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

Episode Date: August 2, 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. And that brings me to this stage, which is our timeline. So the first stop on our journey through our timeline is the prenatal period. And it turns out that for births occurring in winter, vitamin D supplementation actually increased neonatal bone content by almost 10% for moms who are just taking only 1,000 international units of vitamin D. And what about preterm births?

Well, it turns out 80% of the neonatal body's calcium actually accumulates during weeks 36 through 38. So in preterm babies, especially those with very low birth weight, had an increased risk of osteopenia and osteoporosis. So it's recommended that mom takes calcium and vitamin D and that the baby have weight gain and eliminate fat, sugar, and carbonated sodas so that they don't have as much osteoporosis and osteopenia. Well, our children now are taking so many ADH medications, so many stimulants. In this study, looking at a group of individuals between the ages of eight and 20 who were only on stimulants for at least six months, they had 4% lower bone density of

the lumbar spine and nearly 4% lower bone density of the femoral neck compared with non-users. The pediatric endocrinologist in the study stated that failure to attain appropriate bone density by these young adult patients puts them at increased lifetime risk of factors and osteoporosis. And the mechanism that was cited was increased sympathetic outflow. When you take an adrenergic drug like that, it causes the blood vessels to constrict and you're not going to get good blood flow to the bones. And remember that that period of time is so critical because that's when we develop the majority of our bone mass. And another critical time during our teenage years is if we start smoking, because women who smoke actually reach menopause up to two years earlier than non-smoking women. And men can increase the risk of osteoporosis by 230%. Now, part of that is the lack of blood flow, of course,

because of the vasoconstrictive nature of smoking, but also cadmium is a toxin that's found in cigarette smoke. And it turns out that that stimulates osteoplastic activity and inhibits the inactivation of cortisol. And cortisol is our own endogenous steroid, too much of that, and we have poor bone density. Nicotine is also found in smokeless tobacco, as well as regular tobacco, and it depresses osteoblastic activity and increases the rate that estrogen is cleared from the body. And you can see there that that kind of makes sense for why menopause would be earlier and also why there's so much infertility in smokers.

It turns out that the level of cotinine, which is that breakdown product of nicotine, is inversely related to bone mineral density. That's how close the association with is. But the good news is for smokers, if they quit smoking, that can actually build their bone back like our patient did, Lucy. Now, what about inflammatory bowel disease? For a lot of young adults, it's in that young adult period that their condition is first diagnosed. We're talking about ulcerative colitis and Crohn's disease. What they found was in the trabecular bone and the micro architecture of bone is

greatly diminished. And so much so that in these young people, they actually have bone densities that look like women 10 years after menopause. It's pretty shocking. There were, in this particular study, 37 of the individuals had clinical fractures, mostly the forearm, but five of those actually had vertebral fractures. And those are fractures we usually think of in the elderly. They felt that this was both nutritionally based and also all the inflammation that was going on was impacting bone density of inflammation and poor absorption because of the impact of the gut dysfunction. And so their recommendations are going to be similar to our gross B mnemonic, which is, you know, eliminating smoking and alcohol, but engaging in more physical

activity and certainly decreasing glucocorticoids, you know, the steroids and making sure they have enough of their nutrients and testing for nutrients like vitamin D and calcium. What about anorexia or other ovulatory disturbances where women don't have their period? It turns out that adolescents are going to have decreased rates of bone accrual during this period of time if they're not having periods. And again, this is the period of time where we're supposed to be building bone. It was recommended that young people regain weight and start having their menstrual function back because when that happens, they'll be able to build bone again. It was recommended that in patients that are not of childbearing age,

they can take bisphosphonates. But for young people who are planning on having children, they do not recommend bisphosphonates. And what about these subclinical ovulatory disturbances where there are drops in progesterone, which could lead to a short luteal phase? It was found that even if you still have your period, but this is going on, then you actually are going to have a decrease in bone density up to 0.9% each year. And so these are sort of subclinical ovulatory disturbances really underlines how important progesterone is not just estrogen. And what about alcohol, a lot of people in young adulthood and early adulthood, they start drinking more and more. And those who drink more than about 29 drinks a month, will find that they'll have a decrease in bone density also can affect the gut

microbiome. But it was actually found that the resveratrol and red wine and the silicon and beer actually has a actually a beneficial effect on bone density, but you have to limit it. It's a bit of a slippery slope for those who drink too much. If they're going to undergo organ transplantation, if they destroy their liver, that is also associated with an increased risk of osteoporosis. In fact, all of the solid organ transplants have that. And it was felt that that was due to immunosuppressant therapy, probably being on steroids, and also the malabsorption and malnutrition that goes along with these major organ transplantation surgeries. What about surgeries to limit how much we absorb on purpose, like the Roux-en-Y gastric bypass,

the sleeve gastrectomy, and the adjustable gastric band. This was a pretty amazing study when you consider that it was only looking at between six months and a year, and they found this much decrease in bone mineral density among patients who had the Roux-en-Y. In patients who had just the sleeve gastrectomy, there was still significant bone loss in just that first year, even with the adjustable gastric band. So in every case, there was a loss of bone density. And it was recommended that these patients really pay attention to certain mineral absorptions and vitamin D. And in our patient, Lucy, remember, she never had children. So she was considered nulliparous. And in nulliparous women, they can have a 44% increased risk of hip fractures,

independent of their current bone density. All that estrogen that's released while we're pregnant actually is great for bone density. So as women get pregnant, with each pregnancy, there's a reduction in hip fracture risk by 9%. What about the age of menopause? So it turns out for women that go through menopause before the age of 40, even whether or not they're on hormone replacement therapy, they can have an increased fracture risk. So early menopause is an independent risk factor for bone density issues. And this is a conversation that in this particular paper, they recognize that people don't have this conversation. It's not something that we ask women, you women, have you gone through menopause yet? And it's important to know because it can help stratify

who's at higher risk for bone density issues. And the sooner we get involved, the better. Because remember, after the age of 50, there is that natural age-related bone loss. It doesn't have to be severe if we take action. But if we compound that with an early postmenopausal, that deep, steep drop off in bone density, if that happens early on, you're going to see somebody who may have to go on either medication or suffer the consequences of fractures.

And what about certain conditions that really only occur in women and only occur after the age of 50? And I'm speaking about primary biliary cirrhosis. So this is a condition that really hits women versus men about 10 times the amount. And also it occurs in mid to late fifties. This is also when a woman's going through menopause. So it's like a perfect storm. And osteoporosis is very prevalent in people that have this deep and prolonged cholestasis.

And what that means is this is the beautiful biliary tree that exists within the liver. And if this is obstructed, we can actually damage the liver in addition to not being able to absorb our fat soluble nutrients like vitamins, A, D, E, K, CoQ10, fat soluble, important fatty acids like fish oil. So we have to make sure in those patients that they're getting the nutritional support that they need. And they do recommend in these patients, if the nutritional and fat-soluble supplementation doesn't do the trick, they may have to go on bisphosphonates. So, what about as we go through the timeline, postmenopausal issues like breast cancer? This is when a lot of women, if they're going to get breast cancer, this first starts happening.

And osteopenia and osteoporosis are well-recognized side effects of aromatase therapy, which a lot of patients do go on. There are some other adjuvant therapies that will lead to increased bone loss and a higher fracture rate as well. And there's even a condition, they call it actually cancer treatment-induced bone loss. And that's how common that it happens because they've really suppressed the ovary. And without that estrogen, there'sinduced bone loss. And that's how common that it happens because they've really suppressed the ovary. And without that estrogen, there's going to be bone loss.

And then when you compound that with chemotherapy and inflammation and radiation treatment, these women are at high risk for bone density issues. And also when they're on aromatase inhibitors. So let's talk about now, having thought about all the things we've gone through in the timeline and all the imbalances that can occur, all the triggers and mediators, how do we organize that so we can remember it? And we're going to put it in that, that grows B mnemonic to hang onto it. We'll start with G, which is gut digestion absorption. And these are some of the conditions that are absolutely associated with loss of bone density and osteoporosis. And to be thinking

about that, any of these conditions really affect the digestion absorption of critical nutrients that we need. Even things like small intestinal bacterial overgrowth, for example, which is known as SIBO, or we've, we talk about leaky gut, intestinal permeability. Those are also associated. Acute pancreatitis is a severe issue for a lot of patients. You've probably heard a lot of the commercials about exocrine pancreatic insufficiency or EPI. That can also be associated with bone density loss. But in acute pancreatitis, these patients have a higher risk of osteoporosis, particularly if they are women and particularly if they are in that postmenopausal age group.

If they've had several episodes, that increases their risk of osteoporosis more and more. This is a study that looked at children that had been screened for celiac. Now, they didn't have symptoms of low bone density, but they analyzed these children with celiac compared to patients that didn't have celiac. And they found that celiac disease patients had reduced bone mineral density. They had less vitamin D, higher parathyroid hormone levels. You know, parathyroid pulls the calcium out of the bones to keep the calcium levels stable throughout the body. And they also had increased systemic levels of different types of cytokines. And think of those as really inflammation, almost chemical inflammation within the body. What they did though, is they took these children and put them on a gluten-free diet and then

re-examined them at a period of time later and found that those children later, once they were eliminated gluten, had no difference in bone mineral density, vitamin D levels, parathyroid levels, and their cytokine levels were indistinguishable from the controls. So that's good news for those of us who may have gluten sensitivity or even celiac disease to eliminate gluten. Think of gluten as a saboteur of bone density. What about the use of proton pump inhibitors? Now, these are medications that are passed out like candy in the medical world. And this is a study

looking at young adults. These are adults that should not have bone density issues. When they place these young adults on proton pump inhibitors, they found that in children below the age of 18, there was a suggestion of lower bone density, but it wasn't quite significant. In children between the ages of, or young adults between the ages of 18 to 29, there was a significant increase in bone density and fractural rates on those who were on proton pump inhibitors. So let's look at Marcia. She's a case of a patient who saw a colleague of mine originally, and she was an allopurus postmenopausal woman who had had osteoporosis and did not want to go on bisphosphonates. She was very thin, very small frame. She was taking an NSAID called diclofenac, which is known as Volterin, and some migraine

medications, but that was about it. So she was placed on an anti-inflammatory diet and some multivitamins that had a lot of bone building nutrients in them. She was given an anti-inflammatory food that had a lot of turmeric in it. We know turmeric is very helpful. She was given vitamin D3 and K2 and omega-3 fatty acids. She was asked to walk every day to reduce her stress, improve through breathing exercises, and to decrease her Voltaren or Diclofenac. And our goal would be, of course, to eliminate that if possible. She was began on a very small amount of estrogen and progesterone, and she found that her sleep improved with the bioidentical hormones. We also gave her magnesium. So as you see here, this is where her

bone density had gotten to, and this is what triggered the need for the bisphosphonates. She started working with the physician and in two years saw an improvement in her bone density. I first met her around this time and was so impressed with the amount of bone density that she had been able to regain without being on bisphosphonates. But unfortunately, in 2014, she started having reflux and nausea symptoms. And it was at that point that she was placed on Prilosec, which is a PPI. And also she was diagnosed with non-dysplastic Barrett. So in other words, she had some changes that were concerning, but did not look cancerous at that time. She also underwent a cholecystectomy, which can sometimes affect your absorption of fat soluble nutrients. Not always, but it can. She'd lost 10 pounds and now her BMI was, she was even

tinier down at 18.5. So I was really concerned about her and I didn't want her to lose the gains that she had made in her bones. I said, let's do a functional nutrition test and see what you actually need rather than just throw a million things at you. Let's make sure we have some precision in deciding on what you actually need. And what we found through this blood and urine test was that she was indeed low on her B vitamins, as well as several minerals that are very important for creating bone density, as well as vitamin D. Her vitamin D had dropped off. If you notice here, she actually had markers of malabsorption, which made sense because she was on the PPI. And she also had a dysbiosis.

There was an imbalance in the bacteria in her gut. So when we retested her before we took too much action, but we retest her, you can see she did have a drop off in her bone density, certainly the vertebral spine, although her hip bones were staying stable. So when I saw those findings, I said, let's do a stool test and see what's going on in your gut and see if we can fix this malabsorption, this dysbiosis. So in 2015, we had her do that test. And we also asked that her primary care doctor try to switch her from the PPI to just a less harmful Zantac, which is just an H2 blocker. And she was able to be asymptomatic just on a small dose of the H2 blocker. We restarted her bone building multivitamins and kept her on her hormone replacement. What we found in her stool test was that indeed she had low levels of elastase. Now that's a pancreatic enzyme that's

very important for the absorption of nutrients. She also had a lot of fat in her stool. So that probably explained why her vitamin D had dropped down despite taking it. She's not absorbing fat soluble nutrients as well. She also had a high beta glucuronidase, which suggests a dysbiosis and can be a concern when patients are on hormones because beta glucuronidase went high means that her detox pathways are somewhat blocked. So we also found that she had H. pylori, but her gastroenterologist did not want us to treat her for the H. pylori and refused to treat her. So instead, we did everything else that we could to try to help her, including saccharomyces

boulardii, which is a very good, I call it a profungal because it's actually a yeast that helps protect the gut lining. We gave her those bone building nutrients and calcium deep lucrate to help her with detoxification, bile acids to make sure she could absorb all those fat soluble nutrients. And when we retest her, she had a significant improvement in her bone density. And again, we didn't give her a drug. We actually gave her what her body needed so she could do what she needed to do to build bone. And in the future, we actually continued to follow her. And unfortunately, in her last bone density test, they did not measure L1 and L2 and L3 separately.

They combined them and gave us an average, which actually, again, looked very good. And the neck of both the left and right femurs continued to maintain steady without falling into clear osteoporosis. So she hasn't had to go on a medication. It's now been 11 years since her first bone density test. 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.