Tue, Dec 13, 2022 5:07PM • 1:52:08
SUMMARY KEYWORDS
fractures, osteoporosis, mk, bone, medications, bone density test, clinical trials, bone density, study, patients, shown, hip fracture, bone mineral density, calcium, mentioned, reduce, day, osteo, fracture risk, strontium
SPEAKERS
Bill Clearfield
00:01
joins even join okay here we go should be on okay
00:16
go ahead yeah
Bill Clearfield 00:31
all right everybody if you can hear me I apologize. We had some technical issues. I don’t know why we weren’t being connected. Can you hear me? Yeah. Yep. It was. It kept saying I was in a different meeting. Belt. Yeah. That being says he escapes or something else. He
00:56
never got rid of it. So it looks like you’re in different meetings. So you have to make sure if you had another meeting you were to get out of it, I’ve had that happen.
Bill Clearfield 01:17
So, Dr. Newstead, I think you’re on here. I apologize. I don’t know what happened here.
01:23
Nada probably yes, I am on here and not a problem at all. I’m glad we were able to log in.
Bill Clearfield 01:28
You’ve been doing this for over two years. But this has been happening in the last couple of weeks. For some reason. I’m not sure why. But it looks like we got hopefully we didn’t lose too many. So without further ado, everybody, this is Dr. John new stat. He is a naturopath and he’s expert on osteoporosis and he’s going to give us his his his wisdom on the subject. We don’t I don’t I know I don’t want to hear you don’t have to do that. A lot of time at one will try to please mute yourself if you’re not the speaker and I hope I don’t. I hope I don’t mute you John.
02:24
And I did mute you.
02:25
So am I’m unmuted. I’m good. Okay,
Bill Clearfield 02:27
okay. Okay, so I’m just going to make sure everybody else is quiet. And again, I apologize for the technical difficulties. Usually we start right on time, and for some reason I know I’m home tonight instead of my usual on at the office. So I don’t know if that had something to do with it. But anyway, so where the you don’t know where the American Osteopathic Society of integrative medicine and we’ve had quite a year. Right, John? And we’ll have maybe a short discussion when we’re done but Dr. noose that thank you so much for being being here with us. And we’ll let people in as they as they still show up and take it away. A brief introduction about yourself and it’s not a CME so you can talk about anything you want any products any any services. So again, okay, so take it
03:28
away. Okay. Well, thank you for the opportunity to speak to your, your group. I by way of introduction. As Dr. Clearfield mentioned, I am a naturopathic doctor. I finished my training in 2005 and I opened a clinic in Montana. I never thought I’d be specializing in this area. And I’m gonna get back to that in just a moment of how I came to focus on osteoporosis and bone health. But in my career, just as as an overview, I am on the corporate advisory board now for the bone health and Osteoporosis Foundation. I’m the vice president of my State Medical Association and California naturopathic doctors Association, published over 100 research reviews. Elsevier once gave me the honor and recognize me as one of the top 10 cited authors in the world for one of my publications which was on mitochondrial dysfunction and molecular pathways of disease. And I frequent lecturer at medical conferences and my book on osteoporosis, which is my fourth book just came out earlier this year called fracture proof your bones a comprehensive guide to osteoporosis, which I wrote because it really became an emphasis since 2005. In my in my work, not only clinical practice, but in my entrepreneurial venture. I own a dietary supplement company called NBI, which stands for nutritional biochemistry Incorporated. And I started the company because I could not find the dose or combination of nutrients in existing products that were shown in clinical trials to work that I needed for my patients. What happened was I started to have patients coming to my clinic with various conditions, but repeatedly I would see osteoporosis and my mother in law she has had and still has osteoporosis. At the time she was on Fosamax. Her bone density was going up. So she was happy. Her physician was happy. I was happy. I was working with patients. I was tracking their bone density, everybody was happy. And then my mother in law, fell and broke her hip. And I started to think what’s wrong with this picture? Everybody was happy, but what what is wrong? And I started diving more and more into the research and was shocked by what I found. And unfortunately, it’s still the case that the clinicians primarily focus on the number on the test and set a set of the patient sitting in front of them. We’ve known since the 1990s that a bone density test predicts less than half of people who will break a bone and more recently, I believe it was about 2008 the data came out that a bone density test only predicts the area we’re talking about absolute fracture risk, absolute risk, not relative risk, the absolute risk for fracture and women with osteoporosis, as predicted by a bone density test is only 44%. And it’s even worse for men 21% The right now osteoporosis is truly an epidemic. It’s on the rise. Demographics are not in our favor. It’s primarily a condition that affects people as they get older as everybody on this webinar is fully aware, and the population is aging. Currently osteoporosis is second only to cardiovascular disease as a global problem. If you’re a woman, your risk for breaking a bone because of osteoporosis, it’s equal to your combined risk for breast, uterine and ovarian cancer. And if you’re 50 years old or older, your risk of dying from a hip fracture as a woman is similar to your risk of dying from breast cancer. And in fact, osteoporosis is responsible for more days spent in a hospital than diabetes, heart attacks and breast cancer. So how is it that something that we’ve known about since the 1940s How is it that it has such horrible clinical outcomes still, and those of that’s the question that I sought to answer and create programs for people and understanding how I can actually do a better job. I’m going to launch my presentation here. Can I share my screen? Let’s see. Let’s see if I can do this. Can everybody see that? Can somebody let me know if they can see my? Yes, yeah. Okay, perfect. Thank you. So that’s my email. Feel free to reach out to me anytime happy to consult with anybody about patience or answer any questions after after this. Those are my disclosures already mentioned my my supplement company. I’m also president of a pharmaceutical company. We’ve got about a dozen US FDA orphan drug designations for the potential for the potential treatment of rare diseases using natural products. My book that I mentioned was self published out of my company, lymph media, and the rest I mentioned I do have bone support products. And I will mention those so this is this is the book. Those are just a couple of the few of the reviews that it’s gotten. And these are the products for full disclosure. I really encourage everybody to do do your homework, do your research, their citations all throughout this presentation. There are citations all throughout my book everything that I’m telling you is accurate. But I also encourage people don’t just believe me, you can always go and do your own research. I have all the PDFs that are that are referenced in here. So if anybody wants that, feel free to reach out to me. I’m happy to send any of this information to anybody. So let’s just move on then. What the issue seems to be of course, is that the Osteoporosis is not just about bone density. It’s a condition that predisposes somebody to a fracture. So a bone density test and any any test is only as useful as it is as as it can predict fractures. Similarly, any treatment that we recommend any record of any recommendation at all, diet, lifestyle, dietary supplements, pharmaceuticals, whatever they were recommending are only as useful as they’ve been shown not just to change a number on a test, but to reduce fractures. 80% of of osteoporosis is in women, and the majority of that is postmenopausal osteoporosis, the fastest. Bone loss occurs in women when they hit menopause and for the 10 years after, as I mentioned, there are a lot of people that have it 53 million people, either with with osteoporosis or at risk. There are by just a couple of years we’re talking about 3 million expected fractures and 10s of billions of dollars to the healthcare system. And that doesn’t even you know, can take into account I think the impact to families and the communities when it comes to having to have a caregivers that are family members. If you break a hip, if you have osteoporosis and you break a hip there’s up to a 40% chance that you’re going to die within a year. The most often cited statistic is 20%. The biggest risk is within the first six months and then it begins to decline from there. And then if you do survive, though, half the people who survived don’t end up getting their full level of pain free life and mobility back and so a lot of people end up needing ongoing care and so there’s a lot of ancillary costs that I don’t think are factored into into this. Osteoporosis it has a greater impact on disability adjusted life years then hypertension Breast Cancer, rheumatoid arthritis, stomach cancer prostate cancer, very, very cancer and Parkinson’s disease. So I think I’ve driven driven the issue home it’s a big it’s a big There we go. Now I’m unmuted one of the biggest challenges and Dr. Clearfield mentioned that it’s not something that he if I’m if I miss characterizing please let me know. But But deals with that often or sees that often. And there was a study that came out of Europe
11:53
that showed that primary care doctors in Europe are really not sure how to treat osteoporosis there’s a lot of confusion and I believe it’s the same situation in the US there is no specialty for osteoporosis it is usually the primary care Doc’s who are the ones who do the screening, order the DEXA tests, manage the patient, make the recommendations and do the follow up and yet in this study that came out of Europe and I believe it’s the same in the US there’s a lot of confusion. And then the the time that it takes to have the more nuanced conversations around diet and lifestyle. They don’t have the time because there’s pressure for reimbursement and to see more patients and also most doctors don’t feel confident knowing the information and feeling competent to have those conversations around diet and lifestyle and exercise in any any greater detail. So that’s why the default often is medications. That’s one of the reasons and one of the reasons why I think the outcomes are so poor. If you’re looking at screening and somebody comes in quick physical exam may give you a little bit of information of whether they should go for a bone density test. If they can’t stand with their with their occiput against the wall back against the wall, they’re occiput touching a wall. They’ve got a little bit kyphotic at that point, that may be an indication if they’ve lost about over two centimeters over one to three years. Being thin. Less than 112 pounds is a risk if they’ve been losing teeth. Those are those are those are risks for osteoporosis and indications that you may want to get some testing done. The latest US PSDF recommendations is that screening should be for all women 65 years or older. And for postmenopausal women, less than 65 years old. So they’ve had an or had their ovaries removed then or somehow they’ve been put into menopause prematurely, then they need to have potentially have screening. It’s estimated though that 30% of fractures, hip fractures occur in men however, the task force does not recommend men get screened for osteoporosis unfortunately, some organizations take a more nuanced approach. The bone health and Osteoporosis Foundation, for example, recommends that when there are other risk factors, even when they’re less than 65. Not just if they’re there in menopause, while younger than 65. But if they’re comorbidities for example, medications that they’re taking, and I’m going to talk a little bit about medication induced osteoporosis because it’s a big problem and it’s a largely unrecognized problem beyond what I think we all recognize as an issue like prednisone, systemic oral prednisone. Interestingly enough though, the risk for fractures when somebody is on prednisone goes up even before the changes are seen on a bone density test. Similarly, in terms of screening any adult over 50 years old who breaks a bone, it’s recommended by the bone health and Osteoporosis Foundation that they get screened for osteo prosis Despite the limitations of the bone density test, in terms of its ability to predict fractures, that is the diagnostic criteria of a osteoporosis we do need it in order to diagnose the disease and it is one variable that can be that can be tracked over time. So screening rates, unfortunately, despite how many people are at risk, despite the recommendations are are poor. We’re talking about 30% of eligible women and only 4% of eligible men are tested. And when you’re looking at Medicare population, we’re talking only about five and a half percent are getting bone density tests. There’s a lot of room for improvement here. There’s an online tool fracks risk assessment tool that patients can do. It’s interesting. I think one of the one of the it has been validated but I think one of the the main benefits of the fraks tool, as well as the bone density tests are that it opens up the door to or conversation and it opens up the door for people to be more open to being proactive and involved in improving their their health. So let’s just talk briefly a little bit more about the DEXA test. A central DEXA bone density test is what’s required for the diagnosis not a peripheral bone density test. The central bone the peripheral bone density test, though has some advantages in that it’s portable. It can be taken to health fairs, for example, and then if that’s low, they can be sent for a central deck some radiation exposures is very low. I mentioned the peripheral DEXA briefly, and I’m gonna go through some of these slides because I really want to get more towards the the approach to improving bone health and reducing fracture risk, as well as making sure that I have enough time for questions. So the definition of osteoporosis is a t score of minus two 2.5 or lower osteopenia is minus one to minus 2.5. And that is based on a comparison with if it’s a woman with younger women 20 to 29 years old of the same race. Z score in contrast, is compares a bone mineral density of somebody of their same age. Interestingly, a t score is not applicable applicable to pre menopausal women and men less than 50 years old or children. So if you’re getting a younger woman screened, you need to be looking at the z score. And also a z score is important for looking at secondary causes of bone loss like medication induced osteoporosis, endocrine abnormalities, autoimmune disease,
17:47
etc.
17:50
I talked about how well bone density tests predicts fractures so there’s a little more information there. Interestingly, in 2014, the Annals of Internal Medicine published a paper that stated that among persons receiving FDA approved osteoporosis, pharmaceutical treatments, or changes in bone mineral density are not good predictors of the anti fracture effects. So again, primarily in the clinical encounter, doctors and patients are focusing almost exclusively on bone density, but not only does it is a poor predictor of fractures, but now we have a lot of data showing that even when the bone density test is improved by medication that is actually a poor predictor of its effects its ability to reduce fractures. There are a lot of potential errors with DEXA scans. Up to 90% of tests in one study contain one or more errors. There could be artifacts, dietary supplements, if somebody’s taking high doses of calcium or if they’re taking strontium. Strontium is can be a is a popular dietary supplement for bone health. It has been shown to reduce fractures in Europe, but it’s been taken off the market because a regulatory review of the data has since shown that for every one patient helped in terms of reducing fractures. It’s now believed that one patient will have thrombo embolism, venous thromboembolism, pulmonary thromboembolism, and so they ended up taking it off the market. In Europe, the drug medication is called Strontium Ranelate. That’s a proprietary form it’s not available in the US in the US, you see in dietary supplements strontium and Strontium Citrate, there is no safety or outcomes data on Strontium Citrate in terms of clinical trials Alright, so the real risk is breaking your bone every 30 seconds somebody with osteoporosis breaks a bone and it can lead to further disability and mortality. If you break a hip the risk for death is elevated for 10 years after that. And in fact, mortality from a hip fracture is greater from from your risk of dying from breast cancer in the elderly if you’re over 65 years old. There’s the greatest risk of dying is within the first 90 days of a hip fracture. I think I said the first six months but that’s true it goes down after six months as well but within the first 90 days, first three months is the is the is the biggest risk. Interestingly this last bullet, hip fracture mortality is almost double in men than in women. There’s speculation of why that might be. There’s no clear consensus yet. But but it does seem that what may be happening is that as people get older, the comorbidities in men seem to be more severe than in women and that predisposes them to the increased risk of dying from a hip from fractures. 40 to 60% of patients who survived don’t regain the pre fracture level of mobility 50% never returned to full function. And in fact after one year 27% Do not regain their flat did not regain their full independent mobility
21:02
in one study. This is important so
21:07
73% of total fractures are non vertebral fractures. And that’s important to know because most of the medications when you look at the data and start looking at the clinical trials on the medications, they report primarily vertebral fractures and vertebral fractures. It does increase your risk for mortality up for five years after but it’s not as immediately deadly as a hip fracture. That’s the most dangerous fracture. And in fact, there are some predictors of mortality that you should be aware of. And if they’re in a nursing home, so the different predictors nursing home versus community dwellers, poor functional status, comorbidities, I mentioned that and it’s important one of the biggest predictor predictors is gait and mobility. So if you see somebody coming in, and obviously the clinic clinical encounter happens the moment you see the patient, you see them walk, you watch their gait, or they study on their feet. How do they get out of a chair? Are they able to get up out of a chair unassisted? That that’s one of the most validated or what’s the word I’m looking for? That is the best predictor for fractures and mortality as functional status. osteo sarcopenia is another big issue muscle wasting when it’s combined with osteoporosis. You’ve got a higher mortality rate in actually in the mortality rate is higher in men than in women. I don’t know why when they have osteo sarcopenia. But when you do have osteo sarcopenia you also have 28% 28.7% of hip fracture patients were diagnosed with this so look for that as well. It goes back to that functional status. The gait, the muscles, the strength, the balance. 95% of fractures occur because somebody falls so anything we can do to prevent somebody from falling can reduce their risk for fall. related injuries, including fractures. Long term mortality, predictors of mortality, I mentioned the quadriceps weakness. I’m not going to belabor this gait or balance abnormalities. It’s a fall risk, most consistent predictor of future falls, the many other risk factors here quite a few of them are modifiable risk factors. medications may be a modifiable risk factor. Environmental Hazards definitely a modifiable risk hazard. So why isn’t a bone density test a good predictor of fractures the the reason is, is because bone is not just minerals. A bone density test only measures the mineral content of bone but bone is a tissue. All tissues have multiple components and the minerals are just one component. The extracellular matrix in bone has about 200 non collaborationist proteins, and collagen. The major type of collagen and bone is type one collagen. And that’s actually what gives bone its ultimate quality and strength. The the the if you were to dissolve the collagen and bone and are are just left with the minerals it’d be very brittle like a like a column of chalk that breaks easily. If you d mineralized the bone in my histology professor in medical school did this he brought in D mineralized chicken bone that he had soaked in vinegar. And all that was left then was the collagen and it’s like a rubber chicken. You can bend it you can twist it you can pull it and it doesn’t break. That’s the call. That’s the power and the strength of collagen
24:46
and healthy collagen.
24:49
So the northern menopause men the North American menopause society has various fracture risk factors. There they are. A interesting history of smoking is not one of them only current smoking. Previous fracture is a big one 30% of people had an osteoporotic fracture within five I believe it’s five years. I’ve got the slide coming up. We’ll have another fracture. impaired vision making sure vision is checked. That’s really important. Making sure medications glucocorticoids there’s more recent research that not just long term systemic glucocorticoids but even low dose inhaled glucocorticoids and dose pack, short term dose pack. Prednisone increases the risk for fractures. So here’s what I mentioned before the risk after a primary fracture. And it’s really important to start thinking you know, are we trying to prevent a primary fracture or a secondary fracture? And I’ll get into that in a few minutes because the effects the efficacy of the medications are different, whether it’s a primary or secondary fracture. Interestingly, the five year risk of subsequent fractures was up to 75 to 84 years old was 42%, even higher than the group as a whole. And in women when they get up to over 85 years old, it goes down a little bit to 38% Perhaps because they’re maybe less mobile at that point. So let’s talk about drug induced osteoporosis. It’s a big issue because so many people are on not just single medications but fought polypharmacy and there is no no official definition of what polypharmacy is, how many medications does somebody have to take in order for it to be considered polypharmacy? I see in there, you know, the second bullet and it’s an important opportunity for attendees to help that. That’s a legacy bullet point I was giving this presentation to a group of naturopathic doctors at a conference. So also for an osteopathic doctors, any physicians it is it is an important opportunity for all of us to be able to help but you’re taught. Yes, we’re the we’re
Bill Clearfield 27:05
the Renegades John, so we’re good with
27:09
all right. So you’re talking about more, you know, five or more non prescription or prescription medications. per week for women 65 years and older which is the prime demographic who are at the highest risk for osteoporosis. A huge number 12% or two in that age group are taking 10 or more medications either non prescription or prescription medications
27:34
per week.
27:37
So a study looked at drug use before and after fractures. What is you know how well are doctors doing at identifying the medications that could be have been a problem and switching to safer medications and they’re not doing a great job. What what the studies show is that they would switch them if they identified the medication like prednisone glucocorticoids are commonly known to damage bone. So they the number of I’m gonna go to the next slide because I think I’ve got the data on the next slide. Yep. So you can see their oral steroids. On the left column prior to fracture in the three months prior to the fracture after the fracture. They reduced the number of people who were on oral steroids a number of patients but that was offset by the number of patients they put on a proton pump inhibitors and the number of patients they put on hypnotics and the number of patients they put on SSRIs and anti-psychotics all of which either damage bone or increase the risk for falls and fractures. SSRIs we now know based on some studies and people are taking them long term, more people than ever are taking SSRIs that after people who are on them for one to five years for every 19 patients taking an SSRI we would expect one to have a fracture. And I’ve got that citation in the data in a slide coming up. Similar with proton pump inhibitors that were never approved. by the FDA for long term use. It’s available over the counter as you know that the PPIs after four years of use, increase the risk for hip fracture are associated with an increased risk of hip fracture by 60%. And like all medications, dose and duration matter. The higher the dose, the longer somebody is taking it, the greater the risk, we see that pattern over and over. So glucocorticoids up to 50% of patients on chronic glucocorticoids will fracture will fracture and up to 2% of the general population also are you know are actually on long term glucocorticoid therapy. And now we know that even small small doses increase the risk and for every 10 milligram increase in dose there was a 62% increase in risk for fractures. When you look at treatment guidelines glucocorticoid induced osteoporosis treatment guidelines, the college American College of Rheumatology the guidelines, and you can see the last bullet point. They’re all equivocal. So because of limited evidence regarding the benefits and harms of interventions, most recommendations are conditional, you know, uncertain balance between benefits and, and harms. And then when you look at the data of you know, and it even says the first the first bullet because of limited evidence most recommendations again are conditional with you look at the data on Fosamax and Kirlian Forteo the the first systematic analysis wasn’t even published until 2018. And it did not decrease fractures in nine randomized clinical trials Prolia it increased bone density, but it’s underpowered to, to, to determine if it reduces fracture risk. And for to there’s no meta analysis. It may be more effective according to clinical trials and Fosamax for fractures. But they’re just there. There’s no meta analysis yet. We don’t have the strong strong enough data from a natural approach. There is a specific form of vitamin K that many people have heard of probably heard of vitamin K for promoting bone health, m k for it’s a specific form of vitamin K two has had multiple clinical trials of people on prednisone, both adults and pediatric patients and in the adult patients, the dose of 45 milligrams per day has been shown to stop and reverse bone loss and people taking prednisone there are no clinical trials in that population looking at fractures however, there are clinical trials on mk 445 milligrams per day, looking at fractures in postmenopausal women with osteoporosis. So SSRIs and SNRIs. I’m not going to spend too much time on this. But the basic mechanism of this results in 1.6 times higher rate of bone loss, and the majority of serotonin is actually in the periphery. It’s not in the CNS. So what happens is there are their serotonin receptors on bone and it stimulates osteo class. And so when you are artificially raising serotonin whether it’s an SSRI or an SNRI, you are promoting bone loss. That’s the bottom line. Oh even more 95% of serotonin is in the in the periphery. And it actually not just enhances osteo class activity but it reduces osteoblast activity in the in the that that’s the indirect effects on bone, and then peripheral serotonin does act directly on on bone. So as I mentioned before, SSRIs and fractures, this one study for every 42 patients who’d expect one, one fracture. And another second studies found for every 19 users taking the drug for one to five years, we would expect one additional fracture. This is a second and now meta analysis. The first study in the slide I’m showing now was also a meta analysis. So what about SNRIs? I’ve had conversations with doctors I’ve been in and patients coming to me they’re on SNRIs and this my doctor says it’s safe. It’s It doesn’t it doesn’t create fractures, that doesn’t create bone loss. And I ended up having to send their physician, the PDFs and the studies to educate them to get them to change the medications. So even with SNRIs we do have a 68% hazard ratio, risk for a fractures and people with SNRI as well as SSRIs as a 10 year Canadian study, acid blocking medications 50% of those are written for just acid reflux and when somebody actually has acid reflux, the risk for fracture which is prescribed for acid reflux, the risk for fracture is 349% compared to those people who are not prescribed PPIs versus it as a general population, people on PPIs for four years or about four years, I have a 60% increased risk for hip fracture Now, here’s the challenge that I have with with acid reflux and and the reflex the reflexive prescribing of PPIs for acid reflux for many patient patients. Acid reflux can be effectively dealt with just with dietary changes. There are five most common foods that aggravate acid reflux, it’s tomatoes, raw garlic, raw onions, citrus, coffee and chocolate. For other people. Spicy foods might be a problem. So you’re just doing some dietary modifications finding out if those are issues or if something else is an issue. H Pylori infections can cause GERD for tests or testing for h pylori and treating that if it’s there, that also may be the underlying cause instead of just prescribing medication, and there’s a blog on my website if anybody’s interested where I go into those different approaches and some more detail. So as I said, the higher duration the higher the risk. PPI does hip fracture is actually stronger in men, which I mean all of it’s unfortunate, but it’s unfortunate. In additionally, because, as I mentioned earlier, the mortality risk in men with a hip fracture and osteoporosis is double about double what it is for, for women. So when their analysis was restricted to just with GERD, as I mentioned, the odds ratio for hip fracture was 3.49. So 349% greater in patients with h2 RAs, histamine h2 receptor antagonists, it was not significantly associated with increased fracture risk. So look, if they have to be on an acid blocker, it appears that
36:22
the h2 RAs are maybe safer. And there’s a meta analysis also looking at falls and fracture risks, and 2019 PPI is significantly associated with increased risk of falls as well not just fractures, but also increased risk of falls and an increased risk of people who sustained a fall that they would end up in a hospital with an odds ratio of 1.6 to one so 61% greater risk for compared to people not taking PPIs no significant association with these increased risks and people taking the h2 RAS you know, Tagamet and Pepcid. So, again, that that as a category medications would be a safer choice. Let’s talk about big phosphates and ppi. So, what happens in medicine, As you’re all aware, is there’s oftentimes not clinical trials. You know, there’s not the data to necessarily make decisions off off of clinical trials in the patient that you’re treating in the patient population with the same diagnosis, the same medications, the same medical history. And so the go off of clinical guidelines or you go off standard of care, standard of care people were on PPIs and got osteoporosis was to prescribe a, a bisphosphonate and osteoporosis medication. The assumption was, well, it works for postmenopausal osteoporosis. So let’s do it in these other osteoporosis cases as well. And then somebody thought, Well, we really should study this. And they did. What they discovered was actually, when you combine a proton pump inhibitor with a bisphosphonate and oral bisphosphonate, you end up or just a bisphosphonate, you end up with a higher risk for fracture 52% increased risk of fracture compared to people just taking bisphosphonates and it didn’t matter which type of bisphosphonate and today there are no published clinical trials evaluating the concomitant use of PPIs with other categories of osteoporosis medications, look, the mechanism of action for met postmenopausal osteoporosis is a decrease in estrogen. The mechanism of action for bisphosphonate related or PPI related osteoporosis is different. It’s not because of the drop in estrogen. So assuming that just because one medication is applicable to one situation that is going to be applicable to another and we see evidence here that we’re actually doing more harm
38:44
than than good.
38:47
So treating PPI induced osteoporosis as I mentioned, we’ve got an increased risk for fractures. And that’s a repeat slide. Sorry, that’s in there. Twice. So let’s talk about osteoporosis medications as a cat as a overall arching theme. Right. So you’ve got the antiresorptive medications. There’s the list. You got the anabolic medications, and there’s the list as well. The first Avanity was the first drug approved in about the last 15 years as approved in 2017. Now remember, the most important question to ask about any recommendation is has it been shown to reduce fractures? So, if you look at this, these next couple of slides so so the number needed to treat in this study that pulled all this data and looked at this is this is for vertebral and hip fractures over three years calculated from the results of randomized double blind phase three clinical trials versus placebo, and the little green box down here that you know, kind of mentioned before, there’s no common universal definition for adverse drug or drug reaction, just like there’s no common definition of what polypharmacy means. So the number needed to treat with Fosamax is, you know, a lender and eight to prevent a hip fracture, you have to treat 91 people for three years to get one to reduce to prevent one hip fracture. For vertebral fracture, it’s better 14 people for three years and go down the list for reset, donate or act until 91 people treated to prevent one hip fracture 20 to prevent one vertebral fracture. Boniva actually has no hip fracture Prevention’s demonstrated only vertebral fracture, and reclassed were timing 90 was similar to the other bisphosphonates. You’ve got 91 People have to be treated for three years to prevent one hip fracture, and 14 people for three years to prevent one vertebral fracture. Prolia you’ve got to treat 200 People over three years to prevent a hip one fracture, I Avista does not prevent hip fractures. And again, those are the most dangerous type of fractures, conjugated estrogen. Now the bioidentical hormone replacement therapy, there’s no clinical trials on it. But the overall effect is saying it’s not not known. number needed to treat with 40 to 200 to prevent over 19 months to prevent one hip fracture 9011 patients over 19 months to prevent one vertebral fracture. Those are in clinical trials. But what happens in the real world? Well in the real world, you’ve got to have a 70 to 80% compliance to obtain the effect of the drug therapies. But about 50% of people being prescribed bisphosphonate they discontinue therapy within within one year. So in the perfect world of controlled clinical trials, that doesn’t really match what’s happening out on the streets. And in fact, when you start looking at this fascinates in fracture prevention, and you start looking at the clinical trials, it I was so upset when I started to really look at the clinical trials because what happened what’s happening in these studies is they’re they’re enrolling high risk individuals who have had a previous fracture, for example. But as well, there’s different risk if you’ve never had a fracture, and you’re talking about primary prevention versus secondary prevention. And they’re not, you know, teasing apart the data in these clinical trials with the inclusion criteria, and they’re not defining it to that to that level. And so the data when you start looking at it, it’s very confusing. And so you just get these recommendations of oh, well, it prevents a fracture, it prevents these fractures, but the reality is, is they’re not equally effective at preventing primary fractures versus secondary fractures. This study 2015 meta analysis showed that oral bisphosphonates don’t prevent primary fractures. Only Zometa five milligrams every 18 months reduce primary fracture risk, secondary fractures for secondary fracture prevention. The medications are more effective they do work but the problem that I have is that people are treating a number on a test. Doctors are treating a number on a test. They’re sending patients out with these prescriptions that don’t work. The doctor is happy because they don’t understand the patient’s happy because they don’t understand and we got 2 million fractures a year and people dying it’s horrible, the situation is horrible, and we can all do better. Another more recent meta analysis 2020 show that oral bisphosphonates prevent secondary fractures but not primary fragility fractures. There’s a summary table if anybody is interested. Citations Alright, so let’s get to a more holistic approach. So what can we do to reduce people’s risk for fractures reduce people’s risk for for bone breaking down and also build bone not build stronger bone maintain strong bones reduce fracture risk? Well, sleep is crucially important. So people who sleep less than five hours a night sleeping less than five hours a night is associated with a with lower bone mineral density and was associated with hip osteoporosis a 63% increase risk odds ratio of hip osteoporosis and an increased risk of osteoporosis at the spine. So the optimal amount of sleep for adults is about seven to eight hours a night. Most people as they age have a hard time sleeping that long. various reasons for that some of its physiological some of its lifestyle, these devices that we all carry around. There was a study that was that was done a few years ago, people reading on light emitting devices, they’re on their screens before they go to bed versus reading just old, good old fashioned paper. What the study determined is that not only did that deplete melatonin, it made it more difficult for somebody to fall asleep. Now, it only it only increased sleep latency by 10 minutes. When I read that I thought well, okay, that really doesn’t sound like a big deal. But what happened in the morning is people who were on light emitting devices prior to going to bed. It took them hours longer to feel awake. And that indicated to the the researchers and to me that the the participants in the study probably weren’t getting into those deeper stage three and four stages of restorative sleep that we all need for tissue regeneration and for for health. There are lots of diseases also that decrease melatonin, so looking at those you may just need to give somebody some melatonin, medications that decrease melatonin beta blockers decreased melatonin so they’ve just made needs some some melatonin. Here’s the the light emitting devices study I mentioned all these medications cause sleep disruption. So again, doing a good review of medications and the mechanisms, maybe switching them to different ones if possible.
46:16
becomes important.
46:19
With with respect to melatonin, though, I do want to say this. So the half life of melatonin is small only about an hour. It’s short only about an hour and so what often happens when people have a hard time sleeping, the first thing they think about is melatonin and so they take melatonin and it helps them fall asleep because that’s the role of melatonin and has other roles but that’s one of the major roles to the modulating the circadian rhythm. And then they wake up in the middle of the night. And then they end up taking more melatonin and more and more until they take so much they’re knocked out all night but then they wake up groggy the next day because that’s not really the role of melatonin. And after years of looking at this after years of me, you know getting complaints from people and asking me to go and do some research and create something. I did that and I created a product called Sleep relief. And it’s the only biphasic time release delivery mechanism in asleep dietary supplement on the market. The reason I did that is because it sleep is generally in two major categories, right? It’s falling asleep and staying asleep and the mechanisms for falling asleep and the physiology and the endocrinology of falling asleep is a little different than what the body needs to stay asleep. And so the nutrients a little bit of melatonin, but herbs and amino acids and minerals in that formula. In the two phases helps people fall asleep but then also stay asleep or if they wake up in the middle of the night. They’re not so groggy that they’re at increased risk for falling and getting hurt like they are benzodiazepines and then they are able to fall back asleep easier, and it wears off as the night goes on. And they wake should be they should wake refreshed and ready for their day and not hungover and groggy. That product is called Sleep relief. There’s more information and you know research studies on my on my website NBI health.com. If anybody wants to learn more cortisol, not surprising because we know prednisone and glucocorticoids destroy bone, even our natural endogenous cortisol, cortisol destroys bone. Even in normal healthy people. Having elevated cortisol has been inversely correlated with bone mineral density so the higher the in women elevated peak plasma cortisol is associated with lower baseline bone mineral density at the femoral neck and a faster rate of bone loss. So stress management, very important sleep as part of stress management, very important, helping helping people manage their stress by teaching them to say no not being overschedule getting them into counseling, if they need counseling, getting them into doing some self care, all very important connecting with nature very important. Another supplement for supporting the adrenal glands and modulating the stress response that I that I created is called common clear. It’s incredibly effective. That’s another possible something else that you could use. Social support, not commonly discussed. When looking at bone health and osteoporosis. So but what the research has shown is that it’s inversely associated with osteoporosis risk and all cause mortality. Right? That includes dying from a fracture. And it’s not just the size of the network, but it’s the quality of the social support network as well. A research study looked at what how many people in that support network are optimal, and it came out with three not four or five or six. Having three people in a strong social support network was associated with the lowest risk of osteoporosis. And it’s not though just having the network you have to you have to actually access it and do things with these people reach out to these people. And the highest social interaction scores were associated with 30% lower risk of all cause mortality. In another study, it’s not just you know, a lower risk of osteoporosis, but another study showed that people with good social support recovered better when they had a fracture. And so that’s important,
50:35
as well.
50:38
I see some questions are on came up in the chat. I will get those to those at the end of that, okay. Mediterranean diet and fracture so let’s talk about diet. There. Lots of fat there, lots of diets out there, the ketogenic diet, the what is it? Alkalyn acid diet. The only thing that has the the research on it the body of research showing positive effects on bone are the medicine is the Mediterranean style diet repeatedly over and over frankly, it is the most researched dietary pattern that has and I don’t know of any negative clinical, any negative studies. Either epidemiological studies or cohort studies, clinical trials that have shown anything negative about the Mediterranean diet in terms of outcomes. Women with higher adherence to the Mediterranean diet had lower risk of fractures, lagoons, wine, fish, olive oil, all were protective. And this supports previous studies also. Meta Analysis Mediterranean diet is associated with a 21% decrease risk of hip fracture and higher bone mineral density, higher Mediterranean diet adherence also associated with healthier lifestyle and this is what we find in the different domains of health. I call it the four pillars of health. There’s another blog on that on my website, the four pillars of health. Diet is one of those exercises one of those sleep is one of those that as people focus on being healthier in one domain and the research bears this out. As they get success and are feeling better. They tend to also have develops healthier habits in other domains of their life as well. So it’s a great feed forward system. Other studies reported lower, fewer hip fractures with people following the Mediterranean diet. What about vegans and vegetarians? Well, they have those dietary patterns have been associated with higher risks for osteo pyrosis. The speculation is because not all studies were negative most of them are. But the speculation is perhaps the reason why a few of the studies that were positive, compared to the vast majority of studies that were negative, perhaps in those studies was that vegetarians and vegans aren’t getting enough protein. They’re obviously getting enough plants and Whole Foods, but protein seems to be a missing component. And despite even, you know, when I talk to patients, and I’m working with them, and I do a quick dietary recall, and I talk to them about their diet, no matter how adamant they are, that they’re eating enough and they’ve got the healthiest diet in the world and we actually quantify things or look at their diets almost 100% of the time, they are not getting enough protein. And in fact, 50% of people older than 60 years old, are consuming less than this pneus and 75% of the RDA. So many people aren’t even getting the RDA and the RDA for protein which is 0.8 to 1.2 grams per kilogram body weight per day, grams of protein per kilogram body weight per day, we now know is insufficient as people get older for maintaining muscle mass. And when you start losing muscle, you can get sarcopenia you increase the risk for falls. And fractures. So what we want to do is increase the amount of protein or make sure somebody is getting adequate protein. So how much protein is that? Well, the clinical trials the research is suggesting, you know, at least one to two and really you’re looking at 1.2 to 1.5 grams per kilogram body weight per day. In my book fracture proof your bones there is a I walk people through how to calculate what how much protein they need to get for their for their weight. And then there’s protein handouts. There’s a calcium handout. The other thing I have people focus on is fiber because that’s found in Whole Foods handouts in the in the book as well. All of these different topics are discussed in in the book and it helps people go through and helps them create their action plan and helps clinicians understand how they can work better with their patients as well. What about exercise, so 10,000 steps, it’s a myth you only need 7000 is 7500. The research shows that you get a 50 to 70% Decrease in all cause mortality when you’re looking at 7000 to 7500 steps per day. On average and it plateaus at about 7500 steps. There’s a lack of evidence of randomized controlled trials you need about 7000 people. High risk people would be needed to do a randomized clinical trial, but exercise has been associated with reduced risk of fractures by 45%. moderate to vigorous, vigorous physical exercise. How do you know if it’s moderate to vigorous I like to talk test moderate is if you can exercise and have a conversation but you’re you’re a little winded or you are winded but you can still carry on the conversation that’s moderate exercise, vigorous exercises that you’re exercising so much that you can’t carry on a conversation. You just can’t get the airflow to do that. balance exercise muscle strength and you don’t have to go to a gym. There’s things that looked at Chi Gong and Tai Chi. I love the stork exercise actually for balance. I teach people this all the time. I like simple solutions things practical things people can do in their home work into their daily lives. The stork exercise is fantastic. It’s just two minutes twice a day storks they like to stand on on one foot. So I like the imagery. And essentially I’m backing up here so you maybe you can see while somebody’s brushing their teeth in the morning, they stand on one, one leg, you can see my right leg is up and they’re brushing their teeth. They need to study themselves. They could study themselves on the counter a little bit. And then when they go to the top teeth for the second minute, they switch they switch feet, right they switch legs and over time that works. You know that works some of the core muscles than the smaller muscles and it can improve their balance. Now when that becomes easier, you can have them actually switch to their non dominant hand to brush their teeth. And that would also give you know throw they’re a little a little bit of a challenge to their nervous system. So they can get a little more benefits. So I like this exercise and diet consensus that came out of Europe. It’s the only one that I found today that actually incorporates exercise with protein and this is what they’re recommending in terms of protein. I like the upper I don’t like less than 1.2 That’s the minimum for me 1.2 grams per kilogram body weight per day, at least 20 to 25 grams of protein with each main meal. So that’s another way to look at it as well. So let’s talk about nutrients, dietary supplements individual nutrients so the ones at the top. Those are the ones that have been shown to reduce fractures. The ones at the bottom they’ve not been shown to reduce fractures, but a couple of a couple of them like collagen and melatonin do have some emerging compelling research on them. I’m going to jump right to magnesium quickly because that’s a real urban myth. That magnesium, you know is good, you know, reduces fracture risk. It doesn’t. There’s one clinical trials in the 1990s that showed that magnesium as magnesium oxide actually helped improve bone density but it never looked at fractures. There are no studies showing that magnesium reduces fracture risk. And the bulk of the evidence is the opposite in terms of magnesium intake, that actually magnesium intake has been concluded over and over does not reduce fracture risk. Now I love magnesium. It’s an important nutrient and most people don’t do it enough. But specifically we’re talking about bone health. We’re talking about reducing fractures, I believe a targeted approach because that’s what we’re looking at is is better in a good multivitamin or for other reasons having magnesium is important. So calcium and vitamin D. What we’re really looking at calcium, vitamin D may revert reduced fractures by about 10 to 23%. In combination, calcium citrate is one of the more absorbable forms of calcium because it doesn’t require stomach acid. As people get older or if they have autoimmune diseases or obviously if they’re on an acid blocking medication. They have lower stomach acid so their PH is higher in the stomach. And so calcium carbonate can’t get dissolved. It can’t break up disassociate the calcium from the carbonate and so the absorption goes down. Whereas the pH for calcium absorption is the calcium citrate is about 7.5 is higher pH above 6.5. So it’s absorbed in the ileum even when there is low stomach acid.
59:37
So how much vitamin D Do you need? I’m a fan of testing vitamin D and tracking vitamin D. The research shows in terms of an association with fracture risk. Optimal fracture risk reduction is achieved with the mean serum vitamin D of 30 to 44 nanograms per milliliter if you’re looking at immune boosting effects of vitamin D, you’re looking at higher you’ll 50 to 60. I just did a research review for The Natural Medicine Journal. It’s called an abstract and commentary a review of a clinical trial looking at vitamin D in hospitalizations and people diagnosed with COVID 19. And it appears that overall you’re looking at wanting to get that vitamin D level above 50 for the immune stimulating benefits when it comes to infections when it comes to just bone health 30 to 44 nanograms per milliliter is associated with the optimal fracture reduction when you’re looking at fall prevention. Also 30 to 44 nanograms per milliliter. But if you’re looking at bone density and this goes back to the bone density story of how it’s not that great of a surrogate marker, that you get a higher bone density when the the vitamin D is nine to 37.6 nanograms per milliliter. But if your vitamin D is you know 10 Or or or 20 and a clinician saying well that’s great, you’re fine. You’re not actually in that range where it’s protective against fractures and falls because of bone density test. Again is a poor predictor of fractures. The US Preventive Services Task Force recommends against routine vitamin D supplementation to prevent falls in the elderly. I recommend people test for vitamin D and dose and appropriately to get people’s vitamin D into the healthy range. Safety calcium safety has been an issue. There have been quite a few studies that looked at this the consensus at the moment is that calcium supplementation up to 1000 milligrams per day is safe, dietary supplements really should be a supplement to a healthy diet. As the FDA intended not to replace diet routinely doctors are recommending 1000 You know 12 90,000 To 1200 1500 milligrams of calcium acid dietary supplement, and that’s inappropriate because it should take diet into account. The US RDA for calcium for women adult for adults is 1200 to 15 milligrams per day, the average American woman gets about 800 milligrams of calcium per day. So 400 milligrams of calcium as a dietary supplement should be sufficient for most women to get them into that healthy range. And they’re in the position statement of the National Osteoporosis Foundation, which is now the bone health and Osteoporosis Foundation they rebranded the American Society for Preventive Cardiology is that the combination of calcium from the different sources should not exceed 2020 500 milligrams per day that is considered safe for the from a cardiovascular standpoint. And so that’s the position that I’m going with as well also, based on my reading of the clinical trials and the meta analysis. So talking about vitamin K osteocalcin is a common another surrogate marker that’s often tested by clinicians who do functional medicine, all forms of vitamin K there’s vitamin K one and Philo quinoa and found in green leafy vegetables. Vitamin K two is a category of nutrients that includes different sub types of vitamin K to the ones found in dietary supplements are typically MK seven or MK four, all forms of vitamin K will decrease osteocalcin but the question is, have these any of these forms of vitamin K been shown to reduce fractures and first of all, if you’re testing osteocalcin, I would really recommend you think twice about using that blood test. The reason is, there tends to be an oversimplification I think when it comes to many complex diseases, osteoporosis being one of them, and in this case osteo Calcium is a protein. And I mentioned before there are about 200 non collages proteins in bone. And if you’re just testing osteocalcin, boiling it down to just one, one surrogate marker, one protein in bone, you’re missing the bigger picture which is maybe why the osteocalcin as a surrogate marker is really not a great predictor of of fractures, and it has systemic effects. It’s actually now considered a hormone. It increases insulin secretion in the pancreas and beta cell proliferation stimulates adiponectin genes in adipose tissue to enhance insulin sensitivity and bind siliding cells to enhance testosterone synthesis, and inhibits GABA synthesis to help improve learning and memory. paazl SOPAC effect is not supported when you look at the animal studies right? There are no clinical trials that have said okay, we’re just going to change this one marker and with vitamin K and look at fracture down there are clinical trials that use Vitamin K looked at fractures and I’ll talk about that, but they didn’t test osteocalcin at the same time. When you look at clinical trials animals who were bred to be deficient in osteocalcin actually had stronger bones at six months than animals that had normal osteocalcin. A review of osteocalcin cautioned against interpreting it for bone health, that it can be should be considered a marker for vitamin K status. More than a marker for bone health. All right, so let’s look at fractures only the only form of vitamin K that has been approved by any government entity for bone health is mk 445 milligrams a day that since 1995, the Japanese 2011 guidelines state men a Tetra known is the name for MK four is considered to exert its fracture reducing effectively a mechanism action other than increasing bone mineral density. So again, go back to the story of bone mineral density. It’s a more complicated story than just looking at bone density. Alright, so the humans mammals have the enzyme to convert vitamin K one to MK four MK four also accumulates in tissues throughout the body, not just the bones but the testes, the pancreas breasts is used for single lipid production, which actually which points to many other potential beneficial effects of MK for like all nutrients. Magnesium included other nutrients typically have many roles in the body and have other beneficial effects as well. MK seven is not created by humans. It’s created by bacteria. It has a longer half life than MK four, it’s more bioavailable than MK four and therefore people there are studies out there and companies that are promoting MK seven showing it promotes bone mineral density which it does show to help enhance bone mineral density. It has a longer half life and it’s more bioavailable, therefore it’s better than MK four, but they’re missing the most crucial question and unfortunately consumers out there and we need doctors to help interpret this for people. The most important question is Has MK seven or any form of vitamin K ever? been shown in clinical trials to reduce fractures, which is the ultimate indicator of bone strength? The answer to that is only MK four MK seven has never been shown in clinical trials to reduce fractures as the endpoint. In clinical trials with mk 445 milligrams a day, these are the different patient populations that have been tested. People with an interaction of anorexia nervosa, you know osteoporosis caused by these different issues. glucocorticoids I mentioned before disuse from stroke Leuprolide postmenopausal osteoporosis etc. Study and this really fries me because this study I saw it in the North American menopause society and some updated recommendations they came out with. They use this study to say that vitamin K does not reduce fractures. And I’ve seen this recently in another study.
1:08:09
It really upsets me, similar to the the studies on the the efficacy of medications being mischaracterized this study is being mischaracterized because the the the authors of the study even say and this is a quote at the very end bolded the results cannot confirm be confirmatory with regard to the relative effectiveness of different forms of vitamin K regimes. So different vitamin K regimes. What happens is you see it in the literature all the time. They just say it’s vitamin K, I’ve had to actually email researchers and say which form of vitamin K did you use because they’re not the same molecule. And as we all know, in biochemistry, if you change one atom, you can get different effects. Sure, it’s a Venn diagram. There’s overlapping effects, but they’re not all the same. In fact, MK four is the only form of vitamin K. That’s been shown to have anti cancer benefits. One of four of the of the orphan drug designations that I’ve received from the FDA are for the use of MK four for the potential treatment of acute myeloid leukemia, myelodysplastic syndrome, hepatocellular, carcinoma, and promyelocytic leukemia, all based on published clinical trials, up to Phase clinical trials, phase two clinical trials, and in the case of promyelocytic leukemia based on a case report. So that’s all in the public you know, public domain out there. MK seven, Vitamin K one hadn’t been shown to have any anti cancer effects and let me just state for the record. These are dietary supplements. They’re not approved by the FDA to diagnose, treat, prevent or cure any disease, but they can promote health and the clinical trials show it very convincingly with respect to vitamin K. Though, if you look at the different forms of vitamin K and the meta analyses on it, the the picture becomes clearer. So dietary vitamin K one, what we see is that there’s an inverse association with intake and the risk of fractures from diet. Right. So and for each increase of 50 micrograms a day of vitamin K one from the diet, you get a 3% reduced rate of fracture, but there aren’t any clinical trials of diet vitamin K one as a dietary supplement with fractures as the outcome. Here’s a first meta analysis of MK four now I can’t present to you any meta analyses of MK seven for fractures because there are no studies that have had fractures as the primary outcome. Now to be to be fair, yes, perhaps MK seven, may reduce fractures, but the data aren’t there. And so from my point of view, making clinical decisions, if there are data showing, especially for multiple clinical trials over many years and different populations, showing the clinical benefit that I’m going for, that’s what I’m going to recommend and in fact, that’s why I created my my products osteo K and osteo K minis, because the clinical dose of mk 445 milligrams per day didn’t exist in a dietary supplement. And so I created it and combine it with vitamin D and calcium. The only difference between the two products is the amount of calcium. The Ostia came in. He says 400 milligrams of calcium per day. The osteo K has 1000 milligrams of calcium per day, depending on how much calcium somebody needs as a dietary supplement. Both products provide 2000 I use a vitamin d3 and 45 milligrams per day of MK four. I’m so convinced by the data on the MK four there recently and 16 years of working with this nutrient in these products. The product came on the market and almost 16 years 2007 that we recently rolled out a guarantee called the strong bones guarantee that if not only we will guarantee that somebody’s bone density will stabilize or improve within six months of taking either of the products. But if they break a bone, we guarantee that it will maintain bone strength and the best indicator of bone strength is breaking a bone. So if they break a bone while taking the product, we will refund their money for all qualifying purchases between their bone density tests. I have to keep having bone density tests I do think despite the limitations that’s an important test to continue to do. Man MK for meta analysis MK four minute here’s the first one 2006 showed reduction. So there are two studies after this was published that were retracted. But fortunately, the researchers already did a an analysis of a subset of the data that excluded those studies. So that’s already in the original 2006 publication table three, and I believe it’s table three. And even with those studies excluded you still had a 60% reduction in vertebral fracture risk and a 76% reduction in all non vertebral fractures. A 2015 meta analysis was seven studies reporting fractures all use 45 milligrams per day of MK four. You’re talking about a 53% reduction in fracture incidence for people taking MK four. And so I’ll just look look at leave that for for now from that safety. There’s no taller upper limit set for vitamin K. A human coagulation studies go up to 135 milligrams per day of MK four should no significant increase in pathological coagulation risks and rats talking about 250 milligrams per day. kilogram per kilogram body weight did not alter any risk for blood clots. One caution with MK seven if you do end up using it. People with celiac or gluten intolerance are at elevated risk for soy allergies. And MK seven is derived from soy. I’m not going to I’m not going to go into here’s all the strontium stuff but I already talked about the risk of strontium. The second bullet here summarizes a quote from the study. Basically the number of fractures prevented from by Strontium is similar to the number of extra cases of venous thromboembolism, pulmonary embolism and MI caused by strontium. And here are the clinical trials on Strontium Ranelate. It repeatedly showed an improvement in the risk for vertebral fractures, but most studies actually did not show any reduced risk in in hip fractures except for this one, the first bullet point there at the top and the second bullet point are the only the second bullet point. So only one of those six trials showed a reduction in hip fracture risk. Let’s talk about collagen as a dietary supplement. 90% of collagen and bone is type one collagen. The rat study showed that femoral fractures healed significantly faster when they were fed hydrolyzed collagen similarly, fractures experimentally induced fractures in animals did heal faster when MK four was actually given to them as well and another animal study collagen and CT X have you test CT X collagen has been shown to live reduce CTS. CTS is a breakdown product of specifically of collagen. It is associated with an increased risk for fractures. In this study when it was combined with both a low hip bone mineral density, you had an increased prediction of relative risk for fractures as well. When Astra dial was was was low, you also had an increased risk relative to begin with just the highest quartile of C TX so there was a clinical trial again at college and it decreases GX by about 11.4% and the International Osteoporosis Foundation, the International Federation of clinical chemistry and Laboratory Medicine do recommend serum CTS as a reference marker for use in fracture risk prediction and for treating for osteoporosis treatment monitoring. A benefit of that is that these these bone turnover markers can be can be tested more frequently than a bone density test so it can be useful for monitoring response for treatment or continuing these conversations with with patients. Magnesium, I mentioned magnesium before so I’m not going to belabor the point you know significantly lower concentration of serum magnesium and osteo product women compared with controls. Bottom line hypo magnesium hypomagnesaemia is associated with lower bone mineral density. But in terms of fracture risk, prospective cohort study there was no evidence of association dietary magnesium intake with risk of any fractures. And that was in two studies. The Women’s Health Initiative data as well. And there are no prospective clinical controlled trials that have shown magnesium reduce of fractures. Melatonin there’s an intriguing study recently with melatonin showing this is in women with osteopenia
1:17:21
showed that it actually improved in a dose dependent manner of bone density. So there is no no clinical trial showing fracture as a as an endpoint. But it did improve bone density. Boron, no studies, no clinical trials supporting boron at all in the dietary supplement for for osteoporosis or for for bone health. There are no studies showing that improves bone mineral density decreases bone loss or decreases fractures. So I asked the flavonoids the same there’s some observational studies and clinical trials have not shown any consistent evidence that soy isoflavones build stronger bones. And here’s my conclusion, keep it simple. focus exclusively on for on reducing fractures. That’s the most important question. And it really is not more more complicated than that. Don’t ever overemphasize the usefulness of testing don’t rely just on the surrogate markers, maximize diet and lifestyle and for dietary supplements. Again, keep it simple. My first line is osteo K or osteo K minis. And then the second line would be the collagen peptides, melatonin or my sleep relief product if they if indicated because they’re they’re having problems sleeping as well as other lifestyle factors trying to identify other ways you can help them with sleep. There’s a blog that has a checklist for sleep on my website. I also go into it in detail in my book, and then dealing with stress and all the other factors that I that I mentioned. Third line you know everything else based on client need and patient need and clinical indicators. That’s the end.
Bill Clearfield 1:19:00
Wow, great. Thank you so much, Dr. noose that it was that was fabulous. So I love these talks because you know, I learned so much. A lot of my education came from at least in these this area came from a four m and a four m was really high on CTS testing for osteoporosis and strontium for you know, as sort of a first line remedy. That’s what I was taught. And and that’s sort of what we’ve been we’ve been going by so that’s why you know, these these webinars are really invaluable and you know, I know Dr. Hill losses on now he He’s still at a four Emory. He just came back from there. And
1:19:45
I started years ago at a 4am and osteoporosis. I would love to speak there again, as an update. It’s been I think over a decade. I would love to get an update on the research. Yeah, we’re strontium. One other thing that’s important to know if people are using it, because it incorporates into bone and it’s heavier than calcium. Strontium also gives false bone density test results. So that’s important to know that yes, it improves bone density but the test result you’re gonna get is is not is not accurate.
Bill Clearfield 1:20:13
Um, so So um, everybody knows, you know, who knows me here knows on the hormone guy. So other than estrogen, any hormone balancing or replacement that you recommend that for bone density or reducing fractures?
1:20:29
So that is a great question. And I’m going to punt on that because I am not an expert in that field. And I haven’t looked closely enough at the at the research on that. I do. You know, I think there’s there are strong cases for getting a hormones and keeping hormones in the physiological range. But in terms of of looking at fracture risk and bone density, I’ve got a punt on that question for a little later so I can finish
Bill Clearfield 1:21:03
just one comment on boron. Now. You know, we’ll respect the the data that you showed us however, we’re on reduces sex hormone binding globulin which will increase testosterone and testosterone that I know in my research will increase bone density by up to five to 7% in certain instances, so. So that may be an indirect effect, not a direct effect.
1:21:33
So and I think that that’s a great ad. But if you’re just looking at osteoporosis, if you’re looking at look at maximizing hormone replacement therapy, then that is, you know, could be an indication for it. The question I would have is, has testosterone been shown to reduce fractures, and boron should be in a good multivitamin. Anyway, in my opinion,
Bill Clearfield 1:21:54
okay. five milligrams is the dose by the way. Good to know. And again, we use it for to lower sex hormone binding globulin, if it’s very high and they’re free androgen index is is low. That’s what that’s that’s so So I call it an indirect effect. So there’s a couple of questions in the in the in the chat. And this first one is what is your opinion of and I never heard of that CEUs Quadra Lang Maris leaf for severe osteoporosis. I’ve
1:22:28
never heard of it. I mean, I would ask the question Is there are there clinical trials showing that it reduces fractures,
Bill Clearfield 1:22:34
right. Okay. Well, that’s the question of the night of course, and again, I haven’t heard of that either. So, okay, so, Dr. Fishbein, if you’re on still you could chime in here maybe.
1:22:49
I will, when you’re looking at the research and you’re talking about, you know, 76% fracture reduction, just from the MK four, you know, vitamin D and calcium. And then you’ve got all the other lifestyle and all these other things I that’s where clinically you know, I put you know, everybody’s gonna make their own clinical decisions but that’s really where I you know,
Bill Clearfield 1:23:10
we get but as you know, I’m sure you know, too We all have our own you know, sort of favorites or things that we’ve been we’ve been steered toward and like I said the you know, strontium was what what the, what I you know what we were taught at a four m, and he pretty much was blown that out of the water. So, I want to thank you for that actually. And another question here. And we’ve we’ve had a lot of discussion on photodynamic therapy, red light therapy, and any use for that in osteoporosis.
1:23:43
I don’t know of any studies on osteoporosis with
1:23:47
Okay, light therapy.
1:23:48
Okay, well, well, I think I think doctor, as doctor I’m so how are you? Dr. Bill? Yeah, great. I’m in Vegas here. Can you hear me guys? Yes, I’m still in Vegas. Yeah. So anyway, I’m in the sound I hear they have something’s called ranch. And they have a nice bar. And this is my first time although I’m being in Vegas for innovation every year, I think. But yeah, I always want to talk about osteoporosis and I’m a little bit leaning to oxytocin. And think that’s the trend. And there is more than couples of publication that sort of show the connection or the treatment of oxytocin for bone density. But we need to clinical, more clinical data, not just the publication’s so injecting two international units around the umbilical per day, passive intranasal oxytocin altogether and see how that will affect their bone density. That will be something new. There’s published but we can get more clinical from you guys that will be great.
1:25:03
Great information thank you.
Bill Clearfield 1:25:04
We can put put your society on it Dr. Lawson. Dr. Horvitz is the supplementing with five HTP which increases serotonin increase the risk of bone loss.
1:25:19
So there are no studies that I know of that have shown any association with five HTP and bone loss if somebody is concerned about that. You can supplement with L tryptophan instead because the rate limiting step is that conversion. The from L tryptophan to its downstream products, but I haven’t seen any any studies showing any problem with bone loss and five HTP supplementation.
Bill Clearfield 1:25:51
Okay, good. Another question a little bit. So baking soda that promotes osteoporosis like the PPIs.
1:26:00
I have never seen any research showing that that’s the case.
Bill Clearfield 1:26:03
Okay. Anything on things like zinc carnosine or declutter, nated licorice any any information on either of those because those are the other things we’ll use for reflux.
1:26:14
Oh, I think the gel is great for reflux. Yeah, DGL is great. Besides just besides just you know, dietary changes, you know, marshmallow is great, the verb for soothing you know, you get some Malian sort of actions in the in the mucosa in the esophagus for kind of soothing, soothing the tissue. But yes, DGL is great
Bill Clearfield 1:26:41
and of course, we have our jolly Joker here should we didn’t the video on during the lecture to prevent bone losses. It’s dark on the east coast.
1:26:51
So to be fair with the study, they read for four hours, so you know it’s dose dependent, depletion of melatonin I don’t know.
Bill Clearfield 1:27:02
Don’t know either. This is either a question or a statement. I’m not sure IV vitamin C helpful.
1:27:12
For osteoporosis, I’ve never seen any any data one way or the other.
Bill Clearfield 1:27:18
Or is asked osteo Coulson and TLO peptide reliable blood tests.
1:27:25
So CTS in urine or blood is is is reliable. They do have an osteocalcin all of them the have what the bone turnover markers of dire diurnal variations. They see ATX tends to peak in the morning. I believe the osteo calcium is well although not certain on the Tyent time of day. The most important thing though, is to just the test at the same time repeatedly what the recommendations first morning is best, but even better is just to make sure you’re repeating the test at the same time. The other test I didn’t mention is the neutrophil to lymphocyte ratio. There’s a good pre strong association between an elevated neutrophil to lymphocyte ratio and one study and osteopenia and osteoporosis. So that’s another BOC B C’s are common their standard so you can just easily calculate that.
Bill Clearfield 1:28:22
I believe how big a ratio
1:28:25
that neutral lymphocyte ratio associate with osteoporosis was above I think it was 3.17 and for osteopenia was in the twos. I could pull that up.
Bill Clearfield 1:28:36
Because I mean that’s usually indicative of some sort of, you know, inflammation. Yeah, inflammation.
1:28:42
Yeah, I think that that that’s reflected to you can six when you have nitro failure and the shift to neutrophilia is mean there is interleukin six. So which means that there is any study that shows us to process and interleukin six relationship.
1:28:58
I have not looked at that question. So I don’t know.
Bill Clearfield 1:29:03
Do you believe in increasing muscle mass in adults also increases bone health? So
1:29:10
I don’t know of a study that looked at muscle mass and bone health, you know, and by bone health, they’d probably be looking at in the studies they probably would have looked at bone density. What we do know is is weightlifting exercises resistance training has is associated with improving bone mineral density. But they didn’t I don’t know of any studies that also looked at the muscle mass as one of the variables it was evaluated what we do know though is that
1:29:43
you know, that
1:29:46
anything you can do to increase your muscle, it can increase strength and balance, reduce falls and reduce those risks.
Bill Clearfield 1:29:54
Okay, um, what a carnivore diet of whole natural foods be of any assistance currently increasing increasing protein I suppose, right? What a more
1:30:08
current so the state the research seems to support an omnivore diet so getting adequate protein while really having a what would be considered a more plant forward diet, making sure that you’re eating enough, enough Whole Foods, but also getting enough protein. When you’re talking about whole foods like the Paleolithic diet, our ancestors ate about 150 grams of fiber a day. In our society today we’re maybe getting 15 or 20 grams on average a day. So um, you know, I try and tell people just get up to 30 get to 30 grams a day from Whole Foods that’s going to have the plant the plant vitamins and minerals and other phytonutrients to help and it’s that it’s the it’s the overall dietary pattern and again, that Mediterranean style diet, which is more of a plant forward type diet, with lean proteins with lagoons and whole grains that has been consistently associated with better health outcomes.
Bill Clearfield 1:31:08
Okay. All right, rhetorical question here. Can we truly rely on government recommendations for these nutrients? Truly,
1:31:19
I think we can truly take them with a grain of salt and all try and pat ourselves you
Bill Clearfield 1:31:26
know, I got an open it did oh here Okay, so the next one was mine. Dr. Hartman says mk 677, which is growth hormones and oral form of HGH. It’s a peptide it’s a precursor. It’s a precursor of growth hormone.
1:31:50
I I’ve never heard of that. You know, I I’ve not used it. I’ve not looked at the research on it. We actually process I would love to do we
Bill Clearfield 1:31:57
actually use it quite a bit. Anyone in the group is a pediatric rheumatologist. There was a question. Have you heard of osteo strong and or studies that show them and also their use of red light? I think osteo strong as some sort of vibrate, vibratory type of sort of passive exercise I’m not sure
1:32:24
is that the one that has the vibrant for the vibrational plates? It’s yeah, I think that’s what brick and mortar business where they. I have we have one actually not far from me. I’m in San Diego and I went in, it’s a franchise model. I talked with the owner. I asked to see the studies they have some studies on vibrational plates and bone density, but no studies looking at fractures now. Like maybe it works. I’m all for anything where you know the dolphins have increasing balance and some strength so I don’t think it’s a bad recommendation. I can only you know, again, I can only say what the research is, is showing and a doc something and it’s about meeting people, I think where they’re at and if that’s if they want to go into a place and they want to do vibrational plates and they want to do things too. And that’s where their interest is. I’m all for it. It’s
1:33:17
so Joel. I don’t I did it for a little while. They have bio residents. They have a vibrational massage table. They have p e m f mats and then they have cuffs with air that squeezes the extremities, and then they use for different machines where you use anywhere from 10 to 20 seconds of the most amount of strength. You can push Paul, lift and do legs. And supposedly Tony Robbins has gotten involved with them. He has shown and they’re showing some great results on top of the vibration plus the strings so their most of their people are women.
1:34:08
Yeah, I think that’s sounds fantastic.
1:34:10
I mean, it’s something to look into.
Bill Clearfield 1:34:13
Yeah, I think one of the issues though, it’s kind of expensive, isn’t it?
1:34:17
Yeah, I was as a veteran, I was paying 200 a month, and that included a full and actually I’ll be honest, I want to go back. It included a full infrared light plate. That was almost five and a half, six feet tall. And I felt great. When I was going through it. It was actually amazing to be honest. That’s great.
Bill Clearfield 1:34:38
So this now we’re on the other side of question is what heals fractures. A friend sent his mother for hyperbaric oxygen therapy
1:34:47
I’m not familiar on the on the data on hyperbaric oxygen. I do know that MK four and collagen have both been shown in animal studies to heal fractures. There may be other things out there, I’m just not aware of like it’s a huge topic and there as you guys are bringing other ideas to the to the table here. I mean, there’s so much to look at, I don’t
Bill Clearfield 1:35:10
know. You know, we have you know, you know, our group is you know, we have medical doctors, we have physical therapists, we have a naturopaths we have chiropractors, you know we we have a little bit little smattering of everything. So, so everybody has their own, you know, sort of little little likes and vitamins and things like that. So, so early early on in the late 90s and early 2000s. I was in a big insurance based medical group. Before I saw the light, and we were one at one of the things we were we were graded on was did we did we prescribe enough bisphosphonates? You know, you know, per per per 100 patient, you know, visits when that was one of the things that I remember you know, they would they would have to drink a whole glass of water and sit up for 30 minutes I think once a week for the for the Fosamax ones and then Boniva. Can’t wasn’t Sally Fields was was selling Boniva, I think which was a one month one and then now you don’t hear I don’t hear too much about them. So. So are you are you still recommending them at all or, you know, view of DCC clinical patients,
1:36:36
so I only do pro bono consulting now I’m not in a clinic all people contact me and doctors around the country and patients and I’ll review labs and I’ll, I’ll send people back to their doctors say you know, ask this question, have you thought about this? I will give lifestyle dietary supplement recommendations. I’ll say you know, try it, you know, you shouldn’t have this test, you know, test X, Y or Z you’re missing asked for that. But when it comes to prescribing medications, I don’t prescribe the medications even if I were, you know, seeing patients right now, because that’s just not the I frankly, I don’t want to be managing medications would be really the reason if somebody had secondary osteo, you know, if they had already had a fracture, and we’re looking at secondary prevention, that there is an argument to be made for the medications. I believe it’s a it’s a real question about informed consent. And that’s where I think our colleagues and our profession as a whole does a very poor job of really explaining the potential risks and side effects and giving people enough information so that they can make an informed decision. And one of the things I go to great lengths at in my book is educating patients have what questions to ask their doctor so they can get the information so they can make the best decision for themselves. So my position is more trying to educate patients, and it’s their decision whether or not they want to take the medication.
Bill Clearfield 1:38:03
Okay, well, great. Okay, so again, and sometimes we don’t know right away, you know, when those bisphosphonates came out, you know that they were all the rage. And then 10 years later, we get this information that you know, there’s people complaining that their teeth are falling out, and it actually caused what osteoporosis or osteo Malaysia of the of the jaw or something,
1:38:24
Austin Yeah, so let’s go to that bone. So actually, I wrote an article on on bisphosphonate related osteonecrosis of the jaw for a dental medical journal. And the thinking what happens with bisphosphonates? At least in vitro, is it creates reduces collagen production and reduce the connective tissue production. It also what happens because there’s so much pressure in the jaw and the chewing, you end up with micro cracks, micro fractures in the jaw that then don’t heal and it creates a space when the barrier the mucosa is broken when a tooth extraction happens for an infection then to invade the jaw. And then you already have a situation where the healthy bone remodeling has been poisoned, and so the bone can’t repair itself and the infection is already in the bone. And it just starts to dissolve the bone.
Bill Clearfield 1:39:21
Okay, great. Okay. Anybody else have any comments or questions? We always like a quick summary before we let you go for the rest of your day.
1:39:34
Well, thank you. So, the summary I would say is, is keep it simple. I think I would go back to this last slide, that there are lots of things you can do and they may be great clinical strategies and absolutely appropriate the hormone replacement, the boron to lower SHP G, you know, all of those things may be fantastic. For from my point of view, I think it’s important though, to ask the question, Has this been shown to reduce fractures? First and foremost, just so you know, we have you know, has what you’re recommending, actually been shown to have the clinical outcome that you want. If it’s, it’s changing the number on a test a surrogate marker, I think we can all do better, because that doesn’t necessarily translate into lower fractures. So there is a place for changing surrogate markers Absolutely, as part of potentially an overall approach, but at least from my point of view, the first line therapy should absolutely be recommendations and shown in clinical trials to reduce fractures. Okay,
Bill Clearfield 1:40:45
terrific. Thank you so much for your time. This was truly fascinating. Please come back another time. Thank you. I’d love Sure I’m sure. We’re going to have lots of lots of questions in the future. Anybody who’s new, we we will put the video and we have Dr. gnustats slides. On our website. We always do a transcript also, it’s on aos or d.org/webinars. We’ve been here for over two years doing this and we’re, you know, sort of just getting started. Anybody who wants to present anything, please let me know I have endless Tuesdays to fill up. And we’re always always looking for folks like Dr. New stat who I’m not even sure how I got your name. I got it from somebody. And you know just absolutely fabulous. And again, if you Dr. alasa. You’re at a forum. You know lecture with like Dr. gnustats. You’d pay a lot of money to go sit and listen to this. And you know, we get them here. We get them here for we just twist her arm and that’s all I’m trying to be nice to where I can so the iced tea, okay. And iced tea Okay. minis All right, what what makes them unique versus, you know, just going over to, you know,
1:42:13
Walmart So Walmart, you won’t find the MK four in the clinical dose. You definitely won’t find it at all. You won’t find it with calcium and vitamin D. So it is a bone support product that has it’s basically all in one. Now multivitamin on the side further says you know, supportive nutrients may be a great choice as well, but we’re talking about just for reducing, maintaining strong bones as indicated by reducing fractures and has the nutrients in there shown to reduce fractures by more than 70% in those products and that’s all that somebody needs that the research has shown gets those results
Bill Clearfield 1:42:52
we can get it at NBI health.com
1:42:55
mbi health.com, also distributed through Emerson eco logics and fullscript and Dr. Supplements store. And yes, mbi health.com as well.
Bill Clearfield 1:43:06
What is LD counseling and what is the osteo K mini what is that?
1:43:11
osteo K minis is just a variation of the of the product that has less calcium. Let me go back up here and show the bottles. So the osteo K, both osteo K and osteo K minis provide 45 milligrams per day of MK four and we only use 98% Pure MK four by the way, if you look at the raw materials world of dietary supplements, there are two types of MK four that are available 1% MK four and 98%. So the 1% means it’s cut with other stuff. So we only use 98% Pure and it’s really they can’t say that it’s 100% it just you know that’s that’s the limit that they’re able to say, but it’s pure mk 445 milligrams a day. And then 2000 I use a vitamin d3 and the osteo K has 1000 milligrams of calcium as calcium citrate per day. And the osteo K has 400 milligrams as calcium of calcium as calcium citrate per day because there’s less calcium in the osteo K minis. The capsules are smaller thus minis as the word minis and there are fewer of them. So the osteo K, the recommendation is three capsules twice a day with meals and the osteo came in is to smaller capsules per day. Twice a day to smaller capsules twice a day with meals.
Bill Clearfield 1:44:32
What What’s the cost on these
1:44:36
3887 wholesale 6495 retail but I do think we inflation I’d say about Costco up I think after the first of the year we’re going to increase I think by $1.
Bill Clearfield 1:44:49
And you do have like a wholesale accounts.
1:44:53
Yes, we have wholesale accounts and quantity discounts so 10% off if you order 12 bottles of any combination of MBI products not just Asti okay you get automatically get 12 10% off and then 36 bottles or more of any combination of products, you automatically get 15% off and then we do run sales at different times of the year that are eligible for wholesale accounts as well for another 10% off
Bill Clearfield 1:45:23
topic. Give us a heads up on the sales we will we will let our folks know.
1:45:28
Oh thank you and sign up for our newsletter because we announced the sales in there but I will I will let you know as well. We also have if people do have affiliate programs on their websites, we do have an affiliate program as well.
Bill Clearfield 1:45:38
Great. Again, I can’t thank you enough. This was really truly fascinating. And like I said it’s a topic that I don’t really spend a whole lot of time on but I see I should and I hope everybody you know it’s still here is as equally as you know has equally you know, newly informed. Next week we have Dr. John Swartz. He does the bio Photo Scanner. It’s one of these things where you put your hand on some light thing and it tells you what’s wrong with you. I think I mean that’s my understanding of it. So he’ll explain it. So I’m not sure how that works, but he’ll explain it. Everybody have a you know, whatever holiday season is that you’re, you know that that’s that’s in your heart or in your family. Please have a safe and happy holiday season. Thank you for being here. Thank you for your support. You don’t know this, Dr. nustep But we’ve had quite an upheaval this year. The AOA has decided that we were not worthy of them and they decertified us so we’re in a battle but we’re still here. And the at the end of eighth at the end of June the end of January January 22 to the 26th they think the Nevada osteopathic medical association is having their winter conference in Lake Tahoe and we’ve been asked to present do some presentations so if anybody is in the area or wants to come to the area wants to go skiing that let me know. And we we have about eight hours that have been reserved for us that we can we can present and the CME credits will go through and no muss and so we’re not allowed to give them anymore for videos anyway. So anybody who’s interested in that, let me know and we’ll get you get your on there on our on a schedule. Other than that, we will let you know about future events. Anybody that has any questions, comments, anybody who has anything that they’d like to present, as as you can see, we’re non CME. So we’re able to do the brand names. We can talk about your products without the CME restrictions. So you know, it’s a double edged sword, no credits, but we get to find out about things like osteo K meanings, so
1:48:17
and other may have other NBI products as well
Bill Clearfield 1:48:19
that are available. All right, so it’s NBI
1:48:22
health.com in the eye health.com.
Bill Clearfield 1:48:24
And I’ll mark that in the chat in the eye. health.com Dr. nustep I can’t thank you enough and you sent me your book in its sights. I read it from cover to cover in two nights. It’s wonderful. And I haven’t I have it on my desk. Because I I realized that this is an area that I’ve sort of been remiss in and joke there right under you can can vouch for it he was he’s
1:48:53
available wholesale through my website as well. They’re their clinics that are starting to carry them and sell them to their patients and
1:48:59
find a doc. Dr. nustep. I’m on your site right now. And for some reason the newsletter links not working. I just thought I’d let you know really Yeah. At least it’s not on an iPhone. Try it on the iPad. Oh, it should. Sorry about that.
Bill Clearfield 1:49:21
We were having we’ve had all sorts of defective things here. This is the I think second or third week in a row. We’ve had trouble just starting the Zoom call and right like so. So again, everybody then we were a little bit late because I was having trouble getting the Zoom call together. And thanks for thanks for sticking with us. So we’ll have a
1:49:43
if I may, if anybody is having a problem signing up for the excuse me the the sorry, if anybody’s having a problems Yeah, signing up for the newsletter here. It isn’t showing up here on my laptop. Just let me know. And shoot me an email and I’ll make sure you get on there but there shouldn’t be a pop up that yeah,
1:50:07
it worked. It worked great on the iPad, but not the iPhone. Got it.
1:50:13
Yeah. Okay. So iPad and desktop should work just fine. Thank you for that. I’ll let my team now and I’ll chat test it out. We’ll test it out.
Bill Clearfield 1:50:23
Anybody else have anything? John, you got anything for us? You always have words of wisdom before we leave.
1:50:28
Yeah, just words of praise for a nice show tonight. Thank you very much. Thank you so much.
Bill Clearfield 1:50:35
Okay, all right, everybody have a lovely holiday season. We’ll see you again next week. Same time, same station. And like I always say bring one friend and we will double our census. Everybody brings one friend. Okay. Okay. Thank you so much, Doctor. Use that again. Will will, will, we will we will badger you to come back? You can you can bet on it.
1:51:03
Thank you. I would I would love to and
Bill Clearfield 1:51:04
we are here every Tuesday night if you’re, you know interested in any of the other topics that we deal with, which is pretty much anything integrative. Yes, sir.
1:51:15
Dr. Clearfield actually since I’m jarhead I’m kinda curious what Dr. Hartman keeps wheeling along there and he’s sewing looks like apparatus just saying. Yeah, this is a string machine that strings tennis rackets. I should have guessed. I should have guessed ay ay.
Bill Clearfield 1:51:37
Ay ay ay. I was seeing a 50 caliber who want to see. Alrighty. Okay, everybody, you know, it’s almost 10 o’clock 10 o’clock on the east coast. So you guys, have a good night. And again next week, same time, same station, we will see you that there’s news that again, thank you so much.
1:51:59
Thank you for the opportunity to share. Thank you. Thanks. Good night, everybody. And I