unusual instances.

what doctor to see for osteoporosis

what doctor to see for osteoporosis

dr shojai: hi everybody, iã­m here with drkim millman today. hello, doc. dr millman: hi there.dr shojai: welcome, welcome, welcome. dr millman: thank you. iã­m honored to behere. dr shojai: great, thank you. i have actuallyhave a lot of questions for you, because this is a topic that is near and dear to my heart.iã­m not going to blow it, because today weã­re talking about something thatã­s a secret organ.first, i just want to introduce you to our listener base, our viewer base. dr kim isa holistic md who practices in san francisco bay area, molecular geneticist and ex-engineerat [usc 00:00:38], trained infectious disease/epidemiologist and expert in osteoporosis and natural medicine;a stanford-trained md with 20-plus years of

medical research and clinical are no slacker; look at you with that bio.sheã­s on us sharing with the information and advice about how to go about living healthily.she advocates eating colorful, organic diets, moving your body for stress relief, and turningto natural medicine when you have an illness or chronic condition. today dr kim wants totell us about the secret organ that controls our heart, our brain and our hormones. howã­sthat for a secret? dr millman: [inaudible 00:01:16] is important.dr shojai: thatã­s right, so doc, yeah, letã­s have it. letã­s get into the background. iã­veknown you for a little while already. i know that youã­ve got some bulletproof credentials.youã­ve been doing all kinds of amazing stuff,

that just every passing conversation i havewith you just makes me think, ã¬wow, sheã­s so smart!ã® i know youã­ve been really busywith the current research that youã­ve been doing. iã­d love to hear about it. let usknow. dr millman: what i really want to talk aboutwith you and your listeners today is an epidemic. in 2004, the surgeon general came out andpredicted that 1 half of all people in the united states over 50, by 2020 will have thisdisease. this is a disease that can potentially impact your heart, your kidneys, your hormones,your brain, and essentially every organ in your body. what iã­m talking about here isbone disease. now, i know that sounds weird, but hereã­s the thing that you have to know.bones are an organ, and this organ is directly

responsible for controlling the health ofyour heart, your brain and every other organ in your body. if your bones start to degenerate... and the surgeon general predicts that 1 half of all people will have this problemover 50 ... then everything starts to fail. i believe that 1 of the reasons why we takeour bones for granted is because theyã­re such a strong device in our body, so we thinkthat we can abuse them a little bit. well, iã­m here to tell you that you canã­t withoutsacrificing optimal health, because they are so tied to everything else. number 1, i wantto help your listeners today find out if theyã­re at risk for this epidemic, because i knowthat 1 out of every 2 people who are listening here today could be at risk. number 2, evenif these people are not at risk, help them

to strengthen their bones so they can havea healthier optimal life. if they always want to have a clear, crisp mind and a glowingskin, a tiny waist, a great sex drive, they need to be thinking about how to keep theirbones healthy. i know that thatã­s really a paradigm shift for people. keep your boneshealthy, and you stay healthy. let your bones degenerate and your sex drive, your clear,crisp mind, and your tiny waist goes with it.i really want to talk about 5 fundamental things that damage your bones and optimalhealth, and simple little tweaks that you can do to your lifestyle, to your diet, andsome simple botanicals that can really help your bones to get strong, and help you tohave a really fabulous life.

dr shojai: [okay 00:04:07]dr millman: lastly, i want to give people the opportunity to figure whether the thingsthat weã­re talking about today are affecting them right now. i want to give your listenersthe chance to see if theyã­re at risk for any kind of badness that would happen to yourbones and basically the rest of your body. if they are at risk, i want to talk aboutthings today that they can do to reverse that risk. if they know they have osteoporosis,i want to give them things today that they can do so that their bones donã­t get anyworse, and actually to help them reverse the bone damage thatã­s there already. then lastly,if a person is not at risk, who just wants to remain really active and healthy, i wantto also give them things to do that they can

do to strengthen their bones and keep theirbones and their optimal health as amazing as possible.dr shojai: fantastic. fantastic. where do we start?dr millman: the first fundamental reason why bones decay is inflammation. we know weã­rean inflamed society; in fact, in the extreme situations, we have increasing rates of alzheimerand diabetes and autism. these are all inflammatory conditions. i believe that 1 of the reasonswhy we are so inflamed is that since the 1950s, weã­ve given up many of our [folk 00:05:39]foods of old, like raw milk, organic vegetables. these days, weã­ve given them up for so-calledfoods that come out of boxes, that are sugar-coated, high-fructose corn syrup. we have trans fats,homogenized fats, pasteurized proteins. you

know, the fda says that all of these thingsare safe for us, yet weã­re in an epidemic of inflammatory diseases these days.bone disease is an inflammatory disorder. one of the inflammatory markers that i actuallylook at in my patients is homocysteine. if your homocysteine is elevated, youã­re inflamed,so homocysteine is a marker for bone disease. people with high homocysteine are 2.5 timesmore likely to fracture their bones than someone who has a normal homocysteine. 1 of the mainmitigators of inflammation in the bone is a protein called rankl. rankl actually turnson a set of dna that creates this inflammatory little army that goes around. the bones decay,cells increase, and the bone-forming cells actually decrease. so youã­ve gone rankl turningon this inflammatory army that starts to go

and chew up the bone.i think that the best way to really decrease your inflammatory situation is by ... actually,1 of the reasons why i think it will ... the main thing that you need to do is figure outwhy are you inflamed and get those causes handled. 1 of the reasons why i think thatpeople are so inflamed these days is because of these [inaudible 00:07:27] foods that weã­reeating. i believe that weã­re becoming more and more and more allergic to these foods,because our bodies are seeing them, and the digestive enzymes in our gut are used to thefoods actually being natural. we havenã­t evolved to have digestive enzymes that willdigest these gmo foods. weã­re becoming more and more allergic to our food, the food ishybridized, weã­re not keeping pace, we become

allergic to our food, and then our gut liningbreaks down. you know as well as i do that a leaky gut has all kinds of consequences.1 of the things that happens is that we become infected, because we lose that barrier againstinfection. you know that candida is much on the rise. a lot of people are doing anti-candidaldiets and feeling so much better. then the other thing that happens is that mineralsare notoriously difficult, actually, to absorb. because then we have this leaky, inflamedgut, itã­s harder for us to absorb our minerals, and we become mineral-deficient. my number1 tip here is try to become a food detective. figure out what foods youã­re allergic to,and take them out of your diet. i know this isnã­t such an easy thing to do,because what happens is that the symptoms

of food allergies still overlap, so you couldbe allergic to wheat and you could have the same exact symptoms as you would have if youwere allergic to corn. itã­s really hard to figure out, but these are things that a holisticpractitioner like myself and dr shojai can help you with. thatã­s my best tip on inflammation,is get back to the foods of old, eat things that have come out of the ground, and if youã­renot a vegetarian, eat things that eat things that are coming out of the ground, and justget rid of the sugar, high-fructose corn syrup, trans fats, homogenized fats, pasteurizedfats. dr shojai: fantastic. when you say so, basicallyitã­s an absorption issue with the leaky gut and also this rankl thing. rankl ... you guys,for you to look it up ... is r a n k l, for

those of you who curious about what docã­stalking about and want to go google around and try and do some more research. weã­regoing to give you a ton of resources as well after this, so just stay tuned. so thatã­syour number 1 cause for this deterioration? dr millman: the number 1 cause. number 2 isacidity. the ph of our blood is held in a very narrow range. the optimal ph of our bloodis 7.4, and the narrow range is 7.35 to 7.45. now, if we are lower than 7.4, like 7.35,our blood is acidic compared to optimal. we never have truly acidic blood. that wouldbe less than 7, and basically, we couldnã­t survive with a ph less than 7 in our blood.then anything over 7.4 is alkaline, alkaline compared to 7.4. there are many chemical bufferingsystems in the body. 1 of the things is bicarbonate.

another thing that is very important is theshuttling to and from our bones of minerals, because minerals are this counterbalancingfactor to acidity. thatã­s 1 of the ways that our body actually handles acidity, is actuallyto take the minerals from the bones. we have calcium and magnesium, sodium, potassium,iron, manganese and zinc. these are the major alkalinizing minerals that are held in ourbones. theyã­re constantly being shuttled back and forth.these minerals are so important to all physiology, to metabolism. what happens is that in orderfor us to maintain homeostasis, which means that basically that weã­re optimally functioning,the blood gets the minerals first. then the cells get the minerals second, and the bonesget whatã­s left over. this is an issue; if

our blood is always acidic, weã­re alwaysgoing to be shuttling the minerals back and forth from the blood. 1 thing that peopledonã­t realize, and i donã­t even think that mds realize this, is because minerals areso intracellularly kept, you canã­t look at blood levels of magnesium and know whetheryouã­re magnesium-deficient. you need to do something like a red blood cell of magnesium,or you need to do a hair analysis to really see what your mineral levels are.what are the things that make us acidic? well, every time that we have any kind of energy-productionin our cell, it produces metabolic waste thatã­s acidic. anytime we deal with toxicity, weare producing acidic waste. anytime that we eat an acidic food ... and this is where ourcontrol comes from; this is where we actually

can control the acidic load in our body, isthrough our food, but quite a bit of the food that we eat is acidic. if you look at it,sugar is acidic; alcohol is acidic; coffee is acidic; black tea, even protein, nuts,fruit. there is an awful lot of acidic components to our diet.dr shojai: mm-hmm. dr millman: grains are acidic. there hardlyis any alkaline foods. really, basically, thereã­s vegetables, lemon, lime, honey and[inaudible 00:13:45]. what you want to do is counterbalance your acidity by having enoughgreen vegetables, and moderate the acidic foods that you have. if youã­re a big coffeedrinker, you donã­t want to have 5 cups of coffee a day. you want to moderate that; youwant to have 1 cup of coffee a day. drinking

wine nightly ... what i do, is i have a halfa glass of wine, and then i have a half a glass of mineral water. thatã­s going to decreasemy acidic load. the other thing that i tell my patients is to have the half-plate-veggierule. always have a half a plate is your vegetables. thatã­s going to counteract your acidic otherfoods that youã­re eating. dr shojai: how do you feel about some of thesealkalizing agents that are out there? you know, like the [cumbrian 00:14:42] watersand a few other things that help drive alkalinity. is that something that youã­ve looked at theresearch on that or ...? dr millman: i havenã­t done a lot of researchon alkalizing machines, although iã­ll tell you that i own 1. my husband loves the water.i donã­t like it; it upsets my stomach for

whatever reason. i think that some peopleare meant to be a little more acidic than others and can actually handle that reallyhigh alkaline load. iã­m just really a big proponent of doing things from food, and letour bodies kind of get ... iã­m also a big proponent of doing mineral-supplementationas well. thatã­s my next topic, actually. dr shojai: all right, letã­s hear it.dr millman: that was my [trade secret 00:15:36]. mineral deficiency is another big reason whywe donã­t have optimal health in our bones. in fact, 99% of our calcium is in our bones;50% of our magnesium is in our bones, 30% of sodium, 85% of phosphorus, in our bones.minerals are so important to every single cellular reaction that we have. our thyroidneeds selenium and iodine and potassium, and

our heart needs calcium and magnesium. ourpancreas needs chromium and zinc. even our joints need minerals; our joints need manganeseand iron and sodium. there isnã­t an organ that doesnã­t need minerals. theyã­re reallya critical nutrient, and theyã­re in short supply.the reason for this is since the 1920s, the mineral content of our food has drasticallydiminished. this is because of over-cropping and fertilizers. the fertilizers that we useare basically devoid of any trace minerals. they have 4 major minerals in them, and weã­rejust not getting trace minerals in our food anymore. thatã­s even if you eat organic,the amount of minerals in our food is drastically diminished. theyã­re in critical need, andtheyã­re in short supply. thatã­s a recipe

for disaster.the best thing to get minerals, i think, again, is look to your fruit first, but if youã­regoing to supplement, supplement with a really well-balanced mineral. i want to give youmy top 10 best nutrients for calcium, because my top 10 best nutrients for calcium is muchdifferent than the surgeon generalã­s, where basically theyã­re saying to have fortifiedcereal, fortified orange juice, a lot of different kinds of dairy. these are not my top, becauseso many people are allergic to dairy. if you are allergic to it, the dairy that youã­reeating to get calcium into your bones is actually going to cause more inflammation. in fact,youã­re going to be doing more damage to your bone than top 10 nutrients for calcium are sardines

and salmon with edible bones. you have toeat the bones, because thatã­s where the calciumã­s at. chinese mustard greens, turnip greens,bok choy, kale, rutabaga, broccoli, green cabbage, and kohlrabi. 1 of the reasons whyiã­ve picked these nutrients is because they are very low in 2 calcium blockers. the 2calcium blockers are oxalates and phytates. what this means is that if you have somethinglike spinach that is a high-oxalate vegetable, even though it has a lot of calcium in it,you donã­t absorb that calcium because the oxalates prevent you from absorbing that calcium.if you really want to get your calcium, you need to eat vegetables with low-phytates andlow oxalates. iã­ve already picked the vegetables that arethe highest on the list and the vegetables

that are going to give you other mineralsthat are really important, other trace minerals. the salmon and the sardines give you omega-3fatty acids, which we know are very anti-inflammatory and help our health in all kinds of otherway. dr shojai: those things are kind of offsettingthe number 1 on your list, which is inflammation, to begin with. just to be clear ...dr millman: [crosstalk 00:19:28]. dr shojai: sure. sure, [crosstalk 00:19:30].dr millman: all connected. dr shojai: to be clear, you have all theseother organs that are requiring minerals. who gets first in line? are the bones alwayslast in line for the remineralization or how does that work with the way these things getstaged?

dr millman: yeah, i know. thatã­s exactlythe case. itã­s that the bones what is left over. the bones are our mineral storehouse.they are meant to have these minerals in place, but theyã­re constantly giving them up. itã­sa prioritization thing, in that we need our heart to be pumping more than we need to worryabout a broken bone. itã­s heart gets things first, then thyroids, adrenals, brain, andthe bones get everything last. dr shojai: interesting. itã­s almost as ifthey are a repository of vitality, and you got to borrow from the bank. we donã­t thinkabout it because once you have a broken bone or youã­re getting elderly and someoneã­syelling at you about at your t-score, your bones arenã­t really on your mind. this isfascinating for me because no one is really

talking about the bones in a meaningful waylike this. iã­m excited about this. dr millman: thank you. yeah, this is whati try to do, is increase awareness, because i really do believe that the health of yourbones is related to your optimal health. if you look at things in an integrated way likethis, you really can do much more for yourself than just protect your bones. all of these,[the whole system 00:21:13], is related. [inaudible 00:21:15] itã­s like we all somewhat talkabout similar things, but we get different spins on it. my number 4 is toxicity. evenwithin the last few years, weã­re talking about persistent organic pollutants beingtied to diabetes. we have so much pesticide and fungicides in our foods with gmos. wehave cleaning supplies like chlorine that

attack our thyroid. we have so much heavy-metalpoisoning these days. our detoxification system is constantly under attack, and there arefew organs that take the brunt of it, especially, and that is the liver, the kidneys and thegut. this is a huge, huge tip here, is if youã­reconstipated, you will be toxic. you will be toxic. you have got to keep your gut foods with fiber in them, and make sure that your magnesium is replete, because thatcan really cause a lot of constipation. we need other vitamins and minerals for detoxification,especially the b vitamins and vitamin c and other minerals. b vitamins and c are water-soluble,so we constantly need to be eating foods, replenishing our stores. 2 heavy metals thatare very important for the bones are lead

and cadmium. 90% of the body burden of leadis held in the bones. cadmium interferes with the metabolism of calcium, phosphorus andzinc. there was actually a swedish study that showedthat people who had a high body burden of both cadmium and lead had decreased bone densitycompared to people who didnã­t. you know what? another really big tip is that ... i thinkthat your listeners are probably savvy enough to realize that artificial sweeteners cancause formaldehyde toxicity, so please donã­t have artificial sweeteners. i think 1 thingyou can do is to substitute your diet coke with some mineral water with a little bitof cranberry juice or a little bit of cherry juice in it or something like that, or a littlebit of stevia.

always remember about the gum. i canã­t tellyou the number of patients that i have who are hardcore like your listeners, and basicallythey forget about the gum. i have people on my exam table, and if theyã­re chewing gum,i literally make them go and get the box for me and show me that itã­s in ... they go,ã¬well, itã­s sugar-free, dr kim.ã® that has artificial sweeteners in it.dr shojai: right. dr millman: that is really going to turn intoformaldehyde in your body. dr shojai: yeah, and formaldehyde, last timei checked, folks, is not good for you. i fought with this personally. i was a gum-chewer foryears. finally i started reading the labels and going, ã¬what is this? what am i puttingin?ã® i mean, not is it food-grade plastic

that youã­re chewing on nowadays; itã­s justfilled with things that are going to mess up your system. toxicity is a topic weã­retalking about all the time, but now weã­re talking about it getting into the bones. now,this is something weã­re actually going to do a feature and have some discussions aboutchelation in a few weeks. how hard is it to get this stuff out? because the bones arepretty packed in there; theyã­re pretty deep in the body. is it last to go? are you seeingany effects with oral or iv chelation with this?dr millman: honestly, i think that i detoxify differently than any other practitioner inthe country. youã­ll understand when i tell you. my [friends 00:25:29] is really minerals.i love minerals; i think theyã­re really underappreciated,

and i think theyã­re really misunderstoodas well. if you look at trying to get rid of cadmium, cadmium and zinc look almost exactlythe same structurally. in fact, theyã­re right next to each other on the periodic table.if you start to chelate out cadmium, youã­re going to pull in that person who was deficientbefore. the cadmium is sitting on the zinc receptor [inaudible 00:25:57]. now you startto pull out cadmium, and you make that person zinc fact, the way that i deal with cadmium is that i give zinc. the zinc will push thecadmium off of the receptor [inaudible 00:26:15]. i make sure that the people have enough dvitamins, c vitamins and other minerals, and i make sure their liver is working well, theirkidney is not getting congested, and that

their gut is wide open and free to get ridof the toxicity. thatã­s the way that i detoxify. i donã­t use any chelators. i just detoxifywith minerals. it comes off very slowly and very gradually, and people donã­t tend tohave detoxification reactions. dr shojai: fascinating. fascinating. verycool. dr millman: yeah. yeah. the 5th major contributorin bone disease is hormones. iã­m going to hit 3 big ones, which is insulin, cortisoland estrogen for the ladies. cortisol: there isnã­t anyone who comes into my office with[inaudible 00:27:08] who doesnã­t have a cortisol thatã­s sky-high, because we live such a frenziedlife. we have so much so to do, so much stress, so little time. theyã­re all exhausted; theyã­renot relaxing enough, and theyã­re not sleeping,

so their metabolism is so ramped up. cortisolis just like inflammation. it really destroys anything in its path. we know that prednisone,which is a synthetic form of cortisol, breaks down the bones so quickly. itã­s a huge riskfactor for bone disease. it gives your body the breakdown message.people with high cortisols have all kinds of other problems like insomnia, irritability,panic attack, anxiety. they donã­t heal well from cuts. they get ã«buffalo humpsã­ on theirback. thatã­s actually a cortisol thing. they can be wired and tired at the same time. ithink the most important thing for cortisol is sleep. i got a couple of really good tipsfor your listeners about sleep. dr shojai: great.dr millman: the first 1 being is, i have a

lot of patients who come into my office, andthey say, ã¬dr kim, i just canã­t unwind my mind. itã­s just going full blast, and thatã­swhy i canã­t get to sleep.ã® well, thereã­s a bach flower remedy called white chestnut,that i think is really helpful for that. in fact, i use it all the time for myself. itdecreases the kind of internal chatter that doesnã­t turn off. the other tip that i havefor you is b12. i know this might sound a little counterintuitive, because itã­s a bvitamin; you would think that itã­s stimulating. in fact, what happens is there is whatã­scalled the [inaudible 00:28:57], the melatonin/cortisol rhythm. naturally, what we should have ishigh cortisol in the morning, which gives us our get-up-and-go, and then low melatonin,which puts us to sleep. we want high cortisol,

low melatonin, in the morning and just theopposite at night: high melatonin, low cortisol. b12 is actually in the synthesis pathway formelatonin. it helps to drive up your melatonin at night, drive down your cortisol at night.actually that can have such a wonderful effect and give you a really deep, restful sleep.dr shojai: fascinating. fascinating. dr millman: have you used b12 in your practicefor sleep? dr shojai: never for sleep. weã­ve used serotonin.weã­re very careful with melatonin itself for some people; we use a lot of 5-htp topush serotonin over the pathways. occasionally, weã­ll look at b12 being down or somethinglike that would do it. iã­m going to mess around with that. thereã­s no shortage ofinsomnia out in our world here.

dr millman: absolutely. i think itã­s a hugeproblem in my practice. absolutely. then the other really important hormone is insulin.when our sugars are on a rollercoaster ride, this is not good for our bones. in fact, inthe womenã­s health study, they found that type 1 diabetics are 17 times more likelyto fracture a bone than people who didnã­t have diabetes. then when they looked at diabetestype 2, people that were type 2 diabetics were 1.7 times more likely to fracture a bone.itã­s a huge, huge risk for the bones. we just need to keep our blood sugar stable forother reasons anyway. 1 of the ways that you can do that is by eating fat and fiber andprotein in every meal, because that quenches down the effects of the carbohydrates in ourfood.

carbohydrates: when youã­re having a foodthat has a very carbohydrate load, a high glycemic load, a lot of the insulin gets produced.the insulin drives the sugars into the cells, and you get whatã­s called reactive hyperglycemia.whatã­s happening is your blood sugarã­s going up and down, up and down, but if you havefiber and fat and protein in your meals, it will help to actually even that out. the otherthing that happens with a lot of sugar in your diet is when your sugar stays up highfor a long period of time, you start to actually coat your proteins with sugar. we know thatcoating your red blood cells is one of the ways that we look for long-terms effect ofblood glucose on our body. itã­s called hemoglobin a1c. thatã­s really looking at the sugar contentof whatã­s on our hemoglobin. this happens

to other cells as well. the cells in the kidneys,kidneys get damaged, eyes get damaged, heart gets damaged, brain gets damaged.we actually think that now that alzheimerã­s is like the second form of diabetes; thatã­swhat weã­re thinking. i think that 1 of the things that we did was we really gave up eatingfats in our diet with the lipid hypothesis back in the 1950s when ancel keys came outand said that cholesterol was related to heart disease. we gave up the fats in our diet,and we became enthralled with eating carbohydrates and sugar-laden things. we started to eatpolyunsaturated vegetable oils and they go rancid very fast. they almost always haveto have some of kind of trans fat in the vegetable oil, because otherwise they wouldnã­t havea good shelf life. then we started eating

trans fats and fake butter and margarine.these things are not good for us. my suggestion here is to really get a senseof the glycemic load of your food. what this means is the higher the glycemic load, themore insulin gets produced. the more insulin that gets produced, the faster your sugar is going to your cells. youã­remore likely to get reactive hyperglycemia, and because of the high sugar content, youã­remore likely to have a lot of sugar in your blood and get these proteins coated. so limitedyour carbohydrates, learn your glycemic loads of your food, and eat fiber, fat and proteinin every meal, is my tip for that. dr shojai: fantastic. fantastic. in doingso and stabilizing that, i know when youã­re stabilizing your blood sugar, youã­re effectivelyhelping your bones and keeping them from falling

apart.dr millman: yeah, and preventing alzheimerã­s and heart disease and everything else thatwe know are important. dr shojai: yes, i think thatã­s [inaudible00:34:16] dr millman: lastly, for the women, estrogen.after menopause, women lose .5 to 1% of their bone mass per year. our bone mass peaks at35. this is a huge, huge tip. thinking about your bone mass at 50 or 60 years of age isnot ideal. this is not ideal. women who start to get decreased estrogen, they lose theirsex drive. their female juiciness isnã­t as good. they lose their memory, their zeal forlife. it doesnã­t have to be that way. there are really simple things you can do. i lovemaca. i bet you love maca, too. 1 of the great

things about maca, which is a simple botanicalthat you can use: maca has estrogenic effects, which means that it helps to decrease theperimenopausal and menopausal symptoms, like hot flashes, but it actually was shown inrat studies to increase to trabecular bone. thatã­s really important. it does not increaseurine mass, so it doesnã­t have any kind of bad estrogenic effect, and it doesnã­t increaseestrogen either; it just has estrogen-like effect.another thing that you can do is siberian rhubarb. that is very similar, although ihave not seen rat studies on siberian rhubarb showing any increase in bone-mineral density.dr shojai: fantastic. these are both readily available at the health-food store; this isnã­tanything esoteric that people canã­t get their

hands on. just google it, guys. this stuffã­sall over the place. dr millman: yeah. the thing i want to closewith is i want to give your listeners a chance to find out whether or not they are risk forany of the things that iã­ve been talking about here. i created this online bone assessment,because quite frankly most people donã­t have any idea of whether theyã­re at risk at turns out that whenever i give this quiz, almost everybody whoã­s not in optimal healthhas some sort of risk. let me give you a couple of examples. this is going to illustrate whatweã­ve gone over on the 5 points today. i have this patient who is a heavy-duty coffeedrinker. she drinks 5 cups of coffee a day. because of that acidity factor, sheã­s goingto be stealing minerals from her bones constantly,

and her organs, basically: her thyroid, herheart, and her adrenals are not going to have the minerals that they need because itã­sgoing to get shunted into the blood to counteract this acidity fact, 1 of the things that she was complaining about was being mentally sluggish and beingphysically sluggish. what i did was i said, ã¬okay, i donã­t think that you need to giveup your coffee, just to have coffee in moderation. have a cup a day, and then make sure thatyou eat more vegetables to counteract it.ã® iã­ve put her on a basic mineral supplement.she started feeling better right away. this brings home that acidity can really affectyour mineral status and your metabolism and the way you feel. itã­s not just your bones;itã­s your thyroid, your adrenals and your

heart as well. if you drink alcohol daily,i already gave a tip for that, which is just to take your wine ... wine tastes really greatas a little spritzer with a little bit of mineral water in it. wine is going to do thesame thing. even black tea is going to do the same thing. green tea has less of an acidityfactor than black tea, so if you can start to move from black tea to green tea. we knowthat green tea is a great antioxidant. itã­s so helpful in so many other ways, too.then i have my patients who came in and theyã­re drinking cokes, although i see this far lessoften than i used to in the beginning. people are drinking cokes. they have the high-fructosecorn syrups, and they have the blood-sugar issue. they have the acidity issue to dealwith. when somebody is drinking a lot of cokes

and their blood sugar is going up, they couldbe irritable and anxious, but then a half an hour later, their blood sugar is tanking.theyã­ve got their head up on the desk at 3 pm, and their productive day is all overwith. when your blood stays high, your cortisol stays high. it just is such a vicious cokes ... switch this out for a mineral water with a little bit of cherry juice, alittle bit of cranberry juice. if youã­re having the diet coke instead of the high-fructosecorn syrup, you might think that youã­re doing yourself a favor. again, that formaldehydeis causing toxicity thatã­s bringing toxicity into the mix.a lot of people who come to my office, they have some aches and pains here and there.inevitably, these people are inflamed. we

know that inflammation is related to alzheimerã­s,rheumatoid arthritis, heart disease. again, eating a food that youã­re sensitive to canbe a huge culprit here. the problem with inflammation is that there are very few outward signs andsymptoms from it, but there are many indicators of inflammation that iã­ve found that iã­veput on my bone-health assessment quiz. inflammation is a big deal when it comes to the know, itã­s my sincere hope that your listeners are not at risk. thereã­s a reallyeasy way to find out, so i created this online holistic bone-health assessment test. anybodycan take it. you can go through the quiz. there are 5 sections that look at all thedifferent things that we talked about today. answer the questions. itã­ll be about yourmedical history, your symptoms, your lifestyle.

you donã­t have to be a doctor to answer thequestions. at the end, itã­ll take you through my custom algorithm and itã­ll give you ascore in each of the areas as to whether youã­re at medium risk, youã­re at high risk, or youã­resuper healthy. better yet, iã­m going to give you some simpletips and strategies to start addressing any kind of potential problems that you have.itã­s really important that people understand this. i know that people donã­t think muchabout their bone health. we donã­t sit there wondering whether our bones are rotting away,and theyã­re probably not, unless you know you have bone disease. the really importantthing is that your bone health is directly related to your heart health, your brain health,and to the health of every cell in your body.

if youã­re not providing the proper nutrientsto the rest of your body, these organs are going to leach the minerals from your bones.after some period of time, your bones get depleted, and now theyã­re unable to be thisabundant mineral storehouse for the rest of your recommendation is that if anything that iã­ve said to you today sounds like it couldrelate to you, itã­s better for you to know than not to know. take the quiz. itã­s absolutelyfree. itã­ll walk you through these 5 areas weã­ve discussed today. itã­s superfast totake, and youã­ll get your assessment literally within a few minutes after you take the quiz.i want people to be super healthy, and thatã­s why i designed this quiz. are we going toput a link at the bottom of the video, or

shall i give the link here?dr shojai: [inaudible 00:42:07] so we going to have a link at the bottom of the video.weã­ll also put it in the blog post so theyã­ll have access to it everywhere. they just clickon it, follow it through to you guys. highly recommend taking the quiz right now. no bettertime than now. this will only take a couple of minutes, and youã­ll know what you know.from there, docã­s got a bunch of advice for you. these are the types of things that youwant to get ahead of. you donã­t want to find out that you have bone problems when itã­salready too late. nowã­s the time; if youã­re in your 30s, 40s, 50s, nowã­s the time toreally start addressing this stuff, because it is. itã­s a snapshot into your overallhealth. itã­s your mineral bank, and all your

other organs are drawing from it, so you gotto make sure. when you look at your retirement, you want to make sure that your retirementis ... your endowment really is alive and well in those bones.dr millman: yeah, itã­s so true. those are exactly the kinds of things that i want toincrease aware to. if you have friends and family, please have them take the quiz aswell, because we want to get the message out to as many people as possible to really startto think about your bones, and to think about them in a different way. they are not justthe structural support system for your body that you just have to worry about when youfall down and you break a bone, and worry about breaking a hip when youã­re 85. no,you need to think about them now.

dr shojai: itã­s interesting. a correlation:in chinese medicine, the bones house the jing or the essence. itã­s really like the mostvaluable stuff you got for your health is housed in the bones and stored there. itã­sinteresting how the ancients had to have known this somehow, and now weã­re starting to comefull circle with our science, realizing how valuable this secret organ, if you will, trulyis. dr millman: yeah, i know. exactly. i had noidea about that perspective, but thatã­s great. dr shojai: iã­ll send you some on that. ithink youã­ll have some fun with it, seeing the correlations [crosstalk 00:44:09].dr millman: i will. dr shojai: excellent. guys, weã­ve been talkingto dr kim millman, who is just a whiz at everything

she does. sheã­s a delightful person to know.sheã­s done some great work bringing this information out. i hope you enjoyed it. shareit with your friends. take the quiz right now and then let us know how youã­re doing.basically, what we want to do is build awareness about things that could become healthcareproblems 20, 30 years from now. if you do it now, you maintain your vitality; you restoreyour vitality. you do things to prevent illness from coming. you could see the iceberg a longways away. basically, the eventuality is there only if you donã­t change directions to yourcourse. this is an easy way of knowing it, so take the quiz. doc, thank you very much.youã­re lovely to talk to. i loved hearing everything you have to say. looking forwardto having you on again at some point.

dr millman: thank you so much. thank you forthe listeners, too. dr shojai: okay. thank you, doc. keep good.