Kelsey Magnuson (Host): Hi everyone. I'm Kelsey Magnusson, community Benefits Manager here at Emerson Health. Today we have Dr. Mela, double certified in. Internal medicine and endocrinology, diabetes and metabolism. She currently practices as an endocrinologist at Emerson Hospital where she earned several accolades from her patients and peers alike, including being named one of Castle Connolly's top Doctors of 24 and 25, and also having the honor of being on the cover of Boston Magazine Top Doctors this edition this past February.

She earned her MD from the Medical College of Virginia, completed residency at the University of Connecticut and fellowship in endocrinology at Brown University. She has authored various publications and also served as associate professor at Roger Williams University prior to being here at Emerson Health. I know you are a passionate advocate for women's health, and I'm excited for our conversation today, Dr. Mandala.

Sravanthi Madala, MD: Thank you for having me. I'm so excited to be here on the podcast, video podcast today, Kelsey. I'm always thrilled at the opportunity to spread awareness and spread education on, health and what we can do about it.

Kelsey Magnuson (Host): Awesome. We're gonna be continuing our series on how women's bodies change during perimenopause and menopause and how we can best. Support it. So we're hoping to continue to normalize this conversation of symptoms and changes and increase awareness on what we can actually do. So Dr. Meall is here to empower us all on how we can manage these changes and support our bodies.

We know a big aspect of menopause is the drop in estrogen, so how does this affect different parts of our body?

Sravanthi Madala, MD: It's a great question. So estrogen is, peaks in females around, puberty years, and it continues to stay elevated and, and nice and, and. normal ranges until we start to hit the perimenopause years and menopause years. Once we hit menopause, there's a drastic drop in estrogen that is precipitous more than, just a gradual decline, such as we see in testosterone with males as they age with females.

Once we hit menopause, there is a quite steep drop in estrogen, and with that comes. Just overall slowing of many different aspects. Lower metabolism, there's a decrease in muscle mass. There is an increase in insulin resistance and that affects glucose metabolism and regulation increases our risk for diabetes and, affects fat distribution and storage where the results as changes in weight gain and high cholesterol and body composition.

And it also has a great impact on many different metabolic pathways.

Kelsey Magnuson (Host): it's helpful to understand how it's affecting all these parts. so what other big systems does the decrease in estrogen impact?

Sravanthi Madala, MD: As an endocrinologist, one of the big systems I see a change in is your bones. So our bones change dramatically, especially as the estrogen drops. Estrogen and testosterone have a protective effect on bone turnover, and they do this by promoting osteoblasts, which are the bone building cells. They help lay down matrix on the bone and suppressing osteoclasts, which are the bone breakdown cells.

I think of them as little Pacman cells that like to eat up the bone, and a loss of bone density that comes with the drop in estrogen or testosterone for males. Increases our fracture risk because for females the drop is much more sudden than it is in males. And with the loss of estrogen, our bones actually have, estrogen receptors.

And when estrogen is stimulating that, the bone density is up as the osteoclast can do their thing and it suppresses the bone breakdown. so doing their thing and the role of, estrogen is also connected to calcium, calcium absorption. Bone remodeling is, done a lot through the gut. Actually, estrogen binds to receptors in our intestines and stimulates certain proteins that aid in calcium absorption.

Kelsey Magnuson (Host): Great. So it seems like the ways that it is affecting the metabolic system in how our bodies absorb and break down food is also so impactful with our bones, because if we can't break down the food, then our bones can't absorb what we're consuming. Is that

Sravanthi Madala, MD: Exactly. Exactly.

Kelsey Magnuson (Host): Okay. so it's really helpful to get that base kind of start of what's happening in our bodies to then know what can we do about it. And I've heard you talk about these key pillars that we can focus on, in order to thrive through these change. So remind me, what are those four pillars?

Sravanthi Madala, MD: Sure. I love to talk about the four pillars of health. The four pillars of health are the one. The energy you put into your body. What type of food are you ingesting? What are you drinking? What medicines, what supplements? What is going into your body? Two, energy output. What are you doing to expend energy?

How are you expending your energy? Exercise, movement, all that stuff matters. Three. Mindfulness. Stress plays a huge role in how we react to things, and it's a huge inflammatory thing that, affects how our body responds and the body remembers, the body remembers and the body holds onto this. So it's important to have good releases for that stress and be mindful and, and, reduce that tension on our bodies.

And of course, the fourth pillar is sleep.

Kelsey Magnuson (Host): So those really are as you said, the pillars of health and overall health today. So I know that, the tips that we dive into are gonna be helpful to. Everyone. and I know that you're gonna really help us understand how each of those are so important through this key phase of life that women go through of peri and menopause.

so diving deeper, I'm excited to learn about each one. Starting with food. what can you tell us about how food helps us with our metabolic system and bones and through this stage of menopause?

Sravanthi Madala, MD: Sure. So food. We need about 200 milligram of calcium per day, especially as we enter those. Menopausal and menopausal years to help maintain healthy bones. Most women reach peak bone mass around the age of 30, and we all start losing bone slowly after that. Males also start losing bone into their forties and fifties, but it's much slower when women reach that menopause time where our period stop and estrogen drops.

That's where the bone decline really drastically happens. so while it's really important to set up the foundation of our bones in our thirties, it's also really important to maintain that and also help. set it up even further if we were not doing, all the stuff in our thirties So calcium is best absorbed through the diet.

There are dietary sources of calcium and there are supplements. Some good dietary sources of calcium include the dairy products such as milk, which has about 300 milligrams of calcium per cup. Yogurt, which has about 400 milligrams per cup cheese, depending on the type of cheese and. Leafy greens are a good source of calcium too, but it's hard to get that much calcium from leafy greens as much as you get from milk.

You would have to eat about eight cups of cooked spinach in order to get the same amount of calcium as one cup of milk. We all can't be Popeye here, but you get the picture. And, for those that are lactose intolerant, lactose free, food and lactate products also have the same amount of calcium, similar to the standard dairy products.

So if you can't do dairy, if you have an intolerance, then non-dairy, almond milk, oat milk, soy milk, they're all fortified with calcium. And since it's being taken and absorbed through the gut, it is still better than a supplement, even though that is a more supplemented type of, fortification that is done in the fortified products.

We also need vitamin D. It's called the sunshine vitamin for a reason because when certain rays of the sun, certain UV wavelengths of the sun hit our skin, it sets off a metabolic pathway, which ultimately leads to vitamin D production. But where we live, unfortunately, the farther. One lives from the equator.

The sun's rays don't hit our skin at the right angles in order to, produce that vitamin D efficiently. And also, if we have any form of melanin, we don't absorb as much from the sun either. so the farther the distance is from the equator, the more vitamin D deficiency we see.

And. We typically need about a thousand to 2000 international units of Vitamin D three daily, and this is easily achieved via supplements. and vitamin D is really important because it helps absorb calcium. It helps transport calcium into the bones. It helps our muscles move, it helps our nerves carry messages and your immune system fight off bacteria and virus.

And if you're unable to obtain adequate vitamin D from your diet, a lot of the same foods that are fortified in calcium are also fortified in vitamin D. Then you can supplement with vitamin D supplements or calcium supplements if you're not getting enough from your food. I always tell people to supplement as much as you can from food.

If you're not reaching your daily coda, then calcium supplements. Some great calcium supplements are calcium citrate and calcium carbonate. Calcium carbonate needs to be taken with food and calcium. Citrate can be taken with or without food. Calcium citrate tends to be a little bit easier on the stomach in terms of the constipation and other side effects that, calcium carbonate might have.

And. And you can get vitamin D and big jugs at Costco. BJ's. Choose your wholesale, wholesale retailer of choice and a thousand to 2000 international units. Daily is plenty for most people, as long as you don't have a contraindication to any of these supplements. Ultimately, many people do need to go on osteoporosis medications if they are not able to absorb or keep up with their vitamin D or calcium, or if they have risk factors that put them at higher risk for osteoporosis, and you shouldn't be discouraged if you need medications.

They're meant to prevent major fractures, which could be devastating at any age. A hip fractured. On average takes six years off of someone's life if it happens late enough in life. And what determines whether you need medication or not are various risk factors such as your lifestyle, your family history, your genetics, other risk factors that you may have, which all be, taken into consideration when you talk about osteoporosis with your physician or provider.

Kelsey Magnuson (Host): Thanks so much for, breaking those down. You know, going back to calcium and vitamin D and even talking about the medication. And I love how you said, you know, there's no shame or harm in needing these medications because it is a form of prevention as well, and we want to prevent those falls as much as possible because as you stated, they can be devastating.

I had a question about vitamin D, wondering how vitamin K plays a role in it. I've seen a lot of combination vitamins of D and K and how those play into each other.

Sravanthi Madala, MD: Good question. So vitamin K is a co-factor that is needed for some Vitamin D absorption. And, metabolism. But I always tell people of caution with vitamin K. It's also part of the, the clotting cascade. And so too much vitamin K is also not a good thing. And if it comes with the vitamin D supplement, that is usually a, typically safe enough amount.

I would not recommend taking a separate Vitamin K supplement, nor does the data support needing vitamin K in order to properly absorb Vitamin D. We get plenty of vitamin K from our diet as well.

Kelsey Magnuson (Host): good to know. I always love hearing the perspectives because there's so much information online and what different, companies will push to you. So when we can really get solid evidence-based information, that's key for our listeners. So now that we've talked about what we put in our body, now talk about.

What we do with our body to help, during this phase and time to help our bones and metabolic system with exercise.

Sravanthi Madala, MD: Is paramount. You need calcium, vitamin D, but you also equally need exercise. And what type of exercise? There so many different ones out there. The four I like to focus on are the different types. One, weight-bearing exercise, weight-bearing exercises force you to work against gravity, so walking, jogging, dancing, climbing.

Those are some examples of weight-bearing exercises. Two resistance. these help pull on our tendons and ligaments and increase blood flow to those areas, thus bringing nutrients to those areas. Free weights, resistance brands, weight machines. Those are all great forms of resistance exercises, balance and stability to prevent those falls, which in turn prevent those fractures.

These help. in so many different ways. Tai Chi, Pilates, yoga, those are all good forms of balance and stability exercises, and of course flexibility in order to make sure we are nimble and agile enough to catch ourselves, if we were to fall. And also to promote good healing. gentle stretching, yoga.

Those are great forms of flexibility and good ways to get this exercise. There are a billion YouTube videos out there. If you were to. Google or YouTube osteoporosis fitness exercises. But it's important to do these exercises safely. If we do them with poor form or if we do them without, supervision, then we can actually be doing more harm than good to our bodies.

So I always recommend people to look into their local senior centers or even their local community rec centers. They inevitably will offer, some sort of weightbearing strength training, osteoporosis fitness classes and Also can go through a personal trainer or a physical therapist. That is probably my best recommendation to go through a physical therapist, work for a few sessions with a, physical therapist who is actually skilled in this and get your form looked at, get those exercises.

And then after a few sessions, if you feel comfortable enough and if you're physical therapist thinks you are good enough to be discharged, then you can work on those exercises at home.

Kelsey Magnuson (Host): those are so helpful tips of where and how to get started with these. and you kind of took the. Answer out. 'cause I wanted to ask, where can someone get started with this? 'cause when you hear all of these different things, it can sometimes be overwhelming to think, how do I get started or what do I do?

And, is really helpful to break down the steps. Do you have any recommendations of timing of this or, how much time or how much of each exercise is recommended?

Sravanthi Madala, MD: Sure. I usually recommend 30 minutes a day, five to six days a week. you do what you can, it's hard for a lot of us to incorporate something else into our already super busy lives and schedules. So one thing I love talking about is routine based change. If you build something new into something that is already a routine, it becomes easier to do.

One example I love talking about is my, coffee pot example. So if you make coffee, if you're a coffee drinker in the morning, and if you make coffee, you turn on your coffee pot, if that's what you use. And while you wait for it to drip, go into your living room, do some jumping jacks.

And when you're done doing those jumping jacks. You'll be ready to drink your cup of coffee. It's something that you already do, but you're incorporating one slight change into that because that is a lot easier to do than to pack up a gym bag, join a gym, go to a class, things like that.

But these classes are also phenomenal. These classes are phenomenal and I do highly recommend them. depending on how far from Emerson you live, your senior center will definitely have them.

Kelsey Magnuson (Host): and speaking of those super busy lives, of how hard it is to incorporate new things, we're talking about being busy. And being stressed. So the next pillar you mentioned was mindfulness and how we can try to calm our bodies, in different ways to help. So help us understand how we can use mindfulness and what tips and tricks you have for to get started with that.

Sravanthi Madala, MD: Sure stress is a major pro-inflammatory risk It's a deleterious thing and in our fast-paced society, it is really easy to get swept away with all the stress and the minutia and everything just piles on. we need to make time for ourselves, even if it is 10 minutes a day and disconnect and be present.

And great ways to do this are, art, like go color, get a coloring book in color boxed breathing, deep breathing exercises. Yoga is fantastic any kind of classes on this or even if you work with a therapist, they can also help you practice good mindfulness. And this is not just important for osteoporosis or any isolated disease.

It is important just in how we handle ourselves in our life and to decrease our stressors and that. The body remembers the body keeps score, and practicing. Mindfulness will help us age with more grace and resilience.

Kelsey Magnuson (Host): couldn't agree with that more. And Love how you just kind of broke it down to explain the importance of it, and all the different tips of how to get started on that. so the last pillar is sleep. We all know how important sleep is, so what tips do you have for us or recommendations in this area?

Sravanthi Madala, MD: Sleep is crucial for everything but in terms of bone health, it is during sleep that the body performs essential processes like, bone remodeling where old bone is replaced with new bone. Insufficient sleep or sleep deprivation can slow the bone growth and lead lower bone density and increase the risk of.

Fractures. So in terms of bones in particular, that is why sleep is very important and our body heals in our sleep. So it's important to have that restful time at night.

Kelsey Magnuson (Host): Yes, I feel like I can't read anything or open social media without different things, talking about the importance of sleep and what it does for every aspect of our health. So just another reminder to prioritize it and, again, building into routine, to be able to get that good quality sleep.

Thank you for all of these tips. it's been really helpful to hear and I think that when we go back to the basics and focus on these key habits to help our overall body, it can make a big difference in how we feel through all stages of life, but especially through peri and menopause.

I often hear about the groans and dread of this, time in this phase of life. You've talked about ways to change that narrative and turn it into a time of celebration. So tell us more about how we can reframe the menopause mindset.

Sravanthi Madala, MD: Great question. In my years of being a physician, I've had the privilege of interacting with many different, people various cultures and mindsets, and one. Thing that really stood out to me was the Japanese mindset around menopause. In Japan, menopause is associated with years of renewal and regeneration. And women go through menopause.

are honored and revered in society for their wisdom and resilience. Once they reach that stage. But in many Western cultures, this phase is often linked to loss of uterine fertility, loss of this loss of function. And I really do think we can change the narrative of our own lives, and by redirecting our minds into looking at change with appreciation instead of trepidation, which is really hard to do.

But being cognizant of our own biases and narratives will help change that slowly.

Kelsey Magnuson (Host): yes. as someone who is, looking ahead into that timeframe, I love that the conversation is being built up around this I also think that it can increase fear of what is going to happen and what symptoms am I going to have. So if we can look at this time.

Knowing that it is just another phase of our life and that we can look at that with positivity and being surrounded by community of others who are going through it. I think that is so helpful. I appreciate your time and our conversations today. Any final thoughts or encouragement to our listeners?

Sravanthi Madala, MD: So thank you for again, for having me. I can talk for hours about this and so many other topics. I would like to leave you all with lyrics from one. a song that I heard a few years ago. It's The Bones it talks about the bones of a house and a relationship, but I think it's also applicable to our bones.

And our bones hold up. Our body. Our bones are the structure of our inner workings and, and taking care of our bones takes care of so many things that the bones support and the bones protect, and with calcium, vitamin D, weight-bearing exercise, and sometimes with medication if you need it.

Those are good ways to help keep our structure strong. So when the bones are good, the rest don't matter. The paint could peel, but the glass could shatter. But when there ain't a crack in the foundation, I know any storm we're facing, we'll blow right over while we stay.

Put the house don't fall if the bones are good.

Kelsey Magnuson (Host): I love that as I'm a country fan, so knew that song and, um, love the connection to how we can think about it with our overall health. And when our bones are strong then we can thrive too. so thank you again for being here today. And to our listeners, thank you for listening to Emerson.

HealthWorks here. Podcast. Make sure to catch the next episode by subscribing to HealthWorks Here podcast on Apple Podcast, Google Podcast, Spotify or wherever podcast can be heard. And visit Emerson health.org/podcast. To learn more or schedule an appointment with Dr Me, visit emerson health.org or call 9 7 8 2 8 7 8 5 2 0.