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Welcome to ACE Podcasts. Thanks for tuning in as we elevate clinical endocrinology by taking deep dives into trends and topics that can help us improve our patient care and global health. Find the Latest episodes on aace.com podcasts and now let's meet the endocrine experts who will be talking with us today.
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Hello everyone and thank you for joining us for this ACE Podcast on Bone Health Optimization with Food and Fitness. My name is Dr. Layla Tabatabhai. I am the chairman of the Bone and Parathyroid Disease State Network for ACE this year, and I'm very honored to be joined by two amazing experts today, Dr. Deborah Sellmeier from Stanford and Rebecca Rothstein of Buff Bones. And I'd like to introduce both of them in a little more detail. Dr. Selmeier is an internationally recognized expert in metabolic bone disease. She's a renowned endocrinologist who joined the Stanford faculty in 2018 as a professor of medicine. She's been recognized for clinical excellence with induction into the Miller Colson Academy of Clinical Excellence at Johns Hopkins. In addition to her clinical expertise, Dr. Sellmeier maintains a research program centering on the effect of nutrition and and environmental factors on skeletal metabolism. Studies she has conducted include investigating the role of dietary sodium chloride, dietary protein, role of dietary potassium and alkaline salts, targeted exercises on kyphosis, whether structured exercise can prevent bone loss in premenopausal women with breast cancer, and studies validating nutritional assessment questionnaires. I'm very honored to have been Dr. Sellmeyer's fellow during my endocrinology training at Johns Hopkins and our other expert today. Rebecca Rothstein is the founder of the Buff Bones Exercise Method for Bone and Joint Health with online programming and coaching, free public education webinars with UCLA Health, and training for instructors in more than 30 countries as well as locations including Johns Hopkins Rehabilitation Network. Rebecca is an industry leader for movement education, bone health and Pilates for more than 20 years. With a background in dance and sports medicine. She serves on the Ambassador Leadership Council for the Bone Health and Osteoporosis foundation, on the Medical Advisory Committee for the National Menopause Foundation Bone Health Working Group for the Society for Women's Health research, and in 2024, Rebecca was awarded the Robert Gagle, MD, Community Leadership Award from the Bone Health and Osteoporosis Foundation. So truly honored to be joined here by both of you and I'd like to get into some questions so we can have a conversation on food and fitness and how it ties back to osteoporosis. So first of all for you, Dr. Sellmeier, can you talk about the calcium controversy? I think a lot of us have patients who've been told to stop all of their calcium because of the risks of coronary or renal calcification. So how much calcium do osteoporosis patients really need and how are they supposed to get it? What would you recommend?
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So the calcium issue became very controversial more than a decade ago when there was a single study looking at an intervention of calcium citrate, a thousand milligrams per day. And among those randomized to the calcium citrate group, there was a higher rate of self proportion reported myocardial infarctions. So this raised quite a bit of concern. But actually within that study, if the vets prejudicated and non recorded events were included, there actually was no difference even within that initial study. However, the concern raised by that study, and it was published a couple of times in various different ways, really alarmed providers and patients as well in terms of what safe in terms of calcium. And so there were a few studies that kind of rebutted that. But I think the definitive examination of this issue came with two publications, one in 2016, one in 2017, which were massive literature reviews, consensus conferences among four international societies, bone and marrow societies, and cardiology societies. And there were two separate analyses. both conflicts concluded there was absolutely no concern for vascular calcifications, myocardial infarctions, cervical vascular disease among people taking recommended amounts of calcium, either through diet or through supplements. So I think that issue has largely been laid to rest, but it still is a pervasive concern among our patients. And so I think we can use that data to reassure them that at the amounts of calcium that we recommended for people recommend for bone health, there is no concern about heart disease or strokes. So recommended intakes for adults are 1000mg per day up to age 50 and then 1200mg per day after age 50 for women, and for men it goes up to 1200mg after age 70. So roughly 1200mg in the older population. And that is total, that includes both food and any supplements. And, and I think the piece people often forget is that your baseline diet, even with no calcium rich food, has a small amount of calcium. So there's about 250 to 300 milligrams of calcium in just our general diet. So really people only need to identify about another 900 milligrams of calcium in their day. The intestinal absorption of calcium from dairy foods, fortified foods, and from supplements is exactly the same. So people. People can get their calcium from any combination of sources. That works well for them.
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Excellent. That's reassuring, definitely, for our patients, who I think, get a lot of information from well publicized studies that don't necessarily reflect what we know now. So that's really useful information. Yeah. Now, Rebecca, can you tell us about weight bearing exercise? How does this help prevent bone loss? And is weight bearing and resistance exercise the same thing?
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So this really comes down to mechanical stimulus and Wolff's law, that bone has this adaptive response to stress. And specifically, specifically, really compression and tension forces. When we're looking with or when we're talking about weight bearing activities, we're talking about getting the compression from gravity. And then, interestingly, though, weight bearing is not necessarily including resistance. So resistance exercises are a completely different thing. And that is where you're getting the tensile pull from muscle contractions, and it's using progressive overload. So that's what the challenge is, knowing that bone has this adaptive response. You have to continuously increase the challenge, whether it's through additional load, through other forms of volume, with repetitions and sets. But we have to consider how load plus gravity is really the key to a lot of resistance training. And that's often the secret to success. So it's interesting, you have this mechanical side that is kind of unique, especially when we're talking about medication or nutrition and these types of interventions for bone health. The unique side of exercise is the mechanical stimulus, but there's also potentially a chemical side with that, which is that myokines that are released from muscle contraction might actually be at play as well in bone metabolism. So muscle really does warrant a lot more investigation in this.
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Fantastic. That's really good to know. I think we all recognize that exercise appears to stimulate osteoblast activity and potentially help reduce osteoclast. So potentially less bone loss, more bone formation, um, and the role of myokines is really fascinating there. So there's probably even more at play than we know. Um, but clearly, people, patients who are just, you know, completely bedbound or very, very sedentary clearly have risk for. For bone loss. And that can be mitigated a good deal with, with osteoporosis. Exercise. What types of exercise do you believe to be the most effective for osteoporosis?
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Well, and we're talking about effective, right? Just like with medication, your primary goal with exercise is going to be fracture prevention. So where things have have pointed toward, especially in the last decade, is about a multimodal approach. There's not one type. This was really highlighted in the 2014 paper too fit to Fracture out of Canada, which was also then updated to about two years ago, along with consensus papers in Australia and the uk. Really we're seeing three different things. And weight bearing that we were talking about is a given pretty much with all of these. Resistance training, and that's the one that really needs to be prioritized, has come up to the forefront specifically when we're looking at osteogenic effects. And there needs to be not only the challenge and the progressive element to that, but also including functional movements. So things that mimic daily activities, pushing, pulling, squatting, those types of things, compound exercises like multi joint exercises, also an emphasis on axial loading. And then specifically, especially if you're, we're dealing with people with hyperkyphosis getting into back strengthening and back extensor strength. Then the second type is impact training. The quality of evidence is actually a little bit less than it is for the resistance training, but it is still recommended as one of the three most important things that needs to be included. It does have to be accounted for individual risk, but we're looking at ground reaction forces with the impact starting off, you know, with something like heel drops, so it's low impact and progressing to higher impacts as appropriate for the individual. But looking at ground reaction forces that are at least twice the body weight are probably what are needed for bone mineral density changes like in the femoral neck. And then the third aspect is balance training, which is not osteogenic but is critical for fall prevention and therefore fracture prevention. And that can include things like tai chi, pilates, yoga benefits here as well, and often includes some mobility in these aspects. But it's important to note too that strength training also can have a carryover effect with balance as well. And then two things that are not yet considered, you know, the major three, but also do have value and have been pointed out in guidelines, is power and posture. Power train is really interesting because so strength is the amount of force your muscles can generate. Power is how quickly they can do it. So power training has really emerged with some research as possibly even more important than strength training for, for bone density and for function. And then posture also relates to fall prevention, especially useful for kyphosis, very important with neuromuscular control. So essentially these are the main things that we have to focus on when we're looking at different types of exercise. But also we have to account for the fact that especially when we're thinking of the osteogenic side, the exercise has to be site specific. So the bone adaptations are going to occur wherever we have that direct mechanical stimulus. So really being the hip, the spine and the wrist. And it has to be very specific to the individual. And that's one of the things that's really. It has really emerged, especially in the guidelines as well, that research often uses healthy individuals, but that's not always representative of many people and the general public. So we have to be specific to the individual needs with any kind of exercise programming.
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That is fascinating. And thank you so much for explaining that in such great detail. I think oftentimes as endocrinologists and clinicians, you know, this isn't really our language. Right. We are much more familiar with potentially medications, other types of therapies that we can offer for our patients. But being comfortable speaking about exercise and potentially adapting that kind of program for our patients is critical. So we need to hear from more experts like you, Rebecca, I think so we can get comfortable with it. But. So, Dr. Selmer, we spoke a little bit about calcium. Now, switching gears just over to vitamin D. So excessively high level is actually over 80 to 100 nanograms per milliliter became quite common during the COVID 19 pandemic. And other patients, such as those with multiple sclerosis or even colon cancer, have been advised to have high vitamin D levels now for many years. Do you know of any downsides to hypervitaminosis D? And what range do you aim for in your osteoporosis patients?
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We have seen both quite a bit of interest in having higher vitamin D levels for other disease states outside of the skeleton. And. And there really is very limited evidence that there's any benefit to those higher levels, both for the skeleton and for other disease states. And for sure there is an increased risk of nephrolithiasis. So when we get higher vitamin D levels or a high calcium intake, our first defense is to start dumping calcium from the kidney. And so nephrolithiasis and hypercalcemia are our first indications that somebody is overloaded. And in the Women's Health Initiative Calcium of IMD study, there was a higher rate of nephrolithiasis. And so those were even crazy amount of supplements. And women will start getting hypercalculate with calcium intakes over about 15 or 1600 milligrams. So there's a pretty narrow therapeutic window for calcium. And high vitamin D will. Will also cause that same issue right now. Sort of aiming for calcium or, sorry, for vitamin D levels between about 35 and 50 nanograms per milliliter. The level of vitamin D is also has been a controversy. And I think it's what really helps people understand that controversy with the Institute of Medicine recommending levels over 20. Most of the professional societies recommending levels over 30 is to understand that the Institute of Medicine is setting a very specific term. They're setting RDAs, recommended dietary allowances. And the definition of RDA is the average daily intake on nutrients that is sufficient for 97.5% of healthy individuals.
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So first of all, they're not aiming
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to cover everybody that is outside the definition. They're only aiming to cover a large percentage of the population and it's specifically targeted for healthy individuals. So there isn't an exact definition of a healthy individual. But certainly people with skeletal fragility, low bone density, I'm not sure that we would count them in the same group as kind of the healthy general population. So looking at the majority of the data over having a level over 20 does look like it's probably fine for the vast majority of people. But there are a lot of studies that show that there's still secondary hyperparathyroidism, there's still undermineralized bone in a subset of folks with vitamin D levels between 20 and 30 nanograms per milliliter. So if we really want to cover everybody, including people with skeletal compromise, we need to get over 30 nanograms per milliliter. And even the most staunch defenders of the 20 nanogram per milliliter value will admit there really isn't any downside to having levels between 30 and 50. So I think that's what I generally target. Somewhere between 30 and 50 there is seasonal variability in vitamin D levels. There's also assay variability, especially at the lower end. So I try not to have patients, you know, levels clinging to the very bottom of that, that 30, because there's just going to be some variability. They're going to be down in the 20s at some points. So that's why I say sort to 50. I don't think there's any benefit to getting over 50 and you are going to start contributing to hypercalciuria. So I think that's plenty and I don't see any reason to go any higher.
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Fantastic. And what is your thought about using D3 cholecalciferol versus D2 or ergocalciferol?
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Yeah, D2 and D3 have the same binding affinity for the vitamin D receptor. So in terms of physiologic effects, they're the same. D2 is cleared faster. And so if people get a single dose of 50,000 units of D2 and D3, the D2 is going to be gone faster than the D3. It's pretty much gone within two weeks. And so that brings up another issue with vitamin D, which is what about these high dose intermittent regimens? And been quite a number of studies looking at high dose regiments, you know, 100,000 units a month or even 500,000 units once a year. And those data are a bit concerning. In most of those studies there's either been no effect or adverse effect from the high dose intermittent vitamin D. So I would recommend against that. And we still use the 50,000 unit, you know, ergocalciferol to replete people quickly who have very low vitamin D levels. And I think that's fine. But I am getting more and more away from using it as kind of a long term maintenance supplement. And I'm getting people on to kind of, you know, the standard one or two thousand unit daily doses instead. I don't know what the physiology is of that high dose intermittent vitamin D. There's some animal data that suggests there may be some negative feedback on conversion of 25D to 125D. So maybe people are kind of functionally vitamin D deficient with those super high doses. But we don't know for sure. But it's kind of been a surprisingly consistent amount of data now that that intermittent high dose, super high dose vitamin D is not beneficial and actually may be harmful.
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Right, that's really important to know, especially with patients wanting clear guidelines on what to take and exactly how much to take. So Rebecca, you introduced us to be various sort of functions and types of exercise that are beneficial for the bone. Can you speak to how often and how long should someone with osteoporosis exercise each week?
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So the first thing is to point out the importance of consistency. So if you do it once and then you don't continue, it's not going to make much of a difference. So this is something that is essentially needing to be part of your lifestyle, that it's not just you're doing it for a short period of time, duration and for the rest of your life, essentially considering it almost like another activity that you would do of brushing your teeth. You're not just going to do that for two weeks and then forget about it. So taking, let's say that consistency is already taken for granted. Now when we look at frequency and Intensity. You know, the research hasn't been able to exactly determine a lot, but guidelines all really have. So specifically with resistance training, you should be doing it at least twice a week with impact several times a week, and then balance. They say that challenging exercises or tasks should be done several times a week. But really you can incorporate this into your life daily. You know, when you're brushing your teeth, you can be standing on one leg. The biggest thing, though, is to stratify the risk count for the individual goals. Now, what gets really interesting though, when we look at the research is this discussion of intensity, because traditionally, it's always been thought that people with osteoporosis might be more fragile, more frail, and some of this has been changing. So when we talk about intensity, this is. And when we're specifically referring to resistance training, intensity has been measured in something called one rep max. And this also relates to the number of repetitions, but essentially where it's probably that moderate to high is the best for osteogenic effects and has the best potential to improve bone density after menopause with osteoporosis. So the strain and the magnitude of the strain is what really may be important. So things changed. In 2018, a study called the Lift More was published. And it was. It was unique in that it was looking at osteoporotic or low bone density subjects who were specifically postmenopausal women using a supervised version of high intensity progressive resistance training and impact training. And it showed it as safe, whereas commonly this had been considered risky. It had statistically significant improvements over eight months with around 100 subjects. We're talking lumbar spine gains of 2.9%, femoral neck of. They used the same protocol again a few years later in something called the MEDX trial, both with and without anti resorptive medications that time. And I should mention that buff bones was included in that as the control, but I wasn't aware that this was underway, so I have no involvement. But again, when they did this with the high intensity, there were again lumbar spine improvement, and it was to a lesser degree though. And this time there were no femoral neck increases. But it seems that the spine has better bone density effects from exercise than the hip. So that's one of the interesting takeaways because again, this is the big question. It's not just how frequently should I do it, but what intensity. This has been the big discussion that's going on for a while. And yet a meta analysis in 2020 that was looking at exercise and bone Density in postmenopausal women, that was really impressive because it had 100 studies in it. It showed improvements in low, moderate and high intensity for bone density, but it pointed toward the high having the greatest gains. There weren't that many studies, though. That's really the biggest takeaway right here. In addition to a new meta analysis, actually that just came out last month, pointing toward aerobic exercise and resistance training combo having the best outcomes for bone density increase, but they weren't looking specifically at osteoporosis. So, like, the big takeaway, I would say, for all of this is not only is there more research that's needed, but we need more research that's going to look at moderate to high intensity to really be able to determine what dosage essentially. And then also there's a lack of quality research here to really make conclusive statements specifically, because a lot of the meta analyses, I mean, there's not that much research, but the ones that there are and with meta analyses are not necessarily including or not having subjects that are with osteoporosis. And that's important because while we want to look at bone density gains and often with postmenopausal women, we do see from other meta analyses that those with low bone density or osteoporosis may have actually better gains in density from exercise than those with normal bone density. So we need to take this into account. But that's really where things stand at this point.
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Excellent. So it sounds like consistency is needed and this should be something really habitual for, for all patients who have bone density concerns. Dr. Selmeier, back over to you. We spoke a little bit about vitamin D and it seems now that whenever I hear about vitamin D in the clinic, the question of vitamin K comes right behind it. So a lot of supplements now are sold in combination. So for example, a vitamin D3 K2 combo, etc. So it seems like vitamin K has really surged in popularity. Do you believe that supplemental vitamin K is needed and which type would be more beneficial? And could there actually be some harm from too much vitamin K? What are your thoughts on that question?
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Nutrients other than calcium and vitamin D have very little data in terms of skeletal outcomes. And so there's. Every nutrient is important for bone health and some have a very critical role in bone health. Vitamin K is one of those. Osteocalcin, which is a key protein for bone formation, is carboxylated in a vitamin K dependent fashion. So there's no doubt that vitamin K is super important for bones. There've been a handful of small studies, pretty limited outcomes. There was a meta analysis, a couple of meta analyses looking at, putting these together, looking at K1, K2, MK4 and there really isn't a consistent picture on benefits of vitamin K supplements for bone health. So there have been some suggestions in some studies but no consistent effects shown across a number of studies, although the data are very, very limited. There's also kind of a popular theory that you have to take vitamin K and vitamin D together because that helps the vitamin D and the calcium know where to go when it goes to the bone instead of going into the vasculature. And that theory comes because one of the proteins that prohibit inhibits calcifications in the vasculature matrix blob protein is also carboxylated in a vitamin K dependent fashion. And so I think that's where people are trying to tie this together. So if you take the vitamin K then it inhibits the matrix glycerin skin and the calcium is going to go to the bone instead of the vasculature. But we really don't have any evidence that that is the case. And as I explained to patients, you know, it's easy to see that we might need calcium and vitamin D supplements because those are available in very few food foods. It's pretty much impossible to get enough vitamin D from food and calcium is available in a very limited number of foods. So you can have pretty healthy diet and not get enough calcium and vitamin D. It's a little less clear that that's possible for other nutrients because other nutrients are more ubiquitous in our foods. And if you're eating a reasonably healthy diet, you are probably going to be getting enough of these other nutrients. In terms of downside because it is so popular, everybody really wants to take some vitamin K. I can't really find a downside in people who do not have clotting disorders for vitamin K supplements.
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Around the RDAs people are really, really
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want to take some vitamin k. I think 80 or 90 micrograms of vitamin K is probably fine. I can't find any specific harm that that's probably causing other than people who have clotting issues or on anticoagulants and that's sort of thing. So if patients ask, I'll say it's fine. You know, it's probably fine to do that, but I don't have any evidence that it's, it's benefiting you.
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That's really great to know. Maybe a big waste of, of cash really on those pricey D3K2 combinations.
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Unfortunately, I think that is the case.
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Right? Absolutely. Rebecca, in terms of exercises, when you're seeing a client, a patient with osteoporosis, are there ever any specific exercises you advise them to avoid? Completely.
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So this comes down to the individual and fracture history, other elements of injuries, et cetera, but essentially anything that any kind of load that exceeds the strength of the bone can lead to fracture. So it's a fine balance right now. Where guidelines have also moved toward is away from scaring people into thinking that they can't do things and to pointing out certain movements that they might need to modify. So what are these? Especially when we're talking about the spine, this includes end range spine flexion. So an example would be rounding your back completely weighted. So I think of this as loaded flexion. This is something that's really common actually, in Pilates mat exercises, some yoga poses. You're lying on your back and your feet and your hips are in the air. So the entire spine has load on it in that flexed position. Rapid, forceful type of movements as well. And this is all specifically with the spine. We're referring to just repeated, repetitive, sustained type of spine flexion. You keep doing that over and over. But specifically, really, when we're looking at combined movements of flexion, lateral flexion, and rotation. And that combination of the three is what might put too much force on an osteoporotic spine or a spine with low bone density. And especially we can't necessarily separate to say, oh, well, if this person, this patient or this client has osteoporosis, it's different than if they have low bone density because of the greater number of fractures that have actually occurred in osteopenia range or low bone density. So we do just want to keep this in mind for the individual. So knowing the individual's history is important. And especially if there has been a spine fracture, that makes it much more clear that you might likely avoid these types of movements. Because we want to make sure that we don't incur a secondary fracture.
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Absolutely. Safety is always first. I have unfortunately had patients who maybe work with a physical therapist. So sort of in a medical setting, as they're rehabilitating from a fracture, and some have actually incurred additional fractures. So I think there's education needed really, across the board for physicians, for patients, for physical therapists, because you really can't tell. Right. Who has osteoporosis just by. Just by looking at them clearly. So, Dr. Sellmeier, back to you, just on the topic of popular supplements, magnesium comes up a lot as well. So clearly all of our patients are reading the same nutrition blogs or the same sort of health magazine. But do you feel there's any benefit to supplemental magnesium? And if so, which types might be the most helpful?
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Magnesium is also critically important for bone, and about two thirds of our body's magnesium is in bone. It's on the surface of the bone and it is also involved in bone formation. So kind of similar to the vitamin K story, There is no doubt that magnesium is very important for skeletal health and especially for bone formation. The data on magnesium are extremely limited. Right now, we don't really have any evidence that supplements will improve any bone outcome, but it is very, very limited data. One potential benefit to magnesium is, and something I was warned patients about, side effect is it does tend to loosen stools. So for people who are having trouble with constipation from their calcium supplements, if they get a calcium magnesium combo supplement, sometimes that can actually help them tolerate it a little bit better. And on. If you look at population based surveys, magnesium is one of the nutrients that we tend to be low on. So typical intakes are below the RDA on average for magnesium. Again, it's another one that if you want to supplement a bit of magnesium, I think it's fine. I don't think it's, it's going to hurt. As I tell them, you know, stay RDA or less, which is around 300 milligrams per day. And if they're that much or less, I think they're probably fine and they're not hurting themselves. Just be aware for any potential GI side effects.
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A
That's really helpful to know. Rebecca, in speaking about balance, you mentioned how important that is in fracture prevention. Are there some specific exercises that patients can do to improve their balance and reduce fall risk?
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Definitely. So even strength training and resistance training, as I mentioned before, can have a carryover effect to balance. But you can also be just targeting your balance through the various systems. There are three systems of balance, visual, vestibular, somatosensory, proprioceptive. So working on any of these can be useful. But things that are really accessible would be something such as walking, tandem walking, like you're walking on a tightrope, Then you add in the or you mute even stimulus changes. So for instance, you turn your head, you close your eyes. Bringing in things like dual tasking is really effective. That's when you're doing more than one thing simultaneously and especially when one of those is a cognitive task. So for instance, you're walking on your tightrope, you're turning your head and you're counting backwards from 100 in increments of 6. So these are ways that you can make things challenging but also really effective. You can try standing on one leg while you're moving a limb, while you're tossing a ball. It's an example of dynamic balance. We've seen that dynamic balance is more important when we're looking at fall prevention than just static balance. So while it's useful to try standing on one leg, there's a greater relationship to falls when somebody has poor dynamic balance. Other things, especially if you're thinking of strength training, you know, things that are like lunges, those functional movements we were talking about, it's very useful and it's also very relevant. And how do you get up from the ground? Right? You might lunge or you might place one foot down and then you rise from there. So that's an example of a functional exercise that can carry over into strength training. Exercise that also utilizes balance. But then there's also things like dancing. Right. So one of the other big takeaways here is when it comes to consistency, people also have to consider, or we should be considering things that bring joy to people, what is enjoyable. So if you enjoy the exercise, you're probably going to be more likely to do it and then compliance comes into play. So dance is another thing that can be very effective because it can be a social activity. It's something that people might not think of as quite exercise if, if maybe they're resistant to doing other forms of exercise. And as I was mentioning before, there's things like Pilates, Tai Chi, yoga that have a really strong proprioceptive and balance component to them that is so helpful.
- [36:08]
A
Balance is really critical, I think for every single patient, but especially our older population that potentially may not be able to, to do as much in terms of the resistance or the weight bearing, but if their balance can be improved, you know, that's a huge step in fracture reduction. So that's very helpful. Dr. Sellmeier, back over to the supplement world, which is at our patients fingertips, especially with the wonderful Internet and all of the information it provides. Strontium is coming up more and more in conversations. When patients come in, they'll often bring their supplements in a little bag and show you these various concoctions that they may have purchased online or at a functional provider's office. Is there any role for strontium or for boron in the management of osteoporosis? And as Far as strontium goes, is strontium citrate any safer or better than strontium ranelate?
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B
So strontium ranelate is the only form of strontium that has any data at all. And so it was developed as a proprietary compound and available in Europe and it has good fracture data. So both spine fractures and a lesser extent hip fractures were reduced on strontium relate compared to placebo. After strontium ranolate was on the market for a few years, there was a reported adverse event that there were higher rates of thromboses on strontium renalate. So that was kind of added to the label in Europe. And then about 10 years ago in post marketing surveillance, it was demonstrated that there was a higher rate of non fatal myocardial infarction on the strontium renalate compared to placebo. Sorry to patients who were taking strontium la had a higher rate of not myocardial infarctions than the general population. And so at that point it started undergoing more intensive review by the EMA and more and more restricted. And the final ruling left it on the market, but recommended it really only be used in people who had no other alternatives for bone health. So the company that was making it in Europe stopped making it. And my understanding is it's available in a generic form in the uk, but that is the only place that strontium rhenolate is still available. So what's available on the Internet and in health food stores is not strontium renalate, it's strontium carbonate or strontium citrate. And there are no data on those preparations whatsoever. We have no idea if they do anything for bone or if the bioavailability is the same or what an equivalent dose is. We really don't know. And the other problem with those compounds is strontium incorporates into bone, so it incorporates into the hydroxyapatite crystal and strontium has a higher molecular weight than calcium. So when bone density machine does the X ray penetration and is calculating bone density, it's expecting a normal composition of hydroxyapatite. And so if there is a big fat strontium sitting there, the bone density machine interprets that as a huge number of calciums, not as a single big fat strontium. So it artificially increases bone mineral density. And in the clinical trials of the strontium remolate, they did bone biopsies and serum strontium levels and they tried to come up with some kind of calculation to correct the changes in bone density. Which were enormous in the trial to try and get rid of how much was artifactual compared to the strontium due to the strontium. And it's probably about 80 to 90% of the changes in bone density are artificial on strontium. And so if we have people sort of taking amounts of strontium from other corporations and we don't know how much bioavailability is, we don't know how much is in the bone, we're going to see, we could potentially see changes in bone density and interpret those clinically and they're really completely artificial. So I try to really steer people away from strontium. It's gotten easier because of the heart attacks and blood clots and all of that that led it to be restricted in Europe. So I can tell people, you know, messes up your bone density. There was higher rate of vascular issues and it's been withdrawn in Europe. And that usually will get people off the interest in stronthia. Boron. There's a lot interest in boron.
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A
We know a little about boron.
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There's not even an RDA for boron. So we have absolutely no idea what we should do with, with, with boron. There's a little bit of animal data. It may be involved in vitamin D metabolism or maybe important for stomal health in animal models, in vitamin D deficient animals, but there is just nothing we can really say about boron.
- [41:04]
A
Sounds like a data free zone for, for boron. So it's interesting how patients can really latch on to supplements. And, and it's understandable really because, you know, supplements seem safe, they seem more benign than a lot of the prescription medicines that we have. But it's always important to gently remind patients too that these supplements, so called supplements, are not FDA regulated, they're not FDA approved or monitored in any fashion. And so it always has to be safety first. And, and you know, if strontium is artificially elevating bone density, that's going to leave a lot of patients sort of unprotected when it comes to fracture risk. And that could really be harmful in the long run. So that's important to know. Rebecca, back over to you. Are there any common misconceptions about exercise and its role in osteoporosis management that you frequently encounter and how do you respond to those when you, you hear them?
- [42:08]
C
I do. And it's a really interesting time right now because we're seeing some of the misconceptions shift. So traditionally what we've seen is that Those with osteoporosis can't lift more than £20. That was a. That's been a common one, that if you have osteoporosis, you can't jump, you can't round your back, you can't twist at all. And as I was just pointing out, that has shifted quite a bit in terms of even recommendations. But these misconceptions still prevail. And yet we're also seeing the opposite side. So it's kind of extremes. Now. What I'm starting to see a lot of is that everybody must lift heavy. Lift heavy weights. What does that mean? First of all, it's relative. They're really referencing the high intensity that I was talking about previously. So, you know, it's. So much of this is based on the individual as well. And I think that's one of the biggest things, is that people are trying to make very blatant statements, not recognizing that osteoporosis is extremely individual. I was diagnosed when I was 28 years old, and I certainly. And even if I had the exact same bone density, I. As somebody who was several decades my senior, there are so many other factors that are at play. I'd had no fractures. Right. That's one thing to consider. But certainly also function is a huge thing. And I think when it comes to osteoporosis from the exercise standpoint, our approach as whether you're an exercise specialist or you're a physical therapist is very different from that of a physician because I. Our primary lens that we're looking through is function. How does that person function? Because that's going to completely dictate what is the appropriate course of action for them. So it might not be appropriate for somebody who has had multiple compression fractures to be jumping, whereas somebody who has. Who even has a T score of -2.5 and yet has been exercising for a while, has been conditioned up to the point where to be safe for them to be doing jumping exercises. It's totally fine. So it really does depend on the individual. But I would say being cautious of any kind of extremes because that really never takes into account what is going on on an individual basis.
- [44:38]
A
That's really helpful to know. And as sort of a tie in to all of this talk about exercise and muscle. Dr. Selmeyer, talk to us about sarcopenia. So sarcopenia has also kind of come up and been more. More of a focal point when we're discussing aging the elderly and osteoporosis. And sarcopenia often accompanies osteoporosis do you recommend any specific amount or type of protein intake each day for your patients? Does animal versus plant based protein matter?
- [45:14]
B
I could, I could talk to you about protein for probably a full hour. And there's a lot of very, very interesting protein data. Establishing protein requirements is extremely difficult because protein requirements are established by doing nitrogen balance studies. And in order to do nitrogen balance study, you have to bring the person into neutral balance. So if you bring them into neutral balance and then you do nitrogen studies to determine their requirement, does that really reflect their endogenous state where they were nitrogen losing before you brought them into balance to do the study? So, so establishing protein intake requirements is very, very difficult to do. So there's one RDA for everybody and that's 0.8 grams of protein per kilogram of body weight. And that's the same if you're, you know, an 80 year old frail person, or if you're a toddler, or if you're a supo wrestler. It's exactly the same. And I think we all recognize that is not probably appropriate. And so there are a lot of settings where people need more than that. People who are very physically active, long distance runners, older folks, you know, there's a lot of people that we're pretty sure need more than that. But what they do need is not clear. So kind of the best assessment for older folks, they probably need somewhere maybe 1 gram per kilogram, maybe even up to 1.2 grams per kilogram of body weight. And probably depends also on your goals. Are they losing muscle? Do they have low bone density? You know, what their overall, are they underweight? What their overall nutritional status and goals are. But they probably need more than that 0.8 grams that we sort of quote for everybody in terms of animal and vegetable, in terms of getting enough protein and protein for bones, it probably doesn't matter. The animal protein story really goes back kind of the acid base balance in the diet. And so it doesn't really matter where you get your protein. I think the more important feature is make sure you're getting enough base. And base is really alkaline potassium compounds in fruits and vegetables. So you get your protein wherever you want. I think the more important thing is that we are nutritionally, we are not really rich in fruits and vegetables for a variety of reasons. It's better to increase levels, but one of them is because that increases the amount of base in the diet. We have a reasonable amount of evidence that a high acid diet, a net acid producing diet, probably does have a detrimental effect on bones and using alkaline potassium supplements. It's one of the few nutrients. We actually have some decent bone density data showing improvements in bone density with alkaline potassium compounds. So I think there's definitely a good bit of evidence that having an alkaline based diet is probably beneficial to bone. And it'd be wonderful to be able to do a fracture trial. But those are so big and so expensive and I and others have tried to get those going and there's just not enough public interest in trying to do a fracture trial with alkaline potassium compounds. But after calcium and vitamin D, the alkaline potassium compounds have the best data and they would by far be the next most likely candidate to pursue a fracture trial. So I hope that will happen at some point. But for now, I think the data are telling us that from a protein standpoint, either animal or vegetable sources is totally fine. But what's probably important is to increase the amount of base in your diet. And that can be done by consuming potassium freezed fruits and vegetables.
- [48:46]
A
Fantastic. And now I'll throw you a bit of a loop here, and that is prunes.
- [48:51]
B
I've got the prune data. The prune data are some of my favorite data. I don't know what's going on with prunes, but prunes are accumulating a decent amount of data in terms of bone turnover markers and even some bone density data. So I do not know what is up with prunes, but they have some, some backing behind them and I can't leave any downsides. They're reaching a lot of flavonoids, they're rich in potassium, so I don't know what the active compound is, but there is no problem having some prunes because they actually have a fair bit of data.
- [49:24]
A
I love that. And that will also help with constipation, maybe from, from the calcium intake. But I just want to thank both of you so very much. This has been fascinating. I'm here with Dr. Deborah Cellmeier from and Rebecca Rothstein of Buff Bones. And I think we've had just a great conversation on bone health optimization with food and fitness. So I want to thank both of you so very much for your time and thanks for listening to this ACE podcast.
- [49:56]
B
Thanks for listening to another great ACE podcast. Join us for another episode@aace.com podcast and help us in our mission to elevate clinical endocrinology.
- [50:07]
C
Together we are ACE.