Osteoporosis Part 3: It's Complicated. How You Get It, What You Do About It…

A special note about osteoporosis and diet, because it is an area of high confusion.

For most folks, the connection between diet and osteoporosis is reduced to getting a defined amount of calcium in your diet or through a supplement. Our bodies do need a minimal amount of absorbable calcium but there is much more to it. And supplements need to be in the right form to be of value (that will be in a later blog.) ALSO, REMEMBER THAT NUTRIENT INTAKE AND BONE AVAILABILITY ARE DEPENDENT UPON PROPER ABSORPTION IN THE GI, WHICH CAN BE IMPAIRED BY A VARIETY OF CHRONIC GI PROBLEMS AND MANY COMMON MEDICATIONS.

CALCIUM: There is individual variation of how much one person needs, but retrospective population studies of folks who have eaten a traditional diet shows they were getting anywhere from 800-1600 mg. Calcium sources are probably the most important factors. Calcium from whole foods that contain some of the other nutrients that are incorporated in bones are the best. For people who have good tolerance to dairy products, cultured dairy (cheese, yogurt) can give you several hundred milligrams in one serving. The naturally aged, more artisan cheese also provide vitamin K2, which is important for directing calcium into bones rather than soft tissues and arteries. Among the non-dairy foods, the highest content will be from animal foods than have bony residues: bone-in fish (canned salmon and sardines for ex), bone-in slow cooked meats, and traditional both broth. I grew up with traditional foods and we never wasted any bones. A lot of folks make their own bone broth, but if you do not like your house smelling like soup all the time, you can purchase high quality broth in many natural food stores (Kettle and Fire brand for ex). Leafy green veggies and the brassica family (cabbage, broccoli,) also have a decent content, but the bio-availability is low so you need to eat them lightly cooked and preferably with a little fat. Otherwise, there are lots of foods that have a small amount of calcium that add up, so a varied whole foods diet will give you a few extra hundred mg per day.

PHOSPHORUS: Needs a special mention. Not because it is often deficient in folks diet. Phosphorus is a common additive in processed foods and sodas and not labeled as such. Phosphorus in processed foods is in such concentration that it upsets the balance of calcium and phosphorus in the intestines, causing salt precipitation of the two minerals together and preventing them from being absorbed. Bottom line, any processed food will negatively affect your calcium balance.

PROTEIN: Most of the scaffold of your bone is made out of collagen protein. Most of us need about 2/3 of our body weight in grams (150 lbs = 100 gr). You may need more in circumstances like illness, pregnancy, and intense physical activity. Protein needs to come from both plant and animal foods. There is a misconception floating around that animal protein make you lose calcium in your urine. That is not correct. Your body excretes extra calcium it does not need in the urine and animal protein significantly increases the rate of calcium absorption in the intestines, thus leading to a little more spillover in the urine. Animal protein should ideally include some of the soft tissues like skin and tendon because of the collagen amino acids that is incorporated in bones.

FAT SOLUBLE VITAMINS: Your body needs ALL fat soluble vitamins, not just vitamin D3. Vitamin D3 is ideally produced in your skin when cholesterol rings are converted by exposure to UV light. So you need some good sources of cholesterol and some time outside showing a little skin. Vitamin A is often the forgotten fat soluble vitamin, you need both plant and animal sources for optimal status. Vitamin K2 is also not getting enough attention for its role in balancing calcium deposition away from soft tissues and into bones. Highest levels are found in cheese, and fermented products (including some that are not common in the non-ethnic US diet). Fat soluble vitamins tend to be low in patients on vegan diets and on meds that limit the rate of fat absorption like statins

MINERALS AND TRACE MINERALS: Magnesium, zinc, and boron are all important in bone metabolism. Whole foods diets will usually give you enough, but for some folks it may need to be supplemented, especially magnesium.

Sports Nutrition- Hydration Part II

So in Part I we discussed the rainforest and nutrient dense soils, we are going to keep building off of that here in Part II. 

When your body is being nourished, it can actually move water. We want to be able to move water in and across cell membranes. When we think of water moving, we also have to think about water staying. Think of stagnant water that hasn’t had any movement, it usually get pretty gross, hence why not only do we need to be hydrated, but we need nutrients to be well nourished in order to move the water that is inside of us.

Many people have heard “muscles weigh more than fat” and that is not wrong. Muscle also contains 70-75% water and are generally considered storage components for nutrients. Meaning more muscle is storing more nutrients and what did we find out in Part I, “water follows nutrients”. Now, unlike muscle, fat is able to store toxins and it is actually only 10-15% water weight. 

I want to touch a little bit on fascia hydration. In previous Soft Tissue blogs I talk about fascia so if you want more on that feel free to check those ones out. 

So, in this Hydration for Performance talk by Todd Stableton that I had listened to it was brought up that fascia is the delivery mechanism for fluid. Meaning that when I have discussed soft tissue and fascia binding and if you have ever had some additional soft tissue care, your provider usually reminds you to drink some extra water that day, because these bindings are not allowing for the delivery mechanism to flow, the water flow is being stopped. There is a blockage in the system. 

It all comes together, being hydrated isn’t just drinking enough water, but also having the nourished system to hydrate within the cells and keeping fascia unbound and flexible in order to keep the delivery mechanism flowing. It all comes full circle. 

As it begins to warm up here in MN, think about how you are going to keep yourself hydrated.

Osteoporosis Part 2: It's Complicated. How You Get It, What You Do About It…

Last week I reviewed the basics on bone composition and metabolism. Now I would like to review some basics about some factors that both positively and negatively influence bone mass.

Positive

• Weightbearing activity and resistance training improve both the quantity and architecture of bone. Most female patients make the mistake of not incorporating strength training in their routine. Walking is good for many things but not sufficient for stimulating and maintaining bone mass.

• Adequate intake of ALL bone building nutrients: complete protein (including animal protein which increases calcium uptake in the intestines): all minerals (calcium, magnesium, phosphorus, zinc and rare minerals like boron): Fat soluble vitamins like vitamin D, K2 and A.

• Adequate balance of hormones: estrogen, progesterone, testosterone, DHEA, cortisol, and parathyroid

• Close to optimal weight/BMI

Negative

• Inadequate dietary intake or balance (more on that later)

• Digestive malabsorption from various sources (very often missed!)

• Insufficient physical activity and resistance training

• Obesity/High BMI: although obese individuals tend to have a slightly higher bone mass, it is proportionately not enough for the extra weight the bone has to carry

• Being significantly underweight

• Many medications: steroids, estrogen blockers (for hormone positive breast cancer), anti-seizure medications, many anti-acid medications, progestin only birth control implants and injections (especially in teenage women).

• Hormone Imbalance: estrogen deficiency, thyroid overmedication, hyperparathyroidism

Sports Nutrition- Hydration Part I

I was recently listening to a talk from Todd Stableton on Hydration and Performance, the following is what I have taken away and wanted to communicate with each of you.

Hydration is so much more than just drinking your recommended amount of water daily. Sure, it’s a good start, but to truly have good hydration within your systems more is needed. Todd Stableton mentions hydration being the consequence of a good lifestyle, similar to posture.

The term “to water” actually means to encourage health and growth. Just as you were to water your plants, for them to be healthy and grow. 

We can use water as an electrical conductor and us as humans are born at about 70% water. So, that can make us electrical conductors or as Todd said “the more hydrated somebody is, the more potential they have for energy”. Cool. 

So, how do we get hydrated? Water follows nutrients, right? If we look around us and look at soil and dirt, the most hydrated soils are in the rainforests which have the largest amounts of nutrients. Or the fields around us that are more hydrated than deserts but less hydrated than rainforests, must have some nutrient content to them. Muscles can be storage components for nutrients while fat is unable to store nutrients, but is quite able to store toxins. Meaning as people are raising their fat percentage, they are raising their dehydration levels or lowering their hydration. 

You can probably begin to see how accurate the first statement is with “hydration being the consequence of a good lifestyle”.

We want to be drinking nourishing water and can do so by adding back some minerals like a pinch of pink Himalayan sea salt.

Will be continued in Sports Nutrition- Hydration Part II , stay tuned.

Osteoporosis: It's Complicated. How You Get It, What You Do About It…

I have been contemplating writing a blog series about this topic but found the task too daunting for too long. For most patients I talk to, osteoporosis boils down to calcium, and biphosonate medications. The development and maintenance of bone mass is complex, the diagnosis of bone mineral deficiency is nuanced, the efficacy of medication treatment is not as clear cut as we would like. No wonder patients (and sometimes myself) have a “deer in the headlight“ look on our face when discussing the topic.

In this first part I simply want to establish a few simple facts about bone biology.

• Bones are made of primarily collagen protein and minerals. Of those minerals, calcium is the primary but not the only one. (magnesium , phosphorus, boron etc.)

• The resistance of a bone (“strength”) to fracture depends upon not only the total amount of bone (bone density), but also and very importantly the internal scaffolding and architecture of how the bone is organized to resist trauma .

• Bones are not static. They are in a constant state of remodeling over time, both in quantity and in architecture. We have cells that specializes in depositing bone (osteoblasts) and cells that take it down (osteoclasts). The latter are the target of most medications, by preventing the resorption of bones.

• Our bone mass will peak in early adulthood. However, you can still do a lot to avoid losing bones at an excessive rate over time.

DEVELOPING A SHORT LEG AS AN ADULT: HOW AND WHY ?

A few years back I wrote a series on short leg presentation in chiropractic. When it comes to a true anatomical short leg, it is usually acquired during growth with a mild unrecalled injury to the growth plates (very common at the knee). That particular bone stops growing at the same rate as the contralateral leg, leading to a leg differential over time. The severity of the discrepancy depends upon how early the injury happens to the child.

In the past few years I have come to appreciate the development of acquired short legs in adults, especially senior adults, in a way that I did not appreciate before. It is entirely possible, in fact probable, that I missed many of them over time, as the possibility of short leg coming on later in adulthood was not on my radar.

The mechanism by which adults develop short leg is different than youth, since our endplates have fully closed by the age of 20. Some examples are:

• Loosing cartilage in one knee (less commonly in the hip. This can happen over time gradually with a deteriorating knee joint, but sometime can be very abrupt as in the case of knee meniscal removal. The combination of the knee cartilage and meniscus is well over a half inch.

• Having a joint replacement. Depending upon your anatomy and the extent of the damage, the prosthesis can add or substract a half an inch to your operated leg. I have had two cases in the last year alone where the post surgical leg differential was a full inch, because the underlying bone required a large prosthetic peg.

• Ankle/foot fracture and surgeries, which change the height of the foot arch.

Adults with sudden onset of pain in the hip and low back, especially on the opposite side of their leg surgery, should especially be on the lookout for acquired leg difference. How much of a correction you will need needs to be assessed in the office.

Cat Cow Stretches

Cat Cow or Cat Camel stretches are routinely given or performed for lumbar stretching and mobility. I usually give these in the quadruped (hands and knees positions) for individuals that can maintain proper positioning. For those that are not able to be in this position or have a difficult time finding time to complete these, but are sitting for large amounts of their day (cough cough, I see you office workers) we can do a similar stretch or movement while sitting. The goal of the sitting movement is to keep the pelvic mobile in appropriate ways rather than allowing some stiffness to settle in which we all become very familiar with when maintaining one position for long periods of time.

Click the images below to be taken to each video.

Click the image to watch the YouTube video of the Cat/Cow Stretch

Click the image to watch the YouTube video of the modified Cat/Cow Stretch AKA Pelvic Tilts

PAIN IN THE "NETHER REGIONS" AND CHIROPRACTIC

I am trying to find a delicate way to describe a delicate subject, but have found that those patients affected by it have lost any false modesty in describing a problem for which they can be pretty desperately seeking relief. And so it goes.

Dr. Alvarez and I each had a patient presenting with genital/perineal pain in the same week (one was a female patient with acute onset of unilateral labia burning pain and the other a man with severe testicular pain). It reminded me of the very first patient I saw with such presentation, three months into clinical practice, and it made a lasting impression. He was an 18 year old young man with intractable testicle pain on his left side. Long before COVID nasal swabs made us shudder at the sight of a very long Qtip in a sterile pack, the young man’s age and interest in young ladies had earned him, not only one, but three swabs up a different orifice in search of an infection that never materialized. He failed to respond to a broad spectrum of antibiotics. A CAT scan later, he remained a medical mystery. He developed sacroiliac pain that landed him in our office, and to everyone’s delight resolved both his butt and groin pain in a few treatments.

Pain in the genital, perineal, and inguinal area, can have many sources and chiropractic will not fix all of them for certain. But once internal and infectious causes have been medically ruled out, I am amazed by how many folks are sent home without a good reason for their continued symptoms. And in those instances, you really need to look at the neurology of the area and investigate the possibility that this very pesky problem may be a “pinched nerve in your undercarriage”. (line stolen from one of my patients)

The attached image is a good summary of the sensory innervation of the pelvic floor front to back . Of those nerves, I want to circle in on the pudendal nerve because it is the most frequently missed source of pain in men and women. In men, testicular pain can be referred from the mid lumbar spine through the lumbar nerve roots at L2 and L3, and this will usually affect the anterior groin into the front of the testicle. The pudendal nerve will cause pain that is more directly in the groin area and in front of the rectum, slightly laterally. In men this will feel like pain shooting into the posterior aspect of the testicle and penis, and in women the pain will affect the area of the labia, lower vagina. The pain can feel deep and internal, or more superficial like a burning, prickly sensation.

The pudendal nerve has a path that makes it vulnerable to entrapment in several areas, most commonly as it exits the lateral lower sacrum and travels by the sacrotuberous ligament and around the ischial spine. The nerve can be easily injured by sacroiliac strains, falls on the buttocks, and chronic repetitive frictions sitting on the wrong chair. Patients with pudendal nerve entrapment of neuromusculoskeletal origin will frequently report associated pain in the upper gluteal and tailbone pain at some point.

The moral of the story is that pain in your private areas is worth bringing up to your chiropractor if you have no good medical explanation for it. A pinched nerve is a pinched nerve, no matter how “private” its location.