Dr. Celina de Borja presents "Optimizing Bone Health in Young Athletes" at the UCSF Pediatric Musculoskeletal and Sports Medicine Conference 2023 in Berkeley, CA.
OK. So it is my absolute pleasure to introduce Doctor Selena Deora, who's our conference chair and put in all this hard work to create this experience for, for us all. And she's gonna be talking today on the topic of optimizing bone health and young athletes. Uh Doctor Debora, she's a pediatrician with sports medicine fellowship training and she cares for Children and young adults of a wide variety of MS K conditions. A lot of which we talked about today. She completed her pediatric residency at Hackensack Meridian Health at Jersey Shore and then completed fellowship in primary care sports medicine at Boston Children's Hospital. Um She at U C F at U CS F here. She's really active uh with the play safe and run safe um coverage programs uh which serves a variety of sporting uh events in the Bay Area. And she has particular interest in dance and performance medicine and, and also uh serves it as a team physician for the S F ballet. So with that, we wanna welcome you, Doctor Devora. Uh Thank you Rhonda. All right, good afternoon, everyone. Um Thanks uh Rhoda for that introduction. And so as a part of the course planning committee. I got to assign myself a talk and that will be optimizing bone health and young athletes. And that's because it's a topic that really, uh, I find very interesting. Um, and so, um I find it very exciting, um, and it turns a 15 minute fracture visit into 45 minutes, which is great for the patient, but it gets me in trouble because I'm behind uh in the rest of the clinic. So, um well, I don't have any financial disclosures uh related to this uh talk. I just want to reiterate my background is in primary care, pediatrics, um and sports medicine. So both avenues have allowed me to explore this interest in bone health um through working with various specialists in medicine um as well as nutrition and mental health. Um however, I am however not an endocrine specialist uh which limits the scope of this topic. So when things get a little bit complicated, I do myself do phone a friend. And so our two main objectives for today include recognizing conditions that may interfere with adequate bone health. Um and then also to review strategies to optimize bone health in Children and adolescents. So before we begin, you know, what is bone health? Um According to the US, Surgeon General, Bone of Health is a public health issue with an emphasis on prevention and early intervention to promote strong bones and prevent fractures and their consequences. Now, why is that important aren't bones used for movement. Well, not really, not just movement, not just mobility. Um, bones are important because they protect our vital organs. You know, the skull um protects the brain. You know, our rib cage protects our heart and lungs and you know, other uh important organs as well. Um And they're also involved in uh essential uh cell production, say, you know, red blood cells, immune cells, um you know, the bones help with, you know, regulating electrolytes, specifically calcium. Now, when do we need to start talking about bone health? And the answer is now or as soon as you possibly can. Um as you can see on the photo, on the right upper hand corner, you know, Children have this unique risk of for fractures just by one being skeletally immature and two just by their activity levels. And, you know, we've everyone in this room has probably seen a successful and unsuccessful outcome from that photo uh which you know, keeps us busy in practice. Um But most importantly, uh 90% of peak bone mass is actually attained during childhood and adolescence. And so as you can see in the photo, right lower corner, you know, this the process of um collecting calcium into your bone bank um is in this upward slope in your first three decades and then this process becomes slower in your thirties. Then after 40 the skeleton begins to slowly lose more bone than it forms and can lead to osteoporosis. And uh it's funny every time I see this um photo, whether when I'm reviewing a talk or, you know, listening to a talk, it always, you know, makes me think maybe this is where they got the phrase, you know, it all goes downhill after 30. Now, where do we even start? Um Who remembers this diagram from like physiology? One oh one. Um This diagram has always intimidated me since, you know, my early days of of medical training. Um it's calcium homeostasis. Um There's a lot of enzymes, there's arrows that point up, there's arrows that point down, but I like to keep it simple as Carly said, um there's three organ systems and there's three hormones. Ok, ready. So three organ systems include the bones, the gut and the kidneys, right? And uh these three organ systems are controlled by the three hormones that regulate calcium. And the three hormones include parathyroid hormone or P T H and P T H's goal goal is to keep uh calcium in the serum. So most of our calcium is stored in the bone bones and the rest is in the bloodstream. And P T H's goal is keep it in the serum. So when P T H acts up, it takes calcium from the bones. And then secondly, it also increases reabsorption of calcium from the kidneys as well as absorption from the gut. Now, absorption from the gut uh happens through vitamin D, which is our second hormone, uh vitamin D uh is essential for uh absorbing calcium from our diet without vitamin D. We're just flushing out all the calcium that we're getting from all that dairy or nondairy uh uh products. And then lastly, calcitonin, calcitonin works opposite of P T H. So, Calcitonin likes to keep calcium in the bones through reverse mechanisms. Simple right now, who needs to have this conversation about bone health with our uh Children and and athletes. And the answer is all of us, everyone in this room, you know, you could be a clinician or you can be someone who works in in the sports industry. So you can work in primary care, you can work in a subspecialty like orthopedics or rehab. Um You could be a physical occupational therapist, athletic trainer, mental health or nutrition. Everyone needs to stay involved in the conversation regarding bone health because certain risk factors may be more obvious in certain clinical settings, which brings me to my first objective, which is recognizing conditions that may interfere with adequate bone health. Uh We'll start with intrinsic risk factors. And as Doctor Watkins mentioned earlier, these are factors that we can't really do much about, but they're very important so that we can identify, you know, who may be at risk. So with age I mentioned earlier, adolescents is a period of rapid growth. So you know, there may be impairments in bone marrow density. Um as well as an elderly uh uh individuals. Um gender also plays a role as we heard from Doctor Watkins talk a while ago, uh women are more at risk for bone stress injuries, um or other overuse injuries such as compared to men. And then genetics. Um while we see these uh uh bone health impairments um in a wide variety of race or ethnicity, we somehow uh see it most commonly amongst white and Asian women, especially when there's a family history of osteoporosis. Now, for those who work in primary care, who know our patients best, um think about bone health and those with certain medical factors. So, uh first there's G I or fat malabsorption. So in kids with inflammatory bowel disease, celiac or cystic fibrosis, you know, always want to think about their bone health. Um A lot of times G I disease such as I B D or celiac is not um early diagnosed in the kids because they're, you know, very not specific symptoms. So usually I ask them if they have, you know, uh sensitive stomachs, if there's food groups that they tend to avoid because it makes their stomach upset, you know, if they can take dairy well or or not, you know, things like that, that may lead you to maybe investigate further towards A G I problem. Uh Next is, you know, any kid with a chronic disease. So whether it's liver disease, kidney disease, because we know that our hormones, especially, you know, uh calcium and vitamin D are all metabolized through the uh the liver and the kidney, um childhood cancers or chronic disease. Um, as we learned from Doctor Lawson yesterday, um our rheumatologic patients or those with um inflammation, um could also have low vitamin D and so she screens them for vitamin D and then obviously endocrine conditions. Uh next uh would be medication exposure. So, steroids are a big one that we uh consider uh for impaired bone health. Um A lot of times you think about steroids in those with rheumatologic or inflammatory conditions, right? Uh But don't forget the respiratory kids. So, uh when I was um in, you know, primary care, pediatric training, I was training in the east coast. Um and we had very harsh fall and winter seasons. Um and when those seasons hit, you know, it was very hard on our respirator to kids. They would get these respiratory flare ups. And, you know, at some point, I felt like I was on like a, a reality reality show. It was like you get steroids, you get steroids, you get steroids and no one really pays attention to these things. Um Because, you know, when you, when you look at them, you know, we spent three years with the family, for example, in, in medical training, you know, you realize they've had a steroid burst maybe two or three times in that winter, you know, for the past three years and that could have, you know, affected their overall bone health. Um I was also trained in pediatric primary care to give um uh inhaled steroids for asthma control. Right. We, we wanna avoid these steroid bursts um for asthma exacerbation by inhaled uh steroids. However, I did meet a patient in my clinic for multiple fractures who's had some, you know, endocrine abnormality like growth hormone um uh uh disorder. Um and when they, she was seeing a specialist and when they did her overall eval, she was saying that it was secondary to her inhaled steroids. So even though, and, and that was very surprising to me as well because I was taught to just give inhaled steroids to everyone um for control. Um but, you know, it really was such an eye opener um to, to be very, um you know, prudent about these, these medications and, you know, just because they say, you know, inhaled is, is more benign or less um less toxic than, you know, uh um oral steroids, it, it may not be um for everyone. And so I just wanted to let you know about that. Um and then other um medications that are also implicated in impaired bone health include anti convulsant. So, you know, we do have a lot of um you know, Children maybe with neuromuscular conditions or, you know, have seizures, you know, coexisting, seizures on these medications, um antifungals, antiretrovirals and antidepressants. Um It has something to do with the cytochrome P 4 50 metabolism. Again, we'll keep it simple. So we'll just leave it at that. Um And then last, but not least, you know, mental health or behavioral conditions, um also has something to do with bone health. So, um this isn't the setting of um eating disorders or disordered eating, um or undernutrition. So it's important to think about bone health in that setting as well. Uh for us who work in uh orthopedics, um or maybe rehab medicine, we also consider, you know, bone health uh work up. Um if we're seeing them too often for bone injuries. So if they're becoming a frequent flyer for recurrent fractures, so usually two or more traumatic fractures in childhood, um you know, it makes me think about, you know, doing a, a bone health work up. That's also actually the time that the parents start asking questions like, you know, everyone's taking a spill in the playground. Why am I here all the time? Right? Why am I getting these, these injuries? Um Is there something else? Right? Um Stress fractures. Um there's, you know, low risk and high risk stress fractures. Um But you know, this is a, you know, a condition where we have kind of low threshold to think about bone health, um vertebra compression fracture fractures, especially when they're low energy mechanism. Um that's actually a pretty high risk or a red flag for referral. Um And then for others we're in, you know, they're getting a pretty straightforward injuries, say a clo injury that should heal in about 6 to 8 weeks, but it's just not healing enough, whether clinically or red, you're just not seeing enough callus. Um when you start to think about, you know, bone health uh in that setting. And then um as mentioned um yesterday by our, our colleagues at in Ortho and in rehab, you know, um and also this morning uh by Doctor Davis, you know, uh patients with immobilization um may be at risk for impaired bone health. So think, think about these things uh when you're seeing your C P patients or patients with other neuromuscular conditions and then um lastly, other Ortho associations have been seen between vitamin D or impaired bone health and some Ortho conditions. And so, um for Skiffy or scoliosis, things like that, especially if they're operative. Um we, we tend to evaluate their overall bone health just to be sure. So modifiable factors is, you know, something that we'll spend a lot of time on. Uh because again, this is something we can do something about, right? This is something we can improve. So we'll start with a diet. I always ask about, you know, special diets, restrictive diets. Um And, and you gotta ask very specifically, um you know, whether it's for social or cultural re reasons. So say, you know, they wanna be vegan or vegetarian or, you know what it's because it's for a medical reason, they have to avoid dairy or, you know, have gluten free. Um or if you're, you know, a kid is, you know, maybe, um you know, having a, a behavioral condition say they're on the autism spectrum and they're very picky eaters, right? Um You always want to think about um these specific questions that may lead to inadequate nutrition. Um, studies also show um that individuals who have high protein in the diet are high sodium uh may be associated with reduced calcium retention. And then there is good studies on this um and actually published in the A A P uh showing that uh kids especially who consume soda, they're less likely to take um milk and calcium in their diet. And then lastly, obesity. So we mentioned earlier that vitamin D is essential for absorbing calcium in the gut, right? And vitamin D is a fat soluble vitamin and therefore, vitamin D can sometimes be sequestered into the fat cells um in obese individuals. So, weight management is very important um thereby, you know, these individuals having low vitamin D levels and impaired bone health in addition to diet lifestyle is also an important modifiable uh risk factor. So, as you know, we've heard from uh lecturers. Yes. And today, you know, impact helps, you know, build strong bones. So those who um are sedentary may have impaired bone health. Um We heard from Doctor davis' talk this morning. There is a checklist from the A CS M to evaluate, you know, an individual's physical activity, you know, if they're an athlete, it's important to ask, what kind of sports do you do? Are you a high impact, a athlete, runner, jumping athlete or are you low impact, are you a cyclist, swimmer? Right. Um It is also important to ask about those who are not necessarily an organized sport. So say, do you have pe right. Uh Do you have pe how many minutes in a day? How many times in a week if you don't have pe I'm hearing a lot of, especially the old, older kids don't have pe anymore, right? Um You know, do you have recess, you have opportunities to run and right to say, really, there's none of that they're very inactive. You ask, do you have opportunities when you're like walking home or to school or, you know, taking public transportation or having recreational activities during after hours or on weekends? Really? You want to ask about specific um uh lifestyle factors that you can improve to um optimize their bone health. And then next, um sleep, uh sleep is very important and I believe sleep is important for, for a lot of different reasons. At first when I was reading about sleep and bone health, I was a little bit skeptical like I was like, how does that work? Uh But that article um uh with a photo over there is actually um from a study that was out of University of Buffalo. Um It looked at 11,000 post menopausal women and who, who's had D A scans in their institution, right? So what they found was women um who slept less than five hours each night actually had lower B M V compared to those who slept seven hours each night. And so, you know, the researchers explained that, you know, the body undergoes an array of healthy processes during sleep, including bone remodeling, uh during which old tissue is removed and new bone is formed. And so what they're suspecting is that if you're sleeping less, then maybe bone remodeling isn't happening properly. It's science gotta sleep. All right. And then last but not the least. Um we can't have a sports talk without discussing athlete specific factors, right. So the female athlete tried it, um was first described in 1997 by the American College of Sports Medicine. It described this phenomenon where in female athletes um who had eating disorders were losing their periods or having amenorrhea, um and also sustaining stress fractures or, you know, being considered osteoporotic. So the the or uh the red triangle on the left hand corner, um over time, they expanded the definition of the female athlete triad saying it's not just a triangle, it's a continuum or a spectrum where an individual doesn't always have to live in the red triangle, sometimes they travel back and forth. Um Sometimes they're optimal energy, optimal um period and optimal bone health. Sometimes they're in between, sometimes they're in the deep end over time. Uh in 2014, uh the A CS M and the International Olympic Committee came up with the term relative energy deficiency in sport or red S. So what's what's different? What they realized was one, the the main culprit was um low energy availability. So it's not necessarily eating disorder or disordered eating, but individuals who are just not taking in enough nutrients or calories for the amount that they're spending, for example, on exercise, right? So low E A um causes not just uh menstrual dysfunction um or stress injuries that the tribe is only one slice. Um for example of like this big pie that also implicates other organ systems. Um More importantly with the red S um low E A is not only linked to um physiologic uh complications, it's also associated with performance uh complications which out uh gets the attention of our athletes. Um And then last, but not least as uh mentioned in uh Doctor Watkins talk this morning. Um Red S is not just limited to women but also men. So uh earlier she mentioned, you know, low B M I or thinness in men is associated with increased risk for um overuse injuries in, in male uh runners. So that's, that's kind of um the same, the same concept. So now we move forward uh to our second objective uh which is reviewing strategies to optimize bone health in Children and adolescents. So, uh we already talked about this, right? Review their overall general health, you know, which is why, you know, they come to me for 15 minutes, you know, clo fracture, we end up talking for 45 minutes, right? We really have to be very thorough about our questioning, um ask very specific questions, dietary practices, avoiding certain food groups, you know, things like that. Um You know, do you restrict, uh anything? Are you picky? Is, is any type of food, you know, bothering your stomach? Um ask about physical activities or lifestyle again, quantify. Um And you know, ask what type, what quality and then menstrual dysfunction. Um Yeah, in the past, you know, we asked about men and, you know, when they've started their periods, you know, there's an age usually after 15 or 16 that we will say, oh, you're, you know, running a little too late, you have to, you know, undergo a work up. Um But I think it goes beyond that. Um You want to know if they're having regular cycles and while, you know, our young adolescents may have regular cycles, um I usually ask for a specific number. Um because I've been bid once before where someone said I'm regular and when you ask how many they're like six, I was like, nope, that's, that's not regular um in the literature. Um It says that, you know, individuals who are getting less than nine cycles a year, um, should be considered a risk factor for, you know, things like low E A um, or, or red S um, and then lastly fracture history. So, you know, it's, it's more than just asking, you know, how many fractures have you had in your lifetime? What kind of fractures did you get? Um, what kind of mechanism was it from? You know, was it high velocity such as trampolines or, you know, monkey bars which, you know, are reasonable ways to, to get bone injuries or, you know, does make sense for a lot of kids. Um and, and ask, you know, kind of treatment, uh did you need, you know, was this something that healed in about six weeks? Was this something that needed um that took longer than expected to recover? I think those are, you know, very essential um data points. Um Look at your family health again from Doctor Lawson's talk yesterday, you know, she mentioned that, you know, a lot of the chronic medical conditions, you know, um would be higher suspected um in individuals who have positive family, family history. And then lastly, especially for those who um see patients in primary care, looking at their um measurements or their growth chart, you might get, you know, little clues uh about their overall state of health. So, uh the American Academy of Pediatrics does not recommend routinely requesting labs um for everyone. However, you know, if they have a few of those risk factors I mentioned earlier, um they advocate uh for everyone to be proactive about this. You know, a good place to start is vitamin D levels. Um and the, the type of vitamin D to check is the 25 hydroxy vitamins because it adequately um reflects the storage um amount of, of vitamin D. And although the definition for deficiency is less than 20 we want it to be over 30 for Children and adolescents. And, and the reason is because um 30 and above is seems to be the number that's preventative of fractures. So it's not enough that they're not deficient, but we want them over 30 if you um you know, get a vitamin D level. Um and it says, you know, less than 20 they're considered deficient. There is a few different ways to treat it. This table should be in your syllabus. Um There's daily dosing and then there's weekly once a week. Um bo dosing, we usually give that bols dosing for about 6 to 8 weeks. We encourage rechecking those levels after 6 to 8 weeks to see where they're at. If they're still low, then, you know, treat them for another round or if they've bumped up a little bit, then adjust your dosing accordingly. Um 20 to 29 is considered uh insufficient. And so the A P and the endocrine society all recommend supplementing these um kids uh with vitamin D and then uh 30 to 50 is considered uh sufficient or, or optimal. And for these individuals, there's no need to, to give them um additional supplementation, whatever they're getting from the diet or for other sources, like sunlight should be enough um similar to, you know, our rheumatologic talk yesterday, you know, you can get other labs depending on the clinical picture. So a CBC, you know, can give you an overall state of health, you know, show if there's anemia, chronic disease, look for any pancytopenia that may be hiding. Um you know, electrolytes is an easy way to kind of look at their liver G I and kidney function. Um if you're thinking this is, you know, more of an inflammatory condition, you know, Doctor Lawson encourage E S R and C R P as a good baseline. Um And then if you're thinking of endocrine and consider hormones like P T H, uh DXA scan is an imaging modality that measures bone density. Um and dexa skin should only be ordered in patients uh with primary bone disease or at risk of secondary bone disease when patient may benefit from interventions that decrease, you know, their risk for clinically significant fractures. Um It is usually OK to just defer it a specialist to do this. I myself um you know, reach out to our endocrine specialist um to make sure I'm, you know, getting the DXA scan appropriately. Um But I just wanted to mention a few different um details about pediatric DXA scan that make it unique compared to our adult protocols. So, uh the pediatric protocol uh looks at the um uh P A view of the spine and the total body less head um in a pediatric D A scan um report. Uh we use Z scores so you shouldn't be seeing T scores in there. T scores are used in adults. Um Z scores are standard deviations from sex, age and race and ethnicity matched reference ranges. Um Anything that's above negative two uh should be ok in Children. A Z score that's at negative two or less is considered low bone density. And according to the uh the guidelines of the word osteoporosis should not be used in a Dexa scan for Children. Um but it's more of a clinical diagnosis. So if it, if you have low B MD and you have a clinically significant fracture history. So, um these include vertebral compression fracture from low energy trauma or two or more long bone by 10 or three or more long bone fractures by 19. And that's something that um our endocrine specialists have um you know, shared with us. Uh Next diet and weight management um are essential in optimizing bone health as we learned, you know, this morning, too low B M I risk factor, too high B M I is a risk factor. Um We said earlier, you know, individuals who have high fat or high sugar in their content, uh content in their diet. It may impair their calcium intake. Um high protein or high sodium uh may be associated with um calcium loss in the urine. And then obesity right is sequesters vitamin D into fat cells. Um The photo on the right side is the athletes plate. This is something that I've learned from our nutrition specialists um that they recommend to athletes um uh for different phases of training. Um there's the different um kind of uh compartments, but the bottom line is that all macronutrients are essential. So there's carbs, there's protein and fat and that higher intensity training requires more energy to fuel the athletes to avoid red as. So the the bottom foot over there is for hard training as you can see like 50% of the plate um is for carbs. Um Next calcium and vitamin D. Um according to the A A P, most kids do not need supplementation um for any vitamin really, but if they were to eat it, it's usually calcium D or iron. Um So this is this table is the R D A or recommended dietary allowance for calcium and D uh for calcium. As you can see, as a kid gets older, the number gets bigger. Um makes sense. What I wanted to highlight in this um slide was that 9 to 18 year olds need 1300 mg a day. Do you guys know how much that, how much milk. That is right. So this is um the the table that shows us, you know, dietary sources like calcium. As you can see, one serving of milk is less than 300 mg, right? So a teenager needs about four glasses of milk, uh just to get their R D A for calcium. Obviously, there's non dairy sources. Um And so, you know, I, I show this table to families and I'm like, well, you know, if, if, um, if it, it's just not meeting your R D A then, you know, feel free to supplement, um as, as needed. Um, similar story, um goes with vitamin D. So our, our R D for vitamin D really is not that high, it's like 400 or 600 I use. However, if you look at the natural sources, they salmon sardines, mackerel tuna, she talking mushrooms, like who's lunch, whose kid has that in their lunch? Right? Um And so, you know, I, I always push for, you know, dietary sources that's always encouraged. Um I always point out non, you know, non dairy sources. I always point out, you know, fortified, um, you know, sources uh for, for these um, calcium and vitamin D. However, you know, if you feel like, you know, they're very picky or there's any issues with obtaining these naturally in their diet, then, you know, supplementing vita vitamin D would be um recommended. And then last, but not least exercise. Uh I was just reading um an article this morning from B J S M. Um you know, uh and this is like very similar um studies that they've done in a lot of different, you know, conditions, exercise versus medication exercise always wins. Um and, and improving, you know, symptoms, improving outcomes. And so, you know, like I mentioned earlier, impact helps build strong bones. And so physical activity is part of our strategy to optimize bone health in Children and adolescents. The A A P recommends 60 minutes of moderate to vigorous exercise each day. But when we're trying to look, look for low hanging fruit studies show that 20 minutes three times a week uh has shown significant bone growth. So, um if they're at least getting that, then, you know, let's let's encourage that um that method and then again, the type of exercise matters, uh high impact um is how we have, you know, stronger bones, you know, have better B MD. And so if you're dealing with swimmers, especially who hate their dry land exercises, um make sure, you know, they have some form of impact or include plyometrics or resistance straining into their routine. And then, um for those who are high impact athletes, as we heard in the, you know, lower extrem oes injuries earlier, um making sure they're gradually increasing their low, they're managing their low, they're having adequate rest. Uh make sure that they're practicing all those things to make sure we're avoiding stress injuries. And so with that, I end my uh talk uh with two minutes to spare for question and answers. Thank you.