[ MUSIC PLAYING] Let’s is starting. Welcome, everyone, to Good Bones– Building a HealthySkeletal System. My name is Claudia Zurlini, and I’m a Senior Coordinator with the Public and PatientEducation Department at Hospital for Special Surgery. We host a variety ofprograms, like the webinar you’re attending today, inaddition to our virtual world-class and shops. Today we have joiningus Deb McInerney, who is a clinicalnutritionist at HSS, and Jae Eun Yoo who’s a nursepractitioner now at HSS as well. We’re so glad to have you now. Thank you for affiliating us. Thank you. My pleasure. Great. So I’d like to juststart out real general. When we think aboutbone health, why should we be concernedabout our bone health? So bones are really importantbecause, clearly, it’s our skeletal system.But poor bone health canreally lead to fractures, and ruptures can reallyaffect their own lives overall, and your quality of life. And so it can lead todecreased mobility, anguish, sometimes feeling, becauseof the loss of the quality of life– hospitalizations ifyou need any kind of surgical involvement, even, for any of those faultings. So that’s I’ve been focusedfor 18 times about bone health. Wow. So I’ve been working intrauma orthopedic service and metabolic bonedisease at HHS since 2018 with Dr. Joseph Lane. So I’ve been learning that, specially like a hip fracture patient, when youhave a hip fracture there is a mortality upto 20% within a year. Likewise, even within a few years, some people cannot get out of bed anymore. They’re life character is so poor. So Dr. Lane and I thinkit is really important to prevent the big-hearted faultings, rather than simply antidote their issues after it happens. Perfectly. And I think we’re going to talka little bit about avoidance later on.So when we think aboutlow bone density, what are the greatestrisk factors, and who is at riskfor poor bone health? I can’t picture a person. Postmenopausal womenmore than 50 years old with a thin, skinny, or low-toned BMI– Body Mass Index. Maybe Deb can explain more. Also if your mom had aosteoporosis or crackings, then I think that is key. If you are a heavysmoker or heavy drinker, could be a high risk factor. How about– Well I– Oh sorry. I was going to ask if thereare any drugs that could potentially increase your risk? Yes. We do ensure a lot ofpatients who have been using a steroid becauseof their medical mode. They have a high risk forthe osteoporosis also. The interesting thing toois, even though you might have a geneticpredisposition, you might be female, youmight be postmenopausal– kind of, as you lead up tothat, if you think about– so what we consider peakbone mass age– meaning the age at which you cantake in, and build very good, strongest bone is around 30, 35. So should be going beforethat, when I view adolescents, one of the questions I alwaysask is, do you imbibe milk? Because one of the things– I am Asian. If you come from Asia, Africa, almost anywhere other than the United Nation, people didn’t drink milk, or weren’t so focused on beingmade to drink milk as a kid. So if you’re notdrinking milk, you’re not getting– it’s the best sortof dietary generator of calcium. So if you have not laiddown the groundwork– calcium is the largestmineral in the body, so if you’ve not really beenlaying down that groundwork.The other thing is, for bone concentration, weight accepting activity. So if you were a very sedentaryperson for whatever reason, whether it’s from pain, or bedrest from whatever it may be. The other thing is tobacco. Tobacco use is a huge, gigantic, gigantic determining factor for bad bone health, because you can really leach bone if you’re anexcessive smoker or using chewing tobacco. And so the other littlesidebar is, sometimes an undue amountof booze consumption can also be associatedwith bone health, predominantly for beings that aremore, truly, alcoholic. Because if parties aredrinking too much alcohol, they’re probably not focused ongetting all the good nutrients that you need just for generalhealth, let alone bone health.So it’s really broadspectrum, the risks. Absolutely. And Deb, you mentionedleeching bone. Can you describe that a littlebit, and what that wants? So leaching bone is kind ofwhat it’s– so, calcium being the largest mineral in the body, and if you were trying to build the best, strongest bone, up until about 30, 35, there are things that can causea whole number of things that can actually causeyou to leach bone, or lose bone mineralization. So if your whole– we try to get teenagers, then young adults, to really sort of construct thebest, strongest bone matrix, so that your boneslook like, if you had an X-ray, sort of likethis nice, webby mixture.And people that leach bone, or have bone loss over meter, it inspects more sparse, and likea little bit more Swiss-cheesy than we want it to look. So that’s whatleaching various kinds of implies. Even though welove Swiss cheese. Right. And it’s lactosefree, mostly. So how common isosteoporosis and osteopenia? And maybe, Jae, if you could speak to the differences a littlebit, that would be great. The differences betweenosteoporosis and osteopenia we can define by lookingat the bone density experiment, looking at the numberswe call T tally. If the T score isless than minus 2.5, then we define as osteoporosis. If the T score is betweenminus 2.5 and 1.0, we call it osteopenia, whichis borderline osteoporosis– on the way, the kind ofprocess to the osteoporosis. I have just readsome data that said 10 million Americanpeople have osteoporosis more than 50 years old.I ponder 50% of post-menopausalwomen have osteoporosis. Surprisingly, 20% ofmales have osteoporosis. Maybe Deb has moredetailed numbers. Well no, only from the NationalOsteoporosis Foundation, they estimate that over5 0 million Americans have osteoporosis. So it might not be resultingin a lot of hip ruptures, but it might be awrist fracture, a rib fracture, clavicle cracking. Ruptures that might not happenif you had better bone caliber, but are happening if you slipand come, and try to bear– break your transgression with your wrist.That’s a very commonosteoporotic fracture. So are there common warningsigns of osteoporosis, or do I have to wait untilI get a fracture to know that I have osteoporosis? The most common signfor the osteoporosis, we just mentioned crackings. You definitelyneed to investigate why you get faultings. Even though it’s nota major faulting, even though it’s justwrist fracture– oh, I simply had a big accident. I don’t think Ihave osteoporosis. That’s not a good statu. You have to check it out. Too, if you like shrivel morethan 2 inches within a year– like a loss of height– that’s a big sign forpossible osteoporosis. It’s really a silent sicknes, soyou cannot tell until you have those kind of changes.Would there be anyreason, perhaps, that someone would seekout an osteoporosis diagnosis without a faulting, or without the risk factors? Could be. Yes. So we often, ifyou have menopause, then it’s like wedo the mammogram with regular check-upsafter a certain age. We should do the wholebone density as a baseline when you have menopause. Because you do not have anyprotection for your bone state when you do have menopause. There’s no hormoneYou time start to lose the bone dramatically. So you definitelyhave to check it out. All claim. That’s a good point. And is it simply one typeof bone density scan that can diagnoseosteoporosis, or are there different kinds of tests? The bone concentration assessment isjust, like I say, one kind.But they have different machinesfrom different manufacturers. So when you repeatthe bone density, it is better to go backto the same machine, or the same place, becauseit’s hard to compare when you reform the machinein different places. So that, I can recommend. That’s a reallygood tip-off, actually. It’s like apply the same scale. You always want to use the samescale , not different flakes. Right. Right. Or no proportion at all. Exactly. So now I’d like to talklittle bit about rehearsal, because we knowhow important this is in promoting bone health. So what kind ofexercises should we be doing to build thebest bones that we can? We generally recommend likea heavines bearing exercising, the best exercisefor osteoporosis– like moving, canting, a little bit of value bearingwith like, dancing. But the most important thing is, you have to enjoy the exercising and you can continue asa lifestyle everyday. But you are able to avoided likevery impactful workout. oh, I took thiscourse today, I have to start activity tomorrow. All of a sudden, yourun like 20 miles a daytime, you might be injuring yourself.So you have to reallystart exercise gradually, slowly, watchingout for yourself, to prevent another faulting. Right. Like one of thesurgeons that I work with, at one of theclinics here, she says, you don’t start exercisingto get into shape. You have to do things. You can’t just go outof the gate, you are familiar with, like you’re a racehorse. But it is full body– I meditate parties thinkweight allowing and moving. I entail, people haveheard this for decades– walking is one ofthe best works. I like to say acts, merely because practise, the hour you almost said today, parties are like ugh, exercise.Like I have to goto a gym, or– well, if anyone’s ableto go to a gym now. But you know, you can justget outside, accompany anywhere. Walk inside your home ifit’s inclement weather. It’s one of the easiest things. And the low impactfor a lot of people that I construe withsevere osteoporosis is advisable to things like moreelliptical, or low impact.If you’re walking, going on a treadmill, because then there are disallows, if you lose your balance, to hold on to, asopposed to being outside. So like a stair, or stepper machine, that’s another low impact one. But if beings havebalance matters, Tai Chi is a great activity, genuinely to help with balance. And even yard creation, for thoseof you who live in an area that you have a yard. You know, some heavyyard piece and hoisting, that sort of stuff, it sortof is helpful for bones, but it’s helpful for the musclesthat are really surrounding and protecting your bones. So it’s not just the activity. It’s sort of theactivity, but the type of activity, oractivities, certainly, that you’re participating in.Absolutely. Now it’s a greattime to rake leaves. Yeah. A good act. Are there any activitiespeople with low bone density or osteoporosis should eschew? We usuallyrecommend– I entail, it depends on the bonedensity lists or the orientation ofthe low-toned bone concentration. For example, if a patienthas really low-pitched bone concentration in the prickle, withother back concerns, we do not recommendany[ INAUDIBLE ],, or like, spin of the back. Kind of like, golfingis not a good alternative for that population. Right. Certain positions from theyoga class , not a good mind. So we have to treatindividuals a different way, based on their test resultsand their clinical data. Right. Right. Because severe, you wantto avoid the most risky.And that would be likebending, changing, jump-start. So whether it’s running, orjumping rope– a lot of people hop rope. And if you have severeosteoporosis, that’s definitely something you want to avoid. So that would alsobe a good time to maybe follow up witha physical therapist, or an exercisephysiologist– someone who can help you through that. For safe activities.Also being careful inclasses like yoga or Pilates, and really know whatyou can and can’t do. Yes, absolutely. So we talked a littlebit about employ. And now Deb, I’d love todive into your knowledge now on healthy dietsto promote bone health. So what kind of foodshave– what kind of vitamins and minerals do I needto build healthful bones, and how can I get there? So I know, Claudia, you know this, because we’ve donethis a bunch of experiences. But it is necessary to every nutrient. There is not a nutrient onthe planet that appears in our menu that you don’t need. So I think over theyears, beings is truly kind of focused on– and I evensee it when I realise outpatients. Parties come in, and theyhave lost the diet variety because they knowcalcium is important, and they know vitaminD is important, and they’re havingdairy three times a day but like , no vegetables. Because you know, it doesn’t really fit in with eatingyogurt, or having cereal, or milk, or whatever. So any sort of– nomatter the condition , no matter the nutrientsthat you might make sure you wantto get enough of, you still need to roughlyeat from all the food groups if you can tolerate it.Your returns, yourvegetables, your grain, your proteins– whetherit’s meat, fish, chicken. You know, then there’sbeans, the legumes– beans, nuts, that sort of thing. Dairy represents a huge role. So truly, it’s no longerfood guide pyramid. I can’t believe I wasgoing to say that. It’s like a clock dish. And mostly, the platehas a room for– ideally, a snack should have aprotein, vegetable, a complex carbohydratelike a speck, and then have alittle side of dairy, and you might have a fruit. No one is eating thatway, realistically– I get that. So you really want tojust try to do the very best. Unfortunately, yourcalcium– the highest, naturally rich calciumfoods are your dairy menus. So I’ve been accused over theyears of being a dairy pusher. And I’m like, I am no waysaying that you need to. I am telling you thefoods that have “the worlds largest”. But now, so many peopleare using these cow’s milk alternatives.And so some of thebrands are truly what I considerhyper-fortified, because they have 50% more calcium perserving than cow’s milk has. So wishes to time tryto be a smart consumer. And if you’re not reallyalready aware of everything you’re frame inyour torso, “youve been” might want to startreading food names. The nutrient names are basedon– it’s like my biggest thing in terms of calcium. Because the food label, it’s a USDA mandate that it has calciumin percentage points. The percentage on the food labelis based on 1,000 milligram. So milk would be– no matter thetype of milk, if it’s glide, 1 %, 2 %, or whole– it’ll say 30%, whichmeans 300 milligrams. It’s sort of lazymath– you kept a 0 where the percentage sign is. And a lot of people, if you various kinds of do a little of fooddiary, or kind of keep track for a fewdays, sort of how you’re eating, whatyou’re consuming, to see sort of how wellbalanced your nutrition is.Because any diet– youmight have a diet very rich in calcium, but itdoesn’t necessarily– it’s not going toimprove your bone health. That I want to be clearon, because a lot of people that I construe will say, you know, I want to increase my calcium intaketo improve my bone concentration. And I’m like, itdoesn’t work that way. You need that amount tohelp prevent further loss, then there’s the whole partof the medication role.But the calciumspecifically, the needs are based on senilities, gender, andfor women, sort of life cycle, where you are– pre-partum, post-partum, premenopausal, postmenopausal. For men, it’s alittle different, but we know basedon sort of where you are in life, how muchcalcium is recommended. And then if you havea fracture, your needs go up a little bit afterto hopefully remineralize that bone.Vitamin D worksvery differently, and vitamin D is oneof the other things that I would say, fiveyears ago, kind of came out as the nutrientthat everyone focused on. And then everyoneforgot about calcium– and some doctorsincluded, that I’ve seen. And I’m like no– you need both of them. So vitamin D isdifferent because it is a fat soluble vitamin, and a lot of people remember that youwill hold onto it, unlike vitamin C or B. That youdon’t want to take too much. But we don’t really seevitamin toxicity in vitamin D because most peopleare deficient. And so even though it isthe “sunshine vitamin, ” most people are not–especially during COVID– most people weren’t outsideso much, or are outside during summer, heated months, to get enough vitamin D from sunlight revelation. Because most people don’t wantskin cancer and put on SPF– so if you’re wearingsunblock, it’s blocking generally, likeminimum, about 90 to 94% of those UV rays that wouldsynthesize the cholesterol in your bark to stir vitamin D. So a lot of beings thatget lab wield done, if you get your vitamin D levelchecked, we sort of know what to give you based onhow much your blood level is.So a regular array is30 to 80, or 30 to 100, depending on the lab. And a lot of doctors arelike, oh, yeah, 30 is fine. In the bone– if youhave a bone health issue, the serum, the bloodlevel objective, is 50. Research is showing us thatpeople with blood levels in the 40 s, it’s associatedwith better bone health. Which ever draws me laugh, because it’s the closest to 50. But sort of starting– anda lot of people that take a multivitamin, most of thesort of mainstream symbols of multivitamins now haveabout 1,000 milligrams– I make 1,000 IUs of vitaminD.So a lot of parties are getting some every day, if you’re taking a multi. Most of the otherstuff in the multi you don’t need, because ifyou’re taking it every day, your person isn’t exercising itbecause it’s not deficient. But those are sort ofthe two major ones. Vitamin C has been shownto be really important, but vitamin C, to me, isnot worth supplementing.I know a lot of people– extremely now that it’sbecoming cold weather, and it’s an antioxidant. So once COVID stumbled, everyone was like, oh, I’m taking my vitamin C.Vitamin C, and any nutrient, going to get utilizedbest from nutrient. So even though vitamin Citself is an antioxidant, there are so many antioxidantsif you are eating menus naturally with hue. So your broccoli, kale– everyone snacks kale now– anything. So kiwi, strawberries– thoseare two vitamin C rich foods. These are thingsthat you’re also get these phytochemicals. Those good complexions are anotherantioxidant layer in something that you’re consuming. And it exactly passes, then, tobetter food blueprints, and then overall improved weight. And so it’s sort of all related. But you still need adequateprotein, suitable calories. You need kind of broad spectrumof all nutrients, all vitamins and minerals. But we focus on thecalcium and the vitamin D to make sure, because those aretwo of the most prominent ones. Magnesium, phosphorus, those are involved as well. But beings are too quick to justsupplement everything instead of looking at dietfirst, and starting sure you’re getting a servingor two of return a daytime, a few cases performs ofvegetables a day.I mean, an easy rule of thumbfor good diet excellence is try to get vegetables– if we’retalking about a breakfast, lunch, dinner– try to get a fruitwith breakfast, vegetables with lunch anddinner, maybe a fruit snack. Just to kind of makesure that you’re getting some of theregular basic nutrients you need for general state. Because your bonehealth isn’t going to be great if yourgeneral health is poor, and your food is poor. You know, menu canbe our medicine, but it’s not no magiccure for just focusing on a few isolated nutrients.So it was a verylong-winded answer to that, but it’s so broad spectrum. No. And it’s true, andit’s great admonition. You need to look at healthand nutrition as a whole , not specificallyjust for our bones. Are there anyfoods that might be detrimental to our bone state? Perhaps like caffeine? Nutrients with caffeine in their own homes? I see the rule of thumbwith caffeine intake– no matter if it’s coffee, tea, an energy beverage, whatever it is– is roughlyone or two a period. The difficulty withcaffeine is when you have an undue amountof caffeine consumption on a daily basis, it actually can leach bone, kind of demineralizedthe good stuff that we want to keep there, mostly in the presence of inadequate bone nutrients. So if you have nodairy for instance– you’re allergic to milkand milk products– and you don’t take anyvitamins or augments, and you suck three ventiStarbucks coffees a daytime, you might be having someproblems with your bones.So that’s because thenthere’s no moderation, right, if you’re havingthat much caffeine intake? So whether it’s coffee, whether it’s tea, I visualize, parties, you justreally need to be careful. Everything in moderation. The one thing I will sayabout caffeine as well, is people– there is somethingabout a dawn colouring liquor that parties don’tequate with caffeine. So a lot of peopledrink dark-green tea, and dark-green tea isnaturally caffeinated. So you really haveto simply be careful. Even though there are goodantioxidants in that as well, one or 2 goblets of caffeine a dayis really the recommendation. Absolutely.Great. And I wanted to goback to something you mentioned previously, Deb, about fort meat with calcium. Can you get too muchcalcium, and is in a position to do damage caused to your torso? So it certainly depends on howyou are made up as person or persons. So a lot of peoplewill say, oh, well if you get too muchcalcium, you’re going to get a kidney stone. And depending on howyour body is built, it doesn’t mean thatyou’re going to. But there’s nothing proventhat getting too much calcium– and by too much Imean anything over– the upper limit is 2,400 milligrams of calcium. No study has evershown that even get over 2,000 milligrams, or even over 15 to 1,8000 milligrams of calcium a daywill improve your bone state. So I’ve seen somepeople over age, that have been taking 1,200 milligrams of calcium a date, but then they happen to bedrinking like a quart of milk. So I think, well, it’s just too much. Like more isn’t better. It’s sort of the American way, that we envision more is better. But in the case ofcalcium, you want to have divided quantities, whether it’s a natural food form or a supplement.And by complement I want a pill, a chew, the liquid calcium. Or the complement that isreally in these cow’s milk alternatives. So all of these milk– youknow oat, cashew, soy, rice, almond milk– all of thosemilks have a liquid supplement. I kind of call it, Irefer to it, generally, as a liquid supplement, because it doesn’t have naturally occurring calcium. So that’s why you justwant to really be careful, and do a little bit of aninventory of what you’re consuming on a regular basisto see if you have too much, if you have too little. Where you need to fill in thegaps with your diet overall , not just your calcium, andvitamin D, and some other nutrients.Know Great. So let’s say we’redoing everything title. We’re doing the weightbearing practises. We’re eating a calcium rich, andjust generally offset diet. But at times, it seemslike that’s not enough. So when we talk aboutmedications for osteoporosis, Jae, I was wonderingif you could speak to that a little. Oop, you’re muted. You’re subdued Jae.Yeah. You only have to un-mute. Sorry. Yes. We can cure osteoporosis. There are two ways totreat the osteoporosis. When you have early stageosteoporosis or osteopenia, we generally discuss with theoral or IV located phosphonates to maintain your bone andprevent aggravate osteoporosis. Another nature to treatthe osteoporosis– specially when you haveadvanced osteoporosis or major fractures– then we can strengthen yourbones with anabolic negotiators. I can say brandname– the FORTEO, TYMLOS would be anabolicagent to build up the bones. There is a new medicationthat just came out, EVENITY. It’s another anabolicagent to reach the bones– some people reach back tonormal, like a 35 -year old-fashioned. So if you have anytreatment plan, cause us know. We are ready to treat you.That’s great news, that it be cured. That’s really fantastic. And I suspect I’m curiousto know, how much would diet and exercisebalance with prescription? If you take medication, but youdon’t[ AUDIO OUT] nutrition tone or you don’t employ, is itgoing to have the same effect? Definitely. So we do have like morethan 1,000 patients who are taking, for example, Prolia. So I do watch themlike every six months to make sure theircalcium level is good, vitamin D is good, because Prolia can lower on sure-fire amounts, including calcium levels.Whenever I find them, if youdo have a regular exert platform, with agreat nutrition source, and listen to our instructionin terms of, with a good food, and supplements, the newbone concentration next year is tremendously, much better, than who doesn’t time those kind ofexercise or diet direction. So definitely, you need tocombine whole process together to treat the osteoporosis. So it’s not that themedication is a cure-all. It needs to work in conjunctionwith a healthful lifestyle. Yes. Great. So I do see that we havesome questions in the Q& A that I would like to address. If anyone has anyadditional questions, please feel free to addthem into the Q& A. OK. So first issue here wehave, “I’m doing Tai Chi and path three tofive miles each day.Is this good forosteoporosis prevention? ” Yes. This is perfect. So one of the tipsof the exercise– if you do those kindof cross prepare, doing the muscle strengtheningand value accepting usage can affect yourwhole body systemically, so outcome is much better. I foresee she is doingit the perfect style. She already– yeah. Great. Agreed. “How much alcoholintake per week is considered dangerousto bone health? ” So it’s hard to know exactly, without knowing diet– like what thisperson’s usual food is. I suppose anything over oneto two alcohols per date, which would convert toseven to 14 guzzles a few weeks, could be seen as excessive.If, say, you have aregular, healthful diet, and it’s prettywell-balanced, and you’re having a glass of wineor two each night, it’s not the worst thing. But if you’re maybe aone meal a day person, and you happen to have afew boozes every night, then you’re probablyjust cutting out a lot of nutrients that yourbody might need, let alone your bones might need. So it’s hard to say. Again, and on the basis of the sizeof the person or persons, and life of the person or persons, it’s hard to givesuch a black and white answer with a number. But I would say, just forargument’s sake, more than one or two a era. Right. It’s always challengingtoo, because we get other information thatalcohol can be good for– like red wine could bepotentially good for your heart health or something. So you don’t always– A glass a daytime. One glass. A serving a day.Yes. One acting. Yes. OK. So we had a question about milkas not a great form of calcium, because studies that showthat dairy cause inflammation. Deb, do you think youcould speak to that a little? This is one of my– thisquestion is always– so dairy, it actually really depends. It’s not so much– there are things–over the years, I’ve done so many talksabout inflammation and the anti-inflammatory diet. Depending on– havinga glass of milk a date is not going tomake you pro-inflammatory. It really dependson, that’s why you have all of these othernutrients in your organization. If you were drinkingonly milk, and you were sensitive tomilk, where you were having somesort of reaction that you weregetting inflammation, then yes, you probablyshouldn’t be imbibe milk. But having thingsin moderation– you have some milk, youmight have a yogurt, even if you’rehaving some cheese– it’s not necessarilythat chipped and dry. Because I’ve heard this so much, over the past couple of years, peculiarly. And I ever say I’mtotally fine with beings trying, and doing anything.And I always say, if you cutout dairy and you feel better, then it’s probablyworking for you. And that’s fine, but then you have to make sure you’regetting those nutrients that your diet is nowdevoid of some other way. So that’s fine. People don’t wantto consume dairy, they totally don’t have to. But they have to lookto where they’re going to get those nutrients then. Utterly. I know we talked aboutthis a little bit, but is there a amber guideline forbone concentration exams right now? Is there a testbetter than DEXA? So yeah. DEXA is a dual vitality X-ray. That’s the gold standard fordiagnosing the osteoporosis.However, HSS has QCT. We do the CT scan of, often the prickle, hand-picked those certain stages tomake sure the bone concentration through the CT scan, which is more accurate. But we frequently use those QCTfor the patients who are not able to do theregular bone density because the patient already hadtwo hips are already supplanted. We often a bone density inboth trendies, so we cannot do it. Or the patient went througha big, like a spinal surgery, so we cannot measurethe whole spine.So we have to pick certainlevel to measure those area, to make sure the patientdoesn’t have osteoporosis. That’s the secondoption I can tell. But definitely, gold standardis a bone density test. A question– “are thereracial differences in bone architecture, and do they affect appropriateinterpretation of bone density measure outcomes? For example, studiesshow Japanese brides are at less peril for cracking, even when their bone density values are low, because theirarchitecture is stronger.” That’s a good question. So regrettably, bonedensity demonstrated in simply dense. They cannot show structureand other bone issues.Especially when you have otherdisease, could be different. So we can’t define if you dohave a normal bone concentration, but you retain breaking thebone, then something going on. We might have to check otherways with various experiments, or bone biopsy can tell ushow your design looks a lot like. Also I just mentioned that QCTcan tell a little bit better than bone density. Yes. Deb, this one’s for you. “Do you need vitaminK with vitamin D? ” You don’t need to take vitaminK with D. I get wearisome of people. I’ve just noticed recently, a few people that I’ve seen have been taking vitamin K.You time have to be careful. People have to be careful, because for a few grounds. One, it is overweight soluble, soit’s not a regular blood statu that any prescriber orclinician I know is checking. So if you’re just sort ofself-medicating with vitamin K, it’s not necessarilygoing to be helpful, and it could be dangerous.The other thing is, vitamin Kis crucial in blood clotting. And so if anybody ison a blood thinner– but most specifically, Coumadin is the one that really intervenes withclotting and vitamin K– the INR heights, theblood clotting grades. And depending on how oftenpeople are having it checked, it’s just really realise menervous that people are just taking it regularly. There might be some– there is definitelya trace amount in most of the multivitamins. But to take a separate vitaminK , not one person on this, or ever, anywhere, should be just starting to supplement andself-medicate without checking with their doctor.And if someone goes todifferent pharmacies– because I know alot of parties, they might get pharmaciesfilled through the mail, but then they might run justCVS, or Walgreens, or whatever, or a local neighborhoodto pick up something. So there’s nocentral plaza where anyone is tracking allof this, so you really want to be careful withjust making adds-on. And likewise , nothing ofthe adds-on are regulated by the FDA. So you really want to makesure what you’re go is a rather reputable brand– one of the symbols that’sbeen around for a while. If you can’t findany datum except from the company thatsells the vitamins, probably not a good one to take.That’s good advice. And too, that would be agood opportunity for you to accompany a directory, perhaps, ofsupplements to your specialist, or to your clinician. Ever. Always. Yes. OK. We have a few questions todayabout the brand-new medication for osteoporosisthat you spoke about. Oh, the Evenity– E as in Edward, V as in Victor, E as in Edward, N-I-T-Y. OK, enormous. So everyone who asked that– OK. –Evenity. Thank you. And that was the newmedication that you invoked could rebuild bone to age 35? Yes. I signify, the same– same, working in adifferent way, but yes.FORTEO, TYMNOS and Evenityare three drugs that start yourbone concentration virtually reach a the normalrange, less than 1.5. Yes. And Prolia is another good dose. I think there is a questionabout other prescription for the preventionof osteoporosis , not the anabolic negotiator. So the initial therapy forosteoporosis and osteopenia, as I mentioned, is bisphosphonate. The brand name shouldbe Fosamax, Actonel– Boniva would be theoral remedy choice.If you have an issuewith the GI system, we typically hand IV instead. That would be reclastand Aredia would be the option for the management. Clast like osteoclast? Yes. Reclast. OK. “How much calcium you’re takingis reduced when taking a PPI? ” So for those of youthat are taking PPIs, if it’s anover-the-counter, this is something you emphatically wantto speak to your doctor about. Because most people shouldn’tbe on a PPI forever. So it is decreasing the sournes. Calcium, in itself, reallylikes an acidic environment for absorption.So calcium carbonate, one of themost common supplemental words, the recommendation is totake it with nutrient it is therefore stays in your belly longer. If you’re taking a PPI, I wouldjust not try to have your– if you take it inthe morning, perhaps don’t have your calcium, whether it’s a augment or from menu, at the same time.Or the other part ofthat is, I understand parties are taking PPIsfor different reasons, whether it’s like Barrett’sesophagus, reflux, whatever. If it’s an acuteissue, or if it’s a long-term, chronicissue, is really maybe try to look to the thingsthat are whether it’s diet, lifestyle, thingsthat are causing or adding to the reflux. Because I symbolize, duringthe past couple of months, I know so many peoplethat have never had reflux, and have had itjust because the increase in anxiety, orstress in their life. But if it’s more food associated, it can be weight relevant, it can be time ofday you’re eating. It can be a wholenumber of things. And so we sometimestry to treat the reflux to limit, or decrease the lengthsomeone is on that medication. Because it can have a negativeeffect on bone caliber. That’s great.”Is there any research on theeffects of taking vitamin K2 or eating fermented nutrients? ” So K2 , no. Not current studies– unlessJae, you know something differently– in terms of K2for bone health, solely. Fermented foodsare– so there is– I would say, over thepast couple of years, the nerve biome has becomethe newest hot topic. And so I know, Claudia, I suppose, didn’t you do a webinar or somethingrecently, about this? So it’s sort of found tobe really an integral part of every system in our mas, and every form of health– whether it’s bone health, bowel state, mental health issues, physical state, cardiovascular health. So I think there’snothing specific, in areas of probiotics and bone state. Nonetheless, if you’re gettinga probiotic-ey type food, like kefir, like yogurt, it sort of has a dual purpose. I like to kill– I mean, well Iwas going to say– it’s probably not PC anymore tosay to kill two birds with one stone.But if you have dairy, you have some protein, “youve had” some calcium in there. So for those of you thatdo kefir, and you like it, and you imbibe it every day, oruse it in your food every day– or yogurt– it really is givingyou good bacteria, which facilitates populate thegood bacteria in your gut. And then also, it’ll giveyou some natural calcium and some protein. It’s sort of like a 3-in-1. It’s like a perfect– it kind of ticksall these boxes. So it’s not thatit’s crucial to it, but it’s certainly an importantpart of merely general state. And fermented nutrients, whether it’s kimchi, whether it’ssauerkrauts, things like that, they have thisgood probiotics, which are good for your gut health. Which can then, in turn– I always imagine itpositively changes the other parts of yourhealth, and mas in general. That’s right. So there is a recent study– it’s not human. They did like a fecaltransplant to the different rats with a healthy newborn, witha lot of good germs there, the other one is not.They pictured the differencesbetween two rats, in terms of their bonehealth and organizes. So we don’t have evidencewith a human yet, but I obviously recommendtaking those good nerve state complements. There’s no harmin chewing yogurt. Like kimchi– yes, Ithink it’s a great option to improve your bone state. This is an interesting question. “Does osteoporosis alwaysneed to be treated? ” I’m sorry– question? “Does osteoporosis alwaysneed to be treated? ” Always? I should say yes, as orthopedichealth care providers. Again, in order toprevent the crackings. Your life will betotally different. It’s like the same concept– when you havehypertension, you need to control that before you havea heart attack or a apoplexy. It’s like a speechles canker. You don’t feel anything. However, it can come back witha big trauma in your life. So I would say yes. Great advice. Yeah. You would agree? Well yeah. I convey, I was just thinkingthe number of patients that I’ve seen over theyears with crackings, whether they wererelated to osteoporosis, or sometimes found outthat they had osteoporosis from having had a fracture.And so a lot of people– therewas a young, 40 -something year old-time who had a freak accident. But they would havenever, ever, suspected a 45 -year-old malewould have osteoporosis. And when I went to see himbecause the surgeon happened to see me in the hallway–this was like 15 years ago– he said, can you please appreciate him? This guy’s bones were so softwe could take out hardware. They were taking outscrews with their hands– they didn’t need tools. And I was like, what? So I went to see him. He had been asmoker for like 20 — no actually, itwas like 30 years. He started inhaling whenhe was 15 years old. His bones were so soft. And I imagined, wow– I can’t believe I’m sayingthis, but it’s kind of good that you had thisaccident, because you never would have known otherwise.And you cannot smoke anymore. He was like OK. OK. You know. But it can be really depleting, and truly destroying, and certainly changingyour life for the worse. Utterly. “What kind of doctor wouldyou see to go get a bone scan” What kind of doctor? Yeah. Where should you start ifyou’re concerned about your– In degree to test the bonedensity, extremely when you have menopause, you candiscuss with your GYN doctor, primary physician. Likewise, we do have alot of metabolic bone specialists includingendocrinologist, orthopedics. Everybody’s opento help you guys. And person mentionedthey’d recently started making Tymlos daily dose. When should you get testedagain to see if it’s working? I generally follow-upthe Tymlos patient. After we start the Tymlosmedication can change your electrolytes symmetry, so Ido check laboratories within two months to adjust the calciumand vitamin D position. After that, everything is stable. Usually most people are goodto go for up to one year.Even though NOF recommendsbone density every two years, I would double-checkanother bone concentration yearly, got to make sure those medicationscan help for the patients, to check it out. So I would suggest youhave to check yearly to oblige the further decisionthat you need to take another, second year, for the Tymlos. And while we’re talkingabout medications, are there any side effectsto these remedies that beings should be aware of? Yes. Each drug hasdifferent side effects. So it’s going to be– I need a long timeto discuss each.But clearly, when youstart the medication, you have to checkwith your providers very closely interms of the laboratories. You cannot just stop themedication in a abrupt way– for example, like Prolia. During the COVID, a lot of cases just stop it because they don’twant to come to the hospital. They don’t want to do it. Then they came back withother complications, which is not good. So you have to reallymaintain a close relationship with your providers toavoid those side effects. When you start eachmedication, the provider should go over the details, possible complications. But it’s a lot of information, and each drug is so different. So I don’t think we have enoughtime to go over that now. Absolutely. But surely keepan open conversation with your provider. Don’t stop anymedications that you’ve been prescribed withouttalking to your provider. OK. Let’s see whatelse we have here.”Are there any alternativecare cares that help with bone density. For example, acupuncture, massage, meditation, perhaps? ” I convey, “thats a lot” ofalternative therapy alternatives I’ve heard. But nothing isstrongly evidenced by. Like for example, oh, I dohave some reverberation therapy. I make, they’re doing studies, but we’ve never seen strong suggestion, so we cannot recommendas a health care provider. But if you think it’snot destructive, you may try. But again, it’s hardto get better when you have severe osteoporosis. You need to evaluate and treatyourself with a health care provider, immediately. Deb, this one’s for you. And we’ve talkedabout meat a good deal, but could you reputation a few cases ofyour top, calcium high quality foods? I didn’t hear sardinesyet today, so– So I think thatfor the most duty, the ones are– if anyone outthere can tolerate dairy. And by dairy I intend milk, cheese, yogurt, kefir. Even if it’s like a drinkable, or if you do a smoothie, those are pretty much thebest bang for your buck.I used to anecdotally say–or I still anecdotally say– that people thatdon’t potion milk have no chance of coming reallyenough calcium in their diet. I stand by it for this reason. Because if you think about likeyour teenage boys, they drink– a lot of them drinkso much calcium. And anyone on this, who’sparticipating, that has a son and knows, like, theymight beverage a half a gallon of milk aday, they’re going to have a really good bonedensity going into adulthood. For those of us –and by the time, and most people dophase out of it. I think that in the’ 80′ s– and this has actuallybeen proven– but in the’ 80 s withthe soft drink boom, and with all these energydrinks, a lot of babies no longer are boozing milk. It’s just not really anaccepted thing to imbibe. But if anything, it has somesort of protein in there.So when teenagers, a lot oftimes, will say to me, well, I suck chocolatemilk, and our biggest quagmire has always been, well atleast they’re getting milk. I intend, most kidsaren’t imbibe gallons of chocolate milk every day. But if it’s what getsthem to booze milk, it’s a low fat milk. So even though they are they get alittle extra calories from the chocolateflavoring, so be it, because they’re atleast going that. If you can’t reallytolerate dairy, and you’re already use someof these milk alternatives, then you can certainlyuse any of those.But just know it’s aliquid calcium augment, mostly added to the milk. But for the mostpart Greek yogurt– that Greek yogurt boom– I imply, whoever thought1 0 years ago, it would be what it is now? There are so many differenttypes of tightened yogurts, whether it’s Icelandicyogurt, there’s one, quark, from Germany, the Greek yogurt. Any of those damaged yogurtshave more protein per serving, and naturally, theway they are made, it is really skinnedlot of carbohydrate. So the natural carbohydratelevel is a single digit. It might be 4 or 5grams per serving.But where the rest of thecarbohydrates start coming in is just the flavour. So a lot of people thatare lactose intolerant is to be able to toleratethose Greek yogurts because they don’t havea lot of lactose in them. The other thing, extremely, is other than that, other than milk or yogurt, if you do eat some cheese and you don’t have anissue with cholesterol, including a slice of cheese, orhaving little a cheese snack. You know, whetherit’s the individually wrapped like mozzarella stringcheese, which has, typically, 100, 150 milligrams per section, or the little individually wrapped Gouda cheese. The Babybel in the wax has2 00 milligrams of calcium. That’s like a 50, 60,70 calorie little snack. You can grab two of thoseand “youve had” 400 milligrams of calcium.That’s a great amount to have. So just little styles like that. But the cheese, milk, yogurt, are the best sort of bang for your horse, in termsof natural sources of calcium in food. We have a couple minutesfor a duo more questions. “I have repeatedbone concentration measures at the same facilityfor years, and acquires have improved fromosteopenia to regular, but I’m not doing anythingdifferent or new.” Wow. Look at you. Any anticipates on this. It’s really rareto see come improved from osteopenia to regular. Maybe she’s theone, our role model who does exercise everyday, dining healthy nutrient and taking supplementslike Deb says. Probably she does that lane. Maybe she can teach us any tips-off. It’s rare to see that. Bring her on the webinar. “What begins a decrease inbone density post menopause? ” I approximates we’re actually– thisperson’s questioning what the machinists of it are. So what do youhave menopause, you do not have enoughestrogen, who’s been protecting yourbone resorbption– so losing the bone process. So it’s kind of aging process.When you get themenopause, you’re going to feel, oh, everything is different. Everything is achey. You get more puckers. All of a sudden, yourblood pressure starts high-pitched. Everywhere, it’s going to beproblematic, including starting to lose bone dramatically. This is all estrogenation. So when you have aperimenopausal period, it’s a good time to discussit with your GYN doctor about, maybe I need some hormonereplacement care. That one is another good optionfor the perimenopausal women who don’t have osteoporosis yet. But we can delay that processand impede osteoporosis further down, if you are opento the HRT, hormone permutation therapy.So estrogen is the key. And someone had asked aboutHRT as well, so thank you for addressing that. And last-place one. Let’s see. Deb, one more for you– yourfavorite vegan calcium options. Ooh. From food? I guess it’s any of the– I guess any of thosecow’s milk permutations. They all are anywherefrom 350 to 450 milligrams of calcium per eight ounces. So that’s a good way. A pile of beings aredoing overnight oats, or concluding smoothies andusing almond milk, or any of those milk alternatives. Only make sure–usually the ones that exist in the refrigeratedsection have a little bit more than the shelf stable ones. But they do havea long shelf life, even after you’ve openedthem, because they’re really so low-grade in protein.So that’s the onlything, is you’re really losing protein from it. But you want to justmake sure that you’re getting those protein sourcesfrom legumes, then, as a vegan. But that is really the bestbang for the buck for vegans. Great. Well thank you both. We’re at day. Thank you all forjoining us today. Thank you, Jae and Deborah, for unite us and sharing this wonderful information. This webinar will be recordedand posted on our YouTube page, and I will share thatin the follow-up email.If you’d like to learnmore about our planneds, or about the carethat we offer at HSS, delight feel free tovisit us at HSS.edu. Have a great day! Bye. Thank you all. Thank you. Bye. Bye.[ MUSIC PLAYING].