Kamis, 31 Agustus 2017

strontium osteoporosis

strontium osteoporosis

the most effective shoulder specialists inchicago almost always propose the process in the event the soreness on the individualsshoulder is presently not tolerable and cannot be alleviated with other procedures.a large percentage of osteopathic shoulder surgeons advise joint replacement surgicaltreatment when the ache is a lot to deal with, and the upper arm can't work the way it shouldreally, and drugs that are supposed to relieve the discomfort are by now useless.firstly, the physician will be sure that the discomfort inside the shoulder is not owingto broken bones and cartilage material together with the support of further study.from time to time, an individual could truly feel ache close to the shoulders caused bya specific affliction or disorder.

shoulder repair specialists in chicago normallysee to it they have examined everything cautiously before proposing the procedure.after a while, the joints from the shoulder may become decayed or harmed which can induceserious ache to the owner. inside the process, the shoulder's joint isnormally swapped which has a metal implant as well as the entrance or even the glenoidis substituted for a plastic-type material cup that is spherical and supple that mustcompletely fit the head within the ball. this sort of arthroscopic surgical procedurerepairs shoulder in less surgical process and surgeons can deal with rotator cuff tears,labral tears, shoulder dislocations, proximal biceps pathology and ac joint arthritis especiallywithout difficulty and appropriate treatment.

quite a lot of research, trends and advancementshave been created to produce surgical treatment significantly less intrusive by sophisticatedarthroscopic techniques. with the entire outcome the arthroscopy surgicalprocedure has become the best chosen possibility each by people at the same time as surgeonsto treat restorations of rotator cuffs and misaligned shoulders.above the time scientists have created enhanced gadgets for outdated procedures.now you can get substantial tech anchors, better sutures and advanced equipment forengaging in shoulder treatments. this refinement of traditional trends in thefield with finest techniques currently available has provided relief the two for the orthopedicsurgeons at the same time as to the individuals

undertaking surgeries.together with the growth of more powerful stitches and disappearing anchor bolts theactivation of bone construction is now possible. the surgeons can now restore the shouldertears through two or 3 tiny tears as towards the outdated method of post comorbidity, lengthyhospital stay and more rehabilitation of sufferers. as against the complete substitute of shoulderfor youthful sufferers the scientists have refined a process for bone efficiency clinically,in osteoporosis people the top shoulder operating doctors take out the rheumatoid arthritisand after that cap it without any unsettling of the canal.one can find neurological therapies like the utilization of stem cells, platelet fortifiedplasma shots which has obtained a good deal

approval among pro athletes in any respectrange. this type of surgery demands knowledge andexpertise which could be carried out only with the finest shoulder operating specialistsreadily available in the chicago area.

strontium for osteoporosis

strontium for osteoporosis

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�

strontium citrate osteoporosis

strontium citrate osteoporosis

tips to prevent & reverse osteoporosis how to reverse osteoporosis

strontium and osteoporosis

strontium and osteoporosis

if you’re female between the ages of forty-fiveto fifty five you’re probably moving through menopause. you know the signs – weight gain,moodiness, trouble focusing, less hair on your head and more on your face, hot flashesand night sweats.â  â decrease in circulation of estrogen also puts you at a higher risk of bone loss and heartdisease. â there is good news though.â  while menopause is a hormonal transition it’s only temporary.â but that’s no consolation when you’re soaking your pajamas!â â  hormone replacement therapy (or hrt) is out- due to its contribution to risk of breast

cancer, stroke and heart disease, and dementia.in are natural solutions that are safe and effective.â  weight bearing exercise and supplemental calciumis essential for attaining peak bone mass and preventing postmenopausal osteoporosis.â adequate vitamin d intake along with magnesium, boron, strontium, and manganese is requiredfor optimal calcium absorption.â  â kale is really popular because it keeps your bones strong. so eat lots of it and its greenleafy cousins. â natural products like valerian or hops have been shown to help you sleep better and lackof energy can be supported with the herb rhodiola.

but the number one challenge during menopauseis the dreaded hot flashes!â  â sage in supplement form contains compounds that have been clinically proven to reducethe instances of night sweats and hot flashes after just two weeks. and, here’s an importanta tip… ensure your supplemental sage is a fresh, organic, gmo free!â  menopause is a rite of passage, not a disease,so don’t sweat it! â i’m bryce wylde …and, now… you’re healthier!â 

stages of osteoporosis

stages of osteoporosis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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