Kim Vopni (00:01.292)
Hi Dr. Levens, thank you so much for joining me today. I talk a lot about, indirectly I talk a lot about bone health in my population because it's something that a lot of people struggle with and a lot of it is because of movement restrictions they've had throughout their life, sometimes nutrient deficiencies, various challenges, but a lot of it is pelvic health stops people from doing a lot of what...
lot of what helps our bones and I know that this is an area of focus for you. We met through BoneHealth BC. I know that's with Buddy Osborne as well and I really wanted to have your pick your brain a little bit and talk more in depth about bone health and some of the scans that I guess some of the missed opportunities for maybe even diagnosing osteoporosis and osteopenia earlier in life. So
Can you start out by telling us a little bit about who you are and what also, I know you do a lot of things, but what brought you into the world of osteoporosis and bone health?
Dr Todd Levins (00:56.8)
Yeah, I work.
Dr Todd Levins (01:27.908)
We're engaged in all those domains of our life and movement is something that gets really significantly impacted negatively in the sphere of reducing bone health. And particularly this landscape is so populated with fear. So I got interested in bone health because of my
my primary interest in physical health, musculoskeletal health. I do a lot of injection therapy. So the model that we use from an anatomy perspective is having an understanding of how forces of compression and forces of tension positively impact bone. the bone applies compression and then connective tissue muscle applies that positive forces of tension.
Dr Todd Levins (02:43.17)
And then I started noticing that I have these largely menopausal women who led an active lifestyle. And then, you know, they turn 65, they might have that one risk factor that enabled a primary care provider to order a DEXA or they're age 70 and they're getting that DEXA ordered if that actually happens for them because often it's not happening.
And then that comes back with the diagnosis of osteoporosis and then they shut down.
They stop moving. They stop their active lifestyle. They stop wanting to lift their grandkids up. There's just it's parked with fear and and that only compounds the frailty and it's the exact opposite of what we want people to do. It's the exact opposite of what we look at from an evidence based perspective. And it's not good enough. So we we started looking
at ways of assessing.
and getting ahead of this curve, getting ahead of the trajectory in order to screen for this in a way that is meaningful, that's reliable and valid in order to change the trajectory of a condition and to empower patients with evidence-based tools to change bone health in reference to overall health. that's where Bone Health BC came from.
Kim Vopni (04:37.038)
Mm hmm. It's very needed. To your point, there's a lot of fear. As you said, there's a lot of fear in pelvic health as well. And pelvic health is often the reason women stop exercising either because of symptoms or because they're told they need to stop. And then in the effort of trying to quote unquote, protect the pelvic floor, they're now increasing their already increased risks with the bone loss. And you mentioned a couple of ages, 65, 70. And that's
you know, maybe when a Dexa is being ordered, if it's even being ordered at all. And I'm sure you agree and many other people agree that's that's way too late. And we really should be screening for this earlier. At what point do you think?
conversation but also the screening. mean if you think of there's a lot of conversation with Dr. Vonda Wright exploding in the menopause space and so talking about the ages where we are reaching our peak bone mass in 20s 30s but we're just not thinking about bone health there and what I have learned is people are more likely to take action when they have a problem to fix rather than trying to prevent it in the first place. So how can we change this so that we aren't getting to the age of 65 and getting the diagnosis of osteoporosis?
Dr Todd Levins (05:53.411)
The risk of osteoporosis doubles every five years between the age of 40 and 65. yet we have in BC, well in Canada, we have a system that is not powered to assess earlier really than the age of 65. And at that point we have an entrenched disease state that has overall poor management. the individual, the social and the public health
Dr Todd Levins (06:53.284)
of women that experience a hip fracture will die within a year, 33 % of men. One in three women will experience an osteoporotic fracture in their lifetime, and one in five men will. So there's, the government of Canada in 2021 put a report out and it's the cost of osteoporosis to the system is $4.6 billion. And that's a billion with a B.
Kim Vopni (07:19.256)
Billion with a B, yeah.
Dr Todd Levins (07:23.294)
This is a disease state that is that's pervasive, that is so destructive to individuals, social and public health.
and we don't have a system that's powered to get ahead of that curve. we, the numbers dictate that this should not be any different than doing like a fit test for, know, prior to a colonoscopy or a pap test or all these other screening tests that are, that are part of the structure of the healthcare system because of what the implications and the consequences if we don't catch these things.
And we have this health condition and this disease state that carries with it all of the hard numbers that inform that we should be getting ahead of this. Let alone what I was mentioning earlier, these largely women, but of course the numbers speak to men as well, that fundamentally alter
the quality of their life with this diagnosis. if we change this into a screening model and that takes the right assessment tools, which we can talk about, then we can change that from an entrenched disease state to something that's modifiable.
Kim Vopni (08:55.938)
Yeah, yeah, and having the awareness earlier, excuse me, earlier in life. So the screening tool, there are tools, but the one that most people think about is the DEXA. So if we can start out, what is the DEXA? What is it doing? Like how is the test administered and what information do we get from that test to understand what's happening with our bones?
Dr Todd Levins (09:03.937)
Yep.
Yeah, exactly.
Dr Todd Levins (09:20.354)
First, I will start with what the definition of osteoporosis is, because it helps to inform the conversation. that definition is a WHO consensus statement from 1993, so it's been around quite a long time. And osteoporosis is characterized by reduced bone mass, degraded bony microarchitecture that results in a consequent increased risk of fracture. So what's important to note there is that we are talking about bone mineral
bone mineral density, bone mass, and bony microarchitecture. bone mineral density refers to the outer layer of the bone, the compact or cortical bone, and bony microarchitecture refers to what the bulk of the bone is, and that's termed the trabecular bone, spongy bone, or cancellous bone, but most commonly trabecular bone. So when we bring the density and that bony microarchitecture together, now we're talking about bone strength.
DEXA is a tool that was developed in the late 80s for research purposes and then became a clinical tool in the mid, the early, in the early 1990s, which is when we started having this, this, this tool, which became diagnostic to give us insight into what's going on with, with that bone. But it's important to note that that DEXA only assesses the outer layer, the bone mineral density. So,
we have this diagnostic tool that only gives us insight into one of the parameters of the criteria for the diagnosis of osteoporosis. The way that DEXA works is that it is low dose ionizing radiation x-rays that is typically a hospital-based diagnostic tool. So patient will lie on a bed not unlike any other
x-ray and anytime we're assessing like bone or tissue essentially we're just putting energy through matter and then determining what that change is so with an x-ray it's passing through that matter in this case tissue well the tissue that we're interested in is bone and then you know there's effectively a plate on the other side that's capturing that energy and making that into
Dr Todd Levins (11:50.595)
like readable data.
What we'll get out of that is bone mineral density. And bone mineral density is measured in grams over centimeters squared. And what that centimeter squared means is that we are measuring an area, we're not measuring volume. And bone is a volume, right? Bone is volumetric. So we know off the hop that we are using a diagnostic tool that is validated, is the standard that is important to keep in mind that it is what most of our understanding
of bone health is predicated on, but it is only measuring area. It is not measuring volume. And that's not how bone works. Bone is not a flat surface. It is volumetric. And...
The bone, like all tissues in the body is dynamic. It is always undergoing breakdown and rebuilding. So specifically with bone, that breakdown is the resorption and the buildup is the absorption. And there's all sorts of different systemic factors that we look at from, you know, I am an anthropophic physician. I am looking at things from a system based approach, from understanding what's going on within the entirety of
Dr Todd Levins (13:27.232)
But that volumetric side, that resorption largely occurs on the outside of that bone. So that DEXA is the standard. It is what is used to diagnose osteoporosis. And it is really, really important to keep in mind that the definition of osteoporosis, reduced bone mass,
which is used interchangeably for bone mineral density, but it is not the same thing. And then the reduced bony microarchitecture. And that reduced bony microarchitecture is not measured in DEXA. Yes.
Kim Vopni (14:10.105)
Yeah, so the people who have a DEXA come away with either they're told they have osteoporosis and that is measured by the T score number they get. And then there's also the, if you can distinguish between osteoporosis and osteopenia and what the difference of the T score would be there.
Dr Todd Levins (14:21.654)
Yes, exactly. Yeah.
Dr Todd Levins (14:31.874)
So the T score is based off that bone mineral density, that grams over centimeters squared. T score is measured against a healthy control and the healthy control is a 30 year old. that is, there's a reference range for that. And it's important to keep in mind that all those reference ranges are all based on Caucasians. So we don't have any validated T scores for populations, for non-white populations.
Dr Todd Levins (15:31.821)
minus 2.5 or less. Osteopenia is a, it was never a diagnostic term. It's a descriptive term and the bone community, both academic and clinical is moving away from that. However, it is still a diagnostic category. So osteopenia exists between minus one and minus 2.5. The reason that the community is moving away from the descriptor osteopenia
it's because these are not discrete categories. We want to be thinking about this as a continuum and it does support the idea of getting ahead of the curve from an assessment perspective because it gets us thinking both from a clinical perspective and from a patient-based perspective that this is a continuum that largely moves into the more degraded. And so we want to have an understanding of where our patients are with respect
Kim Vopni (16:44.952)
Right, right. So as you were talking and describing, I love the way that you gave a very good image on what the Dexa is actually looking at. As you say, it's just the outside and there is volume to bone. So how do we now assess more in depth, kind of pun intended, getting deeper into the bone and thinking about it from a volumetric point of view?
Dr Todd Levins (17:06.614)
Yeah, yeah, yeah, yeah, yeah, yeah, yeah.
Yeah, well again, I'll go back a step to give a little bit of an idea of how bones work from a metabolic perspective. Bones are always in flux. So that remodeling is always going on more so at peak bone mass, is age 30.
Bone is about a third protein and two thirds mineralized bone. And that represents this shift, that metabolic change over time of that protein becoming mineralized and becoming structurally integral in the bone. So the cells that make bone are osteoblasts. The cells that pull away from bone are osteoclasts and osteoblasts as they mature become osteocytes. So site means cell.
So these are bone cells and all that that bony micro architecture. Those are all osteocytes and osteocytes are the kind of the site supervisors of bone. They regulate metabolism and they respond to one thing. One input and that input is mechanical stress. So if we are not positively stressing bones like bones have to bend.
in positive way, then we're not optimally affecting bone metabolism. So we need to have an idea of what's going on with that bony microarchitecture. there is an assessment tool called REMS, and REMS is Radio Frequency Echographic Multispectrometry. And it originated as a project of the National Research Council of Italy in mid 2010s. It is ultrasound based, so it uses both
Dr Todd Levins (19:05.476)
radio waves and ultrasound waves to give us information about what is going on with that bone. So whereas DEXA uses those ionizing x-rays to pass through the bone, with ultrasound and radio waves, we are directing those waves into that tissue and then they bounce back. So you're using a probe, a transducer, at the regions of interest.
case we are assessing the lumbar spine, the L1 to L4, and then the femoral neck, the same as the same as DEXA. And from that REMS generates a bone mineral density, but then it generates something called the fragility score. And that fragility score is an indication, a validated indication of what's going on with that bony microarchitecture. So it gives a numerical value on that. And
then we can combine those in a matrix score to give us a validated five-year predictive risk of fracture for that region of interest. So REMS allows for a rapid, safe, non-radiation, non-X-ray, so rapid, it's about a 15-minute scan conducted by a sonographer. And then...
Dr Todd Levins (21:30.561)
So it's important to note that it is an assessment tool. It is not a diagnostic tool because it does not go to a radiology review. And that's what happens with DEXA. The machine does the work and then a radiologist reviews that. And then that becomes diagnostic. And REMS doesn't do that because it is an AI generated report that has high validity, that has high reliability,
Dr Todd Levins (22:06.464)
But really what we're wanting to do and what we're trying to affect change in is assessment, is to screen and to have an understanding of where someone is so that we can properly support that individual over a long-term trajectory to avoid the frailty, avoid degraded bone health. know, it's as you were alluding to either earlier that
Kim Vopni (22:29.507)
Mm-hmm.
Dr Todd Levins (22:56.898)
quantitative objective feedback of where you are and how that changes over time is immensely powerful to affect and motivate behavior and change and REMS is REMS is Sensitive enough meaning that it is powered to detect change at eight to ten months Where DEX is is powered to detect change in about 24 months
And you know, the guidelines within Canada anyway, if one has moderate osteoporosis, then front first line therapy is being on a bispocin class drug for three to six years, but typically in that five to six years. And then you stop the drug and then you reassess three years later. And that's a long time, especially that three years without any idea of what, how
Kim Vopni (23:52.879)
Mm-hmm.
Dr Todd Levins (23:56.981)
like from an objective perspective what's changed. We're talking about a population that's already fearful, that's already disengaged from physical activity and now we're prolonging that. having the ability to assess, to provide valid, reliable, objective feedback as to, okay, well these things that you're doing, this treatment plan that we've put in place, we can corroborate that and say, yeah, you're making positive changes.
Kim Vopni (24:30.947)
Do you recommend, because REMS is not diagnostic, even though we can get a lot of really valuable information from it and we can reassess and see what's happening quicker, would you still recommend somebody do a DEXA and a REMS or would you just be relying on a REMS?
Dr Todd Levins (24:48.478)
Yes, we still recommend recommendadexa. because it's, know, both are assessing with their own levels of reliability.
Kim Vopni (24:52.205)
Both, yeah.
Dr Todd Levins (25:01.546)
something that exists independently of what the value that is that comes out of that assessment. So that DEXA is an approximation of bone mineral density. REMS is an approximation of bone mineral density. And we really only can determine that bone mineral density after death. And that's not particularly palatable. So we can't compare it. We can't directly compare the values between REMS and DEXA. And diagnosis is important.
Kim Vopni (25:18.819)
Yeah. Yeah.
Kim Vopni (25:30.595)
Mm-hmm.
Dr Todd Levins (25:31.413)
it triggers certain things within the system in terms of follow-up care, terms of provision of access to medication, referral to androchronology if that's required.
and keeping in mind that that is only available for the vast majority of the patient population at the age of 65. And we've, you we earlier said that the risk of osteoporosis doubles every five years from the age of 40 to 65. So we're just missing so much opportunity to, to assess, to screen, and then to do something meaningful and proactive on that trajectory.
Kim Vopni (26:10.786)
Yeah. Could somebody theoretically be, if they'd had a DEXA that diagnoses them with osteoporosis, they have a REM scan. Let's say they do them within a couple of days, like around the same time. And it shows a low, could they still have a low fragility, a low risk of fracture, even if they had osteoporosis?
Dr Todd Levins (26:32.202)
so if, sorry, if I understand your question correctly, yeah. Yeah. Yeah.
Kim Vopni (26:35.01)
So with REMS looking at the T score and your fragility score, the likelihood of fracturing within five years, could somebody on a REMS score have a T score that could indicate osteoporosis and also have a low fragility, a low likelihood of fracture within the next five years?
Dr Todd Levins (26:54.004)
there.
There should be concordance to a certain degree between the DEXA and the REMS T score, the bone mineral, or more accurately, the bone mineral density. There can be some divergence with that fragility score, meaning that the overall health of the bony microarchitecture is better in relationship to the cortical bone. And yes, that will positively influence, meaning that
overall risk from that validated fragility score will be down. Hips don't fracture just at the cortical bone. That's not where the morbidity and the mortality comes from.
hips fracture through and the region of interest that we're looking at both with Dexa and with REMS is the neck of the femur. the shaft of the femur and then the neck and then the head of the femur. And there's a number of different reasons why that is most subject to fracture. It has a lot to do with the way that force travels through. So it's moving directly up and then obliquely through that. And that neck is a little bit in relationship
to the shaft of the femur, the greater trochanter, there is a higher proportion of compact bone of that cortical bone there. And one of the risks that can happen with the bisphosphaminate drugs is the atypical femoral fractures.
Dr Todd Levins (28:39.314)
And the reason that those are termed atypical is because we see this shearing of that femoral neck there. And that is not a typical fracture. That fracture is more typically like splinter. So that force traveling through disperses in multiple directions and results in a fracture. And the reason that we think that that area is subject to these atypical
fractures in the context of the bisphosphonates is because the bisphosphonates are anti-resorptive medications. So they slow down the resorption of the bone, which is the loss of bone from that cortical bone. But they really don't do much for the bony microarchitecture. So you have...
you have this veneer might not be an overly accurate term for what describing that compact bone, but you have a somewhat strengthening of that, right? Which is, it's going to reflect an improvement in the bone marrow density, but you have like ongoing degradation in that bony microarchitecture. So the structural piece of that is losing integrity. You have some improvement in that cortical
bone and then when that force goes through there it is through a somewhat of a metabolically deranged bone and it shears and that's why we think that that that that that it's subject now you know that it is still a relatively rare
adverse effect of the medication, but it gives us insight into how that bone metabolism is being affected both in the context of the medication. And it supports this idea that, you know, the tool assesses, DEXA assesses cortical bone, the drugs affect cortical bone, and then adverse effects affect the entirety of the bone. And so the lens is on the cortical bone.
Dr Todd Levins (30:50.308)
at the exclusion and at the risk of the entirety of Yeah.
Kim Vopni (30:53.452)
Yeah. Yeah. Yeah. Because my mind thinks that, you know, somebody could technically get this diagnosis of osteoporosis and in a REM still have, you know, if they could walk away from just a DEXA thinking I'm going to break. If they had the REMS information on top of that, it may show, it may give them more information and reduce some of that fear because of
that fragility risk score. That's kind of where my mind was going, which is powerful information.
Dr Todd Levins (31:24.384)
Yeah. Yeah.
Yeah, it's and vital. mean, it's, you know, I don't mean to hammer the point, but the diagnostic criteria for osteoporosis includes that bony microarchitecture. So if we don't have insight into that, we're not fully diagnosing the condition. And because that interior of the bone, that trabecular bone, is where the osteocytes are and because they are responsive to mechanical load, mechanical force only, and there's kind of channels in the bone that
themselves in relationship to the force that goes through them, which allows for proper force to move through the bone to disperse properly through the bone. So if we do an assessment on somebody and we show that yes, there is some loss of bone mineral density and yet your bony microarchitecture is relatively robust, then we have way more confidence to appropriately and often in a supervised way
Put these people through load right because we can't positively impact the The overall health of the bone unless we're loading it so we need to know where we're the state of where the the trabecular bone and the cortical bone is in order to In order to build a help build a plan and there's some great there's some great programs out there to
evidence high level evidence base that show that lifting and lifting heavy is is evidence based high level evidence base to improve both the what we measure so bone mineral density and more importantly outcomes yeah avoidance of fracture and frailty
Kim Vopni (33:16.98)
I want to get into the loading part and then also the the fuel, the substrate that's going to be building the bone because of that movement that we're doing. You said bending bones and that gives people a weird image and we may even think about bending too much and we get that splinter fracture. But what can you elaborate on when you say bones should bend and when you talk about loading the bones?
Dr Todd Levins (33:29.409)
Yes.
Dr Todd Levins (33:33.163)
Yeah.
Dr Todd Levins (33:38.41)
Yes, yeah.
Kim Vopni (33:42.735)
And then the kind of the point I want to also highlight is when you talked about we have the femur and then we have the neck and we have this oblique angle of it and it's going in the head of the femur. When we think of load, at least how I think of load, we kind of think of loading through the spine and we're standing upright and we're experiencing load going through the body. And because of that angle,
Should we be applying load only through the feet or from the top of the head or should it also be from like on the side of our hips to does that make sense?
Dr Todd Levins (34:16.01)
Yeah, absolutely. Yeah, I should clarify what bending bonements and you know, it's that goes back to this, that bone is a third protein and two thirds mineralized, right? So we think of bone as being this like rigid, static structure and it's not, it's more dynamic than that, right? It's more dynamic than that metabolically and it's more dynamic than that from a biomechanic perspective. So that third that is protein,
is a bit flex in the bone. And it is that input into the bone, whether we're talking about the femur, whether we're talking about the vertebra column, whether we're talking about any area of the body that...
Dr Todd Levins (35:18.624)
So it's that that I mean with bending. It's an intentionally provocative statement because that pervasive understanding that bone's static, that it's rigid. And it isn't. It's much more dynamic than that. So we want people thinking in that way. The highest level evidence from a study perspective,
involves these lift more trials. the lift more trials were lifting intervention for, I always forget the acronym, but basically it's strength, strength training and impact loading. So these were, there was a arm and a female arm that of these studies that were conducted in the late 2010s that looked at high intensity, high load training and
So the strength training involved deadlift, back squat and overhead press and the impact load ultimately was looking at jumping chin up bar and drops. So there was also like time get up and go within that and the load was 80 to 85 % of your one rep max, five sets of five.
And whenever I have this conversation, when I talk to groups of doctors, when I talk to the public and I query and I say, thinks they can do 80 to 85 % of their one rep max? And regardless of the demographics of the room, there's very few hands that go up.
because the thought of that can be intimidating. But when we break it down, that's a relative, that's a relative describer, right? So it's your one rep max. You don't need to do your one rep max to figure out what your one rep max is, right? There's equations that help us do that.
Kim Vopni (36:59.182)
Mm-hmm.
Dr Todd Levins (37:15.01)
But if your one rep max on a movement is 20 pounds, then you're working at 16 pounds. And that is much more approachable than the idea of stacking a bunch of 45 pound plates on Olympic bar. And it's important to note that in these studies, this did look at...
Kim Vopni (37:28.674)
Yeah.
Dr Todd Levins (37:40.417)
Men and women in late 40s to late 60s, or even in the 70s, they were on board. So they were taught these movements. And there were no serious side effects. There was no fractures in any of studies. The studies lasted eight months.
Dr Todd Levins (38:31.204)
think it's something that, I know it's something that you talk about extensively with, through your platforms that strength is a wonderful gift that we can give ourselves. It fundamentally changes the way that we move through the world, both like from a mechanical perspective, but even from a confidence-based perspective. And any of us that work with patients or clients and get to witness that transformation over time, it's phenomenal.
Dr Todd Levins (39:12.534)
You know, it's okay that life is hard. We're supposed to do hard things. And if we're strong, it's a little bit easier. And then, you know, there's also just like the, as you progress through in that one rep max that initially is 20 pounds. And as you gain that strength and that number goes up, that is always accompanied with a tremendous sense of completion, of challenge.
Kim Vopni (39:15.893)
Mm-hmm.
Kim Vopni (39:20.738)
Mm-hmm.
Dr Todd Levins (39:42.541)
you know this concept of like positive friction that we all benefit from it just makes us more resilient more adaptive to stress in all senses so that's what we talk about but we also have an understanding that you know not everyone is going to is is going to resonate or or be able to do that type of high intensity loading and
Kim Vopni (39:45.838)
Mm-hmm. Mm-hmm.
Kim Vopni (39:52.097)
Yeah.
Dr Todd Levins (40:11.464)
So the predominant message is some movement is better than none. And we can meet our patients and our clients where they're at in an appropriate way. if they have significant osteoporosis and if their microarchitecture is degraded, then we want to be doing that in a safe and supervised way. Water-based activity doesn't do a ton.
for bone mineral density, but it does more than setting it down. So we want, that's where we talk about relative gain, right? Rather than absolute gain. And then also recognizing that this is a process over time and not all of those results need to be there in a year. So if we're bringing our clients or our patients over time from water-based resistance activity or just movement to land-based strength training, then that's a perfect
Kim Vopni (41:14.828)
Yeah, and progression is an important word that I talk about a lot because we, again, social media is doing a great job of increasing awareness about many things, but the messaging that is often taken from that is all women have to lift heavy and what does that really mean? And again, in my world, people think, well, I can't lift heavy and I've been told not to lift heavy and so they don't and they've become deconditioned and regardless of where you're starting,
Even if you have been an active person lifting, some sort of resistance type training, you still need to go through progressive overload and get to the point where you have good technique and you don't just pick up a heavy weight and now you're lifting heavy. Yeah. Yeah.
Dr Todd Levins (41:54.219)
Yeah, no, that's the last thing we want people to do, particularly when the risk is there, right? No, I mean, we...
Kim Vopni (42:01.037)
Yeah.
Kim Vopni (42:07.938)
Yeah.
Kim Vopni (42:32.492)
Yeah. Yeah. With, I want to end with kind of the, the, talk about protein and so how we are, how we, what substrate we need to make sure that our body has what it needs to build the bone and go through that build and the osteoblast and osteoclast perspective. We need the, the force on the bone. So if, is it, is it most appropriate to be loading in a standing position?
it can like I think about I have a vibration platform and there is evidence that even just standing on it for x number of minutes and that's ideally like you can have maybe a slight bend in the knee but some people are always are are not loading actually through their joints because their knees are already bent or their hamstrings are too tight so should we be vertical
Should we be doing something on the side is kind of to that point again about the angle of the bone or is is loading vertically enough.
Dr Todd Levins (43:34.487)
Loading vertically is enough in the sense that those lift more trials look at close chain exercises like the deadlift and back squat, right? So, both of those like, you know, that's a lift off the ground or a compressive load on the shoulders, right? So it's axial loading. And so what we're thinking about there is axial skeleton, that's essentially the spinal column.
and then the appendicular skeleton, the legs. So anytime that we are pushing off the ground or resisting force down to the ground, are appropriately loading that axial skeleton and the appendicular skeleton, accounting, allowing for variability in terms of slight differences in the way that you're going to load through the left leg to the right leg. And yes, your example of like being on a vibration plate and having those legs lost,
Kim Vopni (44:14.488)
Mm-hmm.
Dr Todd Levins (44:34.44)
versus bent. Yeah, I mean that we're always thinking about how force transfers through the body, right? And when a knee is bent, that is going to dissipate force to a certain extent through that knee and there is going to be less force transferring from the knee up to the hip than if that leg is locked out. So again, that vibration is a mechanical force.
Kim Vopni (44:35.299)
Mm-hmm.
Kim Vopni (44:41.486)
Mm-hmm.
Kim Vopni (44:49.538)
Mm-hmm.
Kim Vopni (44:59.246)
Yeah.
Dr Todd Levins (45:04.26)
a low-grade like mechanical force. Vibration is its own energy input, but it does result in a little bit of mechanical loading. So no, can, when we are thinking about avoidance of fall, and proprioception and all that, then there is benefit from thinking about lunging and those one-legged movements. So we don't want
Kim Vopni (45:31.693)
Yeah.
Dr Todd Levins (45:34.193)
to just think about it from the bone mineral density. We want to think exactly what you're describing. We want to think about it from fall prevention, from agility, from maintaining like some efficient transfer of neurologic energy from the central system to the peripheral system. And that all involves like that agility and one-legged loading. And then to your second question there in terms of
Kim Vopni (45:58.041)
Yeah.
Dr Todd Levins (46:01.698)
How do we rebuild? Yeah, exactly. When we're talking about breakdown and rebuilding, that means that the materials of rebuilding have to be there in adequate quantity. And that is largely protein. We've talked a number of times that bone is a third protein. And that is largely collagen. It is type one collagen, almost exclusively. so ensuring that the diet is
Dr Todd Levins (46:41.602)
The system will preferentially pull minerals, chiefly calcium, because it is a buffering agent effectively. So when there is systemic inflammation, systemic, like low grade infection, acidosis that is lifestyle related, then we are going to be resorbing calcium to buffer both that extracellular matrix and, you know, blood is fairly tightly controlled in terms of that, the pH range, but less so outside
of the blood, but yet vitally important. And so if we're not thinking about those things from a health support perspective and identifying, there are systemic influences here, independent of nutrition that we have to address. that's where that comprehensive kind of system-based approach from an antibiotic perspective or otherwise can be beneficial. But yeah, we need adequate amounts of vitamin D, we need adequate amounts of vitamin K, we need adequate amounts
Kim Vopni (47:32.856)
Mm-hmm.
Dr Todd Levins (47:41.509)
of dietary calcium and to a lesser extent phosphorus and zinc but protein is the number one thing there. it's you know we've been doing the BoneHealth BC has been doing REM scans and supporting patients for only about a year and a half but in that time that is enough time for us to to have an original an initial scan
Kim Vopni (48:02.893)
Mm-hmm.
Dr Todd Levins (48:11.028)
Support like so doing building a plan for somebody looking at you know So we do diet tracking and have an idea of where they are now what what's going on from a lifestyle perspective? putting in place some movement some prescriptive exercise and supplementation and then sometimes Sometimes medications for sure And then you know the the name of the game in you know in conventional osteoporosis is well if you're not losing your gaining
Kim Vopni (48:26.776)
Mm-hmm.
Kim Vopni (48:31.18)
Yeah.
Dr Todd Levins (48:39.65)
And that's understandable, but why not just gain? And we see that. We see that in these patients when we identify these lifestyle diet and movement-based.
Kim Vopni (48:45.292)
Yeah.
Kim Vopni (49:07.522)
Yeah.
Look what happened. Yeah. Yeah. How does somebody go about getting, no, this is obviously very BC centric, but REMS is elsewhere in the world. So in BC, BoneHealth BC, what's the cost for having a scan done in BC?
Dr Todd Levins (49:18.794)
Yes, yeah, yeah, yeah, yeah,
Dr Todd Levins (49:27.17)
So the cost of the scan is $195 plus tax. It's about a 15 to 20 minute scan. get that immediate report that you can bring to your primary health care provider if you have one. We are also, we do offer, you know, we...
One of things that we recognized relatively early on in this is that we were handing these patients a report that they weren't able to act on.
A, it's new technology, B, maybe a third of those patients that were scanning don't have primary care. And that's disempowering. That's exactly the last thing that we want to be doing. So we have built a continuity of care model where people that get scanned can book an online virtual appointment with one of our naturopathic doctors to go through the review of that interpretation and then build a plan.
And we do also offer.
15 minutes complimentary consults for practitioners, for doctors to say, know, I don't want my patient, this is new to me, this technology, I don't know how to interpret this, can you help me with what this means? so, you know, we're trying to affect change at the level of, at the patient consumer, but also in terms of like the educators and the clinicians out there.
Kim Vopni (51:02.446)
So if somebody was living elsewhere outside of BC, potentially other parts of Canada or anywhere else in the world, REMS, R-E-M-S, is there a directory of practitioners elsewhere in the world that you know of or just sort of go to Google and put REMS and...
Dr Todd Levins (51:17.194)
Actually, that's a good question. I don't know if there is a directory. It's more common in the States. So there are a number of centers that are utilizing this more frequently. NASA is utilizing REMS, so they're in their space simulator, they're monitoring change over time with their astronauts' bone health.
Kim Vopni (51:44.846)
see if you can book an appointment with NASA. Yeah, okay, I'll do some research and see if I can find it, if there is a master directory of that, but.
Dr Todd Levins (51:46.144)
Yeah, yeah, yeah, just go to the International Space Station and get a REM scan. Should be easy.
Dr Todd Levins (51:57.473)
Well, you've raised a good point for me, because that's something I should know, so I will be immediately looking on that as well.
Kim Vopni (52:01.622)
Yeah. Yeah. So where can people find you? I know you have your own private practice in Victoria also and where would people find BoneHealth BC?
Dr Todd Levins (52:12.46)
So BoneHealth BC, our website is bonehealthscan.ca. So we have a lot of information on there about the scan itself, about interpretation of the reports, but that will also bring you to a booking link. So because this technology is portable, it travels. The machine travels, we have about 10 sites in the lower mainland, three sites in the Okanagan, three sites on Vancouver Island,
And then patients can look and see where the next available clinic might be and then sign up. And we're bone health BC right now, but we will be bone health and much broader than the... Yeah, exactly. I mean, it's...
Kim Vopni (53:00.726)
In a nutshell.
Dr Todd Levins (53:11.54)
leave strongly in the advocacy and the screening and that is not limited to to to BC this is this is a North American and international concern that we want to make sure that we're doing everything we can to effect change.
Kim Vopni (53:19.757)
Yeah.
Kim Vopni (53:24.066)
Yeah.
Go Dr. Levens. I support you. Thank you so much for sharing all your knowledge. yeah, I've had the test on myself. It's very easy. It's very informative. And I'm actually waiting for a buddy to have a set of due for my follow up. Yeah. Yeah. Yeah. And I had my girlfriends. I recruited my girlfriends for the first time. So we'll be doing it again.
Dr Todd Levins (53:32.012)
Thanks, Kim.
Dr Todd Levins (53:41.398)
Yeah, was about to say we probably need to scan you again. Yeah, yeah, yeah. See if all your... Yes, that's right. Yeah, well, we should, yeah, we should rescan everyone and then see if all your lifting heavy shit is working.
Kim Vopni (53:56.598)
Yeah.
Kim Vopni (54:00.361)
Yeah. Yep. All right. Well, thank you so much. was a pleasure to have you. I appreciate you sharing all your knowledge.
Dr Todd Levins (54:07.895)
Thanks, Kim. I really appreciate it.
