Why Does Bone Health Matter to People With Breast Cancer? with Kevin Ellis

Hello and welcome to the Keeping abreast podcast with Dr. Jen. I'm your host, Dr. Jenn Simmons. And I couldn't be more excited for my guests today because we are talking about something that is on everyone's mind. Like literally everyone is thinking about bone health. So I thought, who better to have on the podcast than Kevin Ellis? Kevin is an integrative nutrition certified health coach and he has the Stronger Bone Solution program. He is the founder of Bone Coach, and he has made it his mission to help over a million people around the globe address bone loss, build bone strength, stop fearing fracture, and lead active lives. So, Kevin, welcome. I'm so happy to have you here, Jen.

I'm looking forward to this. This is going to be a great conversation, and it's such an important topic that I don't think gets enough attention, but it's so important to talk about our bone health.

Yeah, for sure. And let's start with a statistic that I recently learned that I had no idea was true. But, you know, my life is breast cancer. And I am on the same mission to help millions of women on a breast cancer journey to find real health. And a lot of our patients, a lot of the people that have any kind of a breast cancer diagnosis, any kind of a journey, are treated for breast cancer. A lot of the treatments, and maybe part and parcel to the disease itself, these people have serious bone issues as they go through life. I learned that the number of people that die a year as a complication of fracture is the same as the number of women that die every year of breast cancer. That statistic blew my mind. I'm like, where are the ribbons for that? Can you talk to us a little bit about, like, why has bone health become such an issue and why are fractures so dangerous?

Yeah. And I mean, this is such a relevant topic for an audience of, you know, women that are facing breast cancer diagnosis or have breast cancer or have had breast cancer. Because you're right, you know, a lot of the treatments that come with that, they can contribute to bone loss, the radiation, things like that, those can be contributing factors. And it's just something you want to preserve and strengthen the structure that's going to carry you to an active future. And a lot of times when we talk about bone loss and osteopenia and osteoporosis, some of those numbers, that's one statistic that's, you know, it's shocking when people hear things like that. Right. When we, when we look at just Americans, got about 10 million Americans that have Osteoporosis, which is porous bones. Another 44 million have low bone density. One in two women, up to one in four men are going to break a bone in their lifetime due to osteoporosis. And for women, the incidence of low bone density is greater than that of heart attack, stroke and breast cancer combined. Right. So it's something that we need to be aware of, we need to address. Now, the way that you're going to find out you actually have any issues with your bones are through what's called a bone density scan. Now, if you're somebody who's going through cancer treatment or you've gone through cancer treatment and you have not had a bone density scan, you should get one. Right. If you're preparing for that or you've already.

You're talking about a DEXA scan.

A DEXA scan, right? Yes. Dual energy X ray absorptiometry. It's a painless test, kind of like an X ray. Very low levels of radiation. You lay down on the machine, it does a scan and it tells you your bone mineral density, the actual mineral content of your bone, and then it generates a score. And that score, if it's in the plus one or minus one, that's considered normal and healthy. If it's minus one to minus 2.5, that's considered osteopenia. We would call that low bone mass. And that's like a precursor to osteoporosis. And osteoporosis would be negative 2.5 or lower. So negative 2.6, negative 2.7, so on and so forth. The greater the negative number becomes, the more severe the osteoporosis. Most people aren't getting these scans until they're 65 years of age. Right. But if you have a secondary cause of bone loss like cancer, then it's a good idea to get one of those scans done early. Now, one thing I will point out.

About, I should say that the secondary bone loss is usually not coming from the cancer, it's usually coming from the treatments. So a lot of our cancer treatments will accelerate bone loss?

Yeah, absolutely. It absolutely can. And then anything also that's contributing to inflammation, especially chronic, especially long term, or anything stimulating that immune system is going to speak in the same language of the cells that break down bone. Right. So there are quite a few contributing factors that fall into that. Secondary causes of osteoporosis. We'll get into that in just a second. But the one thing I'll point out about bone density scans and DEXA Scans is that you're usually only giving you part of the picture. So usually the, the part of the picture they're telling you is your bone mineral density, the actual mineral content of the bone. What they're not telling you most of the time is your quality, the structural integrity of that bone, the micro architecture, how that bone is organized. Those two things combine to create bone strength. So a lot of times you only have part of the picture. Now you can find out a little bit more about your bone quality by asking if the DEXA has something called TBS technology or capability that is Trabecular bone score. And that can actually help you understand that full picture density and quality. There's another technology too called rems, Radio frequency echographic Multi spectometry technology. That's a newer technology and that can also help understand bone quality too. And then the last note I'll make about bone density scans is that they aren't able to tell you. It's a snapshot in time. They can't tell you if you're actively losing bone right now, present day, as we speak. Right. You need to look at things called bone turnover markers to help you with that. So one of the best bone turnover markers is called the ctx, the serum ctx. It's a CT low peptide test. And that test looks at the activity level of cells that are breaking down bone. And if that activity level is elevated or even really high, that can be an indicator of active bone loss and a root cause issue that needs to be addressed.

So I understood bones as being on a seven year cycle and that depending on where you measure that, your DEXA scan may look different.

Well, so your bones are constantly, and this is for everyone, I mean all of our bones, every single day, they're constantly turning over. Right. And it's a coupled process with the cells that are involved in this. So you have cells within the bone called osteocytes. These are like orchestrators of the bone remodeling process. So they sense mechanical loading and damage and stress and micro cracks and fractures and things like that. And they sense that and they send out a signal to other cells. So the other cell that would receive that would be these cells called osteoclasts. And their job is to chew up that bone and clean out the old damaged bone. And then right behind it, it's a coupled process. There are osteoblasts blast with a bee that come in and build and form stronger, healthier new bone. So this process is happening all the time, every day. If you went, if you Woke up today, you went to the gym, you did a tough workout. This process is happening right now. It's just, it takes a long time for bone remodeling to happen, but it is happening throughout our lives. So your skeleton will turn over multiple times throughout your life?

Yeah. So I understood that to be every seven years. Did I get that wrong?

That could be somewhere in that range, seven to 10 years, something like that, yeah.

Okay, so let's talk about osteoporosis, because I feel like that's a big buzzword and it is somewhat tied to diagnosis on a DEXA scan for the purposes of maybe prescribing bisphosphonates. So can you, can you talk about that relationship a little bit and why. Why that is the solution for most providers?

Yeah, I mean, this is when someone is told, let's say they go get that bone density scan and it says, okay, you have osteopenia, you have osteoporosis. The recommendation that is typically going to be made in that conversation, which is about 15 minutes, is take some calcium, take some vitamin D, go for a walk, here's your bone medication. And that is woefully inadequate. There is a lot more to that picture than that. And you usually, if you're the patient, you need to be able to, in that, in that moment, not react out of fear and worry and overwhelm, which is the initial reaction most people have. It's to pause and operate from a place of education, empowerment and confidence. Know your options. Know that there are probably more tests that can be done and more answers you can get before you jump into any kind of decision like that. Now, let's say we're talking specifically about those medications. These drugs have a dramatic effect on bone physiology. It is not like taking an aspirin. And I always liken their use to that old economic adage, there's no such thing as a free lunch. Right. So there are risks and side effects and short and long term implications with every single thing that we do. And that is no different when it comes to bone medications. The bone medications are broken down, for the most part, into two major categories. So there are antiresorptives and there are anabolics. Antiresorptives are a category of drugs that are designed to slow down the activity level of cells that break down bone. So this would be your bisphosphonates and your rank ligand inhibitors. Your bisphosphonates would be. And this is. A lot of people are probably gonna be like, oh, yeah, I've heard of These before Bamax, Boniva, Actonel, Reclass, those would be your bisphosphonates. An important note on bisphosphonates is the safety and efficacy of these drugs is not really well known beyond five years. And like I had just talked about when we were talking about the skeleton remodeling and turning over, as we're going about our daily lives, doing our daily activities and exercising hard or doing chores around the house, you're starting to get these tiny little micro cracks and micro fractures in your bones. That that's normal. It happens every single day. And then you have those cells in the bone that sense that damage and communicate to come scoop and clean out that bone and fill in stronger, healthier bone. When you're taking these medications, there are situations where you can slow down that activity level too much to where you start to accumulate that old, worn, damage, weakened bone over time. So even if your density shows higher, the quality may not actually be better. Okay, so that is one of the big issues with some of those medications. There are also side effects. A lot of times people report, especially with the bisphosphonates, that they have digestive issues, nutrient absorption problems, they'll get joint pain, or they just have a full body reaction. Or I think some of the bigger ones that don't happen as frequently but are still an issue would be osteonecrosis of the jaw. And that's where the jawbone begins to starve from a lack of blood. So basically you have cells in the jawbone that start to die.

So, and then it may not be frequent, but it is a disaster when it happens.

Absolutely, absolutely. And I do see this, I do see this. So that's bisphosphonates. And then the other anti resorptive medication that people will hear of is Prolia. Prolia is a rank ligand inhibitor. And what most people don't really understand when they start taking that medication is if you come off of it, it will increase your risk of vertebral fractures. So it is not a drug that you can start and then just stop it cold turkey, because if you do it will, you'll have something called a rebound effect. And that's an issue. Right. So then you have to relay off of that medication with a bisphosphonate medication before you can completely come off. So that's antiresorptives and then anabolics. Anabolics are the other category of medications people will be recommended or prescribed. And these drugs are designed to build bone, build better quality bone and build it faster. Can they do that? Yeah, they sure can. But if you it's going to have side effects that come with it and you're also going to have a certain period of time that you can use them for. And you're not just committing to that one drug then you're committing to that drug and then another drug like an anti resorptive after you stop taking it. So in summary, I would say I'm not anti medication, I can't be because I've seen situations where it's necessary and life saving for some people. But there is so much more that people can do in most cases before they just jump into taking a medication.

So let's talk about that because I feel like people go and have their DEXA scan, they get told that they either have osteopenia or they have osteoporosis and they panic and they're told that there's really nothing that they can do other than go on one of these drugs. They are not adequately counseled on what these drugs actually do and what they could potentially do. And then they're so scared that they just go along with it and they never get any healthier along the way. So how should we be responding to the knowledge that our bone density is not what it should be?

Yeah, the first thing that you as the educated, empowered patient can do is just say whenever you get told, hey, here's our recommendation for you. You have the right to say I'd like to get a little bit more information. I'm not saying no, I'm just saying not yet. Or I'm just saying can you help me get a little bit more information before I make this decision? You have the right to create that distance for yourself in that moment and I highly recommend that you do that. And then what you need to do is go get that additional objective information to start making better decisions. For example, if a pharmaceutical is recommended, the majority of the time they're recommended without ever having bone turnover markers done. Bone turnover markers are the, the blood tests and, or the tests that look at the activity level of the cells that are building up and breaking down your bone. So you don't want to jump into a medication if you haven't even looked at what's going on there first. So that's where you would look at a ctx which looks at bone resorption. You would look at a P1NP which looks at bone formation. There are other tests that you can look at also. There's obviously some foundational tests that you can look at which would Be, you know, you're going to get a complete blood count. Everybody's getting that when they go get their blood drawn. You're going to get a comprehensive metabolic panel that's looking at your electrolytes, your kidney function, your liver function, your alkaline phosphatase, those kinds of things. Vitamin D. I think everybody understands how important vitamin D is for your health. It's very important for your bones. And if you have low levels of vitamin D, that's going to be a risk factor for osteoporosis. So you, you get that 25 hydroxy vitamin D test done, look at your levels, see where they're at. And parathyroid hormone, everybody should be getting that. Pth. Done. I think that's a really important one. Hyperparathyroidism, that's where you've got a, an adenoma, a benign tumor, usually on one of your parathyroid glands. And that can be a contributing factor to bone loss. So. And then I would say some of the digestive health tests are really important too. Celiac disease, if you are not sure if you have it or not, rule that out. Right. You don't want to make an assumption that you don't have it, because that can be. Celiac disease is an autoimmune condition where when you ingest gluten, the villi, these tiny little nutrient absorption centers in your small intestine, they'll become blunted and damaged to where they can't do their job, they can't absorb those nutrients. And you know, your, your body still needs those nutrients, especially that calcium and other mineral constituents of your bone. You need those nutrients to execute daily functions with your body. If you're not taking them in and you're not absorbing them because those villi are damaged, your body will still go to the largest reserve of minerals that you have to get those nutrients that is your bones. Right.

So you gotta get literally mobilizing those minerals out of your bones to support your body because it's, it's essentially you have a dietary nutrient deficiency and you're supplementing that by mobilizing it out of your bones.

Yep. And that will lead to bone loss. That is a, that is a secondary cause of bone loss. Now, if we're looking at primary versus secondary osteoporosis, I think that is an important distinction. Primary osteoporosis typically occurs as a result of a decrease in estrogen and postmenopausal women. Right. So estrogen has a protective effect on bone. And I know this is relevant for the for the breast cancer group, right. Estrogen has a protective effect on bone. When estrogen levels decrease, as they do during menopause, that causes an increase in the activity level of cells that break down bone. So that is one that's the primary cause of osteoporosis. But there are secondary causes. Secondary osteoporosis is where bone loss and osteoporosis occur as a result of behaviors, disorders, diseases, medications, and conditions. That is secondary osteoporosis. Now, there's a lot that falls into that. I will dive deeper into that in just a second. But the other piece that we need to understand is, is that your current bone health picture may not be just what's happening right now in your body. It could also be a reflection of what happened in your youth as well. 90% of your bone mass you're putting on by the time you turn age 18. And by the time you turn 30, the remaining 10% approximately fills in. So if when you're younger, you have poor diet, nutrition, if you ate a bunch of candy and drank a bunch of sugary soft drinks, and you weren't getting a lot of nutrients, calcium, vitamin D, magnesium, vitamin K2, if you led a sedentary lifestyle, if you weren't playing sports, moving in short, sharp, dynamic movements, stressing those bones in different ways, if you weren't doing gymnastics or working out or things like that, that can be a contributor. If you took certain medications like glucocorticoids, prednisone, for example, if you had an eating disorder, if you smoked or drank excessively, all of those things could have been contributing factors to you not achieving peak bone mass. And starting with what I call a full bucket. And the reason this is important is if you are listening to this now, you obviously want to take care of yourself, but if you have young kids or grandkids, too, and they're in that window of 1 to 18, you have a prime opportunity to help them extend their life 10, 20, or 30 years before they even know it.

Yeah, that's such an important point, is that for most people, their bone health is established very young, and we have to live the rest of our lives on whatever we established in our youth.

One of our team members says, it's Dr. Sherry Betts. She talks about how it's pediatric condition with geriatric manifestation.

For sure. That's a great line. I love that. How did you get into this? Most of us have a story that kind of leads up to where we end up. So how did you get into this? Because it's so interesting.

Yeah. And it's not usually the young male that's talking about osteoporosis and bone health. Right. And just like, you know, just like, like you, like a lot of other people in the health space, we have our own health journeys or we just want to serve and help other people. And for me, mine actually came through my own health journey. Also, as I was talking about celiac disease, I actually, I was. I spent a couple of years in the Marine Corps, and when I came out of the Marine Corps, I had a ton of different health issues and I couldn't put my finger on what those things were. I had high stress, I had poor sleep, had low energy, chronic fatigue. Some days I could barely even get out of bed. And then I had chronic digestive issues. And I was diagnosed with celiac disease finally. And after I got this diagnosis of celiac disease, I had. It wasn't even all the physicians that I had been working with at the time. It was actually a physician's assistant, I think, that said, hey, you have celiac disease. Has anybody done a bone density scan on you? And here I am thinking, oh, you know, tough Marine. My bones are going to be fine. And we went, we did this scan and sure enough came back and said, you have osteoporosis. Now. Nobody called me and told me this. They sent me a letter in the mail and the extent of their recommendation was take some calcium or. And go on a gluten free diet. And that was it. I remember I knew it wasn't good. When I first read the letter, I knew osteoporosis wasn't good, but I didn't exactly know what it meant. And when I googled it and looked it up, it was porous bones. And the outcomes of that were, you know, medication dependence and fracture. And I was scared, quite frankly. I was just. I was scared. I. My father, he passed away at a really young age from cancer when I was two months old. I had this fear that I was gonna. I was. That was gonna have impacts on me and that I would leave this world too soon as well. And, you know, I. I had young kids that were on the way and I just. That's all I could think about was what do I need to do to figure this out to be there for them. That was the impetus for me doing the reading and the research and figuring all this stuff out and getting the right plan in place. And not only did I get the right plan in place, I realized there's a lot of people that need help with this. So that's why I became a health coach and I built out a credential team and I've developed a program around this. And, and now we have over 180,000 people in our community and we're all over the world helping people improve their bones.

Amazing. Let's debunk some, some rumors.

Yeah, let's do it.

So, you know, the first thing that people are told is take calcium and vitamin D. So doing that alone, what, what is that going to do for someone who is in their 50s, 60s?

I'll tell you what you do not want to take. Now, both of those nutrients. Let's start with this. Both of those nutrients are important, right? You have, you need vitamin D, and not just for your bone health, but for your general health. It doesn't just operate as a vitamin, it's a hormone as well. So you need vitamin D, and that's really, really important. You also need calcium. Calcium is the primary mineral constituent of your bones. If you don't have enough, your body will pull from the bones to get it right. So you need to be taking in calcium. So we don't want to make calcium. I have seen studies and things out there that make it seem like if you take, if you get calcium in your diet, it's a bad thing. It's not. You do still need it. Okay. But if you just take those nutrients by themselves, especially if you're just supplementing with those two nutrients by themselves and you don't have other key nutrients and co factors that go with it, you will increase cardiovascular disease risk, you'll increase your risk of kidney stones, and it's not going to be a good situation. So what are some of the other nutrients that you need to incorporate? Vitamin K2 is one of those. Well, vitamin K, vitamin K2, those are, those are important nutrients. Vitamin K would be. If you're eating dark, leafy green vegetables, right? You could, that's where you can get vitamin k from, specifically K1. And then there's also K2. Now K2 has, that's what's really important for bone health because it aids in bone mineralization and formation by activating something called osteocalcin. And it also activates something called matrix GLA protein, which is going to help make sure that that calcium does not go to the soft tissues like your arteries and your kidneys, and that it actually goes to the bones where you want it to go. Right? So you need those. Now, vitamin K2 sources you can supplement, but there are different forms of it, there's MK4. And if you're going to get it from food, this would be beef liver, grass fed ghee and butter, pastured egg yolks, Those kinds of things. That's. Those were our sources of MK4. Sources of MK7 would be fermented foods, sauerkraut, kimchi, natto, and bacterial fermentation in our guts. Right. So again, you can supplement with this too. But those would be some food sources. So you need this vitamin K2 in your diet. Another really important one is vitamin C. Now again, kind of like vitamin D, everybody hears you got to take vitamin C. It's important for your health. Here's why it's important for your bones. Your bones are a collagen protein matrix upon which minerals are kind of laced in there. Okay. You need vitamin C to stimulate pro collagen, to enhance collagen synthesis and to stimulate alkaline phosphatase activity, which is a marker for bone building cell formation. So it's really important for your bones. Also, if you don't have enough, you're going to increase your fracture risk. Right. So you need to get vitamin C. Great. Whole food sources. You can do berries, camu. Camu berries, citrus fruits, kakadu, plums, acerola cherries. Those are awesome. Great sources. Or just even if you, if I.

Just say that red peppers are the, are the number one source.

Yeah, totally.

People don't know that.

Yeah. So even if we go to the veggie side, right. Peppers, like you just said, that's the number one source of vitamin C. Some people, like, if you have an autoimmune condition maybe, and you don't do well with nightshades, that one may be a hard one to do. But if you don't have issues with the nightshades, the peppers are a great choice.

Yeah, for sure. And you can do broccoli, Brussels sprouts, kale. Like this. All they all have.

Exactly. Yeah. Love it. Those are all great ones too. And, and you can steam those or however, however you want to consume those, which is great. And then one other important nutrient, there are many others, but just for the sake of time too, I'll hit one other big one would be magnesium. Again. We hear about magnesium all the time and how it's important for all these hundreds of functions that take place in our body, but you need it to support your bones also. Not only is it part of your actual bones too. You, you store magnesium in your bones. But when you take in food, specifically protein, right, you take in protein, you Break those proteins down into amino acids. And in order to rebuild those amino acids into anything in your body, your muscles, your bones, your tissues, et cetera, you need to have magnesium for that process. So magnesium is going to get used up and depleted quicker than some of the other nutrients as well. So you just want to make sure you're getting adequate magnesium.

And that's because magnesium is used in over 300 processes in the body. And so. So a lot of things are calling on that magnesium.

Yep, yep.

And so I think what I hear you saying is that yes, calcium and vitamin D are important and they're good recommendations, but we shouldn't be grabbing pills and supplements and we certainly shouldn't be doing that alone. But it sounds like the best place for. To get those things is through diet.

Start with diet nutrition first. Right. Food first. Should always food first. See where you can get your diet nutrition, close the gaps with supplementation if and when necessary. Now, of course, there are certain nutrients or compounds or herbals or et cetera, et cetera, that you're not going to get from the standard diet, even if you're trying to, trying your best to just eat healthy. There are just certain things that you and I. No, you're not going to get unless you supplement with those things. But for the most part, start with your diet first because you can't out supplement any health problem that you've got.

Yeah. And so what for you, what are those things that you feel like people have to supplement? Like, magnesium is on my list. I feel like no matter what you do, our soil is so depleted that you're really not going to be able to meet your dietary magnesium needs without supplementation.

Absolutely agree with that. Magnesium.

Anything else on your list?

I would say, you know, I have noticed as people, as people get older too, protein is a hard one for people to get enough.

It's so true.

Protein is a hard one for people to get enough. Now, if you're somebody who has maybe kidney issues or a history of cancer or something too, and you're maybe restricting or limiting protein intake or. But you still want to get amino acids. You could take essential amino acids. Yeah, right. Where you don't actually have everything else that comes with a big meal full of protein, but you could just get the essential amino acids, which are these building blocks that you need in your body. Yeah, right. So if you're taking 5 grams or 10 grams or, you know, consult with whoever you're working with for that, but that could be one way to help meet those protein needs and Then at your meals too. Right. You gotta hit some protein targets too. You got to try. If you're getting. I don't know what your recommendations are specifically, but especially for like muscle and bone building, hitting that 30 gram minimum per meal is, I think, super important.

Yeah, protein is one of the Goldilocks things in the cancer world. So we definitely don't want too little and we don't want too much. And I do think that that 30 gram per meal is probably most people's targets. And I have them eating two meals a day usually because I have everyone fasting. And I do want to talk about what, what fasting means for bone health.

Yeah, for sure.

But I agree with you that protein is an issue. And it becomes even more of an issue for people over 50 because as we age, we get less and less good at extracting the protein, at digesting the protein in our meals. We become less and less efficient. So, you know, children can exist on diets of macaroni and cheese, and they're so efficient at getting protein that they do. Okay. I am not advocating anyone live on a diet of macaroni and cheese, but I'm just saying that young children tend to not suffer even on these horrid hard standard American diets, whereas adults do not do well there because we get less efficient at extracting protein. And the other thing that I think that we need to think about is in this category is acid, because we become less efficient at making stomach acid. And if we're not making stomach acid, we are not breaking our food down adequately and we are not able to absorb it in the small intestine. So I think those are two things that we have to think about.

What about vitamin D? That's a big one. If we could touch on that for. Just expand on that one just a little bit more with the stomach acid. So important like this needs to be underscored as you age, age. Stress, nutrient deficiencies, gut infections, those kinds of things can reduce your stomach acid. Just like Dr. Jen just said, if you don't have enough stomach acid, you're not going to be able to properly break down and extract nutrients from your food. Calcium, magnesium, iron, B12, those amino acids from your protein, you're gonna have a really hard time with that. And then also a lot of times when people have too little stomach acid, they may have reflux or something like that, and they may think they actually have too much stomach acid. And then what do they do? They go to correct that problem by taking things like PPIs and antacids Yep. And PPIs, proton pump inhibitors. These are designed to reduce the, the production of or increase the suppression of your stomach acid. And again, those drugs alone, even if they are used, they should only be used for a very short period of time. If ever.

They were approved for use in someone who has a bleeding or perforated stomach ulcer for two weeks, two to four weeks maximum. And the average person is on a protein pump inhibitor for four years.

Four years, we see 20, 30 years.

Yeah, absolutely.

30 years.

People just forget. And we have so vilified acid for the purposes of selling acid blockers and proton pump inhibitors because it's a huge industry and we are paying dearly with our health because we are supposed to be acidic in the stomach. And acid in the stomach so serves a whole host of purposes that actually protect our health and allow our systems to work how they're supposed to work. And when the acid isn't there, we are vulnerable to nutrient deficiencies, to infection, to cancer, all those things that you just named. So acid is a huge problem. And even if you're not on acid blockers, acid production does drop diminish with age. And so some people really need to supplement.

Yep, absolutely, absolutely agree with that.

Yeah. Okay, so we talked about magnesium, we talked about protein, we talked about acid blockers and acid. What about vitamin D? Are you someone who recommends supplementation there and do you recommend a certain kind?

Yeah. So first thing I would say is how can we get vitamin D from our best source first, which would be the sun.

Right.

How can you get that midday sun on your skin without the sunscreen? Obviously if you don't want to be burning. Right. Get out there enough not to burn, then put some natural mineral based sunscreen on or something if you are going to be out there. So you're not putting the additional chemicals on your skin, you don't want that.

Or protective clothing or that.

Yep, that's another option. So that would be your first and best source would be the sun. Now let's be realistic. Not everybody's living. If you're in those cold weather months, the sun's rays are probably not strong enough to generate enough vitamin D production. Right. So in those situations, supplementation is probably going to be something that you rely on. And supplementing with D3 can be important. Before you just start supplementing with vitamin D3 willy nilly, you need to check and see where your levels are at. Get the 25 hydroxy vitamin D test, see where you're at. The range on vitamin D is 30 to 1. Hundred NGML. If you're in the US that's a really wide range. Right. And if you're at 30, that's considered normal. That is not normal. Right. Your levels need to be above that. Same thing with you. If you're above 100. Right. Too much vitamin D, especially when you get a little bit higher than 100, that could be where you actually contribute to bone loss too, having too much vitamin D. So get it somewhere in the middle of there, bring it, bring it in a little bit tighter and just check your levels. If you Start supplementing with D3, check your levels to see A, is the supplement you're taking actually working and B, what are your levels at? Like how effective is it? Yeah, if it's not working, because you may be somebody who has, you know, some issues in your genetics that you may have issues with conversion, with transport or with binding of vitamin D. And if you have those things, you need to be aware of it because you may be the person that needs more and needs it more frequently too.

Right, Right. There's so many people that are on these like whopping 50,000 IUs a week doses. And if you're someone who can't transport vitamin D, then you're just taking all of that and it's, it's for naught because you can't transport it to where it needs to go.

Yep.

Okay. Any other, any other things that you think people need to think about in terms of supplementing?

I mean, there are, there are a ton of other nutrients and things like that that are important. Omega 3s are important too. Right. There are different sources. There are, there's, you know, algae based omega 3s. There are fish oil based omega 3s. Just omega 3s are going to be important because they're going to help dampen inflammation. Anything contributing to inflammation, especially chronic, especially long term, that's going to contribute to inflammation.

You can get them from diet too.

Yeah, for sure. You can. Absolutely.

Lots of omega 3 rich foods.

Yep, you absolutely can. And then making sure you are getting enough protein. I think we touched on that one. Yeah, those are, those are probably some of the biggest ones.

So I get this question all the time. I'm curious to hear how you address it because in the cancer population, certainly in the breast cancer population, I am not a fan of dairy and I don't recommend that anyone consume dairy. As someone who has celiac disease, there is a lot of cross reactivity between gluten sensitivity and dairy sensitivity. Since the protein, which is grass, the protein is the same for Both of them. So I get this question all the time. How am I going to get enough calcium in my diet if I don't eat dairy?

Well, a couple. Couple ways that you could, right? If you're not consuming dairy. And by the way, a note on dairy is dairy is not for everybody, right? It is definitely not for everybody. Some people just do not do well with it. And also, it's not about drink a bunch of milk, right? When people think dairy, they just think, oh, let me just drink a bunch of glasses of milk. That is not how you build stronger bones, right? Even though the marketing may have taught us that when we were younger, that's just not the case. There are a ton of other nutrients that play into this. And if dairy is to be consumed by somebody who could tolerate it, it would be cultured and fermented dairy, where you've got kefir and it may not even be an actual cow dairy. It could be a goat or sheep or camel or something like that that may be easier to tolerate. But since we're talking to a group that that's probably not going to be included in that plan or incorporated in that plan. How else can we get it? One way would be sardines or mackerel or some kind of smaller fish, wild sockeye salmon. If you get the cans with the bones in, those bones are not hard, pokey bones that will hurt your mouth. They're actually really soft and they'll kind of melt down when you, when you're chewing on them. And they contain protein. You need those proteins for that protein for your muscles and bones. They contain the bones, which contain all the minerals that your own bones need in the right ratios that nature put them in. And they contain omega 3s. That's the source of omega 3s to dampen that inflammation. So that's like three in one. So that could be one way to get that bioavailable calcium is through consuming those fish with the bones in another one, arugula. Arugula is a leafy green, same cruciferous family of vegetables as broccoli and kale. It's rich in vitamin K, vitamin C, bioavailable calcium. Unlike spinach, Spinach has calcium, but that calcium has oxalate. Also. There's oxalate or high oxalates and spinach. So if you are somebody who cannot break down and degrade that oxalate, or you have oxalate issues, meaning you might have digestive issues, you might have joint pain in different areas. Those kinds of things could be indicators or kidney stones, even that you have issues with oxalate.

Yeah.

Then you can swap that spinach for the arugula and get another. A bioavailable source of calcium there. And then. Yes. Some other ones. Cruciferous vegetables. Right. Could be another. Another great source. Yeah, you've got some there. I think the, the absorbability or bioavailability, there would be like 40 to 60% in cruciferous vegetables. There are. There is calcium and legumes, if that's part of your plan. Sometimes people have challenges with that if they have digestive issues. So there are other ways to get it. And the last part is, if you can't get it through diet, nutrition, close the gaps with supplementation.

Yeah. I think one of the keys to getting the calcium from plant sources is to have it along with a source of vitamin C. So like squeezing citrus in or mixing peppers in. Also, tofu is a great source of calcium. And so there are a lot of great dietary sources. And our bodies really know what to do with food, whereas with supplements it's not the same. And we were not meant to ingest these, like huge doses of a single nutrient. And so it's always better to do it with food. Don't you agree?

Yeah, I would agree with that. And then also, if you are supplementing, you know, you don't want to take. Just like Dr. Jen just said, you don't want to take large doses of certain nutrients, especially minerals and things, all at one time. You can spread those, if you are supplementing, spread them out at different meals throughout the day. Right. So that could be one approach that you do.

That's a great point. That's a great point. Okay. So obviously to build strong bones, we need the proper nutrients. What else do we need? What else are we looking for in terms of improving bone health?

Well, you need good gut health and you need to exercise. There are. There are multiple other things you need good gut health, you need to exercise, you need to reduce your stress, you need to improve your sleep. Those are four big ones right there. I'll touch on each of those just briefly. Right. So the first one would be gut health. Gut health. If you're not absorbing your nutrients, we already talked about, your body's going to go to the bones to get that. You will have some bone loss. Right. So if you have overt digestive issues, just be aware that that could be something that's happening or taking place. So we need to resolve those digestive issues. The other part of your digestive health and your bone health and how that's connected is that we'll tie it back to your bone marrow, actually. So your bone marrow is. Your bones are actually. They're not these static tissues that just hold you up and keep you upright. They do that, and they do a good job of that, but they're also living endocrine organs. And within that, those bones, you have bone marrow. And it's this soft, spongy material that produces 95% of the blood cells in your body. So, you know, if you've got. If you need help with clotting and preventing bleeding, platelets are going to help with that. If you need help with carrying oxygen to the body's tissues and carrying carbon dioxide away from the tissues back to the lungs, red blood cells are going to help with that. But if you need help with fighting infections, healing wounds, anything related to the immune system, that's where white blood cells are going to come in. The cells that break down bone are a form of white blood cell. Right. So anything stimulating the immune system is speaking in the same language as the cells that break down your bone. Where does 70% of your immune system reside? In your gut. Right. So if you have chronic digestive issues, it's not just a matter of, am I absorbing my nutrients? It's a matter of, are those digestive issues stimulating my immune system and contributing to and fueling bone loss? Right. So that is a major connection most people aren't aware of when it comes to bone health and digestive health.

And at the same time, anyone who is in a chronic inflammatory state state, the same thing is happening. Right. Because that is the same signaling that is going to enhance bone breakdown.

Yep. Anything speaking to the immune system is speaking in that same language as the cells that break down your bone, right?

Yeah.

So that's a big one. Gut health is a big one. Stress. I think I'll just touch on this briefly. You need to reduce your stress. Right. It's not good for your health, definitely not good for your bones. And it's more than just take a deep sigh and, you know, on the weekend or when you're sitting in your car, you need to cultivate a healthy meditation or prayer practice or something like that. Whatever speaks to you the most, find that cultivate it. Even if it's just for a couple minutes a day. Right. You can make a couple minutes to scroll through your phone and look at some cat videos. You can take a couple minutes to take some intentional breaths and, you know, get refocused in your body and focus on healing. Bring some Healing energy to your body.

So now why does stress matter so much in terms of bone health? What's happening there on a physiologic level?

Yeah, I mean, a couple things. So it's, it's increasing your bone breakdown, it's reducing progesterone production, which is really important for your bones. It's, it's just increasing the lifespan of the cells that are breaking down your bones. So you definitely don't want that happening. The other piece too. Let's tie in sleep just for a second also. So sleep is really important because that's where your body is obviously repairing and healing and restoring tissues. And it's really, really important. Right. You have to get good quality sleep. Most people know that this is not new. But at the same time, if you don't have good sleep, that will impair bone formation, it will reduce your bone quality. This is pretty well documented. Right. So that's another important area. But I think the, one of the most important areas after that to talk about would be exercise. And just for the sake of time, I'll compress this just a little bit. But exercise is really important for your bones. You could do everything we just talked about. You could take in the right nutrients, you could get the right testing and you could start getting better sleep. If you're not providing the stimulus, your bones need to become stronger. They're not going to become stronger. Right. You may be able to prevent, you know, yourself from losing more bone, but you need to be providing that stimulus on a daily basis. So your body needs two different types of stimulus. You need muscle pulling on bone and you need impact. The most effective interventions are going to use one or both of those things in combination. You also need different forms of exercise. You need weight bearing exercise. Yes. And you need resistance strength training and muscle strengthening exercise. Now, what is weight bearing exercise? That is where your body and your bones have to work against gravity to keep you upright. There are things you are doing on your feet and that's placing a good, healthy stress on the bones. So this would be you're running, you're jogging, you're hiking, you're walking, you're gardening, you're dancing, you're playing with the kids or the grandkids in the yard. Or maybe it's your Tai chi, your yoga, your Pilates, your qigong. Right. All of those things are weight bearing. Notice they don't all sound like formal exercise. Yeah, right. They're just things you're doing on your feet and you're placing some good, healthy stress on Your bones. Then there's non weight bearing exercise. This is where your body and your bones are not working against gravity to keep you upright. This is what astronauts face when they go into space. They don't have gravity, that they don't have that healthy stress on their bones. So they will lose bone density quickly and rapidly if they don't use it. Use it or lose it very much applies to your muscles and your bones. So you need to be aware of if you're doing these exercises, cycling, swimming, those are two of the biggest ones. And when it comes to the these exercises, it's not to say that if you enjoy these things and they bring you joy and they make you happy and you do them with your family and they reduce your stress and it's just part of you having a happy, active life, that's great. You can incorporate those things. Don't overdo it and don't also count that as your only form of exercise. Don't just do laps in the pool five days a week. Get out and say, I did all my exercise, I'm good. You're not, you're not good. You gotta incorporate the next form of exercise, which is muscle strengthening and resistance training exercise. And that's where you bring in your barbells, your dumbbells, your resistance bands, or the weights in the gym. Right, the machines at the gym. And you do exercises like some squats, like some deadlifts, or maybe some overhead presses, or maybe some chin ups and box jumps or something like that. You would work with somebody to help figure out what's the right mix of that for you. But you would slowly work your way up to where you're providing that stimulus you need for your body, your bones, your muscles to become stronger. So that's, that's kind of just out.

Of curiosity, are push ups, sit ups, squats and planks enough or do you need more?

I would say you need a little bit more. Deadlifts or deadlifts are one of the best movements. And I know that sounds intimidating to people, especially if you have not ever lifted a weight or like been in the gym or anything like that. I understand that. I understand that's intimidating. But guess what? You don't have to be perfect.

Or let's say if you had spine surgery.

Yeah. Or, you know, great example, right. So if you have things like a surgery, if you have stenosis, scoliosis, spondylolisthesis, osteoarthritis, degenerative disc disease, you've already had a fracture, right? When these things come into the picture now we look at what are the modifications, adjustments and tweaks we need to make to get you to the point where you're preventing additional injuries. Right. You're doing things safely and you're still providing the stimulus you need to become stronger. And that is where you get to a point where you work with somebody to figure out what's the right mix for you. Right. So really, really important.

Is there any thing extra that you would add to someone who has had a fracture that that is in that acute healing phase?

Maybe not necessarily add, but maybe the overhead loading, like the axial loading, Right. So overhead presses or heavier lifts overhead. Especially if you've had a compression fracture or something like that, that's probably not going to be the best thing in those situations. Healing does take some time to do those things. So what you can do is you can monitor, look at your bone turnover markers, see how that healing is going to on your scans, and just kind of judge. You don't. Whenever you do get back to the point where you're lifting again, it's not like you're going to start back at whatever weight you were at before the injury or the fracture or whatever.

Yeah, you got to rebuild, right?

You got to rebuild. You got to go slow and that's okay, right? Because all of this is a slow process. Just focus on the journey and being active and feeling good while you're doing it. Ego does not need to be involved in this.

I want to end with the 800 pound gorilla in the room, which is estrogen, because estrogen is so instrumental. You talked about this a little in the beginning, that estrogen is so instrumental at maintaining bone health. Then women who are on a breast cancer journey, or if you're just living your life, it's unlike the transition for men where their estrogen levels drop slowly over time, as do their testosterone levels. But women fall off a cliff sometime in their 40s or 50s. If you've been treated for breast cancer and you've had your ovaries removed or you're on estrogen blockade, these people fall off a cliff in a day. Talk about estrogen, talk about the role, and then can we talk about estrogen as an alternative to bisphosphonates and other kind of medical interventions, we'll start with the estrogen.

In terms of what I touched on earlier, which is when we're talking about primary osteoporosis that is typically occurring in postmenopausal women, where we have that decrease in estrogen. Right. Like I mentioned earlier, estrogen it has that protective effect on bone. When those levels decrease, as they do during menopause, that's going to cause an increase in the activity level of the osteoclast, those cells that break down bone. And for those people that are interested in understanding a little more why that happens, the lack of estrogen is associated with an increased release also of these cell signaling proteins called cytokines. Interleukin 1, interleukin 6 specifically. And that is what's going to stimulate osteoclast, which in turn is going to increase that bone breakdown. In terms of.

And those are, those are actually inflammatory cytokines. So they don't just go up with a decrease in inflammation in estrogen, they go up, but they are a sign of inflammation. So if you're in a pro inflammatory state, that's part of what's happening. That's part of what you described before. Like if you don't get enough sleep, that's a pro inflammatory state. If you have some kind of inflammatory situation, too much stress, those cytokines are going up and that's what's happening there.

Yep, yep. Absolutely. And then in terms of. Every single person is going to be different. Right. Usually I won't be the one in. In terms of the way in which we help people, we have multiple team members. I would not be the one to specifically look at and evaluate somebody's situation for whether they would or wouldn't take or what situations would be right for them. With estrogen and things like that, we have multiple people that look at and evaluate those things and make sure that the person has the right plan specific to them for that. But it's important, like, it's just, it's an important consideration that people have to understand that, you know, your hormones play a role, a big role in your bone health. And you need to know how to make educated, informed decisions when you move forward.

Yeah. And unfortunately, because of the Women's Health Initiative and the false conclusions that came out in 2002, millions of women stopped using hormone replacement. And I think that we are certainly seeing the ramifications of that. And that is why we have as many people die a year of a complication of a fracture as we do of breast cancer, because we traded in one problem for another. I want to be clear that estrogen does not cause breast cancer and that if you and your practitioner think that estrogen replacement is appropriate for you in terms of improving your bone health, improving your heart health, improving your brain health, then I don't think that you should fear breast cancer because that's really not what's happening there. On a physiologic level, anything that we didn't touch on today that you feel is important for this audience?

You know, I think we covered quite a bit of ground. I would just say if we zoom out and we look at the whole picture, right. Of what somebody needs to focus on and look at. You need to identify and address the contributors to bone loss, right? That's kind of the first thing you have to do. You, you have the right in that conversation to say, hey, I know I was just told I have osteoporosis. I want to make the most educated, informed decision. Can you help me get that information right? Or. I'm not saying no, I'm just saying not yet or not. Like, give me a little more time. You have the right to say that, right? And then diet, digestion, absorption, that's the next kind of big bucket. You got to nourish your body, so you got to identify why you got to nourish your body. And then you got to build, you have to build strength, a body of mind, a bone in a way that prevents fracture and injury. That is how you preserve and strengthen the structure that's going to carry you to an active future with the people you love most.

I love that. So I'm just going to reiterate that you said identify and address the contributors to bone loss. So if you've had that DEXA scan and you, and you know that you are someone with bone density and not optimal bone health, that you've done all of the tests, then take the time to make an educated decision like there's no urgency. And I know that people feel a lot of urgency in that situation. But the truth is that you do have the time and the luxury to make the right decision for you. And look at diet, look at digestion, look at absorption, and then make sure that you have all of those pieces in place, the stress management piece in place, the sleep piece in place, the inflammation piece in place, that you're, that you're in an anti inflammatory state and that you're doing the things that you need to do to build bone health. Evan, the bone coach, where can people find you?

You can always find me@bonecoach.com we've got lots of resources there. We've got the ability to get help with programs and things like that for building stronger bones. And you know, that's, we've got a lot of people that, we've had thousands of people that have come through our programs. And it's just there are actionable things that you can do every single day to start making progress and improving your bones. So you can find me@bonecoach.com and then Instagram @bonecoach, Kevin. Facebook @bonecoach, YouTube @bonecoach.

And we will have all of this in the show notes. Kevin, it was so great to have you here. And this is such an important topic that literally affects everyone. It certainly affects women more than men because of the estrogen factor. But as you pointed out, this is highly tied to your nutritional state. And if you're in a poor nutritional state, your body is going to get what it needs from somewhere and it's going to mobilize it from the bone. So I think that you laid out a really great plan for people and gave them a really important message. So I thank you so much for doing what you do and for sharing your brilliance with us today.

Dr. Jen, thanks so much for having me and for everybody listening. Thank you for taking the time.

Dr. Jen, see you next time.