Jumat, 30 Juni 2017

osteoporosis center

osteoporosis center

should you take bisphosphonates if you haveosteoporosis? maybe yes…maybe no… fda: more research needed to evaluate risk,benefits of bisphosphonates. robert preidt writing in healthday reportedthe fda has disclosed that more studies are required to determine the “long-term risksand benefits of taking bisphosphonates, a class of drugs widely used for osteoporosis.”dr. marcea whitaker, “the review’s co-author and a medical officer at the fda’s centerfor drug evaluation and research,” said in a statement, “these drugs clearly work.we just don’t know yet the optimum period of time individual patients should be on thedrug to both maximize its effectiveness and minimize potential risks.” the piece notedthat bisphosphonates have been used in the

u.s. “since 1995 to treat people with osteoporosis.” comment: no question these drugs are effective.we just need to know more about them.

osteoporosis causes

osteoporosis causes

how to increase bone density how to improve bone density low bone density osteoporosis symptoms osteoporosis causes what causes osteoporosis exercises for osteoporosis osteopenia treatment hey guys what's going on my name is maxand i'm a fat loss expert which

basically means that i help people loseweight if they're closed better and feel more comfortable in their own skin intoday's video i'll be talking to osteoporosis and what we can do toimprove osteopenia and osteoporosis this video is a little off topic from what iusually make my videos about but one of my clients requested for me to make avideo about this and i feel like i could really help her lot and it may help youas well first of all in case you don't already know osteoporosis is a condition in whichbones become weak and brittle this can lead to a number of different problemsone of the biggest is hip fractures and

the worst part about this is that a hipfracture caused by osteoporosis many times can be a death sentence becauseit's very hard to recover from the statistics for this nasty condition areactually pretty high one of the two females will get osteopenia osteoporosisosteopenia is the precursor to osteoporosis it's one bone densitystarts to go down and roughly one in five males will get osteopeniaosteoporosis there are many reasons why somebody would lose bone density numberone factor is aging and a sedentary lifestyle so we all know the term if youdon't use it you lose it and this applies to our phones as well if we'renot using our bones were gonna lose them

so being sedentary and not exercisingmany times will leave you to lose bone density and eventually it turns intoosteoporosis and next thing that could lead you towards osteoporosis is a poordiet so it's very important that we're having proper nutrients and that thoseproper nutrients are getting absorbed its not only about consuming thosenutrients through a pill or even through your food it's also not consuming othernutrients that will help you absorb calcium for example and another thingthat we see a lot of people on blood thinners or anti-inflammatory medicationthey have a decrease in bone density as well so now that probably scared theshit out of you let's get to some

solutions for this problem one of thebest solutions is the eat more green vegetables i always recommended myvideos for you to have none limited amount of green vegetables inyour diet but it could never be more true than it is right now for thisparticular condition it's been shown that green leafy vegetables are veryhelpful with reversing osteopenia and osteoporosis i recommend a minimum offive cups of vegetables per day that i really hope you get all the nutrientsand minerals that you need to absorb more calcium remember to keep theseveggies limited to the green leafy vegetables those are the best forcalcium and decreasing osteoporosis

vegetables are alkaline in nature sothey're going to decrease the acidity and inflammation throughout your body this is going to be done naturally asopposed to any kind of anti-inflammatories that you may betaking right now milk and dairy products in general havebeen linked to increasing your bone density because they are high in calciumhowever lately it's been discovered that just because something is high incalcium doesn't mean that your body's observing that calcium certainplant-based products are also high in calcium pull over there a lot easier foryour body to absorb and use beans nuts

and green leafy vegetables are the bestto absorb calcium for your body to make sure that you up those in your diet alsoomega-3 was linked to absorption of calcium so make sure that you increasethe amount of omega-3 in your diet the right amount of calcium that's necessaryfor somebody to have healthy bones is up for debate but if you wanna number ofmany doctors recommend you get anywhere from a thousand to roughly 1,300milligrams of calcium per day now that i've told you all the easy stuff thatall of the lazy sedentary people can do this works 100% of the time and it's waymore effective than almost anything that i've already suggested and that crazything is called exercise now many

doctors believe that walking or runningwill help increase bone density but i don't think this is gonna get you guysthe results are you guys want having extra weight on your bones muscles andjoints is not only beneficial for you during exercise but also necessary foryou to prevent things like osteopenia and osteoporosis again if you don't useit you're gonna lose it really any kind ofweight training is going to be beneficial for your osteoporosis howevermany people with osteoporosis do have other problems with their posture thereare many possible deviations so we want to make sure that the correct any kindof possible deviation before we start

training with weights and going hard in the gym actually readymade a video about how you can improve certain types of possible deviationsthat you can check out right over here if you have an exercise in 30 years andyou're gonna go and start doing pushups on the ground you might hurt yourselfyou might be better off doing the walsh of that first and taking it really slowand easy to start off slow and increase and progress as you go if you're justgonna be squatting your body weight every single week yes i don't improveyour bone density but it will cap off at a certain point because there's no morereason for your body to grow and improve

when you're ready up your way andchallenge yourself with carter weight-bearing exercise that's all i gotfor you guys today if you guys enjoyed this video please subscribe to mychannel rica view other videos and tips like this one if you have any questionsfor me or would like to work with me directly one-on-one you could train withme online by visiting my website thanks for tuning in geisel see you guys nexttime

osteoporosis causes symptoms and treatment

osteoporosis causes symptoms and treatment

the root cause of osteoporosis,.. a diseasethat weakens bones and makes them brittle, has long puzzled the medical community---untilnow. local researchers say they might have theanswer,... raising hopes for the development of new treatments.kim min-ji has the details. this is what the bones would look like ina patient diagnosed with osteoporosis,... a bone disease characterized by impaired bonestrength and reduced bone mass. compared to a normal bone,... the spaces inbetween... make them vulnerable, even to the slightest shock.until now, there has been no specific treatment for osteoporosis,... and the current medicationscome with many side effects.

but there is new hope for sufferers,... askorean researchers believe they've uncovered the core cause. this mouse does not have the gene nf1-c,...which is related to the formation of bones. it is much smaller in contrast to a normalmouse,... and its teeth have not developed properly.a micro-ct scan showed that its bone density had been greatly reduced,... just as it wouldin a patient diagnoised with osteoporosis. "in the mouse without nf1-c,... its osteoblastoma,...or cells that form bones,... increase,... but its fat cells decrease." the researchers found that when the mousereceived a bone marrow stem cell transplant...

containing the gene,... its bones developedjust like they would in a normal mouse. the new discovery could pave way for the developmentof new medication or treatment for human patients. "we can use the genes in the form of celltherapy,... but it is limited. our next step is to find a new substance that can enhancethe functions of the genes in order to develop new medication." the findings have been published in the onlineedition of journal stem cell. kim min-ji, arirang news.

osteoporosis causes and treatment

osteoporosis causes and treatment

fosamax, the brand-name form of alendronate,is a prescription medication used to treat osteoporosis and paget's disease. it is alsoused to prevent osteoporosis in postmenopausal women. fosamax is in a class of medicationscalled bisphosphonates. these work by preventing bone breakdown and increasing bone density.fosamax comes in tablet and liquid forms. it is usually taken daily or weekly, dependingon the dose and form, on an empty stomach and with a full glass of water. some commonside effects are stomach pain, heartburn, and constipation. always take this medicationonly as prescribed. keep up to date with medication information by following rxwiki on your favoritesocial media platforms.

osteoporosis care

osteoporosis care

hello, i'm geraldine moses. welcome to this program on the clinical guideline for the prevention and treatmentof osteoporosis in post-menopausal women and older men. osteoporosis is under-recognisedand under-treated. the deterioration of bone can proceedwith no outward symptoms until a symptomatic fracture occurs. recent research indicatesthat only 7% to 20% of people

who have sustainedan osteoporotic fracture receive treatment for osteoporosisto prevent further fractures. this program is the finalin a series of four programs on the new musculoskeletal guidelinesfor general practitioners and other primary health careprofessionals, which have been developed by the royal australian collegeof general practitioners and approved by the national healthand medical research council. the guideline provides recommendations

for prevention and treatmentof osteoporosis our program will discuss how local health servicesand general practices can improve their treatmentand management of osteoporosis. you'll find a numberof useful resources available on the rural health educationfoundation's website - now let's meet our panel. firstly, professor john eisman is a professor of medicineat the university of new south wales,

a staff endocrinologistat st vincent's hospital in sydney and director of osteoporosisand bone biology at the garvan instituteof medical research. john was the chair of the working partyfor developing this guideline. - welcome, john.- thank you, geraldine. cecily barrack is a physiotherapist. she works forthe north coast area health service and the northern rivers universitydepartment of rural health as a research clinician to look atlocal osteoporosis management.

- welcome, cecily.- thanks, geraldine. dr dan ewald is a general practitioner who works in rural general practice and with the northern riversgeneral practice network. dan was alsoon the guideline working party. - welcome, dan.- hello, geraldine. and judy burrows is a pharmacist, and she has a backgroundin hospital pharmacy. she also lectures in thepostgraduate clinical pharmacy program

at the university of queensland and is the queensland healthand university of queensland pharmacy training coordinator. welcome, judy, and welcome to you all. cheers. so, let's just startwith a definition question. john, i wonder if you couldquickly explain - what is osteoporosis? well, osteoporosisis a problem that is common and it developsparticularly as we get older

when, with the remodellingof the skeleton, the bones become a little bit weaker, more fragile, and they really breakwith minimal force. and that's really what the problem is. right, and just so that our audience can understand our panellists'involvement in this, cecily, can you just briefly explain -what's your involvement in osteoporosis? my involvement is looking, perhaps,

at how fragmented carefor people with osteoporosis can be and how we can better organiseour health services and systems so that peopleactually don't fall through the gap and are connected withevidence-based care. right. and, dan, you were involvedin writing the guideline, but i believeyou've got a special interest in what the evidence is showing? well, i'm particularly drawnto this area because of the gap between

what the evidence tells usis good practice and what we can do, and what we actually end up doingin the real world. and also that it's an area wherewithin the last 10, 15 years we've got available to ussomething very useful we can do. so it's relatively new still. and, judy, you're a pharmacist, so what do you seeas the role of pharmacists in the management of osteoporosis? well, i think irrespective of whether

pharmacists workin the community, hospital, or an accredited pharmacistdoing home medicine reviews in the homes or in the nursing homes, i think pharmacists,as part of a multidisciplinary team, have a really big role to play in optimising the healthof patients with osteoporosis. right, now, john, back to you, if i may, can you please explain the extentof the problem of osteoporosis? well, it's a huge problemin the community.

older women, say, over the age of 60 - one in two of themwill have an osteoporotic fracture during their lifetime. and for men,even though the risk is lower, it's perhaps one in three. and these are associated,once you've had one fracture, with increased riskof further fractures and with premature mortality. and we've known these statsfor quite a long time.

are there any trends?are these figures changing? um... well, if anything, the trend is thatwe are seeing more fractures, because we're havingan ageing community. people are living longer, and,as they live longer, the risk goes up. but still, having said that, the peak incidence of the problemsof osteoporotic fractures are in people in their 60s and 70s,not in the really older age groups. - just because there are more people.- right.

so, what's the burdenof all these osteoporotic fractures? well, at the momentthe estimated cost in australia, including direct and indirect costs, is something like $7 billion a year. so it'll cost australia about $1 millionwhile we are talking about it tonight. wow. do we know what causes osteoporosis? well, there's a major part of itwhich is genetic, a very high part of it.

as i always point out to people,choose your parents wisely, but it's usually a bit late. but then there are thingslike environmental factors and there are things like lifestyle,exercise, nutrition and so forth. and then partly it's just advancing age. there are many secondary factors, which i guesswe'll talk about a bit later, but these are also thingsthat contribute to the risk. and are there any medical conditionsthat contribute to the risk?

well, there area lot of health conditions - anyone who's onthings like cortisone, prednisone, people who have got malabsorption, things like celiac disease,which is often not recognised, women who have an early menopause, or men who are on treatment,let's say, for prostate cancer, where the male hormone levelsare dropped - they're also at increased risk. and there are a number of other things -

lung disease,people with a lot of asthma, people witha lot of inhaled corticosteroids - not the normal doses, but thevery high doses can also affect it. now, i think most of us know that osteoporosis is measuredto a certain extent with bone mineral density testing, but the results that people get aren't immediately obviousin what they mean. so can you please explain

the relationship betweenthe t-score and the z-score and what that really meansto real people? ok. when you measure something, you've alwaysgot to know what you expect. so the z-score is the comparison withother people of the same age and sex. now, if you're withina couple of standard deviations - 'cause that what it's measured in -of that value, then the implication isthat whatever your value might be

it doesn't look likeyou should be terribly worried that there's some other secondary cause. but if it's lower,you should really worry that there's something elsethat you haven't thought about yet that you needto be doing something about. but the actual diagnosis, if you like,of osteoporosis relates to the t-score, which is the comparisonto young normal. and there's a very...

somewhat arbitrary definitions that if you're withinone standard deviation of young normal, we'd say it's normal, if you're between 1 and 2.5,we say that's osteopenia, and if you're more than 2.5,we say that's osteoporosis. but these are sort of steps along a gradientof exponentially increasing risk. there's no sudden step in any of these. and, dan, i believe that you like to say

that bone mineral densityis just a risk factor, it's not the disease itself,is that right? i think it's usefulto remind people of that. like we're used to paying attentionto blood pressure or cholesterol, which doesn't present with anysymptoms, but we know it's important because it marks a riskfor something dramatic. and that really should be the way we're thinking aboutbone densities as well. it's a very important risk factor,

but the event that countsis their fracture. so, since we're talking with you, and you know a lot aboutwhat the royal college did in terms ofdeveloping these guidelines, what was the impetus? surely we know enough about osteoporosisalready, we don't need more guidelines? well, a lot of usdidn't learn about osteoporosis and what to do about it,in our training. even in our post-graduate training.

it's only come to us,depending on our age, in later years. and there's been a lot of promotionfrom the drug companies and there's been some presencefrom other agencies as well. so it's very appropriateto try and clear up some misnomersand some misunderstandings, and it's a hugely important issue, still grossly under-recognisedand under-treated. and particularly in rural areas. when we looked at how much bone densityis being done in rural areas

compared to urban areas, it's markedly less,suggesting that rural areas might be missing outon looking after osteoporosis even more than their urban counterparts. oh, that's very interesting. i believe you've gota copy of the guidelines with you. would you like to show the audiencehow beautiful it is? if you download it from the royal australian collegeof general practitioners website,

you can make yourself a little booklet. and there you'll find somenicely summarised evidence around most of the topicsthat might be troubling people. all those debatesabout how long to treat for and when to treat, and age,and the risk factors, etc, are discussed withwhatever evidence is available. how long did it taketo put the guideline together? it's a lot of work,and there's been a lot of hours. - years?- it's been years in the making.

and there's a number ofsupporting documents and programs that are availableto help the uptake of the guidelines. and so there areguidelines for practices to do small group learning exercises and do clinical auditswithin their practice. there's a summary guideline. to fit the whole thing onto two sidesof an a4 page was a challenge, and we've done that as well. and those who getthe australian family physician

will be getting a copy of thatnext month. there's a practice nurse guide, and we might look in the future to the collaboratives programtaking up osteoporosis, there's an edition of the check programcoming out, and we've already had a national prescribing service programon osteoporosis. so there's a number ofother supporting activities out there. so it's available on the racgp website

and it will be inthe australian family physician. will it be advertisedto allied health professionals, like physios and pharmacists? anyone will be able to access thisthrough the college website. - and i'd encourage them to do so.- yeah. judy, do you think pharmacistswill be looking out for this? i mean,should we be raising awareness... absolutely. awareness should be raisedabout those guidelines

and that will be somethingthat we should address as a profession to improve the uptake of guidelines. cecily, do you think physioswill be interested in raising this? there might be a lot about drugs,which often doesn't interest... absolutely. they're at the interfacewith a lot of these patients in the acute and the convalescentrehabilitation phases, and they need to be very awareof what the current evidence is and to give the right advice. so, now let's take a look atour first case study, who's cheryl.

cheryl is 66 years old and she presents at the doctor's surgerywith an acute episode of back pain. she's experiencedepisodic back pain over the years, and she's been takingparacetamol for the pain. she has thoracic kyphosis and she had anorexia nervosawhen she was in her twenties. her bone density at her hipis a t-score of -2.7. so, dan, if she presentedto your general practice, what would you say indicatesthat cheryl might have osteoporosis?

well, i'd hope that my practice will be really tuned into thinking about osteoporosis, and that's the first big hurdle,is to think of it. and then the clues arethat she's female and her age, and that she's got a back painand a kyphosis, she's had a period of anorexia nervosa. all of these things are stacking up, and there's no surprisethat she's got a bone density of -2.7, which is significantly low

and in the rangewhere we call it osteoporosis by the standard who definition, and the evidence for treatment applies. but, clearly, you have to thinkof a differential diagnosis list, so what investigationsmight you have to consider to think of all possible scenarios? well, there's a couple of things,to answer that question. one is she's presented with back pain, so we have to approach back painin its own right

and sort that out in our normal way. and then if the back painis because of a... ..we think it's becauseof a vertebral fracture, a new vertebral fracturebecause of her osteoporosis, then she's also added to her risk, 'cause having one fracture makes her much more at riskof a subsequent fracture. then we've got to approach the issue of what might becausing her osteoporosis.

and we come back to john's mention ofthe z-score. might give us a clue there. if her z-score is close to zero,we're less worried that she's got some other unusualdisease process driving her bone loss. if her z-scores are very low, we'd be looking more closelyfor some underlying cause. what investigationswould you do first up for her, in terms of her potential osteoporosis? well, there's nohard and fast rules for this, but we do want to knowwhat her vitamin d levels are.

and we can't really tellby asking her and looking at her. much as we'd think thateveryone who lives in sunny queensland is going to have normal vitamin d,it doesn't happen that way. we know her bone density,that we can look for... we can do some blood tests to rule out the most commonother causes of secondary osteoporosis. so we can do liver-function tests, we can look at her serum calcium, we can do a full blood count,look at an egfr,

we can do her protein electrophoresisand thyroid-stimulating hormone. but, as i say,you can use some clinical judgement on how much of that battery of testsyou'll apply in every case. now, you're going to end upwith a t-score and z-score, but perhaps i can ask john about the roleof the fracture risk calculator, which i believe your teamat the garvan institute developed. can you tell us about that, please? yes, well, this came out of the workthat we'd done in dubbo,

looking at the factorsthat would predict risk. and this is a population of abouttwo-thirds of the older people in dubbo, who we've been following nowfor almost 20... ..actually, for over 20 years. and what we found is the things that, in a sense, following on what dan said, the things thatreally predict the fracture is what your age is - the risk is higher in womenthan in men -

whether you've had falls, because that alsopredicts your risk of fractures, whether you've had any prior fractures, and what the bone density is. and with those,you can really, very accurately separate peoplewho are at low risk of another fracture from people who are at much higher risk. and it gives you a riskof what their risk of any fracture is or what their hip fracture isover the next five years

and over the next ten years. how is this risk expressed?is it a per cent? it's a percentage - what is your chance? obviously,100% means that you're going to, and if it's 5% or 10%, you could say,well, maybe it's not so high. that must be so much more meaningfulthan a t-score. well, i mean, i think...it includes the value from the t-score, but it takes inall this other information. it allows people to evaluate risk.

i mean, we're not entirely happythat we're there yet, because i think it's still hardfor people to understand risk, absolute risk, in real terms. so we're still working on that. but if people want touse the fracture risk calculator, that's how you'd find it. it's called 'fracture risk calculator'. or you can go to the garvan website,and it'll come up and it's there. and it works for both men and women,and from the age of about 55 onwards.

so, back to you, dan. what are the challenges for gps in diagnosing osteoporosisin general practice? the challenge is to think of it, and recognisethat we need to be thinking of it. once you've switched your brain onto being alert to it and you've got your practice teamswitched on to it - 'cause it's not only the gp who needs to be picking up the conceptof osteoporosis and bone density -

the practice nurse, and all the alliedhealth providers that we work with have to be part of that - then what to dois really quite clearly set out, and you can turn to the guidelinesand even the summary guide to step you through it. i think the big hurdle is to recognisewe need to be doing something about it. mmm. picking it up as early as possible. judy, i wonderif you could comment here. possibly, cheryl was purchasingher paracetamol in a pharmacy.

what's the role of pharmacists in early detection and screeningfor osteoporosis? well, i think, as dan said, if the whole multidisciplinary teamis switched on to the idea of being mindful of osteoporosisas a consideration, then, if someone did come inlooking for some analgesia and they were a regular customerand complained of back pain, that's somethingthat should initiate a referral, a referral to the gp,to have that investigated,

not just assume it's musculoskeletal. that's right,'cause isn't there an old saying that any sudden onset of painin the central back region should be thought of as an osteoporoticfracture in the first instance? is that right, john? i think, if you have somebodywho has an acute episode, particularly if it persists for, youknow, more than a few hours or days, i think you need to think about thatas an osteoporotic fracture. and the other thing too is if somebodysays, 'look, i've really lost height.'

'cause most people can rememberwhat their height was when they were in their 20s. if they'resubstantially down from that - more than 1cm or 2cm,that we all get from disc wear - you really need to think about thatas potentially a fracture. and an x-ray, as happened in this lady, is a very useful way of clarifying that. and if they've got a fracture,that's osteoporosis, really. moving on now to oursecond case study, who is charles.

charles is 68, and he slips and falls whilst playing with the grandchildrenin the backyard. he has considerable wrist pain. he goes to the emergency department,and an x-ray reveals a wrist fracture. after treatment at the hospital, he visits his gp with the dischargereferral, but he has no x-ray. charles has a historyof smoking and of asthma. dan, if charles was your patient,how would you proceed here? he's had a fragility fracture.

that's the first thingwe have to recognise. what do you mean by that? well, he slipped and fell.he's had a fall. he's had a fracture from a fallfrom a standing height or less is an easy way to think of that. it's not a definition set in concrete, and you oftenhave to adapt it to the story, but, basically, he shouldn't havebroken a bone by falling over. and it's his bones that are fragile,you mean?

- it tells us he's got fragile bones.- right. and we want to then start to explorewhy and how fragile, and what are the indicators we can get to get an ideaof his risk for further trouble. so he should get a bone density done. do we have a men's health issue here? do men thinkthey don't get osteoporosis? we do have a men's health issue here. and we found that also, in looking atthe utilisation of bone densitometry,

that the rates per populationare much lower for men than for women. so it's one of the myths out therethat osteoporosis is a women's disease. mm. and do you think that there'sa role here for population screening? i'm happy to hear from any of you here. should we just be doingmass bone density screening to overcome this problem? john, what do you think? mass screening, i think,is always difficult. the only point of doing screening

is if you know exactly whatyou are going to do when you find it. we do have an element of screeningavailable in australia now. if you're a man or a womanand you're 70 years of age, you can get a bone density done. you don't have to have had a fracture. get a bone density done,covered by medicare. at this stage,as i understand it, the uptake is less than 10% of australianshave actually had one of those. - that's very low.- of the people who are eligible.

and so i think there is an issuethat people don't understand. and i think,to follow on from dan's point, is that if you're a manand you have a fracture, your risk of another fracture goes upmuch more than it does for a woman. so although a man and a womanhave different risks when they start, if a woman has a fracture, her riskof other one goes up about two-fold, a man goes up about four-fold. and they're exactly the same, they're about the same assomebody who's 20 years older.

and the only reason that it's actuallyperhaps got a little worse than that is both of them are increased riskof premature mortality, and it's worse in men than in women. and why would they diefrom an osteoporotic fracture? well, that's what we'retrying to understand, but they do, and it's not explicable just bytheir co-morbidities, in our studies. so it really looks like it's a signalthat there's a real problem there and that people needto have something done about, and there's the actually evidence now

that treatment of the osteoporosisreduces that premature mortality risk. does charles' smokingcontribute to his osteoporosis? well, i think it probably plays a part. it depends really how heavily he smokes,and so forth. but i think there are other reasons to convince himthat smoking is not a good idea. assuming that you diagnosed charleswith osteoporosis as well, what would be an appropriatetreatment management plan for him? well, he needs to understand...

part of the plan isthat he understands the condition and what the risk isand what we're talking about. we're talking abouta long-term condition. so, the engagement of the patientin understanding that is critical. otherwise we'll run into the problems of them going out the doorand having forgotten it, not understanding it,and certainly not persisting with it, the changes that he'll need to make. and then it's going to goacross the whole spectrum

of medication choiceand a bunch of lifestyle changes. so, cecily,what sort of lifestyle changes do you think we'd be thinking aboutfor someone like charles? charles needs to consider whetherthere are things in his lifestyle that will accelerate his chances of losing more than the averageamount of bone micro-architecture. and they would be his smoking, and if he has a high alcohol intake. and then there are protective factorsfor his bone density.

and those factorsare an adequate calcium intake, and that can be, in the first instance, achieved through just a dietthat has adequate calcium. and that's three to four serves a daythat he should be advised to take. he should also consider exercisethat would be appropriate, and, if he is provento have osteoporosis, then that needs to bequite individualised and to be made surethat it is appropriate and it's not going to actuallyexacerbate any problems for him

or in fact cause fractures. and the other one is, is he getting enoughexposure to sunlight? and that will actuallykeep his vitamin d levels at a satisfactory level, and that's one of the essential things - for his body to formand keep forming enough bone. i think we'll come back to all thosepoints when we talk about prevention. so, let's now look at ourthird case study, which is belinda.

she's the daughterof charles and cheryl, and she accompanies her fatherto the doctor's surgery on charles' follow-up visit. she's in her early 40s and has become awareof her family history of osteoporosis. she wants to know what she can do to help prevent osteoporosisand future fractures. so, john, what advice would you givebelinda on prevention of osteoporosis? well, she ignoredmy first bit of advice,

which is to choose her parentsappropriately. silly her. but, i mean, you just needto look at all the risk factors. cecily's talked about how we canmake sure that she has a healthy diet, that she's not too underweight,which some women pursue still, that she getsan adequate calcium intake, and, following on cecily's comment, this means dairyor calcium-supplemented foods, of which there are not a lot, really.

that she needs some of those each day. to make sure thatshe's getting adequate sunlight. and if she's tryingto balance this issue of too much and too little sunlight, then checking her vitamin d level, and, if it's low, then she needs to knoweither she has to get more sunlight or take a supplement,both of which are perfectly reasonable. all the healthy nutritional messagesand lifestyle messages -

not smoking, not too much alcohol. but perhapsthe really critical thing for her is that if she's concerned about it,she could get a bone density. unfortunately, she'd have to pay for it. but that might give her an idea of whether she should bemore worried about it, or indeed whether she just knows, ten years' timeshe'll be coming up to menopause, should she bemore worried about it then?

and if she's already low now, then, really, she'd need to bethinking about it very carefully as she approaches menopause. do you think there are any issues,if she has children, that she should be thinkingfor the next generation as well? if she ends up beingat high risk of osteoporosis, then it might be three generations. well, again, she can choose her partner,one who's got better bones. i don't know. but i think...

there's a lot of discussion abouttrying to make sure that with kids... we do encourage them to havemore exercise in their lifestyle. and again, you know, a good diet,with calcium and protein and so forth - the old balanced dietthat we use to talk about. and, hopefully, young kidswill get more exercise playing with wiis than they will playing withjust computer games like this. judy, i wonder if you can commentfrom a pharmacist's perspective about calcium. people seem to misconstruethe dose that they need,

and where you get calcium from, and the messages are very mixed. so i wonder, in your experience, what do you think are the big issueswith calcium intake? well, calcium, really, you can't tell if someone'sdietary intake is adequate by doing a calcium level. but you need to assesswhat someone's calcium intake is. and post-menopausal women,as cecily said,

need four servesof dietary calcium a day. what that means is quite difficult. in some of the studies it means that about 80% of womenin that age group don't get adequate calcium intake. so it's really aboutassessing what the dietary intake is, whether you can maximiseand optimise that by diet alone. if you can't, if someone doesn'tparticularly like dairy, for example, then there is a rolefor supplementing calcium intake.

but we certainly don't needsuper doses of calcium over and above, if you're havingadequate dietary intake. so it's really not calcium for everyonenecessarily, but there will be a lot of peoplewho don't have adequate intake and will require some supplementation. so there is a role to look at that. there's issues around calcium, as the tablets are quite bigand they're chalky. they're not subsidised by the pbs.

but, yes. and compliance is notoriously lowwith that along with other things. is there a rolefor any other dietary supplements? you often see people taking magnesiumalso for osteoporosis. i think the evidencesits around calcium. there's not a lot of evidencefor mineral supplementation. it's similar with vitamin d. you need to supplement that if you're not having adequatefrom the sunlight.

dietary intake of vitamin dis very minimal. cecily, if we could get backto lifestyle issues for belinda, i think exercise oftenplays a great role in younger people who want to help their bonesas much as possible. what would you say would beappropriate exercise interventions or, indeed,what exercises might she avoid? ok, so we have belinda, who, at thisstage, doesn't have osteoporosis. and it would be really importantfor her to understand that there's a scale of exercisethat will help her.

and those exerciseswould be high-impact exercises. they'd be things like joggingor playing netball or tennis in this sort of age group. and that they need to bethree to four times a week, about 30 minutes of duration. but short and sharp and intense is muchbetter than something that's just a leisurely sort of, you know,walk for an hour, because to actually get the bodyto really kick in and form as much bone as possible,

you need to put a certain amount ofstrain and increasing levels of strain on the bones to achieve that. so quite a bit of detail with her about the types of exercise that shemight be prepared to adopt. and it's true thatswimming doesn't help? they're low-impact. swimming, cycling - things that don'tinvolve contacting the surface, and therefore getting that jarringeffect back up through the bones are not going to actually stimulateas much of the normal process

that the body can actually doof actually forming more new bone. aren't there the funny machinesthat vibrate? you can stand on them and it's justjarring your bones but nothing else. is there any evidence to support those? i know that the machines exist, but a level of scientific evidencei'm not aware of. is that covered in the guidelines? there is some evidencefor one of the types of machines, which is actuallya very low energy vibration.

it's actually quite hard to evenfeel it. it feels a bit like buzzing. it's not one of these thingsthat throws you around. but these are still to be... and they've shown they can havebeneficial effects on the skeleton. they haven't been translated yet toshowing that they reduce fracture risk, which is really the bottom linethat we're all talking about. right. judy, over to you. there are some medications that put people at risk of a decreasedbone mineral density.

can you quickly cover those, please? john covered a couple before. steroids - whether they are oralsteroids or high-dose inhaled... geraldine: corticosteroids.- corticosteroids, yes. they're the ones that come to mind. but there's also lots of others.excessive thyroxine intake. proton-pump inhibitors, 'cause theyreduce the absorption of calcium. ssris, aromatase inhibitors, glitazones. anti-epileptic drugs are another group

that can decreaseyour bone mineral density. well, the mentionof proton-pump inhibitors is actually one of the questionswe've had from an audience member. marissa from queensland asks, 'could the increased use of ppisin post-menopausal women cause an increase in the incidence offractures and thus osteoporosis? what should we do, if anything,or is the evidence just theoretical?' john, do you havean expert view on that? do we really believe proton-pumpinhibitors

increase osteoporotic fractures? well, i think it's certainly clear thatproton-pump inhibitors decrease your ability to absorb, let'ssay, calcium carbonates in particular because they require some gastric acidto be absorbed. so... but the evidence that this,on a global scale, is translating toan increase in fractures i think isn't quite there. i think the relevance isthat if you've got a patient who is on a proton-pump inhibitor,

if they're going to usea calcium carbonate, you have to tell themto have it with a meal. 'cause with a meal,they'll still make some acid. or to use one of the calcium citrates, which do not depend on acidfor absorption. other than that, do you thinkthere's any big difference between different calcium supplements? no, i think the major issueis the amount of calcium. and i think, as judy said before,

the evidence that any ofthe other minerals are required - magnesium, manganese, zinc, silica,aluminium, boron and any other that you'd like to name - the evidence that any of thoseare specifically required is approximately zero. yeah. marissa from queensland also asks, 'should all post-menopausal womenbe on calcium supplements due to most being at higher risk?' do you think we should just all be oncalcium supplements

as a matter of course? i think judy has described it perfectly.if you've got a good calcium intake, no. it's more asking the questionand saying, right, you know, 'are you havingreasonable calcium intake?' occasionally, you have to sort oftry and get around the issues. you ask people, you know,'how much calcium do you have?' and they say, 'oh, i have twoor three glasses of milk a day.' and then you ask them,'well, how long does a litre last you?' and they say, 'oh, about a week.'

and those two thingsdon't quite add up. but if you get past that, i think if people have dairyor one of the dairy alternatives like calcium-supplemented soy or some of the othercalcium-supplemented foods - yoghurts, cheeses -they may not need it. but if they don't have it,there's not much point telling people, 'have these things,' when they're notgonna really add them to their diet. and then some improvementin calcium intake with a supplement

makes good sense. what dose does the guideline sayis the appropriate daily dose for calcium supplementation? 1,200 milligramsis what we should be going for. - you had another comment, dan?-yeah. i think we need to... there may be a mistaken notion out therethat dealing with the calcium is... and then you've got it done. you know, we're going to look afterthe calcium and then they'll be right,

they won't get osteoporosis,they won't get fractures. the evidence that calcium -getting the right amount of calcium - can help preserve bone mass is good, but the evidence that taking goodamounts of calcium prevents fractures is not good. so what you really need to dois properly assess the person's risk... geraldine: mm. ..and they may need a lot morethan just thinking about calcium, or they may need nothing at all.

but just doing the calcium-diet historyis not an adequate assessment of osteoporotic risk. yes, it's just the first step, isn't it?that's a very good point. cecily: and one thing with calcium toois there's a lot of aversion to 'high-fat foods', and a lot of the dairy products havebeen dropped out of people's diets because of an assumption that it's notgood for their cardiovascular health. oh, yes. there was a study a couple of years ago,wasn't there,

that people on calcium supplementswere at higher risk of cardiovascular disease? is there any truth to that? well, there's a study -it's actually quite recently, in fact - saying that if you looked at peoplewhose calcium... as a group, the calcium intakefor these people was reasonably good. and if you added on top of thisa calcium supplement, there was a smallbut statistically significant increase in the risk of heart attacks -

not in deaths, but in heart attacks. um, that's led, i think, people to sayperhaps even more, as dan has said, you know, making sure people havea reasonable calcium intake makes sense if people's calcium intake is low, but giving it more and more and moredoesn't make sense. and also, it is only, as you said,the first step in the management. that's sort of the...that's the background - calcium and vitamin d,the lifestyle, the exercise, and then, depending on what the restof the evidence is about their risk,

then you have to build onto that. another question has come in asking whether the treatmentfor men and women is ever different. uh, dan, perhaps you'd like tocomment on that with your view from the guidelinesas well. well, it's different when it comes tochoosing some of the medications, the specific anti-osteoporoticmedications, because a number of themare only relevant to females. that's tricky, isn't it? i mean,how do you get around that?

if a man needs to use strontium,for example, and it's not on the pbs, for men, what do you say? well, you'd be looking closelyat finding an alternative, and there's nowa range of bisphosphonates and, for men,the evidence of effectiveness is much better established forbisphosphonates than anything else. i guess we'll talk about treatmentsshortly. we're supposed to be talking aboutprevention right now,

and, on that point,we've been asked by ben from cairns whether he really needs to measurevitamin d levels in everyone. what's your view on that, john? it's the old storyabout flossing your teeth. you floss the teeth you want to keep. if you want to know if somebody'svitamin d level is low, you have to measure it, but to answer it is thathe might be thinking, 'look, i'm in cairns,there's so much sun around.

my patients won't have that issue.' and the evidence is it actuallydoesn't matter where you are, north and south of australia,in the tropics, in asia, a high proportion of people -probably more than 50% of people - have levels of vitamin d in their bloodthat we would consider to be suboptimal, and the only way you can knowis measuring it. a question that comes acrossmy desk a lot is if the vitamin d levelis critically low, like, say, 20, what dose should be usedto replenish that vitamin d?

should people be using a super big doseonce a week or once a month, or would a daily dose of a normalamount, like 1,000 units a day, be ok but be a bit delayed in its effect? i guess my view of it is,if you start with 1,000 units a day, that's what people needto keep themselves in balance. if they're already depleted, that'lltake you forever and a day or two to get 'em up to a replete status. i tend to use, you know, 5,000 or even10,000 units a day for some months. do i know that that'sa better way of doing it?

well, no, but i think it makes sense to try and get them up to a normal levelfaster and then replace it. sometimes people look at 1,000 units, and they think,'oh, that's a huge amount,' but, of course, it was derivedfor the amount you needed to give a neonatal rat to fix rickets. so it's not... you know,it's a bit misleading. it sounds like a big number,but it just isn't. yeah. but i think there isone other side of it,

is that there was a studythat's just been published where community-dwelling peoplein victoria were given 500,000 units of vitamin donce a year with the idea that this would havea beneficial effect. and, to the distress of the peoplewho were doing the study, it turned out if anything,that people got this super-large - and it's very much biggerthan we're talking about - actually had more fallsand even a few more fractures. so we don't understand why that is.

but i think it means, you know,moderation might be a good idea. - that's what my mother always says.- i know. i was gonna say that. it's what my mother said. - judy, you have a comment?- yes. about vitamin d, it's important to know that vitamin dnot only is inherently important in improving the absorption of calciumfrom your foods, but also in muscle strengthand stability and gait. and so vitamin d supplementationin those who are deficient

will decrease your risk of falls, so that has a major impact as well. so, john, just froma historical point of view, are there any drugsthat are on the market that are no longer recommendedfor osteoporosis? well, when i started in this areaapproximately 40 years ago, one of the most commonly used drugswas deca-durabolin. geraldine: ah, yes. and it was givenas a weekly injection...

testosterone.anabolic steroid, isn't it? yeah, it's an anabolic steroid. and it was given as a weekly injection. and if you gave it to somebody,in six weeks their pain settled, and if it didn't,it took a month and a half. but the evidence thatthat makes any difference, unfortunately, is that almost certainlyat the doses that are used, it made no difference, and if you used enoughto make a difference to bone density,

then you almost certainly hadunacceptable androgenising side effects. there are a few other agentsthat are around where i would argue that the evidenceis less strong for their benefit, and, i think, youknow, really the evidence is that the drugs thatare now considered front-line are things like the bisphosphonatesand some of the other treatments - that i believe judy's gonnaspeak about too - are the ones that you'd thinkthere's really good evidence for. cecily, i wonder if you can commentfor us on fall prevention.

we've been talking a lotabout fracture prevention, but i think your professionplays a big role in fall prevention, which is often a major causefor the fractures. yeah, there has been, i think,increased recognition that the risk of falls actually doessort of overlay in this group of people who also may have a risk of osteoporosisor fractures, and it's very important thatwe do intervene for that falls risk. so there are components to that, and certainly some of those are aroundsomebody's strength and balance,

and, if we can improve those things,they're much less likely to fall. we've already heard aboutimproving their vitamin d levels, or normalising those has a direct impacton people's strength and likelihood of falls. we also need to think very muchabout the home environment, and just simple things likehaving lights that go on at night when someone gets up to go to the toilet has actually been shownto reduce the risk of falls. we need to think aboutpeople's footwear,

we need to know whether people have hada recent eye check, are they wearing their old glassesbecause the other ones broke, all of those things. and they are part ofquite a good checklist of things that should mean thatevery health professional and gps can actually go throughquite a systematic review of all the factorsthat could contribute. dan, i wonder if youcould comment on that as well, as a general practitioner,

how you get your patients reviewedfor their falls risk. i tend not to deal with the interventionaround that myself, and, depending on where i'm working, i'll either get the practice nursesto review that stuff with the person or i may have the capacity to refer theminto a community health service. and that's gonna be fairly patchy inrural settings, your ability to do that. it's not rocket science, and i think we all should be ableto get our head around doing it. it's just a matter of fitting it inand making sure someone does it.

i think all health professionalshave a role to play here, especially pharmacists, as well. judy, you've beena home medicines review pharmacist. is that another opportunity to assesspeople for their fall and fracture risk? absolutely, have a look atthe situation at home, whether there's mats on the floors,pets to fall over, all those sort of thingsthat can play a role that doesn't always get assessedin the home. geraldine: there are medicationsthat contribute to falls risk too?

absolutely - anything that actsin the brain or makes you feel dizzy - antihypertensives, opiates,benzodiazepines - lots of drugs can increaseyour falls risk, and they should be assessed. things with anticholinergic side effectsshould be looked at and reviewed in people who havea high risk of falls. in terms of treatment, what arethe sorts of drugs that we're looking at for osteoporosis treatment? well, as john said,20 years ago we had hormones,

but there are lots of evidence-basedtherapies around now. i mean, hormone replacement therapystill has good evidence. then, about 15 years ago, thebisphosphonates came on the market. they're now given weekly, butthey have very specific instructions about how they should be taken. raloxifine or sermscame on the market since then. for women only, strontium has comeon the market since more recently. for women only, there's parathyroid hormone -it's a subcutaneous injection

which has become availablein the last couple of years. and there's a new drug on the market - denosumab,which is a monoclonal antibody, which i believe is now being marketedin australia, which adds another agentto the armamentarium to treat osteoporosis. and what's compliance likewith all these potential treatments? well, compliance with medicationsin general is really poor - about 50% - and that's similarwith bisphosphonate therapy.

they're a weekly medication, although now there's an iv formwhich has also become available in the last year or so. so i guess there are ways aroundcompliance issues, but there's still a problemwith compliance with oral therapy. geraldine: right. and, john, you have a graphic,i understand, that talks about which kindsof interventions that can be used at different times of life?

john: well, i hope people can see this, but, basically, if you look at that sortof age going along the x axis there, it says 'calcium' and 'life style'. you really need to talk about itfor everyone and think about it. closer to the menopause,you might think, 'well, hormone treatmentis appropriate.' and if you had a hypergonadal male,it may be appropriate as well. in women who are a little bit older,it might be one of the serms, like raloxifine/evista,or tibolone/livial.

that's another option there. we tend not to continue thoseso long these days, but if you've got peoplewho've got very clear osteoporosis, and it's both for men and for women, the bisphosphonateshave really excellent evidence for being very effective, effectivelyhalving the rate of fractures that people might have,and very well tolerated. there's good evidencefor strontium ranelate, particularly in older people as well,

and the new one, denosumab,which has been passed by the tga. i'm not sure if it's on the market yet,but i hope it will be. and parathyroid hormone,or teriparatide, for the peoplewhere they've been treated yet their bone densityhasn't seemed to respond and they've continued to fracture. that is now available in australia. geraldine: it's quite exciting,isn't it? - there's so many options available.- that's exactly right.

- quite different from 15 years ago.- 15 years ago, we had nothing. so now let's look at a filmof a rural model of care that was trialled bythe north coast area health service. this model ensures that patientswho are seen at the local hospital for a minimal trauma fracture are given an osteoporosisrisk assessment by a nurse. this assessment,and any other test results, are then reviewed by a medical team and a referral letteris sent to the patient's gp.

cecily: every day in australia, there are a significant number of peoplewho are admitted to an acute hospital because they've had a fracture, and, whilst we're very goodat managing their fracture, we're not so goodat actually identifying that this is a flag that they may havean underlying chronic disease, which is osteoporosis. so, for these people, having a fractureis a major episode in their life. many of these people don't returnto their prior level

of independent functioning. many people do not return to being ableto live in their own residence again. and there's an increased mortalityat five years for any minimal trauma fracture. so, i just need to establishthat you've fractured your left wrist. - yes.- and how did you do that? i was at my daughter's wedding,and i fell. - ok. did you trip?- i tripped, yes. - ok, so it's just a simple fall.- and landed on my arm.

ok. so, a mechanical fall, we call that. cecily: in our model of care, it was looking atidentifying these people who have had a minimal trauma fracture, which is a fracture that results fromjust a slip, trip, or fall from a standing height or less, as that's one of the first symptomsthat occur for someone who may have a problemwith osteoporosis. so how much physical activity do you do?

- i don't do any.- ok. - is there a reason for that?- i think it's boring. (chuckles) ok. have you ever had a bone density study? - no, i haven't.- ok. that's ok. um, how much time do you spendoutside in the sun? i don't go in the sun.i've got red hair. i burn very quickly, so i just stayright out of the sun. and now we'll take some blood from you.

we'll do some blood tests. cecily: after the patienthas left hospital and gone home, then their osteoporosis risk screenthat was done is then passed through toa multidisciplinary case review session. we have specialist medical staffand nursing staff that come togetherto review that person's risk screen, to look at the pathology teststhat may have been done when the patient was in hospital, what additional tests would be indicated

and to write quite a detailed summaryof that person's risk and their recommendationsfor management back to the patient's gp. the gp does get the latestevidence-based management, so that the gp is then armed to workwith the patient on a one-to-one level to decide ongoing managementof osteoporosis. at the hospital,you did have some tests, and this has been a useful feedbackthe hospital's provided for me. whilst you were there, they measuredyour vitamin d levels,

and they were surprisingly low. woman: oh, ok. and perhaps your habitof not being in sunlight has contributedto you having low vitamin d levels. right. low vitamin d levels means thatyou'll lose more of your bone strength. i think it's important we think aboutboosting your vitamin d levels... ..and we've got an optionof giving you a catch-up dose... - ok.- ..for the first weeks,

or just starting inon a replacement dose. vitamin d also somehow helps peoplehave less falls - it seems to help the muscles and coordination and thingswork a bit better. woman: that'd be helpful. and how do you feel now aboutthe prospect of taking a tablet for many yearsto help protect your bone strength? i don't want it to happen again,so i'm prepared to do whatever it takes to stop this from happening again.

so can i make bones stronger...or just stop them from getting weaker? it's mostly about stopping themgetting weaker. we can't guarantee you'll never haveany more fragility fractures. but the good news is that,using these kinds of medicines, we can have a big impact onthe risk of you having another fracture. it's in the order of 30-50%. um, but it will involvelong-term medication use and long-term changesto some lifestyle factors. - ok.- the diet, the exercise.

perhaps checkingif there's any particular risks of tripping and fallingaround your home. maybe looking at the types of shoesyou wear would be important. getting you into an exercise activity that involves retraining and maintainingyour balance skills. all of these things will be important. ok, that sounds great. cecily: when we developedthe model of care, we were very aware of trying tokeep that as a low-cost intervention,

and we went for as low as you could goand still hopefully be effective. so the model of care costsless than $16,000 per year to run, and that was for a small increasein nursing hours of six hours a week, and the once-a-month medical specialistswho came to do the case review session. we evaluated our model of care and we found that we hadstatistically significant increases in the number of peoplewho were informed of osteoporosis and their risk of fractures, increased numberswho were on effective medications,

and increased numberswho received other interventions, such as falls prevention interventions. so, for $150 per patient, it appears that this model of carecan be very effective. hmm... very interesting, cecily. so can you tell us whythis project was undertaken? um, it was undertaken in a rural area, partly because we perceivedthat we also had a treatment gap similar to our metropolitan cousins,

but we weren't actually sure because there was no sort of studyhad been done in a rural area, and we also wanted to not just know whether or notthere was a treatment gap - we wanted to actually see whetherthere was something we could do about that treatment gap. and that was the model of care that wedeveloped to work in that rural setting where we're not going to have access to so many specialistsor specialised clinics,

and it really is the domainof the general practitioner to manage these people. and how widely employedis that model of care in australia? the model of carewas actually a funded pilot. it was successful, but, at this stage,what we're trying to do is to incorporate this model of care as one of the sort of alternatives to belooked at at a statewide level for implementation throughan osteoporosis working party

that's currently being formedin new south wales. ok. jane, a remote area nurse, asks,'a lot of patients with osteoporosis seem to also have renal impairment. what medicationsare safe for this group?' john, i think your expert viewon this might be helpful. well, i mean, for the... if we just focused, let's say,on the bisphosphonates, which are the most commonly used, unless there is pretty markedrenal impairment

to the extent that you're talking abouta degree of renal failure, um, i don't think it makesa major issue. if you're aboveabout 30 millilitres per minute gfr, it's probably not an issue. if you are concerned about it... particularly, let's say,with the bisphosphonates, half the dose is excreted in the urine. so if somebody had no renal function, you'd argue that reducing your doseby half would be reasonably safe.

having said that, if somebody hasthat degree of renal disease, then they'd probably needexpert management. i know it's not always easyin those environments, but that's the recommendation. and also, judy, i guess a pharmacistcan help with the guidance of drugs used in renal impairment, can't they? - yes, absolutely.- ok. another audience questionis michael from south australia says, 'in some groups of people, vitamin ddeficiency is a known heath problem,

such as dark-skinned people. should we be givingvitamin d supplementation even if they're not yet deficient?' do you have a view on that,john or dan? no, i think, fundamentally, we shouldn'ttreat things that aren't a problem. and until it's a problem,we shouldn't treat it. now, there's another general practicequestion, just quickly - sam from portland asks,'how often should gps follow up known osteoporotic patientsafter initiating treatment?'

so, how frequently? i'm just gonna say -dan is the one that actually does it, but what i'll say is i don't... we've already heard the issue thatcompliance long-term with treatment is not good, and that's true of everychronic condition you can think about. i don't... i think with osteoporosis, your follow-up can be talking with them,discussing how they're going, seeingwhether they're taking their drug.

i mean, that's also a follow-up. and i think if you don't do that, then you're notmanaging your patient properly. and, in some situations, a bone densityor some other types of blood tests of what's going on in the bone are helpful waysof enhancing that interaction, but i think the primary thing is for you and the patient to knowthat you think that this is important. absolutely. dan,do you have anything to add to that?

no, i see it as part and parcelof chronic disease management, which is front and centrewhat general practice does. and it's all aboutthe long-term relationship. with these people, they're quite likely to have other issuesyou're seeing them for anyway, so you'd be melding their proactive carefor their other conditions along with their osteoporosis. it could easily becomepart of a gp management plan in a team care arrangement,

and how often you see them depends onhow often they need to be seen. very much aware of the issues thatcompliance is likely to be a struggle, and that appliesnot only to the medication but to the lifestyle changes as well. we need to wrap up now, so i wonderif we could start with you, judy, on what your take-home messagemight be for our audience. oh, well, i'd like to direct tothe pharmacists out there to really be proactive aboutthinking about bone health, and to really helpin assessing compliance

with anti-osteoporotic medicationto get the most out of the medicines, 'cause they're only as good as if peoplecan take them and take them correctly, so taking them correctly is a big issuewith these agents as well. and, dan, your take-home message? there's an evidence-practice gapwhich we can pretty easily fix. geraldine: that's it? and there'sa great new guideline out to do that. there's a great new guideline.it just steps you through it. geraldine: cecily? every day, there's a large number ofpeople with minimal trauma fractures

who need to be hospitalisedto manage their fracture, and, at a local level,each of those orthopaedic centres needs to set up a local system and have designated peoplewhose job it is to pick up on osteoporosis,their risk of fractures, and make sure they get linkedto the appropriate ongoing care back in the community. geraldine: finally, john?- i think it's all been said. this is a hugely common problemin the community.

one in two older women,one in three older men, and it's a nasty condition. we should look at itas a 'malignant condition', 'cause people go on to fractureand die prematurely. we have treatments that work,we know the uptake is abominably poor, but they're things that can be done. it's a very straightforward approachin many ways, as dan has stressed. and i think if we can get peoplelooking at this guideline and saying, 'instead of ignoring it,we're gonna do something about it,'

there will be very substantialhealth benefits in the community, maybe reduction in premature mortality. and if you justonly worry about the dollars, just think - it's cost us $1 millionwhile we're talking tonight. goodness. well,important work for all of us to do. i hope you've enjoyed the programon the new osteoporosis guideline that's available on the racgp website. our thanks tothe department of health and ageing for making the program possible,

and thanks also to you for takingthe time to attend and contribute. if you're interestedin obtaining more information about the issues raised in the program, there are a numberof resources available don't forget to complete and send inyour evaluation forms to register for cpd points. and i'm geraldine moses.thank you very much and goodnight. captions bycaptioning & subtitling international funded by the australian government

department of families, housing, community servicesand indigenous affairs�

Kamis, 29 Juni 2017

osteoporosis calcium

osteoporosis calcium

hello everyone, i'mbrenda davis, co-author of "becoming vegan expressedition", with vesanto melina. and today wanna talk a little bit aboutone of the great myths about calcium. and a lot of people in ourculture believe that dairy products are absolutely essential, if people are to getenough calcium. and within the last few years, even our national food guides are recognizingthat there are other calcium sources. but it, it really defies rationality tothink that human beings would require cow's milk for their survival. in fact

if you think about it,the milk of all mammals has a lot of calcium. it doesn't make themessential foods. in fact lot of people don't know this, but moose milk and deermilk have about twice as much calcium per cup as cows milk. and yet we don't consider thoseessential foods. so it's really important for us to recognize as well that, people prior to the adventof using animals for dairy. didn't consume any dairy products andmanaged to get about 2,000 milligrams of calcium a day.

so where did it come from?well it came from plants, the very same places that we canget our calcium. and so lets just think about some of thereally important calcium sources for vegans. because, generally most of our nutrition educationmaterials, are focused on omniverse diets. and people,the main source that people are taught, are dairy products. sowhat are the alternative sources? well first of all, one of the primarysources of calcium, in a vegan diet should be dark green leafy vegetables.like kale,

napa cabbage, broccoli and other chinese greens are wonderful sourcesof calcium. it's really important to know though,that with the dark greens, some dark greens even though they containa lot of calcium. we actually can't absorb the calcium from those foods. forexample: spinach, beet greens and swiss chard, contain alot of oxalic acid. which binds to calcium, making it prettyunavailable for absorption. but the calcium inthese dark greens, that are somewhat lower in oxalic acid, or some are verylow and oxalic acid.

we absorb about 40 to 70 percent ofthe calcium from those foods. so these are really wonderful sources ofcalcium. and not only that, but they are great sources of vitamin k.which is also very important to bone health. so,what are some of the other sources? well a lot of tofu is made with calcium andso the, the, you can read the label and make sureit's made with calcium sulfate. and it usually tells you thepercent of the d.v. that you would get from a surving. so you cantake a look at that. and what you want, is you want at least 15/20/25 percent ofthe daily value.

when you're purchasing tofu. thingslike edamame and other egumes, soy beans and, and white beans, navy beans, black turtlebeans. are all relatively good sources ofcalcium. tahini and almonds, in this sort of nutand seed category are good sources. as, are some grains and most of the grains, that are a little bit richer incalcium are the pseudo grains. like quinoa and amaranth. there is a farbit, a lot of people don't realize, but an orange has 60 milligrams ofcalcium, so 2 oranges;

120 milligrams of calcium. andthat's pretty good. 5 figs has about 150 milligrams of calcium,that's pretty good. black strap molasses, 2 tablespoons providesabout the same amount of calcium as what people would getfrom a cup of cows milk. almost 300 milligrams. so again, that's a really rich source of calcium. and thenof course all the fortified foods. calcium fortified foods, like the, soy milks, ricemilk, almond milk, hemp milk. that contain added calcium, most of theseproducts contain

about the same amount ofcalcium as a cup of cows milk. about 300 milligrams. so therereally are a lot of sources of calcium, in a vegan diet. the trick is, is we'vegot to include probably at least5 or 6, or moreservings of these food a day. nice thing is, is that whenyou don't eat meat, almost everything you eat provides some calcium.so you're getting little bits throughout the day. in "bbecoming veganexpress edition", we actually have a, a chapter on minerals.where we go into a lot more depth on calcium. and all of the things you needto know about enhancing absorption of

calcium. and, and minimizing all of the things thatcan inhibit the absorption of calcium. so do check out "becoming vegan expressedition". and learn a lot more about calcium.

osteoporosis calcium supplements

osteoporosis calcium supplements

it says here, that half a million danes may need extra calcium to maintain healthy bones mom, do you take calcium? hey, i am only 48! it says here, that there could be an increased need for calcium, post menopause. for women above 50, calcium and vitamin d helps to limit bone mineral loss in the post menopausal age. low bone mineral density is a risk factor for bone fracures, in the cases of osteoporosis

osteoporosis bone disease

osteoporosis bone disease

osteoporosis bisphosphonates

osteoporosis bisphosphonates

alendronate is a prescription medication usedto treat osteoporosis and paget's disease. it is also used to prevent osteoporosis inpostmenopausal women. alendronate is in a class of medications called bisphosphonates.these work by preventing bone breakdown and by increasing bone density.alendronate comes in tablet form. it is usually taken daily or weekly, depending on the dose,on an empty stomach with a glass of water. there is also an liquid form. it is usuallytaken once weekly on an empty stomach. some common side effects are stomach pain,heartburn, and constipation. for more information on this medication and all other medications,explore the rxwiki encyclopedia on the web or on your mobile device.

osteoporosis best treatment

osteoporosis best treatment

welcome to the vitalife show i'm doctorjanine bowring and today's topic is all about the osteoporosis drugsand these are commonly prescribed drugs across north america europe and unfortunately they have somenegative consequences for your health which a lot of people don't realize andcertainly your doctor probably hasn't told you so what could these commonly prescribeddrugs do as they do build a stronger bone density so

of course they're prescribed forosteoporosis or if you've had you know bone density test and yourdoctor said that your bone density is decreasing and of course happens aswe age well the drug then are implemented andunfortunately the bad news is that it's the qualityand the type of bone that these drugs actually form so yes you are well have astronger and a better bone density so when you're furthertest and the doctor says great your bone density is increasing everything looksgood unfortunately it's the quality of boneis the issue

what happens is that because these drugsin the way that the calcium is metabolized into the bone unfortunately it forms a more brittlebone that means that you're more likely tohave a fracture, so hip fractures are definitely there's a higher incidence of themwith the prescription at these drugs and this is well documented i'm not the only one saying it so do yourresearch and you'll find the studies so

unfortunately this is what's happeningout there and you always have to educate yourself and try to do things more naturally and that's all what we'reall about here at the vitalife show is giving a natural tips how to gethealthier take care of your bones from the insideout taking right types of things and watching your diet as well so in terms of the diet you want to takehigh calcium foods so fruits and vegetablesare great because they help to keep your blood more alkaline

and you need alkaline environment so thatcalcium goes into the bones and is a protective mechanism if youhave too many acidic things on a diet unfortunately what happens is that thecalcium comes out have the bones to buffer the bloodso keep things alkaline keep things healthy if you know like your dairy productsunfortunately it's not a great way to get calcium that goesinto the bones because dairy products for the most part areacid forming so as much in as high as they are incalcium unfortunately you're not

actually absorbing that calcium wellinto the bones so that the big huge misconception out there that you're getting you know greatabsorbable osteoporosis preventing calcium from dairy products its just not true so again there arewonderful supplements and here at vitatree really we have created a whole foodcalcium supplement made from fossilized coral calcium andit's in a powder form there's no hard tablet its easy on your stomach dissolves and is absorbed very quicklyso you just mix one scoop

in a little bit of water juice justbefore bed time because calcium does going to your bones when you're sleeping and always separated from magnesium nowyou do need magnesium in your daily diet and perhaps youmay be deficient which most people are so you can supplement with a high quality magnesium that's whyhere at vitatree we supplement our vitatree magnesium in the morning and our whole food calcium at night theycompete for absorption so they should never really be in the same supplementso that's why we've done it so

differently here at vitatree and thats why we have great results and you'll absolutely love our magnesium and our whole food calcium so again i thank you for joining me todayalways do your research no matter what you're taking whether it supplementsnatural things that you're taking as well of course the drugs readall those side effects and know that there are negative consequences oftaking them and unfortunately you know not always will your doctor orpharmacist tell you these things so

always do your research be sure to subscribe to this channelwere always uploading new and exciting information about your health how to gethealthy from the inside out using natural remedies be sure to like uson facebook and follow us on twitter @vitatree and remember your health really is in yourhands you have the ability to live a very healthy and long life

Rabu, 28 Juni 2017

osteoporosis back pain

osteoporosis back pain

hey everybody it's doctor jo, and it's anatomy time. and guess what we're going to talk about the lumbar spine today. let's get started. so the folks at gpi anatomicals were very nice, and they sent me some of their models. this is a normal spine. so i'm just going to show you some pieces here so you can see what i'm talking about. and if you look at, it it looks nice and

healthy, the bone looks smooth all the way around. your disk and here is nice and circular. the nucleus pulposus is in there, and that's kind of that squishy part of the spine, and when it's not doing well it bulges out. here is your nervous system, your central, your central nervous system, and then these are the nerves that come out. so if

they were here, those would be the ones going out to my legs. and then you've got your spinous process in the back. and so you can see here there's lots of nice space so it's not pushing on the nerves it's not pushing on the nerves going out here. you can see maybe the little bumps here. those are the nerve roots, and so a lot of times if you have the radiculopathy,

that's where the nerve root is inflammed because something is pushing on it here, and it's shooting out that pain to your leg or if it's in cervical spine out to your arms. so as you can see these these all look good. this is how it's supposed to look, but unfortunately even at an early age, we start degenerating and changing and things start happening

over time. so then the next one over would be here. and so you can see a little bit of changes up on top. it shows you a herniated disc where is just bulging a little bit, it's not actually ruptured and pushing all the way through, but it's going to start putting a little pressure there. now a lot of times for the herniated disc,

you're not going to have any symptoms because it's not quite pushing on the spine, but what might happen is you might bend over to lift something up and it puts just enough pressure just to give that twinge where you're like "oh my goodness," but it's not a constant kind of pain yet. you can also see here where it might start pushing out and irritating

that nerve and nerve root a little bit, so at some point when it's bulging if it's big enough, it might start giving some pain going out there. and so you can you see that there's just a minor changes here at the bone some degeneration and stuff, and so that's when it's not terrible a lot of us after the age of 25 - 30 start having these changes, but we

just don't have any symptoms until we have either something that triggers it or we twist the wrong way and it just hits that spot. so then after that it starts getting a little bit worse as we age some more or maybe we do actually have an injury. and then you can see here where the disc is actually ruptured through. and this is when it starts to

get to that point where you might have your leg feeling like it's constantly asleep because it's pushing on that nerve here, or it's pushing out at the at the sides here and then is you just feel that burning feeling, that sharp pain, pins and needles. a lot of times people say it feels like their foot's going to sleep, but the scary part when it's pushing

on the nerves is that nerve is not getting that signal to the muscles like it's supposed to. so then a lot of times when your brain says "lift your toes up because i'm walking," it's delayed because it's not going like it's supposed to, and you go to step and you catch your toes and you stumble down. so that's when it

becomes a scary issue and you really need to go to your doctor, go to your physical therapist and figure out what you can do to start getting that better. and you can even see here on the bone like something right there would be a bone spur and those can cause a lot of pain and irritation especially if they're over around where those nerve roots are

coming out. so you can and you can even see right here where the disc itself is getting smaller because you're just degenerating and it's pushing down and causing pressure. and when the disc gets smaller the space out here, then it becomes a spinal stenosis issue where that it's the narrowing and then that actually narrowing of the bone

is pushing out on those nerves, and so that's why then people start bending over more because it opens up those spaces to take some pressure off of it. and then you have here the the really scary one that you don't really want to see, and this is when it becomes where it's a full stage osteoporosis. and you can see here you can you can barely see

the disk space in between here because everything's just kind of collapsed. there's not even really the nucleus pulposus in there, and so that's when everything is generated, people are really really bent over trying to get that pressure off of it, or they just don't have the stability of the spine anymore and it just starts degenerating away. and

that's when it becomes really scary because as it goes down it pushes on all those nerves and then things stopped working how they're supposed to. so that just kind of shows you, you can see right there that that disk has been pushed all the way out into the nerve. and so that's that's when it becomes very tough, but the thing is it's not a

"okay i have to get up and sit down and not get up anymore and do anything," because with exercises with stretches with the right kind of therapy, you can do those kind of things and actually exercising helps this. so go talk to your doctor go talk to your physical therapist, find out what you need to do, so you don't have to just sit down and

not have a quality of life anymore. so there you got have it their all of them here. if you have any questions leave them in the comments section. if you like check out some other videos go to askdoctorjo.com and remember be safe (take care of your spine), have fun, and i hope you feel better soon.

osteoporosis arthritis

osteoporosis arthritis

yes, you've heard right, gelatine, but make sure it's beef gelatine add a small cup of water (coffee cup size ) two teaspoons of gelatine (aprox 5 grams) squeeze few drops of lemon juice ( it will make it less disgusting for some of you ) leave it overnight you should repeat this treatment twice a year , for 30 days each time for best results

osteoporosis and treatment

osteoporosis and treatment

john: alright, this is john kohler with okraw.comand this episode is actually interview my friend, cecilia star, who i actually met ata woodstock fruit festival, and she got into a health journey about six years ago and startedeating a plant-based, fruit and vegetable-centric, raw food diet about three years ago. and thereason why i wanna have her on is because she healed even, you know, at a much moremature age several different diseases that were ailing her, you know, by literally justchanging her diet. and also to show you guys that it’s never too late to start, if you’rehaving problems, because you literally – the old adage holds true, you are what you eat,and absorb! because if your digestives is not working, you’re not gonna absorb it.so let’s hear from cecilia, a little bit

about her journey. so, cecilia, why did youchange your diet even after being, you know, what, over 65 at that point? cecilia: yeah, i was way over 65 when i startedmy journey. cause i’m 73 now, and so i started it ‘cause i was working, i had so much arthritisin my hands, in my feet, in the back of my neck, it would just burn. and in my field,i needed to have my hands, cause i’m a hairdresser, so i need to feel good and stand on my feetall day long, and so that’s why i decided to look into being a vegetarian, and thena vegan, and after a vegan to a raw vegan. and that’s when i went online to look upjames colburn’s arthritis shot years ago on larry king live, i heard him and i rememberedthat. and so i went online, looked it up,

and it was a vegetarian diet. and so i decidedto give it a try. and that really, really, really helped. when i did that, it didn’ttake long. and my arthritis in my hands and my thumbs and the joints just hurt so bad,and in my feet, that i – and i had cramps and i had the pains in my big toe, and those– i had varicose veins, a lot of things going on. plus i was dealing with the lastfifty years’ worth of yeast overgrowth from too many antibiotics. and with this…andthat is cleared up now, since i switched my diet. which is great. i’m happy about that. john: wow. so yeah, just by simply changingyour diet, you know, your body will allow itself to heal. so what is your, cecilia,how did going from the vegetarian to the vegan

to the raw vegan, did you see incrementalimprovements all during that time, or why did you finally end up going raw vegan? cecilia: well, that’s a good question. iswitched to being a vegetarian and then to a vegan, and then i used to do some cookedfood, and so then i went on a vacation, and i was online, and i was looking for…andi went down to costa rica to the farm of life down there, not knowing that they were a rawvegan type of group place there, and it was wonderful. i had the time of my life. thatwas the best trip i’ve ever taken. it was emotional, it was spiritual, it was healing,it was fun, it was active, ‘cause i like to be active, we went ziplining, we went hiking,we jumped off cliffs, off of waterfalls, went

swimming, and it was just a wonderful, wonderfultime. and that’s when – and most of those people from there except for me was all fromthe woodstock fruit festival in new york. so i came home and i decided i was gonna lookup, the next year, i went to the woodstock fruit festival. and that’s where my journeyjust keeps evolving and going as time goes on, and as i’m growing and getting intoit. so, that’s my story. john: wow. yeah, that’s totally amazing,i mean, in hawaii woodstock, you know cecelia would go on hikes with us and she would keepup with the kids half her age, just about, man. cecilia: and skydiving, also.

john: yeah, she sky — she’s crazy, man!but yeah, these foods, they keep you young, that’s how i’ve – i’ve been doingthis for 20 years, and most people think i’m about ten years younger than i actually am.you know, i’m young at heart, i don’t know if it’s because of my diet or becausei’m just that way, and cecilia’s the same way, she plays tennis three times a week,still has a full-time job, she’s working and does her gardening and all kinds of otherstuff, so if you wanna see her garden, be sure to check my other youtube channel, growingyourdreams.com,actually, there’s a really good piece and episode on cecilia with her garden, becausegrowing her own food is very important. let’s talk about that, how important it is growingyour own food and what differences have you

stopped or started growing and incorporatingsome of that food you grew into your diet. cecilia: well, to me it’s very importantto get the vegetables as fast as you can, eating them, so you get all the nutrients.cause once it’s been picked, you don’t know how long it’s been in the grocery stores,and then it loses nutrients the longer it’s been cut. so when you can grow your own andyou can go right outside and i just love it! i can go every morning right out to my owngarden, ten feet away or less, and come in and pick it and wash it and put it in my smoothieor juice it and i just feel the energy, and that’s what i look at the food when i buyit – is that leaf nice and strong or is it weak and limp? how much energy does thathave? cause if it’s a strong leaf and it’s

not weak and limp, it’s got a lot of energyin it. well, that energy goes into my body, then, and that gives me energy to sustainmy life. so to me it is really 100% important to me that i have as fresh as possible. andorganic, ‘cause i’m growing organic everything, thanks to john kohler and people like him,that i can help me with the knowledge on how to do that, ‘cause i knew nothing, i neverthought sixty years ago or even twenty years that i’d be on this life journey. and ijust so enjoy it so much. john: that’s awesome, yeah, i mean one ofthe things that’s really important to me also that i sense with the food is the lifeforce energy in the food, whether you wanna call it prana, chi, or biophoton, this issomething that science hasn’t really researched

yet. but, you know, in my opinion, life begetslife, and we wanna eat foods as fresh as possible, because not only do they have the life forceenergy, but they have more phytonutrients and phytochemicals as well, which i have identifiedas some of the most important nutrients in the food. now, i know you play tennis andyou do skydiving and you— cecilia: skydiving, hiking and— john: yeah, hiking and— cecilia: this morning in the rain! three miles! john: you jump off cliffs, aren’t you scaredabout breaking some bones? and didn’t you have, like, osteoporosis, and how has theraw diet, and the fruit and vegetable diet

affected that? cecilia: well, also i like doing herbs, ireally believe in the power of herbs, so i make my own little herb concoctions here anddo that with the food, so – that’s what i think that’s important to me, so. john: and how ‘bout – you had osteoporosis,or— cecilia: i did, i had osteoporosis, whichi reversed and i’ve got proof of that. that because they do the bone tests, and the bonescans with that all the time, i’ve had for years, and the other reason why it’s reallyimportant to me to eat healthy is because i come from a large family and my father diedof colon cancer, a brother died of colon cancer,

a sister died of colon cancer, and i’vegot a lot of cancer in my family, and i know one to believe i don’t wanna wait till iget it before i start doing something and changing my diet. i’m into preventing, tomake prevention is, you know, i don’t wanna go to the doctor, doctors don’t make youwell, your body has the power to heal itself. and i’m not short of drugs, but i may beshort of greens and fruits. and so as much as that stuff that i can get into me, thebetter. and juicing – i can juice so much more greens than i could possibly eat if itried just eating it or having a sandwich with a little piece of lettuce or one sliceof tomato on it, when i could eat a whole box of tomatoes or a whole deal of celery,a whole stalk of celery, i could juice all

that and drink it at one time. that’s whati feel the body needs and it’s gonna regenerate, ‘cause the body has the power to regenerateitself if you give it the right foods and the right exercise and a spiritual as well– that’s why i like to pray, i don’t…i like to go out to the ocean, to the beach,walk on the beach, sit on the sand, or go hiking in the woods, be with nature. to me,that’s what god made and the sun, that’s – the sun has the power to heal. and that’swhy it’s so important to be in the sun, and everybody today wants to hide away, everyone’sin the house all the time, and that’s why i try to go outside and do as many fun thingsas i can. john: wow, yeah, i mean she had so many importantparts and points to make in just that little

section, but one of the most important tome is because i come from a situation where i almost lost my life and the doctors didn’thave a heal or couldn’t cure me, you know, when i was in my health crisis, you know,i came out and was a lot more serious about my health and that’s why i focus on a certainspecific kind of raw food diet. i mean, a raw food diet, much like a vegan diet, couldbe healthy or unhealthy, there’s plenty of junk food vegans that could have oreo cookiesand coke, i mean, those are vegan foods, but they’re not healthy foods in my opinion,so you need to be more than just vegan or more than just raw, you need to eat a healthydiet. so a healthy diet to me is— cecilia: fresh.

john: yeah, fresh! foods that you could growyourself, fresh fruits and fresh vegetables, that should be the center of your diet andyou should focus on these foods the most. trying to eat the minimal amount of calorieswhile still maintaining and meeting your caloric needs, but by eating tons of different phytonutrientsand phytochemicals, these are the disease protective properties of a plant that people– and some people, even on a raw food diet, are just not getting because they’re eatinghigh-calorie raw foods like too many nuts and seeds, and too many bananas or high-caloriefruit, dates, or fried fruits and whatnot. cecilia: processed, boxed vegan foods-- john: yeah, boxed, you know, kale chips andall these things. we need to really eat vegetables,

lots of vegetables, leafy greens, and thefruits. so let’s talk about this, cecilia, what’s your daily diet like, on a daily– i mean, you’re a small lady, so you probably don’t eat a ton of food, like asmuch as i do, but you know, what do you have to let people know, like if they’re older,you know, in their senior years, what they might wanna start with or what they mightwanna do if they wanna do something like you’re doing? cecilia: probably the best way to – i tellmy friends who listen to me and what i do is start with smoothies. smoothies are reallyeasy to make, everybody has a blender at home, that’s all you need is a blender to do thatwith, and you can add apples to it, cucumbers,

and i was asked this morning, cause the girlsi was hiking with asked me, “well, what do you do for a treat for yourself?” andi said, well, i make a really good smoothie out of bananas – a frozen banana, and somealmond milk, and i put a little ginger in there, and little turmeric root, both of thoseare fresh roots that i use, and you could put a little vanilla in there and blend thatup and it’s like heaven! ice cream! especially with the frozen banana in there and a littlebit of almond milk, and you could even put some cinnamon in it, there’s all differentkinds of things you can do, but mostly, every single morning, i make either i juice my greensor i make a smoothie with my greens, and i use cucumber, sometimes i put a carrot init, and i always use celery and cucumber – and

a green apple in there, and then i put – itry to every day, use a different green, so i can rotate my greens, i don’t eat the same greenevery day, one day i’ll have two bunches of swiss chard in there, what you buy in thegrocery store that they’re all twisted up in the twister, i’ll put two of those packagesin there that day with the whole cucumber, about a half a stalk of celery and green apple,and i take it to work with me or take it to the tennis courts, and oh my god, you shouldsee what the girls say at the tennis club when i come with my green drinks there, andi’m drinking that on the court, and they’re all, “what are you drinking?” and it’sreally funny. and i enjoy it, so. and i know what its benefit it’s doing me, so that’swhy it doesn’t bother me what other people

say about it, because i can feel the difference.and that’s what my morning is, and then in the evening, i’ll either make anothersmoothie or i’ll make a salad, something to that effect. john: awesome, yeah, so i mean it is reallysimple and easy to eat healthy. right? just smoothies or juices, salads, just increasethe volume of the fresh fruits and vegetables you eat. so now that you guys learn what ceciliaeats, i’m gonna ask her just the final question today, so do you have any hints or tips forpeople out there that are maybe not yet eating copious amounts of fruits and vegetables thatyou’d like to give them that you learned over your journey into health and gettingrid of your arthritis and osteoporosis and

controlling your yeast infections and whatnot? cecilia: start out slow. when i first started,i kept going back to cooked foods, or i would go back to a salmon or a fish or whatever,but then i just slowly weaned myself up. it’s really hard to stop and do it at the pointwhere i am today, i could never have done this six or seven years ago, all at once.so the point is start slow, but steady. and when you make a mistake and you eat a sandwichor bread or you go out one time with your friends, just get right back into it. getback into it, and it gets easier as it goes. and then you learn more, and you talk to otherpeople, like my friend john here who has taught me so much, and i’m watching how he’scooking his – or how he’s fixing his foods

and stuff, and preparing it. so that’s howi learned, from other people, how they do them. but best tip is to go slow and do itin degrees, different degrees. just get a little better and a little better and a littlebetter each time, and six years later, now, it just comes easy and natural to me, andi have no desire to ever go back to eating any kind of animal, they say, “don’t youeat eggs?” and i said no; “dairy?” – to me, dairy is the worst thing you can eat.cause i was so full of mucus in the head, i had tetanus in the ears, my hearing hasgotten better, my eyesight’s gotten better, but the ears, the hearing has gotten a wholelot better. i was gonna go deaf, like most of my clients now, they’re all on hearingaids, men and women. dairy products really

fill our heads with a lot of mucus, and that’swhat caused a lot of headaches, hearing loss, sinus infections. so it’s really importantto try to wean yourself off of the dairy products, and that includes yogurt as well, ice cream,everybody says, “well, yogurt’s supposed to be so good for you,” but it still comesfrom an animal. all the stuff, we forget where the food is coming from, the butter and theyogurt and the ice cream and the cheese, nobody ever thinks where cheese comes from. and so,you just gotta go slow, wean yourself off of it, and you’ll eventually get there. john: yeah. wow, that’s one of the thingsi like to say, by the inch, it’s a cinch, by the yard, it’s hard. start off slow andsteady, you know, just start by changing your

breakfast. and yeah, keep your same lunchand dinner, but at your lunch and dinner, have more fruits and vegetables, so have anextra piece of fruit or two or three at lunch, and have an extra salad or side salad at dinner,and slowly but surely, you know, make the fruit meals a bigger part of your lunch, andmake, whatever, your sandwich smaller. and same with your dinner, make your salads biggerand make your chicken smaller and smaller. and of course, always the breakfast, the besttime to have the raw foods, in my opinion, you know, fresh juices, green juices likei had this morning or fresh fruits or blended smoothies. definitely the best, so yes. i’mglad to have met and know cecilia, she’s doing an amazing job, hopefully she’s motivatedsome of you guys and she’s having her own

successes with her health, and are you beatingyour other peers at tennis and stuff, you can kick their ass ‘cause you’re on ahealthier diet and you have more energy, more vivacious, and quicker reflexes! cecilia: yeah. these kids i play tennis with,believe it or not, are half my age. most of them are either half my age or could be mygrandkids, but i’m playing tennis with and beating them. so my kids get a big kick outof that, they tell everybody that, and they’ve seen me play tennis and they know i play withpeople that are half my age, ‘cause i’m one of the oldest ones on my tennis club thati belong to, and i’m on the team with. and people, they can’t believe, when they’retalking about their kids and then i talk about

mine and they can’t believe i’ve got kidsas old as i have. so. but i do. i love them. john: yeah, you wanna kick ass at tennis,kick ass at life, kick ass at mma or whatever, go plant-based, vegan, fruit and vegetable-centric,man. you’re gonna kick ass just like my friend cecilia here. so hopefully this hasmotivated you just a little bit to include more fresh fruits and vegetables in your diet,if it did, hey, please give me a thumbs up to let me know, i’ll be back to visit cecilianext time i’m in the area, and interview her some more, and share some more words ofwisdom with you guys. also, be sure to check my pass episodes, i have four episodes now,that share with you guys all the different ways to actually incorporate and do raw foods,fruit and vegetable diet, the best way including

ways to save money, all the things to lookout for, the pitfalls and caveats, and be sure to click that subscribe button rightdown below, i have videos coming out about every five to seven days on this channel,you know, with new information that’ll only enhance and encourage you guys to eat morefresh fruits and vegetables, ‘cause that’s what i’m all about. hope you guys enjoyedthis episode, once again, my name is john kohler with okraw.com, we’ll see you nexttime and until then remember: keep eating your fresh fruits and vegetables, they’realways the best.