The Dr. Hyman Show - Dr. Hyman+ Functional Medicine Deep Dive: Osteoporosis Part I

Episode Date: July 5, 2022

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Hey podcast community, Dr. Mark here. I'm so excited to offer you a seven-day free trial of my revolutionary new platform called Dr. Hyman Plus. For seven days you get special access to all the private content included in Dr. Hyman Plus entirely free. It's so easy to sign up. Just go to Apple Podcast on your phone and click try free button on the Doctors Pharmacy podcast. You'll get exclusive access to ad-free Doctors Pharmacy podcast episodes and functional medicine deep dives where a practitioner dives into topics like heart health, muscle health, insulin resistance, and more to help you understand the root cause of specific ailments and walk you through the steps to improve your health today. You'll also get access to all my Ask Mark Anything Q&As,

where I answer the community's biggest health and wellness questions. Because I'm so sure you're going to love this platform, I'm offering you free access to all of this content for seven days and a teaser of my brand new functional medicine deep dive episode diving deep into one of the most important topics in health. Head on over to the Doctors Pharmacy podcast on Apple podcast and sign up for your free trial right now. Okay, here we go. So we've already covered this first part of our agenda, which is why osteoporosis prevention and treatment are so incredibly important to us and to our loved ones. But we're also going to go over why this is such a silent disease that's so widespread. And we're going to look at a special

focus on men because men I think are often not considered when we're thinking about osteoporosis. What are the risk factors and root causes of osteoporosis? And we're going to introduce functional medicine tools. This is the fun part. We're going to look at how we can use a historical timeline to help identify what are the predisposing factors? What are some of the events in our life that might trigger osteoporosis? And what tends to perpetuate the condition. We want to organize

this in a way that we can easily remember what imbalanced biologic processes we might be able to actually correct by leveraging modifiable lifestyle factors. And we want to apply specific functional medicine labs so that we can offer precise treatment plans and also confirm that the treatment plans we've offered are appropriate for the individual. We'll review some of the current pharmacologic treatments. And we'll also, throughout the entire presentation, we're going to look at some inspiring true case reports. So this is a fascinating study that was presented back in 2010. And it shows how we're very concerned about breast cancer in this country, and we sort of ignore osteoporosis. Well, I want to show you that the cases of osteoporosis actually dwarf the cases of breast cancer.

In fact, if you add both stroke, heart attack, and breast cancer together, they all are dwarfed by the cases related to new cases of osteoporosis. In fact, by 2020, it was expected that there'd be 12.3 million people diagnosed with osteoporosis. Now, you know, the CDC has been very busy lately with the pandemic, so we don't really know what those numbers are just yet. I do want to point out, though, that in the white and Asian population, that's the group that's at the highest risk. But osteoporosis spares no ethnic group, and we need to make sure that we're checking it out for all of our patients regardless. In fact, in 2017 and 2018, these are the latest figures I could find on osteoporosis. And you can see that almost a third

of women over the age of 65 have osteoporosis. Now there's a much fewer number in men, but we don't need to ignore men because they also can have osteoporosis. But what if we got involved earlier and looked at low bone density? So low bone density actually impacts over 50% of women over the age of 50. But look how many men are involved. So men actually can have low bone density at the age of 50 at almost a third. And then almost 41% of men over the age of 65 have low bone density. Now, the U.S. Preventative Services Task Force actually indicates that women over the age of 65, because they need to be checked, need to have bone density tests. But they also will point out that women that have increased risk factors need to be checked as well. We're going to talk about what those risk factors are.

Sadly, the same organization recommends against routine DEXA screening for men over the age of 65, and it was due because there was just insufficient evidence to balance the risks and benefits of treating osteoporotic fractures. But I want you to remember that. What are the risks of treating? What could they possibly be? In this study, or actually it's a review article by Renan Anopoli, who is an Italian here in the United States, he states that osteoporosis in men is underestimated, underdiagnosed, and undertreated. And that's pretty shocking when you consider that roughly 29% of osteoporotic fractures in the U.S. are actually from men. And if you're a son of an osteoporotic woman, you are at high risk for having early bone loss, and that's unrelated to your actual age. Men have a higher fracture-related mortality rate.

I mentioned that earlier. In fact, their 10-year mortality rate is almost 10% higher than women. And in hip fracture hospitalizations, the mortality rate is 10% versus 4.7% in women. And after hip fracture, only 8% of men actually receive osteoporosis treatment as compared to almost 25% of women. So there's a real discrepancy, and I really want to bring that to the forefront. In order for us to understand the differences between men and women when it comes to bone, we do have to understand a little bit of anatomy. And this is what this actual schematic is designed to show you. So I want to show you that the periosteum, which is here, the periosteum is the fibrous membrane covering the

outer surface of all bones. Now that inner membrane, which protects our bone marrow is called the endosteum, right? The trabecula, which many of you have heard about are like the struts that exist within the bone and like an airplane wing, which is very light, but has the ability to support the entire airplane full of people, those struts in between the wing actually is what gives it so much support and structure and yet keeps the wing so light. Our bones are similar to that. They're very light, but they have incredibly good support. And that's through this series of columns and rods and connective tissue. So the trabecula is very important. And we'll talk about the difference between trabecula and cortical bone. Now the cortical bone is this outer bone here, and you can see the blood vessels

running through it because the blood vessels need to feed that trabecula. The trabecula will be cleaned through the osteoclasts. And we'll talk about that in just a moment. So what are the differences between men and women when it comes to osteoporosis? Well, it turns out that men, their trabecula tend to thin out a little bit more, but their connectivity is maintained. And what I mean by that is those columns and rods don't break. They don't diminish. They're just thinner. And women, as they age, they actually have less connectivity. And that makes them at higher risk for bone density consequences, which would be fractures. And they also start out with decreased trabecula to begin with. Now, men have

that thicker periosteum, and they also have more trabecular surface. Unfortunately, women have a thinner periosteum and they have smaller diameter of bones to begin with. I mean, look at your husband's hand versus your hand. The bones are smaller and they have earlier bone resorption. There are also characteristics that make women at higher risk for falls.

So you can see why we put so much attention in women. I just don't want us to ignore men. Now we're going to start talking about root causes right now. 65% of the root cause in men is due to extra skeletal causes. So this means something that they're doing outside of the body that's impacting bone density. In women, it's only about 20 to 40% due to extra skeletal causes. And that's likely because the majority of bone loss is really due to menopause. And if we think of menopause as hypogonadism, in other words, a loss of our sex hormones, that's that area where we really start to lose bone density.

In men, only about 20% of osteoporosis is due to a lack of sex hormones or hypogonadism. Now, testosterone in a man is inversely related to their fractural risk. In other words, the more testosterone, the less likely they would fracture. Remember that testosterone in men stimulates bone growth, and it also stimulates muscles. And muscles help support the bone and pull on the bone, help drive blood flow to the bone. So muscle development is really important. And that's why in women, we need to make sure that they have some testosterone as well, because it also by increasing muscle mass supports the bone as well. Now, aromatase deficiency is a genetic condition that some men can have. And when they don't have enough aromatase due to a mutation in the CYP19A1 gene, they can actually have higher risks of bone density issues as well as cognitive

decline because estrogen is so important for the brain and the bones. Okay. Something to keep in mind. Now, men at age 70, according to these two studies that I'm showing you, which are recent studies, I always like to show recent studies, they're 2021 studies. And they show that they really recommend that at the age of 70, men should get a DEXA screen. And right now, only about 11% of men are being screened. Whereas with women, as you saw from the earlier slides, women are recommended to get DEXA screens at about the age of 65, unless they have a lot of risk factors. And at that point, we could justify getting their screens done earlier. Now, I want to teach you a little bit about why this aromatase enzyme is so important. Both men and women have adrenal glands. and if their adrenal glands are functioning well, those adrenal glands can produce DHEA, known as dehydroepiandosterone.

That actually gets converted in both men and women to androstenedione and testosterone. These are two very strong androgens. In the body, through the action of aromatase enzyme, those androstenediones and testosterone get converted into estrogens. And we're going to find out how important estrogen is to bone density, as well as the brain. But what can happen is if we are exposed to things that inhibit aromatase, which could be these drugs like tamoxifen, both men and women take tamoxifen often for cancer reasons, or they're on metformin or ketoconazole.

There's a long list of drugs that can inhibit aromatase, or they're engaged in smoking or exposed to dioxin. Again, other pollutants can inhibit aromatase, but they might have a gene mutation. And those genes can be seen through companies like Intellex DNA, which can show us whether or not that DNA mutation is present and we can actually treat it early on. But if we have an aromatase inhibitor or a lack of that particular aromatase enzyme, then by blocking the enzyme, we can't produce estrogen. Now, estrogen is incredibly important because it limits this receptor activator for nuclear

factor kappa B. It's called RENCAL. You'll hear a lot about that because it's the target of a lot of drugs for osteoporosis. But estrogen also stimulates osteoprotagrin, which is actually very good for us. It helps sort of stimulate our osteoblasts. You're going to need to know the terms osteoblasts and osteoclasts. Osteoblast build bone. That's an easy way to remember it.

And osteoclast clear out or cleave bone. They actually clear the old, dead, nasty bone away so that new bone can be replaced. Think about that airplane wing. Imagine if some of those struts broke through wear and tear. You would want to have new struts placed so that wing is just as stable and secure as it was in the past. And that's why we need some osteoplastic activity. We just want that balance. We want enough bone building to balance the amount of bone clearing. So I want to show you this graph. This is just a representative graph of what

happens to most human beings. You can see that the greatest period of rapid bone growth happens around puberty. That's when we're really solidifying our bones, lengthening them and solidifying them. But the most rapid bone loss occurs during menopause. I mean, look at the steep decline, look at that curve really fall off. And so what I find interesting is that in both men and women, as they age, their estrogen levels tend to drop off. And estrogen is so important for bone density. We just reviewed why. And so in both sexes, there is an age-related decline in bone density, and that leads to increased bone resorption. In other words, increased activity of the osteoclasts, right? Because you don't have the estrogen. And that leads to increased bone resorption. In other words, increased activity of

the osteoclasts, right? Because you don't have the estrogen and also impaired bone formation because you don't have the estrogen and protagrin to stimulate and recruit those osteoblasts, the bone builders. Now this impact really hits women, you know women harder, especially during that menopause where that slope just drops off like it's off of a cliff. Think about what is recommended right now from the U.S. Preventative Services Task Force. Remember, they want to check your level of bone density at the age of 65. As you can see, that's really after most of the bone density has been already taken place. And at that point, it's not surprising that so many women have to go

on medication because we really haven't caught them early enough, have we? But when is the most common age for menopause? It turns out it's about 50 and a half. Okay. So at 50 and a half, we're actually catching women right as they're starting to fall off that cliff. What if we checked their bone density earlier? And what if we started to take action to improve all the things that can improve bone density so that we don't necessarily eliminate all bone density loss, but we bring that curve back up. We sort of blunt the curve, if you will. And what if we as women and men as well, really try to work hard to improve our bone density for the rest of our lifetime? Maybe there'll be a decreased slope of age-related bone density loss. And with that, we might be able to maintain our bone density and not have

to be placed on medications that have so many side effects. Well, that's been my goal. In conventional medicine, what they've taught us to do is to look for signs of this silent insidious disease. And the sad thing that happens is once we see those signs and what we call that that dorsal kyphosis, the dowager's hunt, here's a picture of a man who has it. And I know you've seen this also in women quite a bit, but both men and women can have it. At that point, there's already a lot of vertebral bone loss. In fact, another way of picking up on this silent disease is by looking at the loss of height. Loss of one and a half inches raises the concern that there's

already been some vertebral fractures. Other signs of osteoporosis could be tooth loss or more dental cavities or skeletal pain due to fractures or frequent fractures happening more often. But this is all really too late, isn't it? So what if we could identify the risk factors for osteoporosis and intervene before they fracture and lose teeth and height and function? Well, I hope you enjoyed that teaser of exclusive content that you get every single month with Dr. Hyman Plus. If you want to listen to the full episode and get access to ad-free podcast episodes, plus Ask Mark Anything episodes, plus monthly functional deep dive episodes,

I guess that's why we call it Dr. Iman Plus, then head on over to the doctor's pharmacy on Apple Podcasts and sign up for your seven-day free trial. Hi, everyone. Just a reminder that this podcast is for educational purposes only. This podcast is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical or other professional advice or services. If you're looking for help in your journey, seek out a qualified medical practitioner. If you're looking for a functional medicine

practitioner, you can visit ifm.org and search their Find a Practitioner database. It's important that you have someone in your corner who's trained, who's a licensed healthcare practitioner, and can help you make changes, especially when it comes to your health.