Optimizing skeletal health during childhood will confer benefits for a patient's entire life, so it's never too soon for pediatric providers to discuss bone-building strategies with families, says sports medicine specialist Celina de Borja, MD. She offers reminders of the many organ systems impacted by the bones; describes risk factors for osteoporosis; notes red flags in kids; and discusses simple ways to modify lifestyle factors, such as using calcium and vitamin D supplements and prescribing reasonable exercise plans that won’t daunt sedentary teens.
Uh, good afternoon, everyone. Uh, I'm Selena Deboer. I'm a pediatric primary care sports medicine, uh, specialist here at UCSF Benia Children's Hospital. So my background is in primary care pediatrics, um, followed by sports medicine, uh, training. Um, today we will talk about optimizing bone health in in teens. Uh, no relevant financial disclosures. So our main objectives for today include recognizing conditions that may interfere with adequate bone health and then also reviewing strategies to optimize bone health in children and adolescents. So before we begin with those objectives, um, let's start with what is bone health. Uh, according to the US Surgeon General, bone 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 do we have to talk about bone health? Why is it so important? Aren't bones just for movement or mobility? Well, the answer is no. Uh, bones aren't just for movement or mobility. Bones actually have a lot of important roles, um, in the body. So, first and foremost, bones protect our vital organs, specifically the brain protects our, uh, the skull protects our brain and the rib cage, uh, protects our heart and lungs. Uh, bones are also involved in producing essential cells, specifically red blood cells, immune cells, and is, uh, vital in, uh, regulating electrolytes, specifically calcium. Now, when do we need to have this conversation about bone health? And the answer is, as soon as you possibly can. Um, children have unique risk for fractures due to their skeletal immaturity, and at the same time, their activity levels. Um, but more importantly, 90% of peak bone mass is attained during childhood and adolescence. Um, and this process of attaining calcium into your bone bank actually slows down after 30 years old. And after 40, uh, the bones actually lose more calcium than it builds, uh, thereby leading to osteoporosis. Now, where should we start? Now, this is the uh uh diagram on calcium homeostasis that shows that bones aren't the only organ systems that um are involved in uh calcium or or bone health. Um, there's other organ systems that are also involved, including our GI tract and our kidneys. Um, and these organ systems, uh, are influenced by three hormones, mainly PTH. So PTH likes to keep Uh, calcium, uh, in the bloodstream, uh, thereby, um, uh, reabsorbing it from the bones, um, and reabsorbing it from the kidneys as well as increasing, um, absorption from our GI tract. Now, this process is, um, also influenced by vitamin D. Vitamin D is the second, uh, hormone, uh, That is important in bone health because it helps with the absorption of uh of vitamin, of calcium in our gut. Without adequate levels of vitamin D, we are all just, um, flushing out the calcium that we get from our dietary, uh, sources. And then lastly, calcitonin. Calcitonin, um, likes to keep, uh, calcium in the bones, uh, and so, and so it takes it from the bloodstream through reverse mechanisms. Now, who needs to have this conversation about bone health with the patients and their families? And the answer is all of us, um, most especially, um, you all, um, who are practicing in primary care, who know our patients best. I think it's really important to have these conversations with them. Um, us as musculoskeletal orthopedic or sports medicine providers, we tend to, um, have these conversations, um, during specific issues, and I also encourage any allies, um, for example, mental health specialists or nutritionists or physical therapists to have these conversations because certain risk factors or medical conditions might be more obvious in certain clinical settings. Which brings me to my first objective, recognizing conditions that may interfere with adequate boat health. So, we start with intrinsic factors. Age, specifically during growth or adolescence and during elderly years, um, are common, um, risk factors for boat health. Um, gender as well, we see, uh, impaired bone health issues in more in women compared to men. And you know, while we see impaired bone health issues in a wide variety of um ethnic backgrounds, we see it most commonly in white and Asian women, especially um when there's a family history of osteoporosis. Uh, next would be medical factors. So, like I mentioned, primary care providers are the ones who know our patients best. So, um, please think about, um, issues with bone health, um, if you're seeing them for these medical conditions. Um, first would be gastrointestinal or fat malabsorption. So for example, um, those with inflammatory bowel disease, celiac or cystic fibrosis. You know, sometimes in children or adolescents, these conditions may not necessarily be diagnosed right away. Um, they may present with, you know, um, uh, sensitive stomach, um, you know, lactose intolerance or whatnot, and so in these, um, conditions always think about their ability to absorb, you know, calcium and vitamin D. Uh, individuals with chronic disease, specifically liver disease, kidney disease, um, childhood cancers, or inflammatory processes, um, may be at risk for impaired bone health. Um, those, uh, with exposure to certain medications, for example, steroids, uh, whether it is for chronic disease, uh, inflammatory disease, or say, um, respiratory exacerbations, you know, please think about their own health, um. Other medications, um, include anticonvulsants, antifungals, antiretrovirals, and antidepressants, and it has something to do with the cytochrome P450 metabolism, uh, that it tends to interfere with, um, calcium homeostasis. And then last but not the least, um, individuals, um, especially the adolescent athletes, um, with eating disorders, um, so that could be more on the behavioral aspect. Um, it can, uh, impair their bone health, and we'll, um, discuss a little bit more, um, in the next slides. Uh, for us who work in orthopedics, or if you're ever seeing them in the setting of a musculoskeletal complaint, you know, think about impaired bone health, um, when you see any of these conditions. Um, for children, you know, 2 or more fractures, um, by 10 or more than 3 by adolescents. Um, stress fractures, um, are injuries that make us think about, um, impaired BMD. Um, vertebral compression fractures, especially if low, um, velocity or low mechanism. You know, we, uh, we consider that as a, um, as a red flag, you know, for BMD, um, and then for those, um, individuals wherein they're sustaining a pretty, you know, simple and straightforward fracture, but they're not healing, um, as expected within the 6 to 8 week time frame, um, or, you know, we may consider as delayed union, you know. We, we think about their um metabolic um status um in those situations. And then outside of trauma, there are certain medical conditions, um, say, you know, cerebral palsy or neuromuscular conditions wherein children are immobilized or not as active. Um, where we think about impaired bone health and then, um, some literature have suggested that other orthopedic associations, for example, skiffy or scoliosis, uh, may be related to impaired BMD, um, and so if these cases, um, especially if they're operative, we tend to do, um, some form of workup for them. Uh, modifiable factors, um, are really important when assessing bone health because these are things that, um, tend to have a pretty simple fix. So definitely look at their intake, dietary intake, um, and look for sources, um, for calcium and vitamin D. So in children and adolescents, you know, I asked specifically about restrictive diets. Um, or an adequate nutrition. So sometimes it's um restrictions based on, um, you know, medical issues, um, sometimes it's from Um, social, cultural, religious, um, you know, uh, preferences, or sometimes you just have a child who's a very picky eater, and so, um, you want to make sure that they have adequate source of calcium and vitamin D. Um, studies have shown that, you know, kids who have high protein, high sodium in their diet, they tend to, um, Uh, have reduced calcium retention and so they're just flushing out calcium in their urine. And then studies also show that kids who consume a lot of soda and juices, um, are associated with lower intake of milk and calcium sources. And then lastly, uh, obesity, um, because vitamin D is really important in calcium absorption and vitamin. D is a fat soluble vitamin. Uh, obese individuals tend to have their vitamin D sequestered into their fat cells, and so they have low vitamin D in their bloodstream, and so this impairs their ability to absorb calcium from their diet. So think about that as well. Uh, lifestyle habits, um, can also impact bone health, like we mentioned earlier, you know, kids with neuromuscular conditions or mobilized or inactive, um, you know, can impact their bone health. So ask about the lifestyle of the children, um, you know, and whether that or not they have opportunities for high impact activities, um. If they're not in organized sports, they typically ask about um opportunity for PE or running around in recess, uh, or maybe recreational activities during the weekends that they may do with their families. Um, because that can also, um, help with, you know, making strong bones. Um, sleep, you know, has been documented to, uh, impact bone health. Um, there is a study from University of Buffalo from which this image is, um, obtained from, um. They looked at 11,000 postmenopausal women who have had DEXA scans performed in their facilities, and what they found was that, you know, women who slept 5 hours or less, um, had lower bone mineral density. Compared to those who slept 7 hours or more, and so the um explanation that the researcher suggested is that, you know, healthy processes such as bone remodeling or healing happens when we're sleeping and so if we're sleeping less, these processes aren't happening adequately which can impair our overall um bone mineral density. And then, um, last but not the least, you know, because my, um, area of interest and your expertise is in sports medicine, definitely would want to highlight any athlete or performing arts related factors that can interfere with adequate bone health. So, um, one phenomenon that was described in 1997 was a female athlete triad wherein a female athlete, um, would have an eating disorder, uh, would sustain a stress fracture, and would also have, uh, secondary amenorrhea or missed periods, and that is reflected by the red triangle over here. Um, over time, the American College of Sports Medicine realized that, um, some of these individuals may not always be in the red triangle, but can travel back and forth in between, you know, optimal energy availability. Um, and optimal, uh, menstrual cycles, um, you know, depending on their level of, you know, sports engagement. Um, in 2014, the concept of relative energy deficiency in sport was introduced, um, which showed that this triangle over here, um, is just a slice of a bigger pie, uh, with low energy availability as the, um, you know, main problem. Low energy availability doesn't always mean that they have an eating disorder, but that, you know, individuals, um, are not. Eating or getting as much nutrients, uh, that's uh adequate to keep up with the amount of exercise that um they perform. Um, the important highlights with RED S, um, are that, you know, the problems linked to low energy availability aren't limited to menstrual dysfunction or stress fractures. Um, it also, um, can influence immune function. It can also be associated with gastrointestinal issues and cardiovascular issues and other, um, you know, physio physiologic functioning. Most importantly, um, we realized that this phenomena aren't exclusive to women, but it can also happen to men as well, um, and that they're not just limited to physiologic complications and that it can also impair an athlete or a performer's, um, performance abilities. And so now that we've um discussed um factors that may impair bone health, let's review strategies that can help optimize them um in children and adolescents and reviewing, you know, their overall state of health is, is really important, um, you know, having a good understanding of their dietary practices. Or any restrictions, um, that they may have, you know, discussing, uh, their lifestyle, uh, specifically what types of physical activities they engage in, you know, for women, asking about specific questions about their menstrual cycle. Um, it's not enough that we ask them if they've had their periods or how long their periods have, um, been going on. I think it's really important to ask, um, if they're having regular periods, and although the literature may suggest, you know, it can be anywhere between, you know, 28 to 35 day cycle, I think it's also important to ask, you know, how many cycles they're having in a year. Um, because studies have shown that girls who are having, uh, 9 or less than 9 cycles each year, you know, may be at risk for, um, low energy availability, um, and, you know. Subsequently, you know, read as an impaired bone health. And then fracture history. So, you know, a lot of times we meet them in the orthopedic clinic, um, you know, for, you know, one injury or another. Um, however, I think in primary care, if you know the family well and, you know, have seen in their records that they've had, you know, two or more fractures, um, in, in the past, uh, I think definitely something to, um, to consider. Um, you know, family history is very important. Um, we've learned, uh, through our, you know, rheumatologic and endocrine, um, colleagues that, you know, family history of impaired, um, bone health or osteoporosis, you know, can, uh, be, you know, a red flag for, you know, the child's future, um, uh, you know, bone situation, and then ultimately the growth chart, you know, can give us clues about their overall, um, state of health. And so the American Academy of Pediatrics, um, doesn't necessarily recommend, you know, drawing labs on all kids, um, you know, to evaluate them for bone health. They, you know, do encourage, you know, a thorough history and, you know, physical exam, but they also encourage being proactive if there's any risk factors. Um, a good place to start would be, you know, checking what, um, vitamin D levels, and then that would be the 25 hydroxy vitamin D. Because that would be the, um, you know, best, uh, reflection of, of, you know, vitamin D storage. So, this is a table, um, that, you know, guides us on how we're supposed to treat or supplement with vitamin D and, you know, the ultimate goal is that the level is greater than 30, and that's because that's the number that seems to be protective of uh fractures in children and adolescents. Um, and so if they have 30 to 50, then they're sufficient. They don't necessarily need any supplementation if they're getting it from their diet. Um, deficiency is defined as a level less than 20, um, because there's really high, you know, fracture risk, um, or vitamin D deficiency, um, you know, we recommend, you know, treating these with either the daily dose or the weekly bolus dosing and then rechecking in 6 to 8 weeks. Um, to, to adjust their dose, and then those in between, um, those with levels 20 to 29 are considered insufficient, and so, um, supplementation would be recommended for those, um, individuals. Um, again, um, you know, although labs aren't necessarily indicated for everyone, um, it is encouraged to be proactive if there's any risk factors. In addition to checking their vitamin D, sometimes other labs may be, um, recommended, you know, depending on the clinical picture, you know, a CBC, uh, would be helpful just to kind of, you know, see their overall state of health. Sometimes, you know, we can get, uh, A clue such as um anemia or chronic disease, you know, if there's any, say, underlying inflammatory rheumatologic or chronic um disease going on, um, you know, electrolytes, um. are, you know, good, um, to kind of take a peek at their, you know, overall GI or renal, um, status, uh, inflammatory markers if you're thinking of autoimmune condition and then, um, you know, parathyroid hormone could be checked, um, if you're thinking of an endocrine disorder. Uh, DEXA scans, um, are imaging modalities that, um, are used to evaluate an individual's bone mineral density, although DEXA scans aren't necessarily indicated for everyone. Um, in fact, I do consult with our pediatric endocrinologist, you know, before requesting, you know, for these studies, um, but I just wanted to, you know, mention a few things about the pediatric DEXA scan so that Um, you know, it's not confused with, you know, the adult protocol. So the pediatric protocol, um, includes the spine and the total body loss head, uh, in contrast with the adult protocol which looks at other areas such as femoral neck and, um, whatnot. Um, the report for children should include Z scores and not T scores which are used for adults. Um, these scores are standard deviations that are based on sex, age, and ethnicity, um, match reference ranges, and a Z score up to -2 should be fine, but anything that's lower than -2 is considered low bone density. Um, the term osteoporosis is not necessarily used in, uh, the DEXA scan report in children unless, um, there's clinically significant fracture history, so. Um, that would be DEXA score Z score of, you know, lower than -2 plus, um, either vertebral compression fracture from low energy trauma, you know, 2 or more fractures by 10 or 3 or more fractures by 19. So that's just something that was, has been shared with us by a pediatric endocrinology and, and radiology colleagues that would be helpful. And so, um, you know, maintaining, um, healthy weight, you know, is important, um, in optimizing, you know, bone health. Um, like we said earlier, if you, if weight is too low or energy availability is too low, then it can impair bone health. Um, we also mentioned that obesity. Um, you know, can be associated with, uh, sequestration of vitamin D and, you know, impairments in bone health, so, you know, just managing the weight is, is really important, um, for bone health. Um, this, uh, image over here, um, is the athlete's plate, um, is something that I learned from our, um, mentors and, um, who are registered dietitians. It shows. Um, essentially how individuals, especially athletes, should adjust their diets, uh, depending on their training. Um, as you can see on the top, you know, if someone's having easy training or just, you know, working on weight management, then, um, there's more fruits and vegetables, um, compared to the other. Um, components of, of their plate. Um, however, when, you know, someone's undergoing hard training, then, you know, they need more carbs or grains, um, you know, compared to the other components. Um, you know, bottom line is all macronutrients are important, so carbs, protein, and fat, they're all important, um, for, you know, balanced diet, it's just a matter of, um, proportion that changes depending on their exercise level. Um, and then, like I mentioned earlier, you know, calcium and vitamin D, um, are You know, actionable or, you know, areas where we, you know, can intervene. Um, this, this table is the RDA or recommended dietary allowance of calcium and vitamin D for children and adolescents. Um, as you can see, as the child gets older, uh, the numbers get bigger. Um, what I wanted to highlight though was that, you know, our 9 to 18 year olds. Um, where, you know, is there, it's their kind of, you know, maximum, maximum kind of time, you know, for collecting calcium into their bone bank, and they need 1300 mg a day, um, which, which is a lot and so, you know, I definitely emphasize this with, with families to make sure that, you know, they're thinking of all um sources um from, from their diet, not just thinking, oh, you know, I drink milk and I'm good. And so, um, this, uh, slide, you know, shows, um, different sources of calcium, you know, in the diet. We are all aware of dairy, um, options, um, but don't forget there's also non-dairy options and calcium-fortified foods that could be, um, obtained, you know, for, for the kids. And so, um, just to, you know, going back to what I you know, 1300 mg um per day, you know, from 9 to 18, um, as you can see, you know, a glass of milk is roughly 300 mg and so it really would take, you know, almost 4 glasses of milk to make that RDA and so, you know, making sure we're looking at other sources, say yogurt seems to, you know, be more efficient, you know, delivering about 400 to 450, um. You know, preserving and then also considering other sources um that are not dairy. Um, same goes for vitamin D. Um, while we only really need about 400 to 600 international units of vitamin D each day, um, as you can see, the natural sources are typically from, um, fish like salmon, sardines, mackerel, tuna. Um, or, um, mushrooms and, you know, these aren't necessarily, um, part of your children's diet, so making sure we're looking at, you know, fortified foods, uh, for example, you know, milk, orange juice, you know, or, you know, breakfast. Options to make sure that they're getting adequate um vitamin D in their diet. And then physical activity like we um talked about earlier, you know, physical activity, um, high impact activities, you know, help with making strong bones. The American Academy of Pediatrics recommends 60 minutes of moderate to vigorous exercise each day. However, we all know that that's, you know, been challenging, um, for the kids for a lot of different reasons. We're also kind of living in a different, um, society nowadays where, you know, we're in the digital world and, you know. Um, we're not moving as much anymore. Um, studies show though that significant bone growth can be seen with just 20 minutes of exercise 3 times a week. So we try as much as possible to encourage them to engage in something, um, that will help increase their bone marrow density. Um, the type of exercise also matters and so, um, you know, we have athletes who are lower impact, for example, there's swimmers, cyclists, um, And, you know, although they are, you know, very active, they can have lower um bone marrow density compared to, you know, those who run and jump. So making sure they have some high impact exercises, uh, or plyometrics or resistance training in their regimen, um, is also recommended. And then, um, on the other, you know, end of the spectrum, you know, we, you know, think about, um, overuse or overtraining. So, you know, making sure there's gradual increases in their load and, you know, adequate rest in between um is really important in avoiding um overuse or stress fractures. And um that is it um for me today. Um thank you uh once again um to our physician liaisons for having me um talk today about bone health, um, and if you have any questions, we'll have a Q&A session afterwards, but I just wanted to share, um, as Maria has mentioned earlier, we are hosting again our pediatric and musculoskeletal. And sports medicine conference um in March, it's gonna be March 22nd and 23rd, it's in person. Um, at the MLK Research Center in Oakland, uh, California, um, day one is a pediatric musculoskeletal medicine for primary care. We'll talk about different topics like spine deformity, lower limb differences, fracture care. Um, we also have pediatric endocrinology and pediatric radiology, um, to, to learn from for day one and then for day two, we have exciting topics from our pediatric sports medicine, um, colleagues. Um, including physical therapists and athletic trainers, so, um, we're really excited about this course and we're looking forward to, um, seeing you all there. Um, the QR code on the right upper, um, corner, um, sends you directly to our registration page, but if you have any questions, please don't hesitate to reach out to myself or physician liaisons for more information.
