Dr. Alex Petrushevski - 'Bone health through the low carb lens'

[Music] all right thanks Loren and uh thank you for loward Down Under for allowing me to come and speak to all of you today so I'm Dr Alex petreski and today I'm going to be talking to you about bone health through the lens of low carbohydrate medicine and nutrition um so just just a quick disclaimer before we go on that none of this talk today constitutes any individual medical advice so I'm mainly going to be talking about osteoporosis today osteoporosis is literally porous bones and it's a condition of weak and fragile bones uh with a characteristic low bone density which confers a higher risk of the bones fra fracturing in the long term and it's becoming increasingly common in the western world it's often undertreated and unrecognized because in part it's typically a clinically silent disease unless it manifests in in in a fracture however in the clinic if I'm looking at Patients one clue I would look for is if a patient's height is continuously going down over the years especially if they've got this characteristic stooped posture then that's a bit of a giveaway of all the complications of osteoporosis hip fracture is generally the most feared one because not only do you get the pain the hospital stay and the the potential surgery with it but it carries a a fairly significant Associated mortality risk as well some common risk factors for osteoporosis include advancing age being female and if you are female early menopause gut malale absorption States all increase the risk of osteoporosis so that includes things like inflammatory bowel disease celiac disease and and also post bariatric surgery so we see a lot of those patients in our Clinic as well autoimmune diseases like rheumatoid arthritis and hyperthyroidism increase your risk as do certain commonly used medications including corticosteroids uh and proton pump inhibitors which we will commonly use for patients with reflux or stomach issues uh as well as anti-epileptic medications which are used for patients with seizure disorders and certainly in our Clinic we see a lot of all of these things um on a daily basis really and it's very relevant because at its core osteoporosis is a metabolic disease uh much like all the other metabolic diseases we treat now most people look at bones and think that they're pretty static organs but actually the truth is they're very metabolically active not too unlike fat cells for instance so our bones are con constantly break being broken down and remade primarily through the work of two types of cells so osteoclasts help us break down old bone and create space for osteoblast to to lay down some new fresh healthy bone and this process continues indefinitely this remodeling process helps our bones adjust uh their structure to meet our changing needs so think about weight loss or weight gain or growth spurts during adolescence as common examples it also helps us repair small amounts of damage in the bone matrix and prevents accumulation of old poor quality bone along with uh maintaining very tight levels of calcium in the blood so in an ideal State this balance of breaking down old bone and making new bone should be fairly balanced but if we end up in a state where we're breaking down more bone than we are laying we can run into problems with low bone density in our clinical practice the most common way to measure bone density is with a dexa scan which stands for dual energy x-ray absorbit ometry which is basically two lowd dose x-ray beams passed over the body uh and the X-ray dose is much less than a standard X-ray and so with this we can assess someone's lean mass and their SK skeletal density along with being able to measure their body fat percentage very accurately so we will often do it for patients for that reason alone in our clinic now this bone density can be expressed in absolute terms so gram per centim squar or as a t-core which is more common the t-core represents the a number that compares the condition of your bone density to that of an average young healthy person with healthy bones so a t- score of minus 1 1.0 will mean that your bones are one standard deviation away from a young healthy person and if your t- score goes under minus 2.5 then that's indicative of osteoporosis so this is an example of one of our recent patients is saw us in a clinic a 54y old postmenopausal woman who got her first bone density with us and you'll note here her t- score in her left hip - 2.8 so that's diagnostic of osteoporosis now the standard teaching is you reach your Peak bone mass at about 30 to 35 and typically from that point onwards it's all downhill and so you can see that on this picture here the medium bone density starts to fall at a certain point now there are some exceptions to that but what this implies is um your Peak bone density is going to determine in part at least how careful you need to be about bone density later in life in other words if your Peak was not that great then you may have less bone density to play with than than someone who's got a higher Peak and so you might need to be a little bit more careful about your strategy around preserving bone density now if you want to build bone you need to know what's in it so bone is made up of a bunch of different compounds the primary component of bone matrix is something called hydroxyapetite so that's basically calcium and phosphorus there are other minerals in The Matrix including magnesium potassium sodium copper and fluoride but one thing a lot of people don't realize is our bones are made up of about 40 to 50% protein in the form of type 1 collagen so all these minerals are really encased around this scaffold of protein and that's going to be relevant later on so let's say you've been diagnosed with osteopenia or osteoporosis and we want to prevent a fracture later in life the first thing everyone gets told to do is go and get some calcium and while calcium does make up a major portion of our bone tissue High dietary calcium intake doesn't seem to be that protective against osteoporosis related fractures uh and you can see here the recommended daily intakes for men and women on the slide further to that calcium supplements alone were not that useful in clinical trials in fact if we give people high dose calcium it can actually pose some dangers because it can potentially increase your risk of calci of kidney stones uh and potentially increase your risk of coronary calcification in the arteries because if we if you're eating a sort of large dose of calcium and it doesn't go into your bones it has to go somewhere else and it can end up in the in the blood vessel wall the second thing everyone gets told to do is get some vitamin D and that's potentially reasonable so vitamin D is integral to bone health as it helps us increase our absorption of calcium in the gut it reduces the loss of calcium from the kidneys and it also helps regulate bone breakdown via the Osteo so it's working on both sides of the equation and certainly in epidemiological studies vitamin D deficiency is associated with increased risk of fracture and osteoprosis but similarly if we look at Trials of just using vitamin D alone they're a bit disappoint pointing so either the effects are small or they're nonsignificant and in fact intermittent high dose vitamin D which was quite fashionable for a while is actually associated with an increased risk of fracture so similar to calcium if we just use vitamin D alone it's not that useful so what if we do something really clever and combine calcium and vitamin D together well then things look a little bit better so based on meta analysis if we combine these two supplements you get some increases in bone density and you get some um modest reductions in the risk of fracture so 15% relative risk reduction of total fracture and a 30% relative risk reduction in hip fracture so that's that's really the end point we're after and if we look at just postmenopause women which are probably the highest risk group this modest um effect is still preserved so that's nice so now let's look at some less common interventions Vitamin K is a fat soluble vitamin important for the function of numerous proteins within the body including clotting factors uh Matrix GLA protein which is important for preventing coronary calcification and Osteo calcium which is an important bone forming protein vitamin K exists in several natural forms so it exists as vitamin K1 which is the plant form and you typically find this in green leafy vegetables that's more relevant for clotting factors whereas vitamin K2 is more relevant for the bone and there's several subtypes but the most important to are MK4 which we find in animal foods such as eggs meat Li that sort of thing and mk7 which is found in higher quantities in fermented food so things like Dairy and natto which is a fermented soybean product now it's worth noting that K2 is a relatively new kit on the Block we don't have decades and decades and Decades of study on it but for what it's worth we've got some rdis of 120 micrograms a day for men and 90 micrograms a day for females and it's also worth noting that the modern Western diet's probably deficient in vitamin K2 and actually like vitamin D it's a fat soluble vitamin so if we're restricting our fat content dramatically then we're going to find it a bit harder to get this in the diet as well now about 15 years ago there was a period of intense interest at using high does pharmaceutical grade vitamin K2 as a supplement either a alone or with vitamin D as a bone protection agent and these studies usually measured bone density or markers of bone turnover to see what their results were and they were a bit conflicting so overall combining K2 and vitamin D was a little bit more effective than using K2 alone which only had a modest effect if we look at some more standard dose vitamin K2 trials so our doses that we could access in a pharmacy or a supplement store um the results again are a little bit conflicting but this metaanalysis that came out last year suggested that K2 improved bone density uh without necessarily having a clear Improvement in fracture risk there were Improvement in bone health markers and the effect sizes were more pronounced in people with the worst osteoporosis so if you were older or more frail or had worse bones you are probably more likely to benefit than someone that had just some mild osteopenia which is a milder version of osteoporosis there are also some Regional differences which is quite odd so the Japanese trials always seem to look a little bit better and then when the Europeans tried to emulate that data the the results weren't quite as good so that does raise the possibility that maybe there's a genetic difference in Japanese people that means they benefit for more or maybe their uh their Regional diets just Happ to be a bit more deficient but to sum up K2 it's safe it's cheap it's potentially effective and it's particularly useful for high dose for high risk osteoporosis and postmenopause of women it also carries some non-bone benefits especially for heart disease so a lot of our patients will end up on it for that reason uh our practice is generally to increase K2 in Foods as a priority but combining it with vitamin D and or calcium for higher risk patients is not unreasonable potassium is another bone constituent that often gets neglected and higher potassium intake is associated with lower osteoporosis risk in fact there's a couple of recent studies done where they took a bunch of people and just gave them 50 grams of prunes a day and that actually improved their bone density quite significantly which is primarily put down to the potassium content of the prunes now obviously the prunes have some carbohydrate in them so they're not going to be appropriate for everyone but there are some people who will be able to tolerate that carbohydrate content failing that getting more potassium in our Foods or in salts or electrolyte solution is a common practice for our patients as well somewhat linked to potassium is magnesium which not only supports potassium but also calcium metabolism magnesium also independently supports osteoblast function so helps them lay down new bone and observational studies link higher magnesium intake with higher hipbone density in fact the Magnesium content of our drinking water actually correlates very well with fracture risk and the Magnesium content over water varies quite a bit across the country unfortunately there aren't enough good long-term studies on magnesium supplements but short-term studies show that uh you actually get improve your hip um bone density with just a simple magnesium supplement so that's quite useful and similar to K2 it's worth noting that dietry magnesium deficiency is very common our soil is becoming quite deficient in magnesium so a lot of our patients do feel better when they take a magnesium supplement so perhaps rather than looking at all of these ingredients in isolation we need to be thinking about a more unified strategy if we want to um maximize our bone building potential and so several times through that data you'll see that when we use something in isolation it doesn't seem to be that good but maybe if we combine them together um that's when we can build bone more more effectively and that kind of makes sense because to build bone you probably need appropriate building blocks of all of these things but what about protein as I mentioned before the the bone collagen scaold makes up a significant portion of our of our bone weight and in fact protein intake actually also modulates calcium absorption in the gut which is incredibly helpful and low protein diets are associated with higher bone breakdown and increased risk of not just osteoporosis but fracture in the long term and if we just look at studies of a classic low protein diet which would be the vegan or plant-based diet we can see just how bad it can get if we neglect dietary protein so there's several systematic reviews showing that avoiding Animal product significantly increases your risk of osteoporosis and Fracture risk in the long term even if we ignore the source of the protein be it animal or vegetable higher protein diets are associated with lower hip fracture risk with the optimal protein intake being more in the vicinity of 1.2 G per kilogram per day and this really suggests that the current recommended protein intake of 0.8 migr per kilogram per day is grossly inadequate especially for for older patients who already have higher protein needs now it's one thing to look at observational studies but what about an actual Interventional study well this neat study came out in 2002 and attempted to address a few of these questions at once so they took 342 healthy patients above 65 so classic at risk group for osteoporosis and fracture and over three years they randomized them to either a control trial or an intervention with calcium and vitamin D and through the period of the study they did six-monthly bone density scans and also attempted to regularly um quantify their protein intake with food frequency questionnaires so after after that was all done the patients were split into three groups based on their protein intake so the lowest protein intake group averaged about 69 gr a day and the highest protein intake group averaged about 87 gram per day and what they found was the calcium vitamin D group in Black had a modest overall benefit in um bone density markers over Placebo which fits with the other data that we've looked at already but what's more interesting is once you did that if you then also ate higher protein um you did better on all fronts and and particularly when they looked at femoral density which is the best predictor of hip fracture um the effect was really quite pronounced so this suggests that if you can get the mineral and micronutrient environment right increasing your protein really takes your ability to build a new bone to the next level now I mentioned inflammation earlier in the talk and the reality is that chronic inflammation has a major impact on osteoporosis and osteopenia as it does for pretty much all metabolic diseases in fact we see early or severe osteoporosis as a complicated of several chronic inflammatory disorders such as inflammatory bow disease celiac disease rheumatoidarthritis cancer even even chronic periodontitis is associated with worsening bone health and in fact there's many different Pathways in the inflammatory Cascade that can actually affect our osteoclast and osteoblast and how they function and it's interesting that low carbon ketogenic diets have been shown to affect several of these so the anti-inflammatory effects of your diet can have many benefits for your bone health as well so now let's talk about some things you may want to avoid to optimize your bone health first of these are lectin so lectin are carbohydrate binding proteins commonly found in wheat legumes nightshade vegetables among other things they bind calcium in the gut uh which makes it harder for us to get it where we need to and they can also cause chronic gut inflammation or leaky gut in some people which can lead to malabsorption on its own the second group of foods we might need to be careful with are Fates so they also bind to calcium and can also bind to other trace minerals and you'll find these in rice soy nuts and certain legumes and the third group of antinutrients I'll touch on oxalates which are found in spinach nuts seeds again legumes bit of a recurring thing uh and these tend to bind calcium in the gut as well now normally we're happy for them to bind calcium because it stops the oxalate crystals getting into our blood where they can cause uh problems with kidney stones or joint um issues but if we're trying to prioritize our bone building ability then having having them buy the calcium is not such a great thing now just a quick note on everyone else's favorite vices so unfortunately tobacco alcohol soft drinks and this is where I'm going to get booed caffeine all have a negative effect on bone metabolism yeah know um and they can increase your risk of osteoporosis in um epidemiological studies so we just need to be a bit wary about these if we're struggling with poor bone health so what is an optimal or ideal diet for bone health well it's unlikely that we're going to have a one siiz fits-all approach and everyone's a bit different but if I'm looking at some things I want to see in a diet from a bone perspective it would be a diet that's protein forward that's nutrient dense that's ideally anti-inflammatory and ideally limiting antinutrients so let's have a look the the standard Western diet or the food pyramid diet maybe charitably would say it's protein neutral but it's certainly not nutrient dense it's not anti-inflam it's not limiting antinutrients so not much to recommend there if we look at a plant-based or a vegan diet similarly it's not going to be protein forward charitably maybe it's nutrient uh nutrient neutral um but again probably not anti-inflammatory and certainly not limiting anti-ant so not ticking many boxes if we look at a well formulated low carb or ketogenic diet however we can see something that might actually fit the bill for what we need and hot off the press this year this systematic review uh collated all the available randomized control trial data on available on low carb diets and bone density and these studies were done on adults rather than children uh which is going to be important in a moment uh and there were no appreciable differences in bone mineral density or bone turnover markets so yes it's only seven studies it's not 50 studies yet but it's a pretty good start and there's no signal in the data to suggest that the carbohydrate content of your diet is going to have a major detrimental effect on whether you lose bone mass or not so if that's the case why do we see headlines like this warning us that our bones are going to crumble away if we give up the carbs couple of reasons the first is there is actually some data on ketogenic diets in children for epilepsy that has shown that on average kids that are put through this diet their their bone density is a little bit lower and their growth parameters are a little bit worse now really important to note here that these kids have a very specific problem that requires a very strict diet which is often quite protein restricted so we can't really describe the diet they're getting as a protein forward diet so the protein deficiency by itself could potentially explain for why they are potentially not having great bone health and the other thing is anti combulsiones buffer dietary acid load although the exact magnitude of this effect is a little bit unclear in Petri dishes osteoclasts tend to break down more bone in an acidic environment and Osteo blast lay down less bone uh in an acidic environment um however it's worth noting that when we eat more protein our our urine does contain more calcium but it also um probably contains more calcium because we're absorbing more in the gut um and if you look at acidic Foods they tend to be things like meat eggs dairy rice and alcohol and alkaline foods tend to be most fruits vegetables nuts and legumes and it's also worth noting that most of us are fortunate enough have to have kidneys that work well and our kidneys um do most of the work when it comes to buffering our blood pH so um as long as our kidneys are functioning we shouldn't run into too many problems with dietary acid load and if we look at a systematic review of all this all the data on alkaline diets for bone health that's what we see we see no clear relationship between dietary acid load and Fracture risk or bone density as long as we've got functioning kidneys so alkaline diets just waste of time another point of contention came a few years ago in the form of the Supernova study so this was a study done on 30 world-class race Walkers who were brought into study over a period of several weeks and during this study they were split into a standard high high carbohydrate diet which is more the standard athletic diet I guess and a low carb intervention group with equivalent calories so at the start and at the end of the 3 and 1 half week period they measured markers of bone resorption formation and overall bone metabolism so we can see the protein intake was relatively match between the two groups although maybe a little bit more protein for the high carb group but the major difference was the carbohydrate and the fact content of the two diets at the end of the study the low carb group showed fairly significant rises in CTX along with reductions in P1 NP and osteocalcin and all this combined suggests a shift in the low carb group to less bone formation and more bone breakdown so the study authors concluded that a low carb diet is potentially dangerous for bone health in the long term now before I touched on the importance of certain minerals when it comes to building bone matrix and you can see here that some of these are are listed here and if you look through the appendix of the study to see the nutritional breakdown of both SIDS you'll see that the low carb group had lower quantities of all of these minerals so these two groups were unfortunately not adequately matched when it comes to these so this could potentially explain some of the the markers looking worse but that's not where the issue ended so this study was only done for 3 and 1/2 weeks so that's far too short to determine long-term Exercise capacity the athletes were not fat adapted going to it and many people in this room can attest to the fact that it takes a bit longer for your um body to adapt to to running on fat if you're an athlete and also many people in the room room can attest to what can happen when it comes to keto flu if you don't get your electrolytes right uh in the first week or so of the diet the athletes were not explicitly advised to increase their sodium intake which can help mitigate some of these effects of the the keto flu um and above all else the study didn't actually produce any hard outcomes so nobody got a fracture nobody got their bone density measured um and obviously there's a good reason for that because it's already hard enough to get so many worldclass athletes together in one place but I think it just needs to be something we're mindful of that this data is not necessarily something we can just transfer to the average person and tell them that they're going to have long-term impact on their bones so putting it all together in the clinic this is our framework to proactively manage bone health in our patients we will suggest a baseline bone density in patients at risk or when they turn 50 nutritional assessments done on all of our patients with particular Focus to protein intake micronutrients fatty acids and very diligent attention to their electrolytes we'll use supplements if appropriate so calcium vitamin K2 D3 and a protein supplement if it's needed although we'd rather patients eat their protein any abnormal inflammation or malabsorption markers need to be addressed and followed up because that can be a big driver of malnutrition in the long term term and this talk is mainly touched on diet but just a quick point that resistance training is a really big part of getting people to build appropriate bones so we'll often get people to work with our exercise physiologist or their trainer if they've got someone who can put them through an appropriate program and finally follow-up bone density measurements and body composition scanning is um something that's quite easy to do because a dexa scan is a cheap and very low radiation dose scan so it lends itself well to regular follow-up which helps you individualize your approach so to wrap up good bone health is simply put good overall health bones are more than just calcium and protein is critical if we want to build new bone we need to focus on several important micronutrients and I just want to note that building bone later in life is possible for patients who've been told they cannot and at the end of the day there is no compelling reason that a protein forward low carb or ayic Diet is necessarily going to be detrimental to your bone health so thank you all for attention and just a quick note about our clinic and information if you want to go um find some more information about how our Clinic works thank [Music] you

Channel: Low Carb Down Under

Views: 24,628

Keywords: Low Carb Down Under, LCDU, www.lowcarbdownunder.com.au, Low Carb Sydney 2023, Sydney Low Carb Specialists, Alex Petrushevski, Bone Health, Calcium, LCHF, Ketogenic Diet

Id: O0AVfBzJoN8

Length: 25min 14sec (1514 seconds)

Published: Sat Feb 10 2024