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Orthopedic surgeon Yoshihiro Katsuura, medical student Mark Polemidiotis, and premedical student Cyrus Nasr discuss their article, “Why young people need to care about bone health now.” Yoshihiro, Mark, and Cyrus explain that osteoporosis is not just an old person’s disease but a result of peak bone mass missed during youth. They use the powerful metaphor of a “retirement account” to describe skeletal metabolism, where deposits must be made before age twenty to prevent a “moth-eaten” structure later in life. The discussion highlights the shocking mortality rates of insufficiency fractures and reveals why modern anabolic medications are revolutionizing treatment beyond the old “freezing” methods of bisphosphonates. Learn how to invest in your skeleton now to avoid paying the high price of frailty later.

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Transcript

Kevin Pho: Hi. Welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Yoshihiro Katsuura, medical student Mark Polemidiotis, and premedical student Cyrus Nasr. They wrote the KevinMD article “Why young people need to care about bone health now.” Everybody, welcome to the show.

Yoshihiro Katsuura: Thanks so much for having me, Kevin.

Kevin Pho: All right. We will just start briefly by introducing yourselves. Just say a quick word, and then we will jump right into the article. Yoshi, why don’t you go first?

Yoshihiro Katsuura: Thanks. My name is Yoshi Katsuura, and I am an orthopedic spine surgeon. I practice in private practice in Novato, California. I also run a small research group that we call the Surgical Fitness Research Pod. I recently published a book called Skeletal Metabolism, which is in relation to this article today. It discusses the more hidden intricacies of osteoporosis care and just how your bones work in general from a biological standpoint.

Kevin Pho: All right. Cyrus, a brief word about yourself.

Cyrus Nasr: Sure. My name is Cyrus Nasr. I am a premedical college student attending the University of California, Berkeley, studying neuroscience and economics. I am in my fourth year. I work with Dr. Katsuura as a medical assistant at his clinic, and I am also part of the Surgical Fitness Research Pod.

Kevin Pho: Excellent. And Mark, finally, a brief word about yourself.

Mark Polemidiotis: Hi, Mark. Nice to meet you. I am a final-year med student currently studying at the Royal College of Surgeons in Ireland, where Dr. Katsuura also studied. I am finishing up my applications now, applying to orthopedic residencies all over the U.S. and Canada. I am really happy to be on. I am also part of the Surgical Fitness Research Pod.

Kevin Pho: Excellent. All right. Yoshi, tell us what brought everyone together and then of course talk about this latest article for those who didn’t get a chance to read it yet.

Yoshihiro Katsuura: Osteoporosis care is a huge problem in the United States. I think everyone is going to suffer from it at some point in their lives, and it is a hidden problem. That is a combination of the fact that it is a silent disease (so you won’t know that you have it until it is too late) and that it is poorly understood by most medical professionals.

As an orthopedic surgeon, this is not something that most orthopedic surgeons are actually interested in. They want to fix bones, they want to put in hardware, and do surgery. I do those things as well. But I became really interested in the medical side of care because it was clearly very neglected in my patients. I see a lot of hip fractures and vertebral compression fractures. Osteoporosis is as obvious to me as sunlight is when you step outside; it is a fact of life.

I was really seeing this epidemic at my doorstep. These patients coming in with compression fractures have really debilitating problems. Oftentimes there is not a good solution. If you have to have surgery, then you can get fixed, but you still have to go through that process. There is a better way.

I tried to educate myself on osteoporosis: What are the current standards? What are the simple things that you need to do to take care of it? The only things I could really find were these esoteric resources on the topic. These really thick metabolic endocrinology textbooks described things from a researcher standpoint or from an endocrinology standpoint rather than from a practical manual that you can use.

That is why I was inspired to write this book. This article that we wrote is really an extrapolation of some of the concepts in that book. What if I asked you or told you that you had a retirement account? This is a retirement account where you don’t know how much money is going in or coming out at any given time. In 60 years, you are going to open the retirement account and see what is inside. Now, you may be pleasantly surprised, or you may be crying because nothing is in there. That is how I envision osteoporosis working. It is this hidden retirement account, but you don’t know what is going in. You can’t log in and check what it is at any given time very easily. Then all of a sudden, one day you wake up and the bank account is empty.

That is how your bones work over the course of your lives. As you know, bone mineral density increases to a certain point sometime really in your teenage years or twenties, early twenties, and then from there gradually declines. So that peak bone mass is very critical.

That is what got me thinking about how young people really need to be thinking about this. From the age of Cyrus and Mark (these are my two students who do research with me), I was really interested to hear their perspective. So we got talking about it, and we were like: “Yeah, this is really important. This is a really important concept that is not on social media that no one is really thinking about.” No one is thinking about: “Oh, what are my bones doing today?” or “What should I be doing for my bones?” They are worried about how much they weigh, what they look like, what their skin looks like—cosmetic types of things. You can’t tell what your bones are doing, so the time to invest in your bone mineral density “retirement account” is now.

Kevin Pho: I love that metaphor that you want to bank up on that. I typically use that metaphor when it comes to muscle mass, right? Because as men get older, testosterone goes down. You want to bank up that muscle mass. But I love that metaphor as it applies to the bones as well. I am really eager to hear more about that. Mark, you are just finishing up medical school. You are in your last year. Obviously, you studied the physiology of bone health. But after studying with Dr. Katsuura, tell us some types of misconceptions that you may want to clear up after doing some of this research.

Mark Polemidiotis: One of the biggest misconceptions is that you can start or build up this bone in the later years of your life. One of the things I have learned with Dr. Katsuura is that you can never rehabilitate bone that isn’t there. Even if you break a bone and you stabilize the joint with a replacement, the surrounding bone is still not going to be stable. That is something that needs to be built up at a very young age.

I think the biggest problem is that when you are teaching students, and even in primary school in grades 5, 6, and 7 when they are 13, how to live a healthy lifestyle, you are telling them: “Don’t be overweight in your fifties. Don’t get type 2 diabetes. Don’t have kidney disease.” They are all like: “Sure, but I am not 50. I am not going to be 50 for another 30 years.” But if you can tell those students today: “You only have three more years. You only have a couple more years to build up that bone density,” I feel like that is something that will strike home. That is why I think it is even more important to teach that than it is to teach about heart disease in those formative years of education.

Kevin Pho: Cyrus, you are an undergraduate student, premedical student. Tell us, in terms of the stuff that you have learned during this research with Dr. Katsuura, about what people at your age can do now that could help them later on.

Cyrus Nasr: Totally. As a premedical student, I am obviously very early in my medical studies, and I have come to think about osteoporosis in a different way than most people my age. Learning from Dr. Katsuura and the others in the research group, in classes we learn about it in a textbook kind of way: low bone mineral density, increased fracture risk. But working in Dr. Katsuura’s orthopedic office, I have seen how real it is for all the patients and everyone that comes in. There are just long-term consequences. People that are active their entire lives can be taken out by one fall.

What really hits me is how preventable it seems. We are taught to think of osteoporosis as an older person’s disease. However, the biology just doesn’t work like that because your peak bone mass is being built around my age—early twenties—basically the exact years we are in right now. Most of my friends personally think about their heart health, their diet, and their mental health. Even some of them track their sleep. However, no one I see is worrying about their bones at all. However, these are the peak years that we should be building up our bones, worrying about making sure that we are keeping healthy habits so that we can fill up that retirement account for the future.

Kevin Pho: Cyrus, you mentioned you are also a medical assistant for Dr. Katsuura. So without getting into too much detail—you don’t have to talk about an individual patient; you could talk about an amalgamation of patients—people come to Dr. Katsuura’s office, an orthopedic surgeon, with a bone fracture. Just tell us the impact that has on their life from an amalgamation of the patients that you have roomed and some of the stories that you see.

Cyrus Nasr: Great question. We just have so many patients that come in. I am talking to them as I am rooming them. They are telling me about their entire life story, how active they are, all the sports they love doing. Most recently, one came in that related to me personally because they loved to go surfing. We were talking about that, and they had this hip fracture. After that, they have just been immobile. I have seen how it can affect their lives. You see someone go from being such an active, happy person to being so down and upset. It is something that seems so preventable and just can ruin someone’s life.

Kevin Pho: Yoshi, when you are operating on fractures, you said that you wished they could have done something earlier on, and that is what inspired you to find out more about this. Just tell me, as a surgeon, when you are operating, can you see the impact of osteoporosis? From a primary care standpoint, I just get bone mineral densities, but you actually see it viscerally for yourself.

Yoshihiro Katsuura: Yeah, I see it, feel it, touch it. It is incredibly obvious to me when we step into the operating room. You would be surprised sometimes. I have been surprised where I see especially men who are big, burly guys, and you think: “This guy is going to have great bone. This is going to be a really awesome surgery.” You get in there and you think: “What is this? These bones are empty. There is nothing here.”

As you may know, when you have osteoporosis, your bones become hollowed. Your bones are otherwise filled with blood and bone marrow. So when you have hollowed bones, you bleed more. It is much more obvious to me in surgery when this is happening. So I wonder: “What is the deal here? This guy is supposed to be 65 and muscular, otherwise in pretty good shape. What is up with his bones?” There is no reason for him to have low bone mineral density.

It turns out it has to do with some lifestyle factors. It could have been that he had a 10-year period where he was a smoker. That is like having 10 years of going on a spending spree with that bone mineral density account. You may not recover from that, just as you would not recover from a financial perspective. One of the things that I teach the medical students in my research group is that you have to be very careful with medical debt because that is a financial repayment that leaves a mark for a long time. As I am sure you know, that is a tough financial thing to recover from.

The same thing is true of lifestyle choices. When you are living your life and you are active and healthy and you don’t know it, maybe you drink a little more than you should every day; that is going to have an impact. Maybe you have too many cups of coffee. Again, you are draining that retirement account. Smoking in particular, I think, is very detrimental to your bone health. But it could even be simpler than that. Maybe you are sedentary. Maybe you are a trucker and you are not getting up and walking around enough, not loading the bones enough. Very simple things that we do throughout our life can have this cumulative, profound effect on our bones and can lead to bone and joint disease.

So yeah, it is something I see and unfortunately have to deal with every day. It has become a passion of mine though. So we can attack it not just from the surgical perspective. When people actually deal with these fractures, we repair them and we can get them back. As you know, with hip replacements, kyphoplasty, things like that, we have a lot of tools. But we also have the medical tools now to treat osteoporosis. We have three generations of osteoporosis medications. The times of everyone being worried about bisphosphonates because their teeth are going to fall out or they are going to have GI side effects are over now because we have so many other options.

Kevin Pho: Mark, we are using that metaphor where we want to build up that retirement account, keep our bones healthy going forward. So for someone in their twenties or thirties, relatively young, what are some practical things they could do to bank up that bone health?

Mark Polemidiotis: Dr. Katsuura talked a lot about the risk factors. It doesn’t only apply in old age; when you are older, they have a bigger impact. When you are younger, you want to load the bones. You want to have an active lifestyle. You want to have resistance on the bones. Walking around and biking is good for preventing arthritis and other things, but you want to have good impact on the bones. You want to avoid smoking and alcohol, and you want to have consistency with those risk factors.

Going out and saying: “Oh, I sat around all week. I am just going to go to the gym and work really hard,” is not how it works. Your body will react with consistent, healthy lifestyles, a lot like the rest of your health. Because the bones are a living organism, it does react a lot like the rest of your health as well. It is about consistency, avoiding those risk factors (like smoking), and then again having an active lifestyle consistently.

Kevin Pho: Mark, in terms of active lifestyle, are there any specific exercises, strength training, or weight training that we have to keep in mind to build up that bone health?

Mark Polemidiotis: Yeah. A simple one is running, just running. If you are into weight training, that is a good one, as long as you don’t overdo it. Obviously, having that muscle connection with the weights is good for building up the muscle that surrounds the bone. A lot of those activities like sports, if you can stay in a sports league, are really fun. People tend to be more consistent with that. It is more fun for them. They tend not to treat it like a chore. It is just good for every other aspect of your life as well. As long as you are moving around and you are kind of loading any weight you can on those bones over time consistently, I think you are doing a really good job for your bone health.

Kevin Pho: We are talking to Yoshi Katsuura, Cyrus Nasr, and Mark Polemidiotis. They wrote the KevinMD article “Why young people need to care about bone health now.” Now I am going to ask each of you just to share some take-home messages that you want to leave with the KevinMD audience. Cyrus, why don’t we start with you?

Cyrus Nasr: Sure. One thing I think that really stuck with me from this article is just how perfectly bone density fits the idea of a retirement account. As somebody studying both neuroscience and economics, I think about how the skeleton from a neuroscience side is living, adaptive, and plastic just like the brain. That plasticity is going to have a window, that critical period where you are depositing bone mass at the fastest rate you ever will.

Then from the economic side, the parallel is just almost too perfect. Every time you exercise, every time you choose nutrition over skipping a meal or living on caffeine, every night you decide to sleep instead of pulling an all-nighter, that is a deposit. That compound interest will add up. However, every time you smoke or you are chronically sleep-deprived or drinking heavily on weekends, that is going to be a withdrawal. Most people my age don’t even know that account exists, let alone that they are already spending from it.

Kevin Pho: Mark, your take-home messages.

Mark Polemidiotis: I think I am going to expand on just the very end of what Cyrus said: People don’t know about this. It is a problem that people come in with perfect health; they have kept their weight under control and haven’t smoked, but they just didn’t know about bone mineral density. So I think a big take-home message is: It is really important to teach people about this. Get the news out, get this into the younger minds, and make it a part of early education that bone health is important before the end of the second decade in your teens. I think that is a big takeaway mention that is going to help a lot of people in preventative medicine.

Kevin Pho: And Yoshi, we will review your take-home messages to the KevinMD audience.

Yoshihiro Katsuura: I want to add one thing that I think is a really practical tip that you can use, and these guys will use them with their future patients. It is a simple exercise that you can do to really generate bone mineral density. This has been proven in research studies. I write about it in the book Skeletal Metabolism, and that is just a single-leg hop. Running actually is good for simulating that, but if you want to just jump on one leg, that is a very simple exercise that you can do. It works a number of things. One, it works on your balance, which also deteriorates as you age because you lose muscular coordination. But bones really love it, and it will really strengthen your bones and spur them to strengthen even better if you hop in different directions because, as you know, the forces that are applied to a bone can be multidirectional. If you just strengthen in one direction, it can weaken in another area.

Hopping on one leg sounds kind of silly, but it actually is a very practical tip that you can use with your patients and help them generate strong bones as well as work on other areas of their life. This was something that I wasn’t thinking about when I was in Cyrus’s shoes or Mark’s shoes. I thought bones were boring. It is kind of weird for an orthopedic surgeon to say that. I thought the brain and spinal cord were where it was at—so interesting and intricate. But the bones are exceptionally interesting if you take the time to learn about them and figure out their biology.

That is what I am trying to teach Cyrus and Mark: It is like a coral reef. That is how I think of the bones. It is this beautiful environment where a lot of different things are happening. There are little cells swimming by, and this cell does that, and this cell does this. There is this whole biochemistry that goes into it. It is this very rich area of study that people frankly are not interested in because they think of bones as an inert, dead structure, but they are anything but that. Keeping that in mind, I wrote this book, which hopefully some of your listeners will check out. It is called Skeletal Metabolism. It is available on Amazon, and it is the guide that I wish I had when I started this journey. I think it will be really useful for a lot of your physician and allied medical professional audience.

Kevin Pho: Perfect. One last question. Yoshi, the role of calcium and vitamin D is typically recommended for those who are older. Is there a role in the younger population?

Yoshihiro Katsuura: I personally don’t think so. I think that as long as you have a reasonable diet—obviously if you are malnourished or if you have some disease state where you are wasting calcium, then it becomes a necessity. If you are not getting adequate vitamin D or you live in a northern climate where it is not available in your environment, then yes, I think it is a reasonable thing to do. But you can only ingest so much calcium, and so you can get most of that from a diet rich in leafy greens or dairy products. Same thing for vitamin D: You can just step outside for 15 minutes and you have got more vitamin D than you need. I think you just have to put the phone down for a second and get out of the office, step outside. I make a point of doing this during my clinical days. Just get outside for 15 minutes and that is really all you need. But if you do have osteoporosis, I think it is a different story.

Kevin Pho: Everybody, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Yoshihiro Katsuura: Thank you, Kevin.