Bone Health : Survivorship / Survivorsh!t:

Leah 0:00

for every one of these episodes, can we just come on and say, inflammation?" And then that's it. We just like, we don't have to record anymore. Just, just, just focus on, on anti-inflammatory diet and, and you're good.

Tina 0:13

Yeah, we could just do a, um, lower systemic inflammation and then I don't know what the sound is for a podcast, but basically a mic drop right after that

Leah 0:21

Yeah. And then we're done.

Tina 0:22

We're done we're out.

Leah 0:35

Hi Tina. Hey Leah, how's it going? it's a beautiful sunny day here in Portland and we're going to be talking about bone health.

Tina 0:44

I'm excited to talk about this. I feel like it's one of those things that people can really grasp understand, and then they can do whatever's needed for their own bone health. because it's physical and it's not too abstract. It's easier to understand than some other things that we talk about.

Leah 0:59

Kind of across the board. I mean, anyone who's been through treatment for cancer in some way, their treatment may possibly have affected, bone density through a number of different mechanisms. And so, yeah. Hopefully, people get stuff out of this episode.

Track 2 1:14

And can I add, this is not just cancer care. This is inevitable if you live long enough. You have bone loss after a certain age. So a lot of things are going to talk about would be relevant for everybody as we age.

Leah 1:27

Oh yeah. Oh for sure. But before we do start, I wanted just to kind of talk about the song, our unofficial theme song for today. And it was a song I'd never heard of. I was like doing my search for songs, with bones in the title. And I came up with a song called The Bones by Marin Morris.

Track 2 1:50

Okay, of course. I've never heard of that.

Leah 1:52

it's a pretty good song. I think you'd like it. And what I liked about it is it's not, they're not actually, you know, she's not actually singing about bones, but she's referring to the bones as like a foundation of a relationship. And I mean, the bones are the foundation of our body, right?

Track 2 2:08

Yeah. At least the mechanical aspect.

Leah 2:11

Yeah. I mean, yeah. It keeps us upright. And ambulating and whatever it is that bones do. We're not rubber chickens here.

Track 2 2:21

That's a funny visual

Tina 2:22

picturing a rubber chicken.

Leah 2:24

That's, that's, that's what came into my head. So the most foundational part of bone health would be understanding, how is bone made? I mean, in order to know how bone gets lost, it'd be good to know how bone is made.

Track 2 2:39

Yeah. So I think a lot of people probably imagine that once you grow into an adult, you have your framework, you have your skeleton and there you are for whatever number of years or decades, you're on the planet thereafter. But in fact, it's actually much more dynamic than that. It's not a static thing. It's constantly being broken down and rebuilt. And I think. Is underlying everything we're going to go ahead and talk about today, which is your bones. As we speak are being chewed up by one cell set called osteoclasts and bone is being laid down by another set of cells called osteo blasts. So the rate of each one, determines whether you're building bone. So you're building bone when you're young, of course. And through your twenties, even your laying down bone, that means your osteoblasts, which lay down the bone are functioning faster. And there's a good number of them relative to the breakdown, the osteoclasts. So after about the age of 35, it switches in women anyways, it's 35. So after the

Tina 3:42

age of 35,

Track 2 3:43

the osteoclast begin to function at a faster rate or their population is higher. However, you want to say this, but you basically break down bone faster than you can lay it down after 35.

Leah 3:56

So young.

Track 2 3:57

Yeah. We lose, a large amount of estrogen as women when our estrogen stops being made. Right. So estrogen is one of those. We're going to talk about hormonal influences, but we kind of think about bone loss as a menopausal perimenopausal post-menopausal thing that happens that is called an estrogen bone packet. In other words, if it's a natural menopause over the three to five years that it takes to go through menopause. A packet of bone, um, rather precipitously, and then you level off again. Cause when estrogen goes away, you lose a bunch of bone very quickly and then it levels off. You don't continue on that trajectory on a downhill slope. So the percentage wise, you might lose a larger percent when your estrogen is no longer being made by your ovaries, or you go through a surgical menopause, a chemical menopause, which is chemotherapy can put some people into menopause. So that particular packet of bone is lost during that time. And then you kind of resume the pre menopausal state of bone loss.

Leah 4:58

So even when someone goes through menopause, naturally, you still have a short period of time that the bone loss occurs.

Track 2 5:06

Yes.

Tina 5:07

Interesting. So you, so if you're losing, say you're losing 1% a year, normally during the time of estrogen deprivation or deficiency, you might lose 2% or 3%. You're going to basically the decline is going to be faster.

Track 2 5:21

So these osteoclast and osteoblast are constantly chewing up bone and laying down bone, chewing a bone and laying down bone all of our life. And we can affect it when we're going to talk about what affects bone health. But just remember what we're doing ultimately is influencing this balance between the osteoclasts and the osteoblast. Now I probably should give you the, the way I've always remembered osteoclast because these two words are so similar. There's

Leah 5:49

And they don't make sense. Like you, you think osteoblast is like, you're blasting a building and it's like being destructed. I know these I've talked to about this before. Like those words just throw me every time

Track 2 5:59

Yes. Yes. The osteo blasts are actually laying down bone

Leah 6:04

they're building bone, the blasts build bone.

Track 2 6:07

They're building the bank of bone. There's a lot of BS. They can, a lot of alliteration we can use to remember osteoblast or building bone bank and the osteoclast think of the sea, like a Pac-Man right. So a sea like the Pac-Man at the arcade we used to play Pac-Man right

Leah 6:27

back in the day.

Track 2 6:31

back in the day when we put a quarter in, so the little Pac-Man eats the bone, right? So

Tina 6:37

you have a "C" for osteoclasts.. That's how

Track 2 6:39

I

Tina 6:40

have always remembered it.

Leah 6:41

Perfect. I feel like we need the Pac-Man music in

Track 2 6:49

Yeah.

Leah 6:49

the background. So I think it's a perfect time to start talking about risk factors.

Track 2 7:00

Yeah. So risk factors in general for osteopenia and osteoporosis, which we probably should define. So osteopenia is defined as a certain amount of bone loss reflected on the DEXA scan and without going into too much detail about what these scores mean, there's a T score and a Z score on every DEXA scan and the T score reflects one's bone mass compared to a healthy 30 year old female. If it's we're getting a female DEXA scan. If it's more than negative one. So if it's between negative one and negative 2.4, it's osteopenia every flex, a certain amount of bone loss. If it's 2.5 or below, then it's osteoporosis. So it means there's even more bone loss. And all of this is relative to a T score of zero, which is a healthy 30 year old female skeleton.

Leah 7:51

That is a perfect explanation. and for most people, I think, well, it's mostly women because women are the ones who are most susceptible in a general population to bone loss. Um, I believe that evaluation starts after the age of 65, but when you throw cancer treatments into the mix, then it is, you know, it's sooner. So I know with inhibitors, It's every one to two years. And I believe that's probably based on other risk factors. So two years might be for someone who's younger, but then if there are other things like age and smoking and you know, we'll talk about all of those that then maybe that's why it increases to every one year. And then for patients who are on androgen deprivation therapy, it's every two years.

Track 2 8:42

So, yeah. So if there is a low level of estrogen or testosterone, respectively in the two drug classes, you just mentioned

Leah 8:50

right. And So that's typical. And anyone who is undergoing treatment for prostate. Okay.

Track 2 8:55

Yeah. And you know, the naturopath in me goes a little farther. I'm actually pro DEXA scan as a preventative measure. Basically just all women in particular from the ages of between 50 and 55, depending when, when one is able to do it or what they've gone through. As far as menopause, I think everyone should get a baseline DEXA scan. That's my recommendation to most people and insurance often doesn't cover. But it's a glorified x-ray. So the cost is usually not a lot of money compared to having osteopenia osteoporosis over time. And I say that because there's so much we can do to prevent bone loss. It's very hard to reverse it as we get older. It's one of those things that if you know, you already have a tendency to low bone mass, you can do a lot to prevent further degradation of the bone. That's very achievable.

Leah 9:51

Right. And these risk factors apply to pretty much everybody. I mean, a lot of people will have maybe one risk factor, you know? So, so it is a good, it's a great, it's a great monitor.

Track 2 10:04

As far as the DEXA scan, you mean?

Leah 10:06

Yeah. The DEXA scan could be a great, a great way to monitor. And like you said, you know, we think preventively. So why wait for it to get to osteoporosis? Why wait for a bone break?

Tina 10:15

Yes. Unfortunately that's usually when I see a DEXA ordered is after someone falls and breaks their wrist or, you know, has, uh, some other accident and break something and then they'll get a DEXA scan eventually. But like I said, I think it's a good preventative thing to do for everybody.

Leah 10:30

speaking of bone breaks, that reminds me of a little story. When I started treatment, I underwent one cycle of chemotherapy And then I received an injection of Goserelin, which shuts down your ovaries. And I believe that I received two of those injections over the course of my chemo. So I complete treatment. And then that, I think it was that winter. I was in Arizona. So it's hard for me to imagine, cause it was like sunny. So it could be any time of year that winter for my birthday, I got a bicycle, so I would be more active and we used to ride our bikes to go get brunch. So we kind of ride through the preserve and we'd go somewhere and grab brunch and cause that's, that was my motivation for exercise was, was food.

Track 2 11:21

that makes sense. Okay.

Leah 11:23

And we were coming back from brunch one day and I was startled on my bike and I fell off and it turned out, I broke my foot. I broke a bone in my foot My foot was treated and everything. We didn't repeat the DEXA because I had just received one prior to even starting treatment. And then at the two year mark, I got my DEXA and it showed that I had osteopenia. So that just always makes me wonder w you know, those two shots of Goserelin. Is that what, what sped it up? Because within, yeah, within the two year mark,

Tina 11:58

So if I hear what you're saying was that DEXA scan that you did at the baseline before treatment, was it normal?

Leah 12:05

It was totally normal.

Tina 12:06

Okay.

Leah 12:07

Totally normal DEXA scan. And then at the two year mark, it showed osteopenia. And I mean, since then, I broke my ankle in the same, in the same foot, but my last DEXA scan and it's hard because it's, they were done at two different facilities, but my last DEXA showed a little bit of improvement in, in, in the bone density. So I my oncologist and I were just kind of going with that, like, it's like two different facilities, but maybe, maybe there's something positive in the things that I've been doing.

Track 2 12:39

yeah. And we're a little, we can talk in detail about that whole idea of estrogen deprivation and you also receive some steroids during those that two

Tina 12:47

year period, didn't you?

Leah 12:47

Yeah, I mean, but it was just, it was a very short course. I mean, I just did the steroids during, it was just during the Adriamycin Cytoxan. I don't know. Maybe I did do the steroids during the Abraxane, but I don't think so. I think they stop it during the taxane, but I'm sh maybe I got a huge dose when I had my, my allergic reaction to the Taxol, but digress

Track 2 13:08

In any case, in two years, and

Tina 13:10

two from

Track 2 13:10

normal bone to osteopenia

Leah 13:12

Yeah.

Track 2 13:13

During treatment?

Leah 13:14

During treatment. enough about me, enough about me. Let's talk about, let's talk about risk factors. We can talk about me later.

Track 2 13:23

All right, circling back to the risk factors. so smoking top of the list

Leah 13:28

Yep. So smoking affects bone because it reduces the blood supply to the bone, which you know, that your blood is transporting the nutrients back and forth. So that's part of how it affects it. And then also nicotine slows the production of osteoblasts.

Track 2 13:45

Yep. And we're going to constantly go back to that. Like anything that slows down the osteoblast or speeds up the osteoclasts is going to lead to bone loss.

Leah 13:53

Yeah. And so, and then there's also, I think somehow it affects the absorption of calcium as well.

Track 2 13:59

yeah. I like to think of it like anything that can lead to a deficiency in the building blocks of bone. I kind of lump those all together. So that could be not enough calcium in the diet. It could be not enough of the trace minerals in the diet. So that's things like, silica and boron and manganese, trace minerals that are necessary for the structure, not enough magnesium, which is a very common deficiency in the United States anyways.

Tina 14:28

Magnesium is often deficient in people.

Track 2 14:31

So I think of deficiencies first. So what I'm going to, I'm going to say not just low calcium diets, but low mineral diets.

Leah 14:37

So one of the things that can affect how we even absorb our minerals are certain medications that people take, PPIs, proton pump inhibitors. People take that for reflux, and various other gastrointestinal issues. You need stomach acid in order to absorb nutrients. And so we are reducing the stomach acid and taking a PPI can actually prevent you from absorbing not only vitamins, but minerals that are important for bone building.

Track 2 15:05

Yeah. That's a, that's a really good point. Cause anything that leads to a reduced stomach acid will make the absorption of the minerals less efficient. So, yeah, and if the PPI's were never really, approved to be used, long-term, they've just kind of been adopted that way. The idea behind all of these stomach acid reduction agents, whether it's a PPI or a H two antagonist, doesn't matter. If it reduces the stomach acid, it was really approved for a short course, two weeks to two months. In perpetuity

Leah 15:38

I mean, people are on those for year.

Track 2 15:41

yeah. Yeah. And the links there's definitely, um, studies showing the association between taking those PPI's long-term and having higher risk of fractures due to low bone density. So yeah, that's, that's been a proven risk factor for sure.

Leah 15:57

other things that cause malabsorption, there are, there are other medications that can affect the absorption of minerals, but then there also are conditions like celiac, inflammatory bowel diseases, certain treatments for cancer, surgery where we're part of the GI system is removed you will be affecting the absorption of some vitamin or mineral that may in turn be what helps to build bone.

Track 2 16:21

Yeah, because we have to remember that the stomach is needed for the acid and the small intestine. Are really where it's all absorbed. Right? So most of it in the upper part, the very first foot or so of your small intestine, but essentially the first few feet up to six feet of the small intestine is where most of the absorption of our nutrients takes place. So any surgery that has removed any part of the intestinal track can definitely affect absorption

Leah 16:48

Other things like, alcohol intake, a sedentary lifestyle.

Track 2 16:52

Yeah. And then, and that'll be the polar opposite of exercise, which we're going to talk about in a little bit and how exercise helps. So the extreme opposite of exercise is a sedentary lifestyle.

Leah 17:03

Right. And some people aren't able to move around as much. Um, you know, what's always fascinating is, astronauts, right. Being an astronaut and being up in space, that's a risk factor.

Tina 17:15

Yeah, anti-gravity because gravity is one of the ways that our body knows to build bone. So when we walk our bones have this little vibration that goes through them. And that actually signals the osteoblasts that bone is needed for our structure.

Track 2 17:29

And that's ultimately why a lot of times you're going to hear about walking in particular or jogging or running, whatever you're capable of is very good for bone health.

Leah 17:37

And then there are their hormone issues, right?

Track 2 17:40

Yeah, hormone issues like high thyroid function, so too much thyroid hormone. And that could be people taking too much as a replacement dose. So clinically they have a low thyroid condition, but they overdose the

Tina 17:55

medication that bone

Leah 17:57

Another aspect of something that's diet. And I think it's a big surprise for some people is, is drinking a lot of Cola's.

Tina 18:04

Yes.

Leah 18:05

And it's not, nt's not like soda or pop across the board. It's Cola's and it's, definitely a culprit

Tina 18:13

Yeah. It's the phosphoric acid in there. So if you look at the label of a carbonated beverage and you see phosphoric acid, you're going to have to buffer that phosphoric acid with calcium in the body. And you know, if you're, if you're having that and you're doing what, wasn't it on Laverne and Shirley didn't Laverne drink Pepsi and milk.

Leah 18:34

Oh my gosh.

Tina 18:35

Unbenownst to her. She was mitigating the effect of the phosphoric acid.

Leah 18:39

That would you just, you just pulled that out of nowhere. I'm impressed.

Tina 18:45

In any case, she was mitigating the effects of the phosphoric acid, because basically when you drink the phosphoric acid, you have to, to find calcium somewhere in your system to buffer that acid. And, an experiment you could do at home is, you know, if you're eating any kind of poultry, especially like a small bone from a chicken, you can put it in Cola or Pepsi for a day or two, then pull it out and you'll end up with a rubber bone because all the calcium has been sucked out of the bone and you end up with just the collagen left and you know, it's a good kind of home science experiment for the kids.

Leah 19:16

Have you done this?

Tina 19:18

Yeah. You can do it with soda pop and you can do it with vinegar too. And I actually, this is going to sound odd, but I actually had people do this. They would take their vinegar and put a bone in it. And that way, when they, you would use their vinegar and cooking, they were getting calcium with it as well. A little cooking tip Pepsi and milk and vinegar. Yeah.

Leah 19:38

and chicken bone

Tina 19:39

have we gone podcast?

Leah 19:42

The chicken bone has to be cooked

Track 2 19:44

Yes. Yes. No raw chicken bones.

Leah 19:48

For more recipe tune into The Cancer Pod.

Tina 19:53

Yeah. Yeah. What I use the kitchen for and what you use the kitchen for are two different things.

Leah 19:59

Yours is a laboratory. Okay. So again, let's come back to hormones because that estrogen loss the testosterone loss, like that is what we see a lot with cancer patients. Chemotherapy also has an effect on the cells that build bone. And in addition to chemotherapy, there are certain cancers, multiple myeloma, you know, that, affect bone as well. But I, I think, yeah, the hormone part is a really big contributor.

Track 2 20:27

it is. I mean, it's relevant to cancer care. And if you age it's somewhat inevitable, right? So you could be taking an aromatase inhibitor or something that blocks testosterone, one of those androgen deprivation drugs, and that will reduce the hormones or you can. Be elderly, you know, and with every decade of life, we produce less and less testosterone and less and less estrogen. So either way, what you're looking at, is both testosterone and estrogen lead to longer life of those osteoblasts. So there's more osteoblasts. Also, they, to some extent block the osteoclasts. So the estrogen testosterone will block the osteoclast from chewing up the bone. And so when they're gone, the osteoclast gets to run more wild. another thing that happens with estrogen, I know in testosterone, I believe is that there is more inflammation in the bone when that hormone is not present. So if someone is on an aromatase inhibitor or someone is on an androgen deprivation drug, Just post-menopausal or pass the age of say 60 or so. One thing you can do is less than inflammation in general, and that should have some effect because the process within the bone is still an inflammatory process and the inflammation is actually higher on the bone surface because of the lack of the hormone. So those are the sex hormone influences, but too much thyroid hormone can lead to bone loss. And of course, steroids, um, like our own production, high cortisol, a high cortisol state will lead to more bone loss. I think of steroids, our production and the prescription of them kind of under the same umbrella because all the, the effects are very similar.

Leah 22:13

I think of people with asthma. I like I've had patients who have taken steroids for a really long time because of asthma or because of, an autoimmune condition. And they'll take steroids for a really long period of time. And then they kind of notice that bone loss, another cancer treatment that leads to bone loss is radiation. And so someone may get radiation to a certain part of their body. And then a delayed side effect of that would be bone loss.

Track 2 22:41

Yeah. And that has to do with what you were mentioning. Some of that has to do with the vasculature changing due to the radiation. And some of it has to do with hitting those osteoblasts and osteoclasts at the surface. So there's less potential for restoration of the bone. There's less dynamic turnover of bone in general.

Leah 23:00

So we covered a lot of the risk factors for bone loss. Um, I think we need to talk about the nutrients that help to build into sustain bone density.

Track 2 23:28

So I think when people think about bone health, the first thing they think about is their calcium and their calcium intake. Right?

Leah 23:33

Oh, absolutely. Absolutely. And, one of the things I think that we have in common is that we both emphasize food sources of calcium because you're getting all the other nutrients that you need for other processes as well.

Tina 23:47

yeah. And a lot of

Track 2 23:48

the calcium in nature is found in healthy green, leafy vegetables and broccoli, and

Leah 23:54

Right. It's not exclusive to, yeah. It's not exclusive to, cow products. And when, when talking with a patient, I typically evaluate their, their calcium intake. You know, like their average, you know, some days you might have a little bit more greens or more cheese. And so just kind of take an average of what their calcium intake is. And then that's what I based their supplementation on.

Track 2 24:17

Yeah. Cause you, do want to get it primarily from a diet and this is where if you take a supplement, it is a supplement that you're taking for. Safety net to make sure that you get enough, but if your diet is adequate you could get away with not needing a calcium supplement. If you're not on a medication that requires it, or some other reason, you can get enough calcium from your diet. And the recommended total is how much?

Leah 24:40

well, the recommended total, which when I double-checked the dosage, from food and from supplementation. Um, the recommended total is if you're under the age of 50, it's a thousand milligrams a day. And if you're over the age of 50 it's 1200 milligrams a day

Tina 24:56

And that's diet

Track 2 24:57

plus supplement.

Leah 24:58

That's diet plus supplement and that's they're not on, a bisphosphonate

Track 2 25:04

diet and supplement put together. Upper

Tina 25:05

limit is what, around 2,500 mg/day?

Leah 25:08

Twenty-five hundred. Yeah. So if somebody is on a bisphosphonate, or, one of the medications that you get when you have bone loss from osteopenia, or if you have cancer in your bones, you also get a bisphosphonate. Um, the recommendation for that is between 1200 and 1500 milligrams a day calcium.

Tina 25:31

So, slightly more.

Leah 25:32

Slightly more. Yeah. I think one thing that I really want to mention is oftentimes I would see patients who were told by their doctor that they needed to take a thousand milligrams a day and they hate taking pills and they get these big horse pills, these big calcium carbonate horse pills. And they complained because it's so big to swallow and they just take it all at once.

Tina 25:55

Umph.

Leah 25:56

And I have to explain, like, you're not absorbing that much. So calcium is one of those things that smaller doses more frequently is better because you'll actually absorb more.

Track 2 26:08

Yes. Yeah. And the irony of the calcium carbonate in particular is that you need really good stomach acid to absorb calcium carbonate. So that might be fine if you're, you know, young, but we all make less and less stomach acid as we get older. So calcium citrate and other calcium forms are probably better as we age so that we absorb more of it. And we'll never absorb a hundred percent of any mineral we put in our mouth.

Tina 26:33

Right. We absorba small amount

Track 2 26:34

of every mineral, whether it's from diet or a supplement. So

Tina 26:39

frequent dosing is your

Track 2 26:41

best bet to kind of slowly drip it into the system.

Leah 26:45

Yeah. Cause I think that, 500 milligrams is like the limit as to what you can absorb. And so you're, you're kind of wasting, I mean, it's just, you're just struggling to take this huge giant pill. and then calcium citrate is also really good if somebody is on a medication or has some sort of malabsorption issue.

Track 2 27:03

Yeah. It's less dependent on stomach acid to be absorbed in general.

Leah 27:07

yeah.

Track 2 27:08

So I have a story about high dose calcium.

Leah 27:13

No, no, I'm afraid.

Track 2 27:15

Well, it's, it's a cautionary tale.

Leah 27:17

Okay.

Track 2 27:18

I had someone with osteoporosis who came in and she had spasms in her calves, debilitating spasms. I mean, she was having these muscle spasms in her calves that kept her from being able to walk and they would happen suddenly. And in the intake we went through everything she was doing. She's seeing an osteoporosis specialist in Portland who had her on 2,500 milligrams of calcium. And when I asked her about magnesium, she wasn't

Tina 27:44

taking any. And she'd been

Track 2 27:45

doing this for quite a while. I don't know how many months maybe it was a year. Yeah. High dose calcium without magnesium

Tina 27:54

over time, w

Track 2 27:56

just make any magnesium deficiency that much worse. Right? So she had this imbalance between her calcium and magnesium, and I suspected that her high-dose calcium was causing this symptom of magnesium deficiency in our calves. So we just did an intravenously. We just pushed some magnesium right then and there. And, um, she felt much better.

Leah 28:16

Immediate. She had like immediate

Track 2 28:19

Well, it took 24 hours to really set in. But the next day she called the office and said, oh my God, this is amazing. And, um, it was a very simple solution to a simple problem, but she had been suffering for many, many months at that point. And for whatever reason, I don't know if she didn't hear it or it wasn't given, she didn't take magnesium alongside her calcium. So ever since then, I'm vigilant that people take a calcium magnesium ratio. That's at least two to one. So if you're taking a thousand milligrams of calcium, you're taking 500 milligrams of magnesium.

Leah 28:50

In divided doses again.

Track 2 28:52

Yes. Ideally in divided doses over the course of a day,

Leah 28:55

So yeah, that brings us to magnesium. So what is the role that m

Track 2 28:59

it's also part of the bone structure, right? So magnesium not only acts as a muscle relaxant and has a, it's a co-factor and all sorts of reactions in the body. I think upwards of 400 chemical reactions in the body require magnesium, mostly in the liver, um, some in the brain, but as far as the bone health goes, it's actually integrated into the bone structure.

Leah 29:21

And it also helps with the absorption of other minerals. all of the minerals kind of interplay off of each other.

Track 2 29:26

Yeah. And of the two magnesium deficiency is more common than calcium deficiency, at least here in the United States.

Leah 29:32

Right. But if you get calcium from dark leafy greens, you're also getting magnesium. And so I think, what we are suffering from in the United States is a dark leafy green deficiency.

Track 2 29:45

Yeah, you're probably right.

Tina 29:49

Yup.

Track 2 29:50

Well, and the other nutrient we need to discuss alongside the calcium of course is vitamin D D as in dog.

Leah 29:57

Oh yeah, for sure. Because that one definitely has a relationship calcium.

Track 2 30:04

Yeah. Yeah. So vitamin D ultimately, all you have to know is that vitamin D improves the absorption of calcium in the gut and it prevents its loss in the urine. So it basically helps you retain your calcium, absorb your calcium from your diet or a supplement and retain it in your body and not pee it out as much.

Leah 30:25

and there there really isn't an established, like what should your vitamin D level be 30 nanograms per milliliter is kind of thrown around as what that should, the baseline should be. but then when you've been through cancer treatment, I know my naturopathic doctor recommends that my vitamin D level, my baseline is higher.

Track 2 30:44

Yeah. And I just want to say that 30

Tina 30:46

nanograms per milliliter

Track 2 30:48

is 75 nanomoles per liter because internationally, I think

Tina 30:53

they use the nanomoles more, more

Track 2 30:55

likely using nanomolar amounts. And as you know, we're

Tina 30:59

really big in Bhutan.

Leah 31:01

That's right. We are. I forgot about that. No, it is important. Yeah. It is important for me to try to include, boats of those measurements, because we do have a lot of international listeners outside of Butan.

Track 2 31:16

Yes. Yes. All kidding aside. Although we're not number, we're not in the top 10 anywhere else, but Bhutan.

Leah 31:22

That's true. It's good to be liked no matter where it is

Track 2 31:26

the best thing about Butan is they have a gross domestic happiness index instead of a gross domestic product. So it's, it's pretty cool to be big in Bhutan.

Leah 31:36

Oh, for sure. Especially because I don't necessarily think of everything that we talk about is happy. So...

Track 2 31:42

no, that's true. That's true. I'll give you that.

Tina 31:48

So what other nutrients?

Leah 31:50

Um, vitamin K2.

Track 2 31:52

Yep.

Leah 31:52

It's not vitamin K, which is the one that affects blood clotting that you actually find in green leafy vegetables. It's vitamin K2, which tends to be in fermented products. I know aged Gouda actually has some vitamin K2 in it as does, natto, which is a fermented soy product common in Japan.

Track 2 32:17

Yeah, the

Tina 32:18

vitamin K1 and vitamin K2 are two separate

Track 2 32:21

molecules. while they are both for bone health, to some degree,

Tina 32:25

vitamin K1 is the one

Track 2 32:27

that can interfere with Coumadin or warfarin the drug class is designed to block K. That's what they do.

Leah 32:36

Right. and that is something that a lot of patients that I had where, taking.

Track 2 32:41

Right? So green's aside,

Tina 32:43

vitamin K2 you can

Track 2 32:45

get from fermented products, like you mentioned, cultured and fermented things. Interestingly, a lot of the cheeses make more of the K2 products when the goat or the cow has grazed on grass. it's actually the K from the grass that's makes its way into the milk that is then fermented into a vitamin K2.

Leah 33:06

That's a cool fun fact, So grass fed dairy.

Track 2 33:09

Oh, I'm full of them today. Uh,

Leah 33:15

again, we need, we need a little sound soundboard, fun fact fun fact. Okay. That sounded like Wayne's world. Nevermind. That's all that came to my head. So vitamin K2 and not all K2's are, the same. I mean, they're not.

Track 2 33:31

No generally they're, designated MK dash and then a number. And that number is what chemically makes different compounds. So they're popular and supplements right

Tina 33:40

now is MK4 four and MK7 seven. And

Track 2 33:45

MK four is interesting. I use that in higher doses, um, much like it's used in Japan where it's been approved as a, an anti osteoporosis agent.

Leah 33:57

So it's an actual medication in Japan.

Tina 33:59

It's a medication in Japan used for osteoporosis. Its approval is for use for osteoporosis and it's MK4 that's used there in high doses milligram doses. And here that's a supplement, not a drug. Also found as a supplement here is MK7 and it's a slightly different molecule, but they're both considered vitamin K2.

Track 2 34:20

So K2 is not one molecule. It's a family of molecules. they're

Tina 34:25

called Vitamers, -mer. Viamers. So there's

Track 2 34:28

a

Tina 34:28

bunch of vitamers under

Track 2 34:30

the K2 designation.

Leah 34:32

the one I take is a calcium magnesium. It's like a mineral complex with the MK7 because MK4 is harder to come by.

Track 2 34:41

Yes.

Leah 34:42

and especially finding a good quality product.

Track 2 34:45

it is. I agree.

Tina 34:46

MK7 has

Track 2 34:47

become much more popular.

Leah 34:49

Is there any truth to MK7 being better absorbed than MK4? Like what's the difference between the two.

Track 2 34:56

I think of them as two totally different things.

Tina 34:58

I think MK7 is

Track 2 35:00

enough to ensure that you're not deficient in vitamin K2. And I think

Tina 35:06

of the MK4 as what

Track 2 35:08

I would consider a nutraceutical, like something that's approaching a pharmaceutical, but it's not a pharmaceutical, right? it's a naturally derived agent. So, I think of it as a bigger gun of sorts to

Tina 35:21

use the MK4 in high

Track 2 35:22

doses than just

Tina 35:24

doing an MK7 in

Track 2 35:25

a combo formula or alone to make sure you're just not.

Leah 35:29

Is there still benefit in taking K2 as MK7?

Tina 35:33

Yeah, because the deficiency of vitamin K leads to greater bone loss. So in that sense, yes. You want to make sure you have enough vitamin K in your diet or in your diet plus supplements to make sure you're not deficient. So as always with nutrients, I think of it as two different things, making sure someone's not deficient is different than giving someone a high dose of a single nutrient for a specific task.

Leah 35:55

And I'll put up a list. there's probably a more comprehensive list of K2 foods besides grassfed aged Gouda.

Track 2 36:04

although it does sound delicious.

Leah 36:06

We could just stop right there. Grassfed aged Gouda. Love it. there are a couple of minerals, that are a little controversial. One that you often find in formulas is born. And we often recommend that our patients with a history of breast cancer not take boron over three milligrams.

Track 2 36:28

yeah, that has to do with some old studies that showed

Tina 36:31

boron in high

Track 2 36:31

doses led to higher amounts of estrogen and or testosterone in circulation. So I think it's out of an abundance of caution that people not take a lot of boron because it's possible that an it creates more hormonal production.

Leah 36:47

And then another supplement, which I saw a lot when I was doing my training, is strontium and strontium would be recommended for patients with osteopenia. Studies have shown that strontium may change the way that the bone appears on a DEXA scan, but there was no reduction in fracture risk. So it's, it's one of those things that, I think I kind of compare it to, like, you're just kind of drawing on the you're drawing on the x-ray. You're just kind of filling it, filling in the bone on x-ray to make it look more dense, but you're not actually helping. And so, that's one thing that I often deter people from taking that supplement.

Track 2 37:27

Yeah, cause a better picture on a DEXA scan is not really our goal. Our goal is to reduce fracture risk. So yeah, it's important to know that those are two separate things because strontium does

Tina 37:37

make it look whiter. So it looks

Track 2 37:40

more dense because it's a denser substance. And I don't know much about this, but I know in Europe, strontium ranelate is approved for osteoporosis, but I don't know what form of strontium that is. strontium comes in different salt forms. I don't know anything about the drug strontium ranelate I know what we have available in the United States. Strontium citrate for the most part, is not something that I'm too gung-ho about either.

Leah 38:07

So if you're, if you're listening and you're in Europe and taking strontium ranelate, that is different than what is available here in the U S and the U S it's available as a supplement. And it's not the medication that you're taking that actually does show to reduce the risk of fractures.

Track 2 38:21

so strontium normally is found in bone, but we get it from whole foods, like all the other trace minerals, right? So you do need a little bit of boron and you need a little strontium and you need a little silica and you'll need a little manganese, but you really should get that from your food sources because their trace amounts, you don't need large amounts. I would argue if you're eating a healthy diet and it's organic, you should be getting that completely from your diet. Not from any

Tina 38:45

supplement

Leah 38:47

That's a good point. And I think what you were saying about, reducing inflammation overall, so eating a low inflammatory and anti-inflammatory diet, that's rich in fruits and vegetables and grains, provides a lot of those, trace minerals that, that are needed. So we covered a little bit of diet. We covered some nutrients. The other thing that supports our bones it's the big guns it's exercise.

Track 2 39:13

Exercise, exercise. Go on everybody. Do you exercise and freeze? Did it do to do during.

Leah 39:23

I don't

Track 2 39:23

Where, where are you as a child? Didn't you grow up in front of a TV.

Leah 39:26

I grew up in Spain. I grew up in Spain. We didn't have that. I missed out on so much American culture.

Track 2 39:35

seventies where the bomb, man.

Leah 39:37

I was watching Laura Ingalls Wilder and speaking Spanish with an adult woman's voice. The first time I heard. Melissa Gilbert's voice as a child, like speaking in English, I was so shocked that she had such child's voice because I was used to speak.

Tina 39:58

She wasn't a grown Spanish woman.

Leah 40:00

She wasn't a grown up Spanish woman. Okay. All right. Okay. So we covered the risk factors. We covered the nutrients that are needed, to help, to support against bone loss. And I think now we move into our, our big guns exercise.

Track 2 40:36

Yeah. This is a use it or lose it by definition, right? I mean, unfortunately you lose bone if you don't use bone and if you are sedentary or you aren't able to use the bone, they will degrade

Leah 40:50

So the types of exercise that are important, we always hear about weight bearing exercise. So walking, you know, rebounding would be like an extreme, but, anything that creates that vibration that you mentioned.

Track 2 41:03

yeah. Vibration. And then anything that builds muscle

Tina 41:05

because the truism is if

Track 2 41:08

you build muscle, you must build bone, right? so if you think of your bicep, for example, and think of it as a lever, you put something in your hand and you raise it up. Well, if you're increasing the size of your bicep, you have to increase the bone underneath because eventually you would pick up something that's too heavy for the bone to handle and you would break. So you have to be able to have enough bone for the muscle structure of the body. So everything that builds muscle will build bone.

Leah 41:35

And when you're doing resistance exercises or weightlifting or whatever, it may be even yoga. I mean, yoga has been shown to help to. Maintain or increase bone density. When you're moving like that, your, your muscles, your tendons, they're all pulling on the bone and that pulling on the bone is what stimulates

Track 2 41:56

yes. it's very responsive to the mechanical stressors, right? Whether that's gravity making us vibrate with every step we take

Tina 42:05

yoga and the pull on the bone.

Track 2 42:07

So it's responding to the mechanical stressors and saying, "Oh, you

Tina 42:11

need me."

Track 2 42:12

you're demanding this of your bones and your bone responds. And this is interesting. The way that we now know that muscle creates its own cytokines. And we often talk about cytokines in the context of inflammation. cytokine is a fancy word for a messenger molecule. So it's just a signaling molecule. It's a fancy name for a signaling molecule. So the muscle builds these signaling molecules. One of them is called myokine one of the things that happens with this myokine, which is a type of cytokine that is actually made by the muscle itself, is that goes out into circulation. When it finds its way to the bone, it actually stimulates the bone growth. So we now know the chemical messenger that tells the bone to grow. Are these molecules that are made by the muscle that go and tell the bone we need you, we're going to build up.

Leah 43:09

Myokines

Track 2 43:10

So can kind of think of muscle as... as strange as it sounds by definition, that makes it an

Tina 43:17

endocrine organ, because

Track 2 43:18

it's creating, innately, creating a messenger molecule that

Tina 43:22

is having effect on

Track 2 43:23

a distant tissue. So by definition, it is having an endocrine effect.

Leah 43:28

I learned so much, Tina. Tina's geek out moment. so yeah, we already talked about astronauts and how gravity is important when building bone density. For people who aren't able to do weight bearing exercises, you can do things like chair yoga and using resistance bands or weights to also get benefit.

Track 2 43:50

Yeah,

Leah 43:51

There was a doctor that, was a yoga practitioner and he came up with like a 12 minute yoga regimen that can be done. There are multiple modifications that can be made, including chair yoga. And it's a sequence of yoga postures that have been shown to increase bone density. And so I will, put some information on that in our show notes.

Track 2 44:16

That's a great idea.

Leah 44:17

Um, but you know, somebody might think like, "oh, I'm going to go hop on my bicycle," is bike riding. Okay?

Track 2 44:24

No strangely enough, especially kind of the tour de France folks, the people who go a really long way on a bicycle, long distance bikers in general have lower bone mass, not higher bone mass. So it's not just the muscle mass. I mean, you can swim, you can bike, do that to build muscle and stay fit. But without that kind of

Tina 44:43

jarring or tensile kind of mechanical

Track 2 44:48

stimulation through yoga through other means, or having that vibration through walking even, without that, the bone doesn't get the signal that it's needed.

Leah 44:57

So cross train. So keep swimming, keep riding your bike if you love it, but add something else in to focus more on bone. And another important thing with exercise, is maintaining balance. because. As you get older after treatments with neuropathy and you know, other things that can happen, um, as the result of cancer or cancer treatment, there are issues with balance. And so the goal is to prevent falls. And if you are to fall to prevent fractures.

Tina 45:31

That's a really good point. Yeah, it's better to bend than to break. If you have good balance, you may not fall in the first place. If you are limber enough, you can fall in, uh, you know, healthier manner. And half of bone is collagen.

Track 2 45:47

So we're talking all about these minerals and stuff, but it's really only 50% of the bone. The other half that doesn't show up in a DEXA scan is collagen. And that's what gives it some flexibility. I mean, I don't know if you've ever seen a child take a fall in slow motion. You can see them actually bounce. Where as adults...

Leah 46:06

I have never a child in slow-mo.

Track 2 46:10

oh, okay. Well, it's kind of one of those things in medicine that they used, it reinforced the idea that growing bone and less dense bone is much more flexible. As we age, we lose flexibility, but doing something like yoga or stretching, those kinds of things that keep us limber, I think is really important because one, you don't want to fall in the first place, but if you do fall, you want to take a good fall, not a bad fall.

Leah 46:35

And so you mentioned collagen. We're going back to the supplement section, I mean, would taking college and be beneficial to someone who's trying to prevent bone loss.

Track 2 46:45

It can be, it can be. I do that kind of selectively depending on what their diet looks like. You know, amino acids are involved in collagen production. Um, and what type of cancer history they have because

Leah 46:57

I think that's an important part, right? So it's not like collagen supplementation would be safe for anyone who's had a history of cancer.

Track 2 47:06

no, there are certain cancers that we know prefer certain amino acids. So we don't want to give amino acids to people who have a type of cancer, a subtype of cancer that prefer amino acids as their fuel source. So what comes to mind right away is triple negative breast cancer. I may not

Tina 47:24

give collagen into somebody

Track 2 47:25

with a history of triple negative breast cancer, knowing that that particular type of cancer can use amino acids as its own fuel source.

Leah 47:33

So just what's good for one person who may have had one type of cancer might not be good for you if you've had a different type of cancer. I mean, we're all individuals, and so the way that we treat our patients is on a person by person basis. It's all individual. So just use caution before starting well, before starting any supplements,

Track 2 47:54

Yup. Yup. Always So we discussed bone physiology, the osteoclast and osteoblast. We covered the Pac-Man Astia re-classed we covered risk factors and we covered some minerals that we recommend for people to make sure they have plenty of. And then we went into some hormonal causes and how the hormones function at the level of the bone building and remodeling. And then finally we covered exercise and the idea that muscle is an

Tina 48:23

endocrine.

Leah 48:24

I think that's it.

Track 2 48:26

That's everything right.

Leah 48:27

I think that's everything.

Track 2 48:29

had a lot today.

Leah 48:30

We did, but I felt like it went more smoothly. We're learning. We are learning people.

Track 2 48:36

Only one way to go. We will only get better.

Leah 48:41

Well, if, if you know someone who will benefit from listening to this episode, please share it. I think this one is one that, like you said, initially goes beyond just cancer and cancer support and yeah. Check us out on, on the social media and I'll put up a link for our, our Spotify again,

Track 2 49:02

Sounds good. And our website has all of the podcasts on there as well.

Leah 49:06

and also. I've put a couple of posts up, I guess I should send out our first update, um, as to what is new on the website. But yeah, go check it out. If you aren't already signed up, you can sign up on the website, subscribe to get updates.

Track 2 49:21

And the website is very easy to remember because

Tina 49:23

it's just thecancerpod.com.

Leah 49:26

that's, that's a good point. We should mention to find us.

Track 2 49:31

We try to keep it simple.

Leah 49:32

Um, and so on that note, I'm Dr. Leah Sherman,

Track 2 49:35

And I'm

Tina 49:36

Dr. Tina Kaczor

Leah 49:37

And this is The Cancer Pod.

Track 2 49:39

UNtil next time, take care.