S3E36 Carlos Moreyra MD
SUMMARY KEYWORDS
patients, people, diet, arthritis, bone, fracture, osteoporosis, knee, medications, joint, surgery, orthopedic surgeon, surgeon, bone density, hospital, decreases, hear, problems, studies, protein
Announcer 00:10
He was a morbidly obese surgeon destined for an operating table and an early death. Now he's a rebel MD who is Fabulously Fit and fighting to make America healthy again. This is Stay Off My Operating Table with Dr. Philip Ovadia.
Jack Heald 00:38
Alright, folks, welcome back. It's the Stay Off My Operating Table podcast with Dr. Philip Ovadia. I'm you're talking hairdo, by the way, Phil, if you notice my hair is getting better.
Dr. Philip Ovadia 00:48
It is. It must be that carnivore diet.
Jack Heald 00:52
That's it. Let's go with that. I'm Jack Heald. And we are joined today by another surgeon, which I think is pretty cool. Phil, introduce our guests for us. And let's get this conversation started.
Dr. Philip Ovadia 01:08
Yeah, really excited to have Carlos Moreyra on with us today. He is a fellow surgeon who is also working on keeping people off his operating table. And we've been interacting over on social media for quite a while now. And really excited to hear some of his story and some of what he's observed in his surgical world as an orthopedic surgeon. So, with that, Carlos, why don't you introduce yourself to our audience? Give a little bit of your background, and then we can dig into how you got into keeping people off your operating table.
Jack Heald 01:56
And if I may, please explain what an orthopedic surgeon is. I know I should know this, but I've never had to deal with one. So, I don't actually know what that is other than surgeries involved.
Carlos Moreyra MD 02:08
Thank you, Dr. Ovadia. Thank you, Jack. I’m Carlos Moreyra, an orthopedic surgeon like you said. An orthopedic surgeon is basically a surgeon that deals with the bones and the joints of the arms and the legs, including hips. Some of them do spine surgery as well with special training. I got interested in metabolic health and health optimizations some years ago, I think, one of your previous guests who by the way, he says hello to both of you. Dr. Sean O’Mara, he kind of got me into it. He first emailed me probably back about maybe 2013, 2014, some pictures of MRI scans of one of his patients, and the most impressive thing, probably the biggest, the most important picture that I have ever seen in my educational, in my medical education or my medical career, and it was basically an MRI scan, where he showed that there was a completely occluded artery in the brain in one of his clients. And that after seven months, that artery was completely wide open. And he did it just to natural interventions, diet changes, lifestyle changes, no medications. And I thought to myself, well, that is amazing. That's not even using kind of medications, statins or whatever. So, it kind of got me interested now, he's really being like, full force of that, not being kind of on and off for several years until maybe about four years ago, and I was beginning to, I was like putting some weight and my knee was bothering me a little bit more. I had an osteochondral lesion on my knee. And that's basically a lesion of like, bone, involving bone and cartilage. We don't call it a fracture, but it's almost like a little crack inside your joint. And so, I felt I need to really do something about it. And plus, at that time, I was starting a new, full-time practice. And so, I had some dietary instructions that one of my professors in residency, I did my residency at Temple University Hospital in Philadelphia, his name is Dr. John Kelly. And I have the instructions that he used to get to some of his patients, but that was already like 10 years ago and so I talked to my friend Sean, “Hey, Sean, what do you think about this, about these instructions?” Like, well some of this stuff is good. These other things I would not recommend, maybe do this instead. And I started just writing my own instructions for my patients, and basically over the next, like two, three years and just continue to make modifications and just kind of got more into it. I saw some changes myself in my own health. During the pandemic, I lost about 20 to 25 pounds interesting during a time when it seems like most people were actually gaining weight, because they were like staying indoors and not getting sun, not being active, and so forth. But I actually lost weight myself. And at this point, I feel like I'm just never going to look back to the times of like being maybe overweight or having some chronic pain on my left knee or what have you. So that's how I like, in a nutshell how I got started with this.
Jack Heald 05:49
So, when I hear a cardiac surgeon talk about metabolic health, it's pretty clear to me being a non-health care professional that if you're obese, and you get rid of all that weight, that you're less likely to end up on the table have a cardiac surgeon, but it is not at all obvious to me how that affects someone ending up on the table of an orthopedic surgeon, other than there's just less weight on your legs. Is there more to it than that?
Carlos Moreyra MD 06:24
Yeah, there's more to it than that. And I think during my training, medical school training, I would have thought, well, yeah maybe arthritis gets better if you just simply removed the weight, but it's more than just weight. Because if your weight alone, then people who are big, tall and really muscular like Dr. Shaun Baker, then they'll be like screaming arthritis, in arthritic pain. And that's not really the case. What I've come to realize is by reading the literature myself on this subject, not something that our board would expect us to know, or not something that will get taught in residency, but basically, I have had to look this up myself is that there is an inflammatory component. And that inflammatory component is primarily driven by diet. Now, I wouldn't say that it's all just diet alone, they probably are some other components as well as like mechanical alignment of the knee. Because if we were just inflammation from diet, I think that perhaps patients who had a partial replacement of the knee would never do well, but some of them do well. But quite a few of them don't do well and then they go on to have a revision where they go from a partial knee replacement to complete knee replacement, or a total knee replacement. So, there's certainly a big dietary component. And that's something that I've had to kind of learn on my own. And it's just amazing, like finding papers that talk about this for instance, one big paper that I came across in 2020, during the middle of the pandemic was a study out of China, where they took cartilage cells from the joints that were getting resurfaced during knee replacement. And then they put them in tissue culture. And they find out that if you have high insulin levels, it induces inflammation, like they took this tissue from the knee, and they cultured it and under high levels of insulin induced inflammation. Then I think it was later that year, a study out of the University of Alabama at Birmingham, they found out in a randomized controlled trial that a low carbohydrate diet is better for decreasing pain and improving function than a low-fat diet or a standard diet. And so now I have the basic science and I have the clinical data, both showing that if you're trying to cut back on your carbohydrates, it will make your arthritic pain less and it would allow you to improve your function. So now there's other articles that I've come across to simply stating similar things.
Dr. Philip Ovadia 09:26
Yeah, so given that we have this in the literature, why don't you think it's talked about more amongst your community, the orthopedic surgeons and the rheumatologist that are treating things like arthritis? And we hear a lot about the medications and many people will have seen the advertisements on TV for arthritis, magic medication, we have sort of the, we'll call them the next generation of medications that have come out in the past few years, very expensive medications that are targeting things like arthritis, and they're targeting the immune system and inflammation. And yet again, we really don't talk about, well, maybe just changing your diet can eliminate that inflammation.
Carlos Moreyra MD 10:32
That's an excellent question. And I think part of the answer is, can be explained by some of the roadblocks that I have faced myself in trying to do this. I was at a hospital working once where I started giving instructions on diet, low carbohydrate diet and eliminating vegetable oils and things like that. And this was a hospital that I was traveling to, I know I do locums tenens, just like you do. I traveled to hospitals where they have a critical need for an orthopedic surgeon. And on the first trip back there, I needed, I had to have a meeting with the head of dietitians and the director of the food service and the vice president of the hospital because they were not really liking much what I was saying in my instructions. They basically came down that, at least from their point of view, is that whatever I said had to be in accord with standards that are accepted by the Government. And in terms of the hospital that receives money from Medicare, then they have to abide by like USDA dietary guidelines. And so, they didn't want me to say something that was like outside of that. So, they told me, "Well you could talk in the office all you want, but at the hospital, we can't really have that, because then we might have problems with accreditation.” And it wasn't Jake, it wasn't the Joint Commission, but they were being accredited by some organization. And then at another hospital, apparently, some patients complained to the office of the medical staff that I'm like talking about diet and lifestyle and telling them that they don't need surgery when they fact they do need surgery. So, there is there's even resistance from the patients themselves. And that one is hard to overcome, because if they don't really want to hear then you start getting your bad reviews and things like that, or they complain to the staff, I mean to medical stuff for the hospital, then the third one is just a conflict of interest particularly joint replacement surgeons, arthroplasty surgeons, it's not in their interest to understand or to promulgate to their patients how to avoid surgery, because they are making their money from doing a joint replacement. And I've kind of followed the joint replacement literature for years, and many, many, many years ago, I used to work for a joint replacement surgeon. And what I found out is that the literature, particularly for joint replacements, is heavy on articles dealing with money reimbursement, all kinds of business aspects and the reimbursement aspect of joint replacements. But when it comes to decreasing pain from dietary changes, it's like almost nonexistent. And so, and they make their living from doing joint replacements, and I'm not saying that the surgery is not needed or shouldn't be done. I do think, though, that there's just no drive for them to want to learn how to avoid having to do the surgeries of the patients. Because it goes against their livelihood.
Dr. Philip Ovadia 14:16
Exactly. What would you estimate? So, I've publicly said many times now that I believe that probably 90% of the heart surgeries that I do could have been prevented if we were paying attention to metabolic health, and people were paying attention to that early enough in their life. What would your guess be as to the percentage of the, and let's just limit it to joint replacements, knee and hip replacements, which are probably the two most common surgeries that you do. What percent of those do you think we could avoid if we were paying attention to metabolic health?
Carlos Moreyra MD 15:11
Probably depends how far back you want to go on the modifications for diet, because I would say if all patients that are getting joint replacement, and this is a very rough guess, okay, but if all the patients that are getting joint replacements, if they would have made some drastic dietary changes five years prior to obtaining their surgery, I would say the majority of them would avoid it. Maybe it could be in the realm of maybe 60 to 75%. Okay, that's a guess. Now, there's still other patients that have had inflammatory arthritis from a younger age, but we can still make the argument that a lot of these autoimmune disorders, or maybe the great majority of them, who knows if all of them, are really caused by some sort of dietary insulins early in life, even if it's juvenile rheumatoid arthritis, or what have you. And so, if you were to have a completely clean diet from the get-go, I would say that at least 90% of the direct cases will be avoidable. The only time when you might have run into issues where like, well patients still relatively healthy, but the joints is getting a hard time, maybe those patients that are suffering what is called Post Traumatic arthritis, which is really just like osteoarthritis, except that happening after trauma. And that trauma could have been maybe a fracture on the knee that involves the articular surface that involves the cartilage. It could be an ACL tear, anterior cruciate ligament tear, and then they undergo reconstruction for that, but whether you do surgery for an anterior cruciate ligament tear, it doesn't really decrease the incidence of arthritis, it actually just simply helps with stability of the knee, but the surgery is not even done. A reconstruction of the ACL ligament is not done to avoid arthritis, and they can still get arthritis later on. When I looked at the literature regarding, like, why they get arthritis? I think the best guess is that it's probably due to the amount of force during the original impact. But I think probably surgical factors may come into as well, if the surgery was not an easy one, if there is a lot of bone debrief still floating around that, those can be factors. So, I think in summary, I would say, if diet changes are made early on, you could probably avoid at least 90% of the joint replacements.
Jack Heald 17:52
When you were talking about keeping people off of your operating table, and just speculating as to why the literature for orthopedic surgeons is so heavily focused on reimbursement rather than treatment. I couldn't help but think that even if everybody in America was eating well, we still play football, we still play basketball. It seems like the market for orthopedic surgery, while it may get smaller is certainly unlikely to go away as long as we continue to be two legged beasts that run around doing crazy things. And that led me to this question. Suppose you're an athlete, and that whole business of dealing with the long-term stress on the joints, like professional basketball players, professional football players deal with is just part and parcel of how you work, will this dietary change, in your opinion, or is there any literature that would indicate that you're less likely to suffer either a traumatic injury or long-term arthritis as a result of these diet changes, even though you're involved in this high impact athletic events?
Carlos Moreyra MD 19:30
Yeah, that's a tough one to answer. I could only think that it could help but how much help, it's kind of unknown. And there's so many other factors as well particularly for the knee. You can be talking about mechanical alignments, and people who are bow legged or people who are have like knock knees that don't have like the neutral mechanical alignment, they can have more of a predisposition for cartilage issues or meniscal issues and the meniscus are this like wedge shaped colleges that are inside the joint that they can help disperse the force of gravity. If you get one of those torn, that increases the risk of arthritis joint. So, when I looked at studies that relate to diet, they mostly relate to mechanisms of injury, or mechanisms of cartilage degradation. For instance, recently, I saw one involving the oxidized LDL, stimulating some receptors that induce cartilage destruction of the joint. So that leads you to think, well, avoiding vegetable oils can help with that, because that's a mechanism that LDL can get oxidized. But how does that translate into real life, whether it's somebody can prevent arthritis in the knee, it's, I think it remains to be seen, but certainly worth trying. And there are athletes that do have bouts of arthritis. I like to sprint, and I competed on my first ever track meet, which was because I turned 50 years old, I was able to qualify. And I met this sprinter, I don't know how old he is, but he's definitely older than me. He's probably, I think maybe he was like in this 60 and up category, and he was sprinting with a partial knee replacement. And I'm like, wow, that's pretty aggressive. So, I know I can’t even tell you firsthand that a lot of these professional athletes, they do have, or collegiate athletes end up with arthritis. And like in the practice with the joint replacement surgeon that I used to work with decades ago, I think he took care of some former NFL players, and their knees would be all beat up. So, I think it's multifactorial, but I think it's important that no matter whether the patient or has a history of sports, pivoting activities, or injury is definitely worth a try to make dietary changes, because it can make a difference between requiring a surgery or non-surgery. It can make a difference between requiring or not requiring corticosteroid injections. Now, the injections, they help me a lot with pain, but they actually make your arthritis worse. And that's something that patients commonly get all the time. I mean, I give injections, but I tell them that this is good for pain, but this is not going to help with anything else, it's going to make your tissue worse. I do think they have their place. 95-year-old grandma's got knee pain, she's not going to get surgery, just make her feel better, give her an injection, and then she loves it. And then she comes back like several months later for another one. And I think that's fine. But the younger the patient is the more hesitant I am. Now the literature is coming back saying that, in patients who get steroid injections to their knee, their arthritis gets worse than all those patients who don't get the steroids. We already kind of knew that for the hip. And I know, I'm like going into different subjects here, but patients will get steroid injections to the hip and some patients that arthritis is dramatically worse very quickly. Kind of hard to predict in one room. And it's only a small percentage, but I have seen it to the point where I don't even offer it. I don't refer them for a steroid injection to the hip, because it can happen. But for the knee, I recently saw a study showing that looking at two cohorts, and the people who get the steroid injections that their arthritis gets worse as well. Maybe not to the extent as like patients with hip arthritis, but it still gets worse. So, I mean diet works. I can tell you anecdotally I've had a patient too. This is another story. I had a patient that I saw for shoulder problem once and she told me that year's priors, they had told her that she had some knee replacement, and she was morbidly obese. They had discussed bariatric surgery and so forth. But she decided to get the bariatric surgery first. And she did lose weight. And with that all her pain went away in her knee. And then she only saw me some years later for some shoulder problem that was unrelated. No, I mean, I'm not saying that bariatric surgery is like a fix or anything like that. They can have complications as well. But with the weight loss that she had, her knee pain went away. Even myself, I totally, when I when I lost 10 pounds, I noticed a significant difference in my left knee just from 10 pounds. Now, it's actually less weight or because I was decreasing, like some sort of baseline inflammation, I don't know. Probably both.
Dr. Philip Ovadia 25:26
Yeah, that certainly I think is both. I just want to go back. I need to acknowledge that you're certainly the first orthopedic surgeon I've heard mentioned oxidized LDL. And how happy it is it makes me to hear you talking about that.
Jack Heald 25:45
I had a question about that, Phil? Because I'm not a medical professional. Explain why this oxidized LDL is important and how that translates for us lay people? What does that mean for just day to day lives?
Dr. Philip Ovadia 26:03
Yeah. So, everyone will be familiar with LDL cholesterol, because it is such a focus of our medical system. And oxidized LDL cholesterol is basically a damaged form of LDL cholesterol, these are damaged cholesterol particle. Oxidation, again, to kind of translate that, rust is oxidation. If you have a bottle of vegetable oil that you leave out on your counter and it goes rancid, that's because it's getting oxidized. So, oxidation happens within our bodies. And there's lots of evidence that oxidized LDL is what contributes to heart disease. So, it's not all LDL, it's only the damaged LDL, that really seems to get trapped within blood vessel walls and ends up contributing to plaques and causes. It is in and of itself part of the inflammation process. So, it doesn't surprise me to hear that it's related to inflammation elsewhere in the body besides the blood vessels, and again, one of the problems that we maybe have with the LDL theory of disease is that the blood is circulating through our bodies, and LDL cholesterol is always in our bloodstream, so why isn’t it causing problems all over the body? Why is it only in particular places in the blood vessels of the heart, and some of the evidence there is that it needs to be damaged first, basically, to become problematic. And I think that goes along with what Carlos was talking about these oxidized LDL particles contributing to inflammation in joints, in cartilage, and contributing to arthritis as well.
Jack Heald 28:21
And what's the tie in with seed oils?
Dr. Philip Ovadia 28:25
So, seed oils containing a high amount of polyunsaturated fatty acids are more prone to oxidation, because they're more unstable. So, the unsaturated portions of these fatty acids are where the oxidation occurs. And saturated fatty acids occur in things like animal fat don't oxidize. You can leave...
Jack Heald?
Because they're stable? They’re chemically stable?
Dr. Philip Ovadia
Because they’re stable. So, you can leave a thing of lard or a thing of beef tallow out on your counter, and it's not going to go rancid, whereas vegetable and seed oils will.
Jack Heald 29:16
Okay. All right. I apologize for that little rabbit trailer we went down, but I didn't understand this stuff. So, I want to understand it.
Dr. Philip Ovadia 29:25
Yeah. I wanted to ask Carlos his thoughts on maybe if we look at sort of the other end of the orthopedic spectrum, and look at children, and it seems that there's a definite uptick in children developing orthopedic problems, children getting these injuries, requiring orthopedic surgeries. I can just think a number of my daughter's friends have already had injuries that seem like didn't occur back when we were children 30, 40 years ago. There seems to be a noticeable intake, uptick in the incidence of childhood orthopedic problems. And of course, we know that there's an uptick in childhood metabolic problems, obesity and type two diabetes, for instance. And I was just wondering if you think those two are related because the mainstream explanation for this is that oh, well, children are just doing sport to your round, and they're more active. And that's why they're getting injured more. But that doesn't really seem to be the case. If anything, children seem to be less active, and they're getting injured more. It's kind of my observation, but I'd love to hear your thoughts on that.
Carlos Moreyra MD 30:58
Yeah, to me, I think it for children is multifactorial, and it depends really what kind of injury we're talking about, what if it's a fracture or an ACL tear, or things like that. I do think there may be a component of diet with ACL injuries, but I think that, there maybe some people will burn me for saying this, I think that contribution is probably minor. And I know I've had some disagreements with Tucker Goodrich of this on Twitter. But, and I'm not saying that the contribution is zero, I would certainly think that the contribution of diets to rotator cuff tears over the shoulder in middle aged and older adults is much higher, like the relationship to diet, and it scales up. There's so many factors involved, if we just stick to ACLs, I think, as sports, the demand of sports, having demanding coaches. Most patients I get ACL tears are women. And I think with a lot of women's sports that soccer, volleyball that they ended up getting what the ACL tears.
Jack Heald 32:12
Most of your ACL tears are women?
Carlos Moreyra MD
Yeah.
Jack Heald
Like a statistically significant difference?
Carlos Moreyra MD 32:21
I believe so. I think that's what I've seen. And I think that's what I've seen in practice, maybe not so much when I was in the Navy, because most people in the Navy, at least when I was in active duty, are men, but they do have a higher rate ACL tears... So, if you were to take, like a hundred collegiate athletes that are male and female, you're gonna have more ACL tears in women. Various factors, I think it has to do with their cycle, with the anatomy, with the way that if they look at how they jump, or how they land, they tend to land a little bit differently. It depends on the strength of the external rotators of the hip, there's so many factors involved, and you could, they're like whole lectures, and probably even books written about this, but I don't think that maybe diet has something to do with it too, as well. But I think the dietary changes have not taken effect, like they do for older folks to undergo shoulder injuries. And that's where I can almost exclusively put a blame on diet. As far as other things, because I haven't seen, Philip, I haven't seen really many ACL tears for like, kids that are not like active in some particular sport. What I see the injuries in children that are not particularly active, I think it tends to be similar problems that I might see in the older adults. Maybe obesity, it'd be one issue. Maybe they trip and they fall and then unable to break their fall as easily. And I'm seeing more children too, with metabolic diseases and I have diagnosed acanthosis nigricans in my office, which is, that's like a condition where the skin of the joints gets a little bit darker, or you can have some darkness also happening around the neck.
Jack Heald 34:27
Oh yeah. We have another guest talking about that. I don't know, what's the condition called again?
Carlos Moreyra MD 34:33
Acanthosis nigricans. Nigricans, basically meaning black, so it's like a darkening of the skin at the joint surface. It could be here at the elbow, it could be at the knuckles, and I think they come misconception of patients, they think oh, I thought that was just dirt like my hands are dirty and I'm playing outside or whatever. Like no, no, that's not dirt. That's just it's like increased pigmentation, that's a precursor, most I mean, there are various reasons, causes for that, but most commonly, it's a precursor for diabetes later on in life. So, I've told patients and their parents this is like an early warning sign to work on the diet, work making dietary changes, and it goes away. And once that gets fixed, the darkening tends to go away. What I have seen acanthosis nigricans in children that come into the office for like, fractures, so those are the two things that I've noticed, though, it's basically your typical metabolic pawns occurring at a younger age, and sometimes increased sports injuries, but I think those tend to be more related to just demand at this point. And some kids are just doing sports, maybe there are things for trying to do a year-round, and pitchers, you have them, like throwing so many pitches, and then they show up with, like, similar injuries. So, but certainly, I've seen metabolic problems in the kids in the office as well.
Jack Heald 36:19
Phil, did you have something in mind when you asked that question?
Dr. Philip Ovadia 36:23
Well, I'm gonna kind of follow, I think this leads us into you discussed the relationship of diet and lifestyle and metabolic disease to osteoporosis, kind of weakening of the bones. And I want to get into that. I want to hear your perspective, and have you explain that, but I also was wondering if children that are not having a lot of processed food, a lot of vegetable and seed oils in their diet, if their bone growth, their bone formation is affected by that. And if that's one of the factors that make, that seems to be making them more prone to injuries.
Carlos Moreyra MD 37:22
It could very well be, but not something I’ve closely looked at. I didn't know, maybe about two, three years ago, here in the US a published study looking at supplementing children with vitamin D. And I think in the results showed that it helped, I have seen more studies in terms of nutrition regarding vitamin D, and protein for children in India. But I have not noticed, for instance, like with weaker bone, I mean, and maybe perhaps the bone density is not as good as it should be. And that decreased bone density has seen me but at least I haven't seen it. What is clear to me is the big markedly decreased bone density and as a process, unlike some of my older patients, that is just so clear cut, it's like night and day. So now, Jack had the question about what is osteoporosis. So, Osteoporosis is a condition in which your bone decreases on its density and becomes more prone to fracture. Now, by definition, the quality of the bone is the same, but the quantity of it is decreased. But I would add a caveat to this, that I will say the quality is not the same, but by the definition, the quality is the same, it's just that there's less of the bone. Why do I say the quality is not the same? Well, as we age, the quality of the bone decreases, even for somebody who may have good bone density. And I think one of the primary ways that the quality of the bone decreases is to what we call advanced glycation end products. So basically, what that is that you have proteins that get peppered by glucose molecules or other different molecules that are attached to those proteins. And that reaction doesn't require any enzymes in it, over the long term, what it does is it makes bone less elastic and becomes more brittle.
Jack Heald 39:36
Okay, so this is...
Carlos Moreyra MD 39:40
So, phrases, well hemoglobin A1C, which many people have heard, it's basically looking at advanced glycation end products in the red blood cell.
Jack Heald 39:55
Advanced glycation end-products.
Carlos Moreyra MD 39:56
Okay, on a red blood cell, you have these glucose molecules basically attaching to like the hemoglobin. And that's when you look at a hemoglobin A1C, you're looking to see how much of these, like glucose molecules have attached to these hemoglobin or to the red cells over a period of time, usually for the last few months. But the same process of that occurs in the red blood cells occurs in virtually every other tissue in the body, including bone, including the meniscus in the knee, including ligaments, including tendons. What that does to bone, and what that does to ligaments and tendons, it makes them less elastic, and more brittle. Okay, that affects the incidence of fractures. On top of the... I've dropped the phone... I'm doing this from my phone. On top of the fact that advanced glycation end-products doesn't even factor into the diagnosis of osteoporosis, but factors into the osteoporosis is decreased bone density. So, if you have a patient with osteoporosis, their bone density is lower. And because they're older, and maybe especially if they were diabetic, now their bone is less elastic and more brittle, then you have more of a recipe for fracture, after a simple fall. Okay. And I think that's the explanation why patients with diabetes, they tend to, they may not even have osteoporosis, but yet there have a higher incidence of fractures than somebody who is not diabetic. And just, I think it's because of the fact that the bone is more brittle even if they don't have osteoporosis.
Dr. Philip Ovadia 42:06
And so most people when their doctors talk to them about osteoporosis, the recommendations are going to be around supplementing calcium or getting enough calcium in your diet. Because the perception I guess I'll say is that our bone is made up of mostly calcium. That's kind of the common misconception, really, even amongst doctors. So, what advice do you have for people that have osteoporosis, and they're trying to stop it from getting worse, or trying to improve it?
Carlos Moreyra MD 42:49
Well, very quickly, why me? I guess I could talk for hours on this. But well, first of all, we'll look at their diet, because bone is about, dry bone is about 40% protein. So, protein makes up a significant portion of this. And there are studies that looked at calcium and vitamin D that don't even show that they make a real difference. And it's not because we don't need the calcium, it's not because we don't need vitamin D. In fact, most people are deficient on vitamin D. So, we definitely need vitamin D. But I think it's kind of just looking at the wrong way. To me, making bone or trying to at least slowdown that process of losing bone, it's like building a house, okay? You gotta have all the ingredients in there, you cannot just take a cement truck, or concrete truck, I guess, and just dump more concrete on the building sites and expect to get a bigger house out of it or more houses. You got to have all the ingredients, you got to have your wires, you got to have your plumbing material, you gotta have everything that you need, the sand, the ground or whatever. You need to have everything and I think that's where a lot of these studies may miss the point where they say, Well, we're going to look at calcium, oh, calcium doesn't work. As a matter of fact, I think some study showed that supplementing postmenopausal women with calcium, all it does is that increases the incidence of calcification of their arteries in the soft tissues. That doesn't mean that we don't need the calcium, but you just like taking it, just increasing one ingredient and you're expecting a house to be built and it doesn't work that way. So, I think what people need to focus is about, look at their diet. Make sure you kind of clean it out, cut the sugars, grains, refined carbohydrates... Focus on protein, because bone is going to be 40% protein. Okay? And mostly it's going to be type one collagen. And then I will focus, and the nutrients that I will tend to focus will be Vitamin D, Vitamin K2, which is important basically K2 tells the calcium to go to the bone and not go to these other soft tissues. And K2 only comes from animal sources with the exception of natto fermented soybean, but it's not the soybean that has the K2. It’s the bacteria that are fermenting the soybean, the ones that are making the K2. But you can also get it from the egg yolks and beef flavor and things like that. And then also learn to focus on magnesium too. So, with, now I tell patients, if you're going to supplement calcium, then you should supplement in all these three. I don't have any evidence that that's the way it would work. But I certainly would not recommend supplementing calcium alone, or supplementing calcium with only vitamin D. Because more likely than not, it's not going to work. Or it can lead to calcification of blood vessels. And so, we don't want that so. But it'll be interesting to see if by supplementing those four, that you can actually help increase the bone density. The other thing that can help increase the bone density, just like it will help with building a house, is that you gotta pay your contractors, you can’t just tell like the osteoblast to just make more bone and not really pay them. I mean, you can’t tell the construction workers just build a house and not pay them but not offer them money or excessive spread. And the incentives to make bone come from doing weight bearing exercises, strength training, okay. So, some studies that looked at people who are in bed rest, for instance, at a hospital, if you are on bed rest, like not getting up, not moving around in a hospital for 10 days, your lower extremities will lose already 10% of the lean body weight, of the lean weight, just from inactivity. I mean, and that's just the lean, I'm not including whatever fat burned during that time, just loss of lean mass, that’s basically muscle and bone from inactivity. So, doing strength training, doing a strengthening exercises is basically like saying, hey, we'll give you the osteoblast this amount of money. And then once you meet these certain milestones, we’ll keep paying you. That’s gotta be the incentive, you gotta pay your workers. You do it for...
Jack Heald 47:47
I love that metaphor. That's a powerful metaphor. You can't just dump concrete on the plot and hope that the house builds, and you got to pay your workers. That's good. That's really good.
Dr. Philip Ovadia 48:06
Yeah, what amazes me about those recommendations that you just gave, is that they are basically the same recommendations that I give to people who say, How do I minimize this calcification that's occurring in my arteries, in this plaque that’s building in my arteries, and I tell them, you want your vitamin D and your K2, because you want that K2 to get that calcium out of the walls of your blood vessels and into your bones where it belongs. And of course, eating protein and magnesium and eliminating vegetable and seed oils and processed food and sugar are all the things that we recommend. So, it's not surprising to anyone who's really thinking about it that what helps your heart should help your bones and the rest of your body as well.
Carlos Moreyra MD 49:06
Absolutely, and even one factor that I didn't get to which I need to get to, because I think it's very important. It's the medications.
Jack Heald 49:15
Yeah, you said something about chronic medication in our prep for the show, and I'd never heard that phrase used before.
Carlos Moreyra MD 49:25
Well, I think so many of our medical conditions are just created as side effects or adverse reactions of medications that we take for something else, and it's just a vicious cycle. So, there are two... Well, I'll get into maybe three types of medications and there's actually quite a few but for osteoporosis, under my own observation, the biggest culprit, medication-wise, are the PPIs, proton-pump inhibitors. Those are like your, your anti acids that are brought up on inhibitors like omeprazole, lansoprazole, Prilosec. These used to be by prescription, but now, like, just over the counter. And I would say, almost all of my patients with osteoporotic fractures like osteoporotic, like hip fractures, almost all of them or the great majority of them are on pump inhibitors. The ironic thing is they get admitted to the hospital. And then the hospital is still ordered some more of the proton-pump inhibitor, and I tell patients I think this is probably the biggest reason why you have this fracture, I even had a patient that, he's a cattle farmer, he rides horses, he's not obese, he looks pretty good for his age. Again, he came in from with a hip fracture, that just happened because he was just simply squatting down, and he just kind of twist it, he was not holding any weights, he just barely twists a little bit, cracked the bone. And then, I'm getting the history and I'm looking at the X rays, he had a similar problem, like two years before, on the other hip, like he also had another fracture, the other one was fixing with a nail that for this one, I had to do a replacement of the hip. And digging from the history, he's not a smoker, and he's not on steroids. Will also add to these, steroids. Chronic use of steroids is very bad for osteoporosis. Patients are on like, on prednisone for long term and things like that. But his only risk factor was proton-pump inhibitors. And it's like, how long have you been taking them? It's like, I've been taking them for like years, and he already had a hip fracture like two years prior. So, proton-pump inhibitors are just bad actors. And in something that there's already people on social media are very active in saying that, in that actually now, there's some evidence that is probably show that at low carbohydrate diets, a lot of people with their acid reflux goes away, or at least it gets better. So, but...
Jack Heald 52:19
I can testify to that personally. Whenever I get acid reflux, it is almost 100% guaranteed that I've had too many carbs. And it goes with if I just have a big ol hunk of meat and slathered some butter on it and life's better that way,
Carlos Moreyra MD 52:44
I suppose. The proton-pump inhibitors are definitely a problem. Another one that I would, this one, I've been looking into it more recently, and I don't know how strong the data is. But there's definitely an association between statins and tendon ruptures. And I cannot even say that the orthopedic community has not known about this, at least some people have because one of the studies that I looked at was actually published in JBJS, the Journal of Bone and Joint Surgery, which is like the premier journal for orthopedics years ago. Finding an association between the statins and tendon ruptures. And I can say that for probably a good portion of patients that I’ve seen with tendon ruptures including the shoulder like rotator cuff tears that they are taking some form of statin for their cholesterol. So that's something else to be careful with. And, of course, like I mentioned, steroids are not good. They're not good for healing. They're not good for bone density. Sometimes people are on steroids for whatever autoimmune disorder might be though, but they have to understand that they do have to risks. Then some diabetes medications can lead to osteoporosis process too. And neuroleptics can do it too. I had a patient... Neuroleptics, so like anti psychotics medications for people who have schizophrenia or bipolar-disorder or what have you. And just about two months ago, I had a patient who has a history of schizophrenia, and she's been on medication for years. And, I mean, she was younger than me and she just had like a little simple twist and fall while going to the bathroom and she had a severely comminuted fracture of the tibia, meet of the tear that to me that she had, like an osteopenia or osteoporotic fracture, the bone density was not good at all. The fracture was in many pieces at the level of the joint, of the knee joint. It was basically like taking care of a fracture of somebody who was like 80 or 90 years old, even though she was in her like, early 40s. And the only thing that can attribute to that is from her medications for schizophrenia. So that's why, that's what I mean by chronic medications, because we really have to dig deeper to what causes some of the conditions people get. And sometimes you don't even have to go as far as diet, although we should be evaluating everybody's diet. But sometimes the answer isn't the medications that they're taking.
Jack Heald 55:35
Well, we are closing in on an hour here, and I've got a couple other questions that I really want to ask you. I always research our guests before they appear. And I was stalking you on Twitter, and I see these photos of various plates of food. Um, what, if I may ask, is tripe?
Carlos Moreyra MD 56:03
Well, that's one of the things, the ruminants are like things like cows, they have like, I think it's four chambers for like four different stomach tubers. And then so the honeycomb tripe is like one of them. You're basically eating like some sort of intestinal wall. I know it sounds disgusting. And people say that it smells bad. But it's actually delicious, to be honest with you. You just have to make sure it's very well rinsed, I cook it in steak fat, with lard with some bacon on it. It's very chewy, definitely very chewy, but it's chewy because it has a lot of collagen. So, collagen is good. It's good for many reasons. I think it adds some benefits that you don't get from just eating pure red meat. Because the collages can be high in glycine. And there are all these studies showing glycine, and you can extend the lifespan of like animals and things like that. Plus, it's an important component of collagen. And collagen is in our bones, in our joints, in our blood vessels. So, you asked what tripe I is, at least the way I cook it, it is so good. I've had it for like eight days in a row at times.
Jack Heald 57:21
I can confirm you've publicly testified on your Twitter feed how much you love tripe. I always thought it was a fish. So, I'm glad I asked the question. All right, that leads me to the follow up question, which is talk about the nutritional function of organs as a food. We talk about protein in general. And then we tend to think of meat. But what about organs? What's the nutritional benefit of consuming organs, as opposed to just the muscle of animals?
Carlos Moreyra MD 58:03
I think there are benefits maybe Shawn Baker makes a, Dr. Baker makes a good point that perhaps it’s not necessary and he does not eat organs. But I think that there's benefits you can get from them, especially if you can actually enjoy them. Now for tripe and for other organs that may be the benefit of collagen. Now, the most common amino acid and amino acids are the building block of proteins and most common amino acid in collagens is going to be glycine. Glycine is not an essential amino acid, meaning that we can make it ourselves, but it is thought that perhaps we don't make it to an optimal amount. And so, it's probably better to include it in our diet. Some studies show at least for animals that glycine supplementation can expand the lifespan, I don't know how that will translate to just eating a bunch of tripe for a human, but it could certainly help. Then other organs like liver that can, they're just going to be packed with a lot of nutrients including vitamin D, vitamin A, and so forth. And so, I think that can be very helpful. I think they can help more quickly optimize health in some patients. Patients already have a clean diet, and they're eating pastured eggs. They're eating Walcott seafood like salmon or so forth. I'm not so sure how much they will benefit from it. Or if it's just like almost like overkill, but I do recommend eating organ meats or at least the ones that people will actually enjoy. I'll be honest with you. I try kidney ones just for the jiggles of it. It didn't really taste very good, and I tried it the second time and then I'm like that said I think I'm done with kidney. I'm not trying this again. Very cheap. But when I asked the butcher at the supermarket is like oh yeah, people buy it. They feed them to their dogs.
Jack Heald 1:00:03
Well, dogs lick their own butts, so.
Carlos Moreyra MD 1:00:05
Exactly. But there's a big difference between tripe and kidney. And there's a big difference between like sweetbreads, which has nothing to do with bread, and kidney. So, there are some organs out there like tripe and sweet breads that I truly find enjoyable, I will go to a restaurant to like a steak house, several times I've ordered at this particular Argentinian Steakhouse in Miami, sweet breads, and I enjoy them. So, I think that benefits, whether absolutely necessary, probably not, but I think it can help, particularly those patients that are coming out from a poor diet to get optimized more quickly.
Jack Heald
Very good.
Dr. Philip Ovadia 1:00:52
Yeah, I'll certainly endorse eating heart, and sweetbreads, I'm a fan of as well. The liver and the kidney, little rough, I usually get it mixed into some ground beef to do that, and I haven't tried tripe as of yet. I’ll get that on the list.
Carlos Moreyra MD 1:01:13
I just got tripe today. But I had to ask for it at the supermarket, though.
Jack Heald 1:01:20
That's good to know. Because one of my follow up questions was going to be how the heck do you get it? So, they have it at the supermarket apparently. All right. Phil, are there any questions we have left unanswered here?
Dr. Philip Ovadia 1:01:35
No, just maybe, yeah, wrap up by talking about how you're sort of integrating this into your professional life these days? And where people can connect with you and find you?
Carlos Moreyra MD 1:01:52
Yeah, so the way integrators into orthopedic practice is basically I have my instructions on nutrition. And I have also additional instructions of bone health. So, a lot of these things that we discussed about cutting sugars, cutting excessive carbs, and greens and vegetable oils, include these things in the diet, all those things, I haven't just two sheets of paper that I give to my patients. And as we only get about seven minutes with each patient, but I try to make the most out of it. Even if it's just above, just discussing diet and nutrition, even if it's just for one minute. Some patients are receptive to it. Some of them are not. That's just kind of the way it goes. I can be reached mainly on Twitter. My handle is more MoreyraOrtho – M O R E Y R A O R T H O, so my last name and ortho. And I'm active on Twitter. And I tend to answer questions and post interesting articles as I see them.
Jack Heald 1:02:54
And we'll post those things on our show notes. So, folks will be able to just click on those links and follow them. All right, well, Dr. Carlos Moreyra, thank you for being with us today. I love it when we get surgeons because I know absolutely nothing about what you guys do other than use knives and cut people open. And it's really fun to find people who are working to not do the job that they trained so highly for, even though it's essential. I think people like this, like, one of the reasons I love working with Dr. O, it gives your words far more weight that if people actually follow your advice, you will have less business. And that to me that that just reeks of credibility. And I appreciate it. Thank you very much.
Carlos Moreyra MD 1:03:51
Thank you for both of you to having me.
Jack Heald 1:03:53
It's good to have you. All right, well, another good one. Any last words for us, Phil?
Dr. Philip Ovadia 1:04:01
Just eat real food and take back control of your health.
Jack Heald 1:04:07
We should probably make that our tagline, “Eat real food. Take control of your health.” All right. Well for Dr. Carlos Maria and Dr. Philip Ovadia. I'm Jack Heald. This is the Stay Off My Operating Table podcast. And we will talk to you all next.
Jack Heald 1:04:25
America is fat and sick and tired. 88% of Americans are metabolically unhealthy and at risk of a sudden heart attack. Are you one of them? Go to ifixhearts.co and take Dr. Ovadia's metabolic health quiz. Learn specific steps you can take to reclaim your health, reduce your risk of heart attack and stay off Dr. Ovadia's operating table.
Jack Heald 1:04:53
This has been a production of 38 atoms