Episode 66 - Bone and Spine Health With Dr. Stephanie Plummer
Select tabs below to read the show notes or the full transcript of this episode.
Episode Summary
We all feel invincible sometimes, even as we age. Our minds do a great job of remembering how active and agile we were in our 20s and 30s. Even if we maintain an active lifestyle into our 50s and 60s, there are silent diseases that could be lurking in the background. Whether we feel it or not, osteoporosis can sneak up on us, so it’s important to be proactive.
Dr. Stephanie Plummer, a physiatrist at Carolina NeuroSurgery & Spine Associates, joins Back Talk Doc host Dr. Sanjiv Lakhia to share how women — and men — can best support their bone health to avoid disease and injuries as they get older.
As an avid marathon runner, Dr. Plummer is quite active. But she emphasizes the importance of adding strength, flexibility, and balance work into our routines to help build bone density, as she’s done in her own workout regimen.
“The flexibility and balance component is huge, and I think is really overlooked,” she says. “It’s great if we build good bone density and bone structure. That’s important for helping to prevent fractures. But if your balance is poor — or you don’t have the mobility to be able to prevent falling in the first place — then you may still be at higher risk.”
Dr. Plummer and Dr. Lakhia also discuss the differences between osteoarthritis, osteopenia, and osteoporosis. They touch on hormonal influences as a reason why women are more likely to develop bone disease, as well as the role diet and sleep play in bone health.
Featured Expert
Name: Stephanie Plummer, DO
What she does: Dr. Plummer joined Carolina NeuroSurgery & Spine Associates as the first female physiatrist in 2021 & has been practicing physiatry in the Charlotte, NC area since 2013.
Company: Carolina NeuroSurgery & Spine Associates
Words of wisdom: “I still am young enough that it’s easy to feel invincible sometimes. But I think that’s something that all of us fall into — a category that all of us may fall prey to. Our minds are very good at remembering how active and agile and easy it was for us to do things when we were in our 20s and 30s. And then as we get into our 40s, 50s, and 60s, a lot of us still maintain pretty decent muscular strength and fairly active lifestyles. But these things are going on in the background. They’re not obvious. We talked about osteoporosis being a silent disease that’s happening there in the background, whether you feel it or not. And it’s really important to be proactive about it.”
Connect: Website, LinkedIn
Anchor Points
Top takeaways from this Back Talk Doc episode
Know the signs and intervene. Family history, losing height over time, and minimal pain with fractures are just a few of the warning signs of a serious health condition like osteoporosis. The older we get, the higher risk of bone loss we face, especially for women. It’s important to implement early the many tools at our disposal for building up bone mineral density.
Add weight training and mobility to your routine. Being active is generally a good thing. According to Dr. Plummer, what’s even better for bone health is adding something extra to put stress on the bones. Training with light weights is perfect for this. And flexibility and balance are also key to preventing fall injuries as we age.
Dairy and diet matter. While the verdict on milk remains somewhat inconclusive, the fact is adding whole foods, green leafy veggies, beans, fatty fish, and all the components of a Mediterranean food plan to your diet helps elevate your calcium, magnesium, and vitamin D — all the elements of healthy bones.
Episode Insights
[00:00] Welcome to Back Talk Doc: Find answers to some of the most common questions about back pain and spine health, brought to you by Carolina NeuroSurgery & Spine Associates.
[00:38] Introducing the featured expert: Dr. Plummer joined Carolina NeuroSurgery & Spine Associates as the first female physiatrist in 2021 and has been practicing physiatry in the Charlotte, N.C. area since 2013. We welcome Dr. Plummer back to the show for a second time — her first appearance was in episode 42 where she helped us break down radiofrequency ablation.
[02:02] Getting our “osteos” right: Dr. Plummer clarifies the differences between osteoporosis, osteoarthritis, and osteopenia.
[10:21] Signs of osteoporosis: From losing height to minimal pain from fractures, Dr. Plummer shares a few instances where she may get suspicious that a patient is developing osteoporosis.
[11:47] Men should be paying attention, too: Although not as common, men experience bone loss as well. Dr. Plummer warns men not to pretend this doesn’t exist for them.
[13:51] Hormonal influences for women: Women are more susceptible to bone loss for many reasons. Dr. Plummer outlines the role hormones play.
[15:26] Pick up those weights: Dr. Plummer is incredibly active. She’s a regular marathon runner averaging between 20-40 miles per week. However, running alone won’t help maintain bone strength. She talks about the importance of adding resistance and mobility training to your regimen.
[22:38] Yes or no to dairy: Historically, dairy — especially cow's milk — has been associated with better bone health. Dr. Plummer and Dr. Lakhia talk about what to look out for in dairy and other parts of your diet to make sure you’re getting proper nutrition to keep your bones healthy. They also discuss a video by physician and author Dr. Michael Greger on why milk may not be the best choice for adults.
[27:42] Bone health and sleep: The effect that sleep has on bone density may be minimal, according to sleep experts. But because sleep is the only time when our body is actually repairing itself, Dr. Lakhia says it can’t be overlooked.
Subscribe & Contact
If you enjoyed this episode of Back Talk Doc, check out our recent episode Battlefield Acupuncture for Pain with John Howard.
Enroll in Dr. Lakhia’s 6 week course to lower inflammation:
https://www.drlakhia.com/offers/WanLnrxk
Apply for an Integrative Medicine consult with Dr. Lakhia (NC/SC residents only)
https://www.drlakhia.com/apply
For more information on Dr. Sanjiv Lakhia and the podcast visit BackTalkDoc.com.
Subscribe in your favorite podcast app.
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
We all feel invincible sometimes, even as we age. Our minds do a great job of remembering how active and agile we were in our 20s and 30s. Even if we maintain an active lifestyle into our 50s and 60s, there are silent diseases that could be lurking in the background. Whether we feel it or not, osteoporosis can sneak up on us, so it’s important to be proactive.
Dr. Stephanie Plummer, a physiatrist at Carolina NeuroSurgery & Spine Associates, joins Back Talk Doc host Dr. Sanjiv Lakhia to share how women — and men — can best support their bone health to avoid disease and injuries as they get older.
As an avid marathon runner, Dr. Plummer is quite active. But she emphasizes the importance of adding strength, flexibility, and balance work into our routines to help build bone density, as she’s done in her own workout regimen.
“The flexibility and balance component is huge, and I think is really overlooked,” she says. “It’s great if we build good bone density and bone structure. That’s important for helping to prevent fractures. But if your balance is poor — or you don’t have the mobility to be able to prevent falling in the first place — then you may still be at higher risk.”
Dr. Plummer and Dr. Lakhia also discuss the differences between osteoarthritis, osteopenia, and osteoporosis. They touch on hormonal influences as a reason why women are more likely to develop bone disease, as well as the role diet and sleep play in bone health.
Featured Expert
Name: Stephanie Plummer, DO
What she does: Dr. Plummer joined Carolina NeuroSurgery & Spine Associates as the first female physiatrist in 2021 & has been practicing physiatry in the Charlotte, NC area since 2013.
Company: Carolina NeuroSurgery & Spine Associates
Words of wisdom: “I still am young enough that it’s easy to feel invincible sometimes. But I think that’s something that all of us fall into — a category that all of us may fall prey to. Our minds are very good at remembering how active and agile and easy it was for us to do things when we were in our 20s and 30s. And then as we get into our 40s, 50s, and 60s, a lot of us still maintain pretty decent muscular strength and fairly active lifestyles. But these things are going on in the background. They’re not obvious. We talked about osteoporosis being a silent disease that’s happening there in the background, whether you feel it or not. And it’s really important to be proactive about it.”
Connect: Website, LinkedIn
Anchor Points
Top takeaways from this Back Talk Doc episode
Know the signs and intervene. Family history, losing height over time, and minimal pain with fractures are just a few of the warning signs of a serious health condition like osteoporosis. The older we get, the higher risk of bone loss we face, especially for women. It’s important to implement early the many tools at our disposal for building up bone mineral density.
Add weight training and mobility to your routine. Being active is generally a good thing. According to Dr. Plummer, what’s even better for bone health is adding something extra to put stress on the bones. Training with light weights is perfect for this. And flexibility and balance are also key to preventing fall injuries as we age.
Dairy and diet matter. While the verdict on milk remains somewhat inconclusive, the fact is adding whole foods, green leafy veggies, beans, fatty fish, and all the components of a Mediterranean food plan to your diet helps elevate your calcium, magnesium, and vitamin D — all the elements of healthy bones.
Episode Insights
[00:00] Welcome to Back Talk Doc: Find answers to some of the most common questions about back pain and spine health, brought to you by Carolina NeuroSurgery & Spine Associates.
[00:38] Introducing the featured expert: Dr. Plummer joined Carolina NeuroSurgery & Spine Associates as the first female physiatrist in 2021 and has been practicing physiatry in the Charlotte, N.C. area since 2013. We welcome Dr. Plummer back to the show for a second time — her first appearance was in episode 42 where she helped us break down radiofrequency ablation.
[02:02] Getting our “osteos” right: Dr. Plummer clarifies the differences between osteoporosis, osteoarthritis, and osteopenia.
[10:21] Signs of osteoporosis: From losing height to minimal pain from fractures, Dr. Plummer shares a few instances where she may get suspicious that a patient is developing osteoporosis.
[11:47] Men should be paying attention, too: Although not as common, men experience bone loss as well. Dr. Plummer warns men not to pretend this doesn’t exist for them.
[13:51] Hormonal influences for women: Women are more susceptible to bone loss for many reasons. Dr. Plummer outlines the role hormones play.
[15:26] Pick up those weights: Dr. Plummer is incredibly active. She’s a regular marathon runner averaging between 20-40 miles per week. However, running alone won’t help maintain bone strength. She talks about the importance of adding resistance and mobility training to your regimen.
[22:38] Yes or no to dairy: Historically, dairy — especially cow's milk — has been associated with better bone health. Dr. Plummer and Dr. Lakhia talk about what to look out for in dairy and other parts of your diet to make sure you’re getting proper nutrition to keep your bones healthy. They also discuss a video by physician and author Dr. Michael Greger on why milk may not be the best choice for adults.
[27:42] Bone health and sleep: The effect that sleep has on bone density may be minimal, according to sleep experts. But because sleep is the only time when our body is actually repairing itself, Dr. Lakhia says it can’t be overlooked.
Subscribe & Contact
If you enjoyed this episode of Back Talk Doc, check out our recent episode Battlefield Acupuncture for Pain with John Howard.
Enroll in Dr. Lakhia’s 6 week course to lower inflammation:
https://www.drlakhia.com/offers/WanLnrxk
Apply for an Integrative Medicine consult with Dr. Lakhia (NC/SC residents only)
https://www.drlakhia.com/apply
For more information on Dr. Sanjiv Lakhia and the podcast visit BackTalkDoc.com.
Subscribe in your favorite podcast app.
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
Voiceover (00:01):
Welcome. You are listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health, brought to you by Carolina Neurosurgery & Spine Associates where cutting edge nationally recognized care is delivered through a compassionate approach. This podcast is for informational purposes only and not intended to be used as personalized medical advice. Now, it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Dr. Sanjiv Lakhia (00:38):
Hey, folks. It's Women's Health Month. We're in May of 2023, and thanks for tuning in to another episode. I am delighted to bring back on the show an interview with my partner, Dr. Stephanie Plummer. Today, we're going to talk about women's health, particularly bone health. So Stephanie, welcome back to the show.
Voiceover (00:56):
Thanks for having me, Sanjiv. It's really nice to be back on the podcast again.
Dr. Sanjiv Lakhia (00:59):
Yes. Some of you may recall, we did an interview together about radio frequency ablation. If you haven't had a chance to hear Dr. Plummer break down a very complex topic in a simple way, that's episode 42 folks. We'll link to that in the show notes and feel free to take a listen. But Stephanie is very qualified for today's topic and that she lives a very, very active lifestyle that we touched on a little bit prior on the prior episode.
(01:27):
I think what I really want to get into with you today is just talk about how women can support their orthopedic, their spine, their bone health and try and remain active. So let's get to it.
Stephanie Plummer (01:39):
Sounds great.
Dr. Sanjiv Lakhia (01:40):
Yeah. When you talk about women's health and particular bone health, the obvious topic that comes to everyone's mind is osteoporosis. I think what I observe in my clinic is a misunderstanding at times about what exactly is osteoporosis, why it's important. So let's open up, why don't you share with everyone what is osteoporosis?
Stephanie Plummer (02:02):
Sure. And that's such a great way to put it because it's actually something that I see on a regular basis as well where there's a lot of confusion about what osteoporosis is. I think there's a lot of confusion with osteoarthritis. So obviously both words start with that prefix osteo and that's just comes from Greek for bone. So in this case, osteoporosis has a similar sounding English word, porous. We're talking about porous bone. So I think it's really easy for us as adults to forget that bone is actually living the structure within us.
(02:35):
It has cells and it's constantly being formed and reformed and broken down. I think it's more intuitive when we think about kids growing over time and the growth plates so that bones can become longer and children can become taller. I think it's more intuitive when we think about a broken bone healing over time makes sense that bone is living and needs to be able to repair itself, but bone is constantly being broken down, reformed.
(03:01):
That's just a vital part of the function of bone. We're constantly having little micro injuries, micro damage to bone, so it's necessary for bone to continue to repair itself in this way. Well, actually as we think about when we're much younger, we actually build our peak bone density very early on in life. So our bone is never more dense than it is when we're young. And that actually varies in figures. I've seen anywhere from 16 to 30. I think it's probably much more on the younger end of that age range, but over time we're actually losing bone density.
(03:31):
So porous bone means that's osteoporosis. It means that our bones are not as dense as they once were. Thinking through that, it makes sense that obviously it'd be more at risk for fractures or injury to our bone over time if the bone is not as dense.
Dr. Sanjiv Lakhia (03:44):
Now that's an excellent introduction to kick off the topic here. As a board certified physiatrist and fellowship trained interventional spine specialist that you are, and working out of our Valentine and Gastonia offices, I know routinely you get asked by patients about the difference between chronic, lumbar, degenerative disc disease, pain per se and osteoporosis pain. So can you distinguish for people, or differentiates probably a better word, the characteristics about these two entities? 'Cause I know you encounter this question all the time.
Stephanie Plummer (04:20):
Sure. When we think about different types of problems that can happen to the spine, the more common ones that we see with aging are age-related wear and care change processes. So degenerative disc disease falls into that. A disc is not bone structure, but you can think of it like the cushion in between our vertebrae allows for mobility, shock absorption, a lot of different things.
(04:41):
Over time, those wear down as well. And when the disc wears down, it's called degenerative disc disease and that can be directly painful or it can cause the disc to become misshapen, lose its shape and push on other structures like the nerve and then you get a pinched nerve and sciatica. Those are things that people are all familiar with as causing pain.
(05:01):
I get it quite frequently where patients come in and they say they have pain from their osteoporosis, which if you think about how osteoporosis functions, a lot of times it's called the silent disease because osteoporosis in and of itself doesn't often cause pain. All you're doing is losing... If you think of bone as being kind of... The interior part of a bone, bone has two parts. It has an outer hard shell area and then an inner network of mesh like or honeycomb structure. So over time you're losing, especially in that honeycomb structure, the density of it becomes more of an open mesh over time as opposed to a less dense one.
(05:37):
So that's not really something that we perceive as being painful, but if you do happen to lose enough of that bone density or bone structure that you have a fracture, you have a broken bone, whether that's... In our case we're thinking about spine fractures. So for people, we call them insufficiency fractures because the bone is not sufficient to basically hold its own weight up anymore. That can certainly be very painful.
(05:59):
So it's not so much that it's the osteoporosis that's painful, but the fracture that is caused by the loss of bone density is quite painful, especially acutely. And then over time, if you're losing... When the vertebrae fractures, even though it heals and can heal over time, typically you're not regaining height in that vertebrae. So the vertebrae, the main part of it, the body part of it, I know it's hard to sometimes visualize just listening to an audio show, but the main part of your vertebrae is a square circular 3D structure.
(06:29):
Over time, if you have a fracture, it's not going to regain that height and that can lead to a lot of postural changes. So I think people are familiar with looking at older women in particular who are more rounded forward through the upper back. They have more rounded forward shoulders. That can put additional stress or strain on the adjacent structures of the spine. So additional stress on joints, additional stress on the disc structure, additional stress on tendons and ligaments as well as the muscles and all of that can certainly be painful.
Dr. Sanjiv Lakhia (06:57):
That's exactly correct. I like to think about osteoporosis as someone of the first domino to fall in terms of creating a very uncomfortable situation for people. Number one, you just said it, kyphosis or rounded posturing, which leads to a lot of stress and strain on the spinal ligaments and muscles. And in terms of spinal fractures, analogy I like to use is if you ever took an empty Coke can, which ironically the phosphoric acid content and the coke is going to leach the minerals from your bones, but if you took an empty Coke can and you... Everyone has done this before where you step on it to kind of crush it, that's what can happen to the endplates, the top side of the vertebral bodies as they can just collapse on down.
(07:40):
And then of course you observe loss of bone height and ultimately it can affect the postural height as well. So that's why it's so key to have conversations like this to help people arm themselves with information on how they can put into life best practices to avoid developing osteoporosis.
(07:58):
Another term that is thrown around where there's some confusion, people will come in with bone mineral density reports or DEXA scans and they'll be diagnosed with osteopenia. What's the difference between osteoporosis and osteopenia?
Stephanie Plummer (08:12):
Yeah. So you actually kind of said it. So osteopenia, you can think of it as a precursor to osteoporosis. It's low bone density. Doesn't meet the strict definition for osteoporosis, which does confer a much greater risk of actually having a fracture. But in starting down that pathway of low bone density or osteoporosis is then directly putting you at risk of having osteo... Or osteopenia is directly putting you at risk of having osteoporosis.
(08:41):
We measure that, you mentioned DEXA scans. So that's the formal way, a bone density scan of looking at what your bone density is. If you have one of those tests done, you receive a score called a T-score. And if you're an older adult, that's actually comparing you to someone much younger who has healthy bone structure. So imagine a 30-year-old with normal bone density and they will basically give you a comparison score. So if your score is minus one or greater, so minus one zero plus one, that's considered normal bone density.
(09:12):
If it's minus 2.5 to minus one, so you start using these negative numbers, thinking about things getting more negative as opposed to larger, then that's low bone density or osteopenia. And if your T-score is lower than minus 2.5, then that's osteoporosis.
Dr. Sanjiv Lakhia (09:29):
Important to get that type of information. I don't actually remember what the guidelines are in terms of Medicare coverage if it's over the age of 60.
Stephanie Plummer (09:37):
65 for women.
Dr. Sanjiv Lakhia (09:39):
65, yeah and they can get them checked how often?
Stephanie Plummer (09:40):
I believe it's yearly at the age of 65.
Dr. Sanjiv Lakhia (09:43):
Yeah. That's really one of the only ways to know where you are with things. So I like that as a tool in a toolbox to help evaluate where people are with their bone mineral density. Now, when you get those reports from a physiatry lens, I'm concerned about what's the downstream effect. In particular, we're looking at spinal fractures, hip joint fractures and wrist fractures as the initial ones to look at. What do you see quite often foot fractures.
(10:12):
I know you're a runner. What are some of the things that you see in your clinic in terms of how it can make you a little suspicious that osteoporosis is developing?
Stephanie Plummer (10:21):
Sure. I see it actually in a variety of ways. So one thing is we'll be going through just basic intake forms and someone will tell me that they've lost height over time. I used to be five seven and now I'm five five. Okay. Well, why is that? Could be from loss in the disc height in the vertebrae, but it could also be from loss of bone height or sometimes I did mention that these fractures can be very painful, but sometimes they can happen without a lot of pain or discomfort and can be missed.
(10:50):
So that's sometimes a flag for me that that process is occurring. Also, I see it quite a bit when we send people for screening X-rays. Now, regular X-rays are not a way to diagnose bone density, but sometimes it can be very hard to start to make out some of the anatomical relationships on a normal x-ray.
(11:09):
And that can be a sign that perhaps there's been bone loss or we'll see it on live image guiding, fluoroscopy guided procedures when we're doing injections where it's just more difficult to make out anatomical structures and the bones just look thinner than they should be or compared to the 30-year-old that I just did a procedure on 15 minutes before.
(11:27):
So those are some of the direct things that we can see. Someone tells me that they have a family history of people having... Especially women in their family having broken their wrist once they're over the age of 50 or 60 or broken their hip or have had these vertebral compression fractures or insufficiency fractures. So those are all things that I'm on the lookout for.
Dr. Sanjiv Lakhia (11:48):
Now, it is women's health month. But before we dive into why women are a bit more susceptible to bone loss than men, I do want to say that this is an issue for men as well. It's not as common, but in this day and age, particularly when we are observing a lot of men, a lot of guys late 20s, 30s, 40s who are developing very low testosterone levels, there are metabolic effects on the bone.
(12:14):
So again, if you're out there and you're wondering about it, I don't think as a guy you can just pretend this doesn't exist. You certainly want to take healthy lifestyle steps as well. I mean, have you seen that as this has gone across the spectrum as far as I'm concerned?
Stephanie Plummer (12:28):
Sure. I'm glad you brought that up. I was going to mention it later that it doesn't just pertain to women. It has to do too with aging. So the older you get, men and women alike are at a higher risk for osteoporosis or low bone density. You mentioned some of the nutrition aspects of it. So having things like vitamin D deficiency, inadequate calcium intake.
(12:49):
If you're a male who's had prostate cancer, sometimes hormonal treatments can lead to an increased risk for low bone density or osteoporosis. If you're someone who has celiac disease, I actually read in preparation for talking about this with you, a case study about a gentleman who's celiac disease was only discovered because of DEXA scan that came back with osteoporosis in absence of other risk factors. So that was kind of interesting.
Dr. Sanjiv Lakhia (13:15):
Well, yeah, exactly. And in fact, celiac disease, if someone has a diagnosis of celiac disease, they have to have their bone mineral density checked. I mean, it's an inflammatory issue and it's a absorption issue of nutrients. So that is pretty well known in the gastroenterology literature about the correlation between celiac and osteoporosis. But yeah, it's something that we should be on the lookout for sure. Now, in terms of women, what are some of the specific issues in terms of hormonal influences that really lead to this being a major issue?
Stephanie Plummer (13:51):
Sure. So there's actually a couple things. So hormonal and non-hormonal. So women are more susceptible for a variety of reasons. One is that we tend to be smaller in general, thinner and develop less dense bone as we are going through puberty and early adulthood than men do. But then bone loss becomes more prevalent during and after menopause, and that's because of the role of estrogen.
(14:18):
To kind of go back to your point about men and women together, both men and women have estrogen. And estrogen is actually for both men and women, a critical regulator of bone turnover and bone health. However, in women it has as they go through menopause and perimenopause and post-menopause, the imbalance of estrogen to other sex hormones or testosterone becomes a lot more apparent. You basically become estrogen deficient.
(14:45):
Estrogen is interesting in that it does a couple of things. It increases bone reabsorption but also inhibits bone turnover. But if you lose that over time, the net effect is that you're losing more bone. You're having more bone reabsorption and not building more bone.
Dr. Sanjiv Lakhia (15:04):
Right. So that's a big reason why I think it's so important to implement some of these other tools to help build up your bone mineral density. So for example, look, you are all into fitness, right?
Stephanie Plummer (15:19):
Mm.
Dr. Sanjiv Lakhia (15:19):
Why don't you share with our audience, let's say a typical week in the athletic life of Dr. Stephanie Plummer?
Stephanie Plummer (15:26):
Sure. So a typical week, I do a lot of... We talked about this the last time. I do a lot of running. And for a long time all I did was running when I was getting into running. So not uncommon to run 20, 30, 40 miles a week. Sometimes I don't get into some of the crazy high distances that some people who run marathons do, mostly because I'm time limited with my day job. But it's not uncommon to run 40 or if it's peak week before a marathon, 50 plus miles.
(15:54):
So there are a lot of different types of exercise that can actually help maintain and build bone strength and bone density. Anything that you're doing that is gravity assisted or weight bearing is a great exercise to help basically put additional stress on the bone. Remember how we talked about bone being a living part of our body that responds to things that we do? It turns out that one of the things that really responds to is having load or stress placed onto it to become more dense over time.
(16:24):
So anything that's going to be land-based exercise with a bit of added stress to it. So that can be weights, that can be impact, is going to be good for building bone density.
Dr. Sanjiv Lakhia (16:36):
So running for sure, walking, weight training. Another one that I really like is the mini trampoline. I think that can get a lot of benefits for building bone density.
Stephanie Plummer (16:36):
Sure.
Dr. Sanjiv Lakhia (16:47):
Now, exercises like rowing and swimming, while great cardiovascularly, they do not stimulate bone growth. I think that's an important lesson or something to understand as you're putting together your own weekly exercise plan. You want to have something that stresses the bone a little bit.
(17:05):
Now, the other aspects of exercise, as we kind of dive into these lifestyle interventions for bone health, I think it's very important, and I'm curious if you add this into your routine that especially as we get older men and women to be working on flexibility and our balance, certainly those are aspects that can keep our risk of falling diminished.
Stephanie Plummer (17:27):
Sure. So what I was starting to allude to is that now as I've gotten wiser in my running career. I've been doing it for running marathons for over 10 years now. Come very much to realize that that's not sufficient in and of itself for a variety of reasons. I really need the strength component. But certainly as I actually get older as well, it's become very important to me to do the strength flexibility, balance component just for general fitness and just knowing that myself as a white slender come from a family of small build females, probably at much higher risk for osteopenia, osteoporosis than someone who does not fall into those categories.
(18:10):
So I've become a big proponent both for myself and for my patients of doing weight-based training. So lightweight exercises. So I'm not out there trying to look like Arnold Schwarzenegger, but I'll select low to medium weights to do resistance training with, or sometimes even just do band resistance training and trying to hit the major muscle groups on a weekly or twice weekly basis.
(18:33):
But the flexibility and balance component is huge, and I think it's really overlooked. It's great if we build good bone density and bone structure that it's important for helping to prevent fractures. But if your balance is poor or you don't have the mobility to be able to prevent falling in the first place, then you may still be at higher risk. And especially as we get older, because, again, we talked about peak bone density being something that we hit in our teenage to early at early adult years, even if you are doing a pretty good job of maintaining bone density, you're still going to be at higher risk of having a fracture as you get older due to comparatively lowered bone density.
(19:12):
So the flexibility, balance training, those are things that go hand in hand with the strength training to help keep you mobile, agile and either help you prevent falls in the first place, or if you do say a... You missed a curb. You took a funny step. Instead of falling and losing your balance, you're able to actually catch yourself and prevent yourself from having a more catastrophic injury.
Dr. Sanjiv Lakhia (19:35):
Oh, that's excellent. I want to put a plug in for two things to that regard that I think people should consider. Number one, if you live in the Charlotte area, setting up a session with our physical therapy department to look at your balance, get it assessed and implement some exercises right away that can improve your balance and reduce your fall risk. Physical therapists are so essential.
(19:59):
I think as you get into your forties and beyond, if you want to maintain an active lifestyle, having a good physical therapist on your healthcare team is essential. And then the other one I'd put a plug in, and this is one that I learned a lot more about during my integrative health fellowship, would be Tai Chi. Tai Chi has excellent data in the medical literature for fall prevention and reducing fractures. It also can build bone density and promote flexibility.
(20:26):
The local YMCAs typically hold classes, and you can also go online. There's plenty of online resources through YouTube. There's videos you can buy and do it from home. I practice Tai Chi periodically, and I find it to be number one, very meditative focusing and grounding, but when you go through a full circuit, it looks very slow, but you definitely get some exercise out of it. I think it's something that we should look at promoting more for our patients.
(20:57):
Now, yoga has probably got the biggest brand name out there in the country right now, and there's also tremendous benefits with yoga and flexibility obviously. So it's really just about offering people different things that resonate with them. But I'm glad to hear that you've modified your exercise program and you're accounting for that, and because I really didn't think anything could slow you down.
Stephanie Plummer (21:20):
I still am young enough that it's easy to feel invincible sometimes, but I think that's something that all of us fall into a category that all of us may fall prey to. Our minds are very good at remembering how active and agile and easy it was for us to do things when we were in our twenties and thirties. And then as we get into our 40s, 50s, 60s, a lot of us still maintain pretty decent muscular strength.
(21:46):
We maintain fairly active lifestyles, but these things are going on in the background. They're not obvious. We talked about osteoporosis being a silent disease. That's happening there in the background whether you feel it or not. And it's really important to be proactive about it.
Dr. Sanjiv Lakhia (22:01):
If you look at the World Health Organization, what they list is a number one concern with aging and developing comorbidities, it's sarcopenia. So it's loss of muscle mass and that goes hand in hand with our discussion on osteoporosis. In my mind, they're inseparable. If you're losing muscle mass, you're losing bone mass. And it's something that as we just outlined, as you just said, there's hormonal influences, there's lifestyles, they're nutritional. There's all sorts of things working against us, so you have to be intentional about it.
(22:32):
But let's circle, go back. You briefly mentioned nutritional influences. There's a couple hot topics out there that I wanted to get your thoughts on. Number one, when it comes to bone mineral density, time and time again, I was told when I was younger the importance of drinking multiple cups of milk per day. I sent you a PubMed link. When you look at large meta analyses, these are research studies folks where they basically pull the data from multiple studies, and it's not a perfect way of looking at science, but it can give you large numbers, population based numbers.
(23:07):
When you look at the meta-analysis, it's really conflicting evidence in terms of the potential benefit of dairy and bone health. And in fact, a lot of the populations where they have the highest consumption of dairy, they have the highest risk of hip fractures. Now, I'm not necessarily saying it's cause and effect, but it does make you pause. I was just curious if you've had any thoughts on this or a chance to dive into the research or just what you feel about consuming milk and it's effect on bone health?
Stephanie Plummer (23:33):
So it's an interesting topic and it's certainly one that's, I think gained a lot of traction in the past maybe five to 10 years or so. I hear it out there a lot where dairy, cows milk, especially because of these large studies looking at the countries that are consuming the most milk products are also the ones that where you see the greatest population incidence of osteoporosis and fragility related fractures.
(24:00):
Interesting, from my background as a child, milk was a product that I did not care for the taste of. So I did not consume a lot of milk products, which my mother was very, very, very concerned about because again, all you hear, especially when we were growing up, when we were kids, multiple glasses of milk a day for bone health over time. So she was actually pretty good about making sure I had multivitamin or a calcium supplement.
(24:24):
Milk is a great way to receive calcium through your diet, which we talked about calcium and vitamin D being integral and required for the formation of strong bone structure. But there's other things happening in milk too that probably go along more with our American or unhealthy lifestyle in general. So you talk about fats and sugars and things like that, and if you're consuming a lot of those things, perhaps you're increasing propensity for being overweight or obese, or heart disease and those things.
(24:53):
If you look at health in general, if you have multiple medical comorbidities, so other medical problems, you're probably not also doing a lot to create increased bone density. And I think that's where you're seeing some of those data. Or you're looking at populations that maybe they also have a lot of smokers in this society, and we haven't touched on that yet, but that's a huge risk for developing osteoporosis.
Dr. Sanjiv Lakhia (25:14):
Yeah. That's a great way to look at it. One of the papers that came across off of Dr. Michael Greger's site, and Dr. Greger is a little bit controversial. He's a big proponent of a whole foods plant-based diet, which is a whole other episode.
Stephanie Plummer (25:27):
We could do a whole episode on that at some point.
Dr. Sanjiv Lakhia (25:30):
Right. He put out a video and we can link to it where he cites a paper that basically is pointing the arrow at galactose in milk in terms of galactose can be very toxic to the cells in general, creating a lot of inflammation. And potentially there's literature showing that increased galactose intake can be associated with elevated saturates in CRPs.
(25:52):
So that's one of the theories is that one of the milk sugars at high levels, because when babies have galactosemia where they are born deficient of an enzyme to metabolize galactose, they have a whole host of neurologic problems of which bone loss is one of them. So he postulates the theory, or at least the author of the study he mentioned postulates a theory that is the galactose when consumed in large quantities that can account for the paradoxical effect of diminished bone density in spite of increased calcium intake.
(26:21):
So anyway, it's just something that I'm still learning about and trying to figure out. For myself I've typically avoided dairy simply because it's very mutagenic for me and growing up with science congestion and such. So I don't drink a lot of it, but there are other nutrients. I think you mentioned vitamin D, calcium, magnesium, phosphorus. And folks, really, the way to get this in your food is once again coming back to the Mediterranean food plan, and we'll link to that episode that I recorded on it, but you want your green leafy vegetables. You want your beans. You want your good healthy fats, your olive oil.
(26:56):
If you're going to eat meat, you want your healthy grass fed meats, certainly fatty fish. It's all the same stuff like when you eat a rainbow-colored diet that's high antioxidants and polyphenols, you're going to get your calcium, your magnesium, your D, the rest of your minerals that you need to promote healthy burn bone growth and proper bone remodeling as you talked about earlier. So I think that's why-
Stephanie Plummer (27:20):
And some of the...
Dr. Sanjiv Lakhia (27:21):
Yeah, go ahead.
Stephanie Plummer (27:22):
Oh, I was just going to say, I do have a list that I usually... Just because of some of the controversy out there now with milk and the galactose, as you mentioned, the ones I usually recommend are collard greens and kale, soybeans, figs, broccoli, oranges, and then you mentioned the fatty fishes, sardines and salmon.
Dr. Sanjiv Lakhia (27:37):
Wow. I'm hungry,
Stephanie Plummer (27:39):
I know. Me too. It is dinnertime.
Dr. Sanjiv Lakhia (27:42):
All right. So you did a great job. You touched on exercise. We've done nutrition. I also want to get your thoughts on an underrated lifestyle intervention that plays a big role, I think in bone health, and that's sleep. And I forwarded you an article and we'll link to this in the show notes as well where it looks like in this study where they looked at a fairly large group of men and women, it looks like women who get less than five hours or less of sleep have increased bone turnover equivalent to a year of aging. I don't know if you had a chance to review that, but just-
Stephanie Plummer (28:15):
I did. I read through it and that was a little bit interesting to me because I'm a big proponent of sleep for getting quality and sufficient quantities of quality sleep for other reasons. But if you listen to some of the sleep experts out there, I'm thinking of people like Matthew Walker. Andrew Huberman has a podcast where he's had him on a couple times. He's been on some other shows. But I don't know that I've really heard bone density or osteoporosis come up as a negative of lack of sufficient quality or quantity of sleep. So this was very interesting to me.
Dr. Sanjiv Lakhia (28:48):
Yeah. It's not a high power study, and frankly, the negative effect is not a dramatic one that they observed in the study. But I wouldn't be surprised. We know that sleep, at least in my opinion, especially after reading Walker's book, which we'll link to something it's called Why We Sleep.
Stephanie Plummer (29:06):
Why We Sleep.
Dr. Sanjiv Lakhia (29:06):
Literally when I have someone in front of me and we're going over the pillars of health, which will be nutrition, exercise, stress, and sleep, if they only have capacity to improve one of those, I always start with sleep because it's the only time your body repairs itself. I have to think there's going to be a relationship with the melatonin, cortisol, diurna and it's influenced on bone health in terms of the link being inflammation.
(29:34):
It's something that I'd have to dive deeper into, but folks, it's just another reason potentially like you needed others to try and get really good, adequate, high quality sleep. Particularly a lot of people listen to this podcast deal with pain and back pain in general, and it's very, very hard to go through about a pain when you're not well rested or at least attempting to get good sleep. It just amplifies all your symptoms by at least three times.
Stephanie Plummer (30:00):
Sure. You mentioned all those different pillars of health. It's the only one that we... If you go without one of those things, you can go without sleep for the least period of time, surprisingly.
Dr. Sanjiv Lakhia (30:12):
Oh, wow. Never thought of it that way.
Stephanie Plummer (30:14):
So it is performing all kinds of vital, important functions for us. So I think that's great advice. If you're going to focus on any one thing first, probably sleep.
Dr. Sanjiv Lakhia (30:22):
I'm just curious, when you're preparing for one of your marathons or races, what's kind of your three, four, five day prep schedule in terms of sleep leading up to that?
Stephanie Plummer (30:33):
That's an interesting question because a lot of the races that I do involve travel. So I really enjoy running big city marathons. The world marathon majors are some of my favorites because network of friends that I've formed over the years that we like to meet up in these big cities. We're not necessarily running together, but in the lead up to and after we have time to just enjoy each other's company and talk about the race and talk about our training.
(30:55):
So the most recent marathon I did was actually in London, and I'm usually not leaving for the race just with work schedule and everything else until about two days before. So I'll leave on Thursday night for a Sunday race, and that involves trying to sleep overnight on the flight there. That's the only way I'll do it anymore is if I can almost guarantee that I can sleep close to a very normal six plus, at least minimum of six hours of sleep on the flight over.
(31:22):
And I do that in a variety of ways, but I really try and make sure that I've eaten before I get on the airplane that I sleep. And then when I get there the next day, I usually go to bed quite early because I know that I've probably come close to that six hours, but maybe not, and really aim for eight hours of sleep the two nights before the race.
Dr. Sanjiv Lakhia (31:38):
Wow. What a challenge. That's amazing that you're able to pull that off. I've been watching a lot of the NBA playoffs right now, and one of the things when they interview LeBron James in terms of his preparation at the age of 38, going through major minutes, a lot of toll on his body, the thing he almost always mentions in his post-game interviews is, "I need to go home and I'm going to get my sleep, and tomorrow I'm going to get my sleep."
(32:03):
This is what he literally does and starts with because athletes know that if you have higher quality, more quantity sleep, you perform better. So good luck with that as you pursue your endeavors with the races and everything else. But I'm really glad to hear you've diversified your exercise program. You're just a perfect voice for this issue, and I hope people take this information, take it to heart.
(32:26):
Look, there's a lot of our things that we could talk about on this. I mean, you mentioned smoking and certainly there's other things I think that are detrimental. Smoking and sugar intake and inflammatory foods. And then of course there's medications for osteoporosis. And then our group offers... And I might do an episode, separate episode on this, but there's interventions for bone fractures like kyphoplasty and vertebroplasty.
(32:48):
But I felt like you were just the perfect person to talk about it really from a lifestyle lens, because you walk the walk. You really focus on your health and your fitness and your mindset, so you can be the best physician and just the best person that you can be.
Stephanie Plummer (33:01):
Yeah. I've been lucky in a lot of ways growing up because just in my family, my parents were really attuned with it, and I think it may have come a little bit out of... I think there's a big push for milk consumption, but at least it was an awareness right when I was a child. So it is always been in the back of my mind, and I can certainly think of my maternal grandmother. She was not a tall woman to begin with, which is kind of funny if anyone who's out there, one of my patients or someone who's met me for an injection. I'm a little bit on the taller side, but she was five-foot-two at her tallest, and I think by the time she passed away at age 80, she was closer to four-10.
(33:42):
So almost four inches of height loss and very kyphotic rounded forward posture. She lived with us when I was a teenager or so. I think just seeing that and having some awareness and recognition that it was probably related. And she certainly suffered. She never had a hip fracture, but she had a wrist fracture from a very low impact kind of trip and fall forward. So it's always kind of been there in my awareness, and it's something that I've really tried hard to do for myself, and I think it's really important to try and make sure that others are aware of it as well, especially my patients, and make sure that y'all have the tools and resources to start now. It doesn't matter what age you're at, there's things that we can do to start working to prevent significant complications from osteoporosis.
Dr. Sanjiv Lakhia (34:27):
And I'd be remiss if I didn't mention working in a neurosurgery practice. If you are someone who may end up needing spine surgery, the surgeons are going to have a hard time offering it or trying to fix your problem if your bone mineral density is poor. So there's so many benefits. It's much better to look at prevention than treatment, and I hope those that were listening take all the information you just laid out and sort through it and see what resonates with them and just get to work on being their best version of themselves and keeping their spine, their posture strong. So many positive downstream effects. So Stephanie, thanks again for sharing your knowledge. I really enjoy it. You're an easy interview. I'm sure this won't be the last, and I look forward to talking more with you in the future.
Stephanie Plummer (35:10):
Likewise. It's been my pleasure and look forward to the next episode.
Dr. Sanjiv Lakhia (35:10):
Thank you.
Voiceover (35:13):
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.
Welcome. You are listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health, brought to you by Carolina Neurosurgery & Spine Associates where cutting edge nationally recognized care is delivered through a compassionate approach. This podcast is for informational purposes only and not intended to be used as personalized medical advice. Now, it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Dr. Sanjiv Lakhia (00:38):
Hey, folks. It's Women's Health Month. We're in May of 2023, and thanks for tuning in to another episode. I am delighted to bring back on the show an interview with my partner, Dr. Stephanie Plummer. Today, we're going to talk about women's health, particularly bone health. So Stephanie, welcome back to the show.
Voiceover (00:56):
Thanks for having me, Sanjiv. It's really nice to be back on the podcast again.
Dr. Sanjiv Lakhia (00:59):
Yes. Some of you may recall, we did an interview together about radio frequency ablation. If you haven't had a chance to hear Dr. Plummer break down a very complex topic in a simple way, that's episode 42 folks. We'll link to that in the show notes and feel free to take a listen. But Stephanie is very qualified for today's topic and that she lives a very, very active lifestyle that we touched on a little bit prior on the prior episode.
(01:27):
I think what I really want to get into with you today is just talk about how women can support their orthopedic, their spine, their bone health and try and remain active. So let's get to it.
Stephanie Plummer (01:39):
Sounds great.
Dr. Sanjiv Lakhia (01:40):
Yeah. When you talk about women's health and particular bone health, the obvious topic that comes to everyone's mind is osteoporosis. I think what I observe in my clinic is a misunderstanding at times about what exactly is osteoporosis, why it's important. So let's open up, why don't you share with everyone what is osteoporosis?
Stephanie Plummer (02:02):
Sure. And that's such a great way to put it because it's actually something that I see on a regular basis as well where there's a lot of confusion about what osteoporosis is. I think there's a lot of confusion with osteoarthritis. So obviously both words start with that prefix osteo and that's just comes from Greek for bone. So in this case, osteoporosis has a similar sounding English word, porous. We're talking about porous bone. So I think it's really easy for us as adults to forget that bone is actually living the structure within us.
(02:35):
It has cells and it's constantly being formed and reformed and broken down. I think it's more intuitive when we think about kids growing over time and the growth plates so that bones can become longer and children can become taller. I think it's more intuitive when we think about a broken bone healing over time makes sense that bone is living and needs to be able to repair itself, but bone is constantly being broken down, reformed.
(03:01):
That's just a vital part of the function of bone. We're constantly having little micro injuries, micro damage to bone, so it's necessary for bone to continue to repair itself in this way. Well, actually as we think about when we're much younger, we actually build our peak bone density very early on in life. So our bone is never more dense than it is when we're young. And that actually varies in figures. I've seen anywhere from 16 to 30. I think it's probably much more on the younger end of that age range, but over time we're actually losing bone density.
(03:31):
So porous bone means that's osteoporosis. It means that our bones are not as dense as they once were. Thinking through that, it makes sense that obviously it'd be more at risk for fractures or injury to our bone over time if the bone is not as dense.
Dr. Sanjiv Lakhia (03:44):
Now that's an excellent introduction to kick off the topic here. As a board certified physiatrist and fellowship trained interventional spine specialist that you are, and working out of our Valentine and Gastonia offices, I know routinely you get asked by patients about the difference between chronic, lumbar, degenerative disc disease, pain per se and osteoporosis pain. So can you distinguish for people, or differentiates probably a better word, the characteristics about these two entities? 'Cause I know you encounter this question all the time.
Stephanie Plummer (04:20):
Sure. When we think about different types of problems that can happen to the spine, the more common ones that we see with aging are age-related wear and care change processes. So degenerative disc disease falls into that. A disc is not bone structure, but you can think of it like the cushion in between our vertebrae allows for mobility, shock absorption, a lot of different things.
(04:41):
Over time, those wear down as well. And when the disc wears down, it's called degenerative disc disease and that can be directly painful or it can cause the disc to become misshapen, lose its shape and push on other structures like the nerve and then you get a pinched nerve and sciatica. Those are things that people are all familiar with as causing pain.
(05:01):
I get it quite frequently where patients come in and they say they have pain from their osteoporosis, which if you think about how osteoporosis functions, a lot of times it's called the silent disease because osteoporosis in and of itself doesn't often cause pain. All you're doing is losing... If you think of bone as being kind of... The interior part of a bone, bone has two parts. It has an outer hard shell area and then an inner network of mesh like or honeycomb structure. So over time you're losing, especially in that honeycomb structure, the density of it becomes more of an open mesh over time as opposed to a less dense one.
(05:37):
So that's not really something that we perceive as being painful, but if you do happen to lose enough of that bone density or bone structure that you have a fracture, you have a broken bone, whether that's... In our case we're thinking about spine fractures. So for people, we call them insufficiency fractures because the bone is not sufficient to basically hold its own weight up anymore. That can certainly be very painful.
(05:59):
So it's not so much that it's the osteoporosis that's painful, but the fracture that is caused by the loss of bone density is quite painful, especially acutely. And then over time, if you're losing... When the vertebrae fractures, even though it heals and can heal over time, typically you're not regaining height in that vertebrae. So the vertebrae, the main part of it, the body part of it, I know it's hard to sometimes visualize just listening to an audio show, but the main part of your vertebrae is a square circular 3D structure.
(06:29):
Over time, if you have a fracture, it's not going to regain that height and that can lead to a lot of postural changes. So I think people are familiar with looking at older women in particular who are more rounded forward through the upper back. They have more rounded forward shoulders. That can put additional stress or strain on the adjacent structures of the spine. So additional stress on joints, additional stress on the disc structure, additional stress on tendons and ligaments as well as the muscles and all of that can certainly be painful.
Dr. Sanjiv Lakhia (06:57):
That's exactly correct. I like to think about osteoporosis as someone of the first domino to fall in terms of creating a very uncomfortable situation for people. Number one, you just said it, kyphosis or rounded posturing, which leads to a lot of stress and strain on the spinal ligaments and muscles. And in terms of spinal fractures, analogy I like to use is if you ever took an empty Coke can, which ironically the phosphoric acid content and the coke is going to leach the minerals from your bones, but if you took an empty Coke can and you... Everyone has done this before where you step on it to kind of crush it, that's what can happen to the endplates, the top side of the vertebral bodies as they can just collapse on down.
(07:40):
And then of course you observe loss of bone height and ultimately it can affect the postural height as well. So that's why it's so key to have conversations like this to help people arm themselves with information on how they can put into life best practices to avoid developing osteoporosis.
(07:58):
Another term that is thrown around where there's some confusion, people will come in with bone mineral density reports or DEXA scans and they'll be diagnosed with osteopenia. What's the difference between osteoporosis and osteopenia?
Stephanie Plummer (08:12):
Yeah. So you actually kind of said it. So osteopenia, you can think of it as a precursor to osteoporosis. It's low bone density. Doesn't meet the strict definition for osteoporosis, which does confer a much greater risk of actually having a fracture. But in starting down that pathway of low bone density or osteoporosis is then directly putting you at risk of having osteo... Or osteopenia is directly putting you at risk of having osteoporosis.
(08:41):
We measure that, you mentioned DEXA scans. So that's the formal way, a bone density scan of looking at what your bone density is. If you have one of those tests done, you receive a score called a T-score. And if you're an older adult, that's actually comparing you to someone much younger who has healthy bone structure. So imagine a 30-year-old with normal bone density and they will basically give you a comparison score. So if your score is minus one or greater, so minus one zero plus one, that's considered normal bone density.
(09:12):
If it's minus 2.5 to minus one, so you start using these negative numbers, thinking about things getting more negative as opposed to larger, then that's low bone density or osteopenia. And if your T-score is lower than minus 2.5, then that's osteoporosis.
Dr. Sanjiv Lakhia (09:29):
Important to get that type of information. I don't actually remember what the guidelines are in terms of Medicare coverage if it's over the age of 60.
Stephanie Plummer (09:37):
65 for women.
Dr. Sanjiv Lakhia (09:39):
65, yeah and they can get them checked how often?
Stephanie Plummer (09:40):
I believe it's yearly at the age of 65.
Dr. Sanjiv Lakhia (09:43):
Yeah. That's really one of the only ways to know where you are with things. So I like that as a tool in a toolbox to help evaluate where people are with their bone mineral density. Now, when you get those reports from a physiatry lens, I'm concerned about what's the downstream effect. In particular, we're looking at spinal fractures, hip joint fractures and wrist fractures as the initial ones to look at. What do you see quite often foot fractures.
(10:12):
I know you're a runner. What are some of the things that you see in your clinic in terms of how it can make you a little suspicious that osteoporosis is developing?
Stephanie Plummer (10:21):
Sure. I see it actually in a variety of ways. So one thing is we'll be going through just basic intake forms and someone will tell me that they've lost height over time. I used to be five seven and now I'm five five. Okay. Well, why is that? Could be from loss in the disc height in the vertebrae, but it could also be from loss of bone height or sometimes I did mention that these fractures can be very painful, but sometimes they can happen without a lot of pain or discomfort and can be missed.
(10:50):
So that's sometimes a flag for me that that process is occurring. Also, I see it quite a bit when we send people for screening X-rays. Now, regular X-rays are not a way to diagnose bone density, but sometimes it can be very hard to start to make out some of the anatomical relationships on a normal x-ray.
(11:09):
And that can be a sign that perhaps there's been bone loss or we'll see it on live image guiding, fluoroscopy guided procedures when we're doing injections where it's just more difficult to make out anatomical structures and the bones just look thinner than they should be or compared to the 30-year-old that I just did a procedure on 15 minutes before.
(11:27):
So those are some of the direct things that we can see. Someone tells me that they have a family history of people having... Especially women in their family having broken their wrist once they're over the age of 50 or 60 or broken their hip or have had these vertebral compression fractures or insufficiency fractures. So those are all things that I'm on the lookout for.
Dr. Sanjiv Lakhia (11:48):
Now, it is women's health month. But before we dive into why women are a bit more susceptible to bone loss than men, I do want to say that this is an issue for men as well. It's not as common, but in this day and age, particularly when we are observing a lot of men, a lot of guys late 20s, 30s, 40s who are developing very low testosterone levels, there are metabolic effects on the bone.
(12:14):
So again, if you're out there and you're wondering about it, I don't think as a guy you can just pretend this doesn't exist. You certainly want to take healthy lifestyle steps as well. I mean, have you seen that as this has gone across the spectrum as far as I'm concerned?
Stephanie Plummer (12:28):
Sure. I'm glad you brought that up. I was going to mention it later that it doesn't just pertain to women. It has to do too with aging. So the older you get, men and women alike are at a higher risk for osteoporosis or low bone density. You mentioned some of the nutrition aspects of it. So having things like vitamin D deficiency, inadequate calcium intake.
(12:49):
If you're a male who's had prostate cancer, sometimes hormonal treatments can lead to an increased risk for low bone density or osteoporosis. If you're someone who has celiac disease, I actually read in preparation for talking about this with you, a case study about a gentleman who's celiac disease was only discovered because of DEXA scan that came back with osteoporosis in absence of other risk factors. So that was kind of interesting.
Dr. Sanjiv Lakhia (13:15):
Well, yeah, exactly. And in fact, celiac disease, if someone has a diagnosis of celiac disease, they have to have their bone mineral density checked. I mean, it's an inflammatory issue and it's a absorption issue of nutrients. So that is pretty well known in the gastroenterology literature about the correlation between celiac and osteoporosis. But yeah, it's something that we should be on the lookout for sure. Now, in terms of women, what are some of the specific issues in terms of hormonal influences that really lead to this being a major issue?
Stephanie Plummer (13:51):
Sure. So there's actually a couple things. So hormonal and non-hormonal. So women are more susceptible for a variety of reasons. One is that we tend to be smaller in general, thinner and develop less dense bone as we are going through puberty and early adulthood than men do. But then bone loss becomes more prevalent during and after menopause, and that's because of the role of estrogen.
(14:18):
To kind of go back to your point about men and women together, both men and women have estrogen. And estrogen is actually for both men and women, a critical regulator of bone turnover and bone health. However, in women it has as they go through menopause and perimenopause and post-menopause, the imbalance of estrogen to other sex hormones or testosterone becomes a lot more apparent. You basically become estrogen deficient.
(14:45):
Estrogen is interesting in that it does a couple of things. It increases bone reabsorption but also inhibits bone turnover. But if you lose that over time, the net effect is that you're losing more bone. You're having more bone reabsorption and not building more bone.
Dr. Sanjiv Lakhia (15:04):
Right. So that's a big reason why I think it's so important to implement some of these other tools to help build up your bone mineral density. So for example, look, you are all into fitness, right?
Stephanie Plummer (15:19):
Mm.
Dr. Sanjiv Lakhia (15:19):
Why don't you share with our audience, let's say a typical week in the athletic life of Dr. Stephanie Plummer?
Stephanie Plummer (15:26):
Sure. So a typical week, I do a lot of... We talked about this the last time. I do a lot of running. And for a long time all I did was running when I was getting into running. So not uncommon to run 20, 30, 40 miles a week. Sometimes I don't get into some of the crazy high distances that some people who run marathons do, mostly because I'm time limited with my day job. But it's not uncommon to run 40 or if it's peak week before a marathon, 50 plus miles.
(15:54):
So there are a lot of different types of exercise that can actually help maintain and build bone strength and bone density. Anything that you're doing that is gravity assisted or weight bearing is a great exercise to help basically put additional stress on the bone. Remember how we talked about bone being a living part of our body that responds to things that we do? It turns out that one of the things that really responds to is having load or stress placed onto it to become more dense over time.
(16:24):
So anything that's going to be land-based exercise with a bit of added stress to it. So that can be weights, that can be impact, is going to be good for building bone density.
Dr. Sanjiv Lakhia (16:36):
So running for sure, walking, weight training. Another one that I really like is the mini trampoline. I think that can get a lot of benefits for building bone density.
Stephanie Plummer (16:36):
Sure.
Dr. Sanjiv Lakhia (16:47):
Now, exercises like rowing and swimming, while great cardiovascularly, they do not stimulate bone growth. I think that's an important lesson or something to understand as you're putting together your own weekly exercise plan. You want to have something that stresses the bone a little bit.
(17:05):
Now, the other aspects of exercise, as we kind of dive into these lifestyle interventions for bone health, I think it's very important, and I'm curious if you add this into your routine that especially as we get older men and women to be working on flexibility and our balance, certainly those are aspects that can keep our risk of falling diminished.
Stephanie Plummer (17:27):
Sure. So what I was starting to allude to is that now as I've gotten wiser in my running career. I've been doing it for running marathons for over 10 years now. Come very much to realize that that's not sufficient in and of itself for a variety of reasons. I really need the strength component. But certainly as I actually get older as well, it's become very important to me to do the strength flexibility, balance component just for general fitness and just knowing that myself as a white slender come from a family of small build females, probably at much higher risk for osteopenia, osteoporosis than someone who does not fall into those categories.
(18:10):
So I've become a big proponent both for myself and for my patients of doing weight-based training. So lightweight exercises. So I'm not out there trying to look like Arnold Schwarzenegger, but I'll select low to medium weights to do resistance training with, or sometimes even just do band resistance training and trying to hit the major muscle groups on a weekly or twice weekly basis.
(18:33):
But the flexibility and balance component is huge, and I think it's really overlooked. It's great if we build good bone density and bone structure that it's important for helping to prevent fractures. But if your balance is poor or you don't have the mobility to be able to prevent falling in the first place, then you may still be at higher risk. And especially as we get older, because, again, we talked about peak bone density being something that we hit in our teenage to early at early adult years, even if you are doing a pretty good job of maintaining bone density, you're still going to be at higher risk of having a fracture as you get older due to comparatively lowered bone density.
(19:12):
So the flexibility, balance training, those are things that go hand in hand with the strength training to help keep you mobile, agile and either help you prevent falls in the first place, or if you do say a... You missed a curb. You took a funny step. Instead of falling and losing your balance, you're able to actually catch yourself and prevent yourself from having a more catastrophic injury.
Dr. Sanjiv Lakhia (19:35):
Oh, that's excellent. I want to put a plug in for two things to that regard that I think people should consider. Number one, if you live in the Charlotte area, setting up a session with our physical therapy department to look at your balance, get it assessed and implement some exercises right away that can improve your balance and reduce your fall risk. Physical therapists are so essential.
(19:59):
I think as you get into your forties and beyond, if you want to maintain an active lifestyle, having a good physical therapist on your healthcare team is essential. And then the other one I'd put a plug in, and this is one that I learned a lot more about during my integrative health fellowship, would be Tai Chi. Tai Chi has excellent data in the medical literature for fall prevention and reducing fractures. It also can build bone density and promote flexibility.
(20:26):
The local YMCAs typically hold classes, and you can also go online. There's plenty of online resources through YouTube. There's videos you can buy and do it from home. I practice Tai Chi periodically, and I find it to be number one, very meditative focusing and grounding, but when you go through a full circuit, it looks very slow, but you definitely get some exercise out of it. I think it's something that we should look at promoting more for our patients.
(20:57):
Now, yoga has probably got the biggest brand name out there in the country right now, and there's also tremendous benefits with yoga and flexibility obviously. So it's really just about offering people different things that resonate with them. But I'm glad to hear that you've modified your exercise program and you're accounting for that, and because I really didn't think anything could slow you down.
Stephanie Plummer (21:20):
I still am young enough that it's easy to feel invincible sometimes, but I think that's something that all of us fall into a category that all of us may fall prey to. Our minds are very good at remembering how active and agile and easy it was for us to do things when we were in our twenties and thirties. And then as we get into our 40s, 50s, 60s, a lot of us still maintain pretty decent muscular strength.
(21:46):
We maintain fairly active lifestyles, but these things are going on in the background. They're not obvious. We talked about osteoporosis being a silent disease. That's happening there in the background whether you feel it or not. And it's really important to be proactive about it.
Dr. Sanjiv Lakhia (22:01):
If you look at the World Health Organization, what they list is a number one concern with aging and developing comorbidities, it's sarcopenia. So it's loss of muscle mass and that goes hand in hand with our discussion on osteoporosis. In my mind, they're inseparable. If you're losing muscle mass, you're losing bone mass. And it's something that as we just outlined, as you just said, there's hormonal influences, there's lifestyles, they're nutritional. There's all sorts of things working against us, so you have to be intentional about it.
(22:32):
But let's circle, go back. You briefly mentioned nutritional influences. There's a couple hot topics out there that I wanted to get your thoughts on. Number one, when it comes to bone mineral density, time and time again, I was told when I was younger the importance of drinking multiple cups of milk per day. I sent you a PubMed link. When you look at large meta analyses, these are research studies folks where they basically pull the data from multiple studies, and it's not a perfect way of looking at science, but it can give you large numbers, population based numbers.
(23:07):
When you look at the meta-analysis, it's really conflicting evidence in terms of the potential benefit of dairy and bone health. And in fact, a lot of the populations where they have the highest consumption of dairy, they have the highest risk of hip fractures. Now, I'm not necessarily saying it's cause and effect, but it does make you pause. I was just curious if you've had any thoughts on this or a chance to dive into the research or just what you feel about consuming milk and it's effect on bone health?
Stephanie Plummer (23:33):
So it's an interesting topic and it's certainly one that's, I think gained a lot of traction in the past maybe five to 10 years or so. I hear it out there a lot where dairy, cows milk, especially because of these large studies looking at the countries that are consuming the most milk products are also the ones that where you see the greatest population incidence of osteoporosis and fragility related fractures.
(24:00):
Interesting, from my background as a child, milk was a product that I did not care for the taste of. So I did not consume a lot of milk products, which my mother was very, very, very concerned about because again, all you hear, especially when we were growing up, when we were kids, multiple glasses of milk a day for bone health over time. So she was actually pretty good about making sure I had multivitamin or a calcium supplement.
(24:24):
Milk is a great way to receive calcium through your diet, which we talked about calcium and vitamin D being integral and required for the formation of strong bone structure. But there's other things happening in milk too that probably go along more with our American or unhealthy lifestyle in general. So you talk about fats and sugars and things like that, and if you're consuming a lot of those things, perhaps you're increasing propensity for being overweight or obese, or heart disease and those things.
(24:53):
If you look at health in general, if you have multiple medical comorbidities, so other medical problems, you're probably not also doing a lot to create increased bone density. And I think that's where you're seeing some of those data. Or you're looking at populations that maybe they also have a lot of smokers in this society, and we haven't touched on that yet, but that's a huge risk for developing osteoporosis.
Dr. Sanjiv Lakhia (25:14):
Yeah. That's a great way to look at it. One of the papers that came across off of Dr. Michael Greger's site, and Dr. Greger is a little bit controversial. He's a big proponent of a whole foods plant-based diet, which is a whole other episode.
Stephanie Plummer (25:27):
We could do a whole episode on that at some point.
Dr. Sanjiv Lakhia (25:30):
Right. He put out a video and we can link to it where he cites a paper that basically is pointing the arrow at galactose in milk in terms of galactose can be very toxic to the cells in general, creating a lot of inflammation. And potentially there's literature showing that increased galactose intake can be associated with elevated saturates in CRPs.
(25:52):
So that's one of the theories is that one of the milk sugars at high levels, because when babies have galactosemia where they are born deficient of an enzyme to metabolize galactose, they have a whole host of neurologic problems of which bone loss is one of them. So he postulates the theory, or at least the author of the study he mentioned postulates a theory that is the galactose when consumed in large quantities that can account for the paradoxical effect of diminished bone density in spite of increased calcium intake.
(26:21):
So anyway, it's just something that I'm still learning about and trying to figure out. For myself I've typically avoided dairy simply because it's very mutagenic for me and growing up with science congestion and such. So I don't drink a lot of it, but there are other nutrients. I think you mentioned vitamin D, calcium, magnesium, phosphorus. And folks, really, the way to get this in your food is once again coming back to the Mediterranean food plan, and we'll link to that episode that I recorded on it, but you want your green leafy vegetables. You want your beans. You want your good healthy fats, your olive oil.
(26:56):
If you're going to eat meat, you want your healthy grass fed meats, certainly fatty fish. It's all the same stuff like when you eat a rainbow-colored diet that's high antioxidants and polyphenols, you're going to get your calcium, your magnesium, your D, the rest of your minerals that you need to promote healthy burn bone growth and proper bone remodeling as you talked about earlier. So I think that's why-
Stephanie Plummer (27:20):
And some of the...
Dr. Sanjiv Lakhia (27:21):
Yeah, go ahead.
Stephanie Plummer (27:22):
Oh, I was just going to say, I do have a list that I usually... Just because of some of the controversy out there now with milk and the galactose, as you mentioned, the ones I usually recommend are collard greens and kale, soybeans, figs, broccoli, oranges, and then you mentioned the fatty fishes, sardines and salmon.
Dr. Sanjiv Lakhia (27:37):
Wow. I'm hungry,
Stephanie Plummer (27:39):
I know. Me too. It is dinnertime.
Dr. Sanjiv Lakhia (27:42):
All right. So you did a great job. You touched on exercise. We've done nutrition. I also want to get your thoughts on an underrated lifestyle intervention that plays a big role, I think in bone health, and that's sleep. And I forwarded you an article and we'll link to this in the show notes as well where it looks like in this study where they looked at a fairly large group of men and women, it looks like women who get less than five hours or less of sleep have increased bone turnover equivalent to a year of aging. I don't know if you had a chance to review that, but just-
Stephanie Plummer (28:15):
I did. I read through it and that was a little bit interesting to me because I'm a big proponent of sleep for getting quality and sufficient quantities of quality sleep for other reasons. But if you listen to some of the sleep experts out there, I'm thinking of people like Matthew Walker. Andrew Huberman has a podcast where he's had him on a couple times. He's been on some other shows. But I don't know that I've really heard bone density or osteoporosis come up as a negative of lack of sufficient quality or quantity of sleep. So this was very interesting to me.
Dr. Sanjiv Lakhia (28:48):
Yeah. It's not a high power study, and frankly, the negative effect is not a dramatic one that they observed in the study. But I wouldn't be surprised. We know that sleep, at least in my opinion, especially after reading Walker's book, which we'll link to something it's called Why We Sleep.
Stephanie Plummer (29:06):
Why We Sleep.
Dr. Sanjiv Lakhia (29:06):
Literally when I have someone in front of me and we're going over the pillars of health, which will be nutrition, exercise, stress, and sleep, if they only have capacity to improve one of those, I always start with sleep because it's the only time your body repairs itself. I have to think there's going to be a relationship with the melatonin, cortisol, diurna and it's influenced on bone health in terms of the link being inflammation.
(29:34):
It's something that I'd have to dive deeper into, but folks, it's just another reason potentially like you needed others to try and get really good, adequate, high quality sleep. Particularly a lot of people listen to this podcast deal with pain and back pain in general, and it's very, very hard to go through about a pain when you're not well rested or at least attempting to get good sleep. It just amplifies all your symptoms by at least three times.
Stephanie Plummer (30:00):
Sure. You mentioned all those different pillars of health. It's the only one that we... If you go without one of those things, you can go without sleep for the least period of time, surprisingly.
Dr. Sanjiv Lakhia (30:12):
Oh, wow. Never thought of it that way.
Stephanie Plummer (30:14):
So it is performing all kinds of vital, important functions for us. So I think that's great advice. If you're going to focus on any one thing first, probably sleep.
Dr. Sanjiv Lakhia (30:22):
I'm just curious, when you're preparing for one of your marathons or races, what's kind of your three, four, five day prep schedule in terms of sleep leading up to that?
Stephanie Plummer (30:33):
That's an interesting question because a lot of the races that I do involve travel. So I really enjoy running big city marathons. The world marathon majors are some of my favorites because network of friends that I've formed over the years that we like to meet up in these big cities. We're not necessarily running together, but in the lead up to and after we have time to just enjoy each other's company and talk about the race and talk about our training.
(30:55):
So the most recent marathon I did was actually in London, and I'm usually not leaving for the race just with work schedule and everything else until about two days before. So I'll leave on Thursday night for a Sunday race, and that involves trying to sleep overnight on the flight there. That's the only way I'll do it anymore is if I can almost guarantee that I can sleep close to a very normal six plus, at least minimum of six hours of sleep on the flight over.
(31:22):
And I do that in a variety of ways, but I really try and make sure that I've eaten before I get on the airplane that I sleep. And then when I get there the next day, I usually go to bed quite early because I know that I've probably come close to that six hours, but maybe not, and really aim for eight hours of sleep the two nights before the race.
Dr. Sanjiv Lakhia (31:38):
Wow. What a challenge. That's amazing that you're able to pull that off. I've been watching a lot of the NBA playoffs right now, and one of the things when they interview LeBron James in terms of his preparation at the age of 38, going through major minutes, a lot of toll on his body, the thing he almost always mentions in his post-game interviews is, "I need to go home and I'm going to get my sleep, and tomorrow I'm going to get my sleep."
(32:03):
This is what he literally does and starts with because athletes know that if you have higher quality, more quantity sleep, you perform better. So good luck with that as you pursue your endeavors with the races and everything else. But I'm really glad to hear you've diversified your exercise program. You're just a perfect voice for this issue, and I hope people take this information, take it to heart.
(32:26):
Look, there's a lot of our things that we could talk about on this. I mean, you mentioned smoking and certainly there's other things I think that are detrimental. Smoking and sugar intake and inflammatory foods. And then of course there's medications for osteoporosis. And then our group offers... And I might do an episode, separate episode on this, but there's interventions for bone fractures like kyphoplasty and vertebroplasty.
(32:48):
But I felt like you were just the perfect person to talk about it really from a lifestyle lens, because you walk the walk. You really focus on your health and your fitness and your mindset, so you can be the best physician and just the best person that you can be.
Stephanie Plummer (33:01):
Yeah. I've been lucky in a lot of ways growing up because just in my family, my parents were really attuned with it, and I think it may have come a little bit out of... I think there's a big push for milk consumption, but at least it was an awareness right when I was a child. So it is always been in the back of my mind, and I can certainly think of my maternal grandmother. She was not a tall woman to begin with, which is kind of funny if anyone who's out there, one of my patients or someone who's met me for an injection. I'm a little bit on the taller side, but she was five-foot-two at her tallest, and I think by the time she passed away at age 80, she was closer to four-10.
(33:42):
So almost four inches of height loss and very kyphotic rounded forward posture. She lived with us when I was a teenager or so. I think just seeing that and having some awareness and recognition that it was probably related. And she certainly suffered. She never had a hip fracture, but she had a wrist fracture from a very low impact kind of trip and fall forward. So it's always kind of been there in my awareness, and it's something that I've really tried hard to do for myself, and I think it's really important to try and make sure that others are aware of it as well, especially my patients, and make sure that y'all have the tools and resources to start now. It doesn't matter what age you're at, there's things that we can do to start working to prevent significant complications from osteoporosis.
Dr. Sanjiv Lakhia (34:27):
And I'd be remiss if I didn't mention working in a neurosurgery practice. If you are someone who may end up needing spine surgery, the surgeons are going to have a hard time offering it or trying to fix your problem if your bone mineral density is poor. So there's so many benefits. It's much better to look at prevention than treatment, and I hope those that were listening take all the information you just laid out and sort through it and see what resonates with them and just get to work on being their best version of themselves and keeping their spine, their posture strong. So many positive downstream effects. So Stephanie, thanks again for sharing your knowledge. I really enjoy it. You're an easy interview. I'm sure this won't be the last, and I look forward to talking more with you in the future.
Stephanie Plummer (35:10):
Likewise. It's been my pleasure and look forward to the next episode.
Dr. Sanjiv Lakhia (35:10):
Thank you.
Voiceover (35:13):
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.