← The Dr. Gabrielle Lyon Show
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- [00:00]
A
I saw the circle and the trap that I had put myself in where I was doing great surgery. I love the operating room, but I felt like I was really cleaning up metabolic mess over and over and over again. He was young. He was listening to his doctors. He was following their advice, and their advice was killing him.
- [00:18]
B
We are going to see an epidemic of osteoporosis and sarcopenia that no one is prepared for.
- [00:26]
A
Our bone is not something that we need to consider. We're going to lose as we age, for the most part.
- [00:32]
B
What's wrong with that approach?
- [00:33]
A
The conventional medical model is what it is. It has been for over 100 years. Diagnose, treat with pharmaceuticals or surgery. That's the system.
- [00:41]
B
Why are we losing bone? And specifically, selfishly, I want to know how much this has been very controversial. Calcium.
- [00:48]
A
Most cases of osteoporosis are not a calcium deficiency issue.
- [00:54]
B
The biggest misconceptions that we have heard over the years is that protein is bad for bone. What else is an absolute? If you want to destroy bone, here's your playbook.
- [01:03]
A
Yeah. If you want to destroy bone, under. Eat protein, right? Eat an inflammatory diet. High ultra processed foods, high quantities, get poor sleep, live in chronic stress.
- [01:12]
B
Are there a handful of medications that people take routinely that affect bone?
- [01:17]
A
The ones that I would say that surprise people would be.
- [01:28]
B
Doctor Doug Lucas, formerly a Stanford surgeon. You're an orthopedic surgeon. You went to Stanford and you gave that up?
- [01:38]
A
I did.
- [01:39]
B
Unusual.
- [01:40]
A
Very.
- [01:41]
B
Why?
- [01:42]
A
I saw the circle and the trap that I had put myself in where I was doing great surgery. I love the operating room, but I felt like I was really cleaning up metabolic mess over and over and over again. Foot and ankle was my subspecialty. There's probably not a subspecialty that is more perfect to see this issue than looking at the foot because of the combination of all of the downside of diabetes, metabolic disease, and how that plays out.
- [02:10]
B
Was it different? Was it different than you thought as an orthopedic surgeon? And also, you're a very fit guy. If you guys are listening to this, you should watch him. I always have a ton of respect for physicians who practice what they preach. When you went into orthopedics, were you thinking it was gonna be sports?
- [02:26]
A
I knew I was going into foot and ankle. But it is very different once you're in practice than it is when you're in training. In training, you see new patients all the time. You only do the surgery. You have short follow up. It's very exciting. But in Practice, you follow patients for a much longer time and you see how the surgery that looks so good doesn't end up having the effect that you hope it would over the long term. And it can be quite a letdown both for you and the patient.
- [02:52]
B
Yeah. And to be fair, Stanford is one of the most competitive orthopedic surgical residencies. To even get there is a long and arduous and full of sacrifice road to then get there. It's very, I would say, very few times in our lives where we go, I have really worked so hard for this and I've dedicated years, I mean, that's over 10 years to say no thanks. Was there a moment?
- [03:28]
A
There was a moment. And so just to be clear, I did a fellowship at Stanford.
- [03:33]
B
Even better.
- [03:33]
A
And so my residency was at Ohio University in Columbus. But yeah, going from there into practice and then starting to understand what was happening with my patients. The moment that the switch flipped for me was an emergency case, middle of the night, 3am, diabetic patient, foot ulcer gets infected. They call me in to do an amputation. And I remember very clearly, skeleton crew, middle of the night scenario. Nobody was prepared to do what we were doing. I remember the patient almost falling off the table. Not enough people to keep him on the table. I was, you know, underneath his leg, this, you know, unfortunately, very overweight individual trying to put on a tourniquet so we could literally save his life. Time was of the essence. And I stopped right then and I thought, what the hell am I doing? I could have saved this guy's life and I did. But I could have prevented what we were doing and what I learned from that guy afterwards because again, long term follow up in practice. What I learned from that gentleman is that he was young, he was listening to his doctors, he was following their advice and their advice was killing him.
- [04:42]
B
It's a really, no pun intended, hard pill to swallow as a provider actually being so invasive surgery, no matter how it's done, is an invasive procedure. I think it's tremendous that you decided you weren't going to do that anymore.
- [05:00]
A
It was a really hard decision.
- [05:01]
B
I can only imagine. What I appreciate about many of the things that you say is you and I are really on the same. We are two sides of the same coin. I am obsessed with muscle and part of muscle, it's called the skeletal muscle or muscular system, is bone. Quite frankly, I've wanted to ignore bone forever. But in reality, I believe, and I'm curious as to your perspective, we are going to see an epidemic of Osteoporosis and sarcopenia that no one is prepared for.
- [05:39]
A
Absolutely.
- [05:40]
B
Because of the use of GLP1s and their effectiveness.
- [05:43]
A
Absolutely. I agree.
- [05:45]
B
In terms of longevity and these biomarkers of how we. Well, why don't you just frame up bone for me before we go into these biomarkers that we were chatting about and this incoming epidemic, just frame up bone, its importance and how we need to be thinking about it. Oof.
- [06:01]
A
Thank you.
- [06:02]
B
No pressure.
- [06:04]
A
So I love talking about bone. And as I got into the integrative space, I didn't initially think, like, bone is going to be my thing, but I love talking about bone because it is something that is so intrinsic to our success from a longevity perspective, healthspan perspective, bone. But it is so much more than just the framework, literally, that our muscles are attached to. It is a dynamic organ system. It is talking to us every day. There are biomarkers that we're going to talk about. There's imaging that we can do. Our bone is not something that we need to consider we're going to lose as we age, for the most part.
- [06:37]
B
Is that true?
- [06:38]
A
It is true. I'll give you evidence for that. But our bone is something that is going to help us to understand if. If something is wrong underneath the hood. And this is what I want everybody to understand. So I talk about all day long with these biomarkers and imaging. Is that in our community and our clinical practice, what we see is that almost agnostic of age, we see people plateau their bone loss and many of them are improving bone density, the quote unquote reversing osteoporosis, if you want to call it that. But ultimately they're defying the average bone loss of 0.5 to 1% per year. Right. They're almost all defying. It's. I don't think we can avoid it forever, but I don't think that we have to accept it as something that is inevitable throughout the majority of our health span. And what I've really come to identify bone loss as is a biomarker of health span, meaning if we're losing bone, there's probably something wrong, like something's going on. We don't know what it is yet, but we can use this as a red flag to say, hey, your body's talking to you. Something's going on. We need to figure out what it is.
- [07:43]
B
0.5 to 1% per year is bone loss. And when does that typically start? Is it around the same time that one would think about sarcopenia around 35 or 40 when someone's done growing.
- [07:55]
A
Yeah, I think it starts a little bit before, but they're going to coincide because I think the underlying mechanism is probably very similar. I think we just can measure it in bone faster.
- [08:04]
B
There seems to be a correlation basically is kind of what you're saying. What would be a reason if someone is thinking about this and personally muscle, you feel you're sore, you tore, grew it didn't. But bone, the way that bone has always been presented to me as a physician and someone who trained a fellowship in geriatrics is a very static organ system. Until all of a sudden it's not. How should we begin to think about our bone health? If as someone is sitting here and they're 35 and they are looking at their 7 year old child, how do we think about it?
- [08:49]
A
So actually the seven year old child is a great example of this. Our bones are a dynamic organ system. Imagine what happens in a seven year old's body, right. How quickly are they growing? All of the open growth plates, all of that growth that doesn't stop when you reach your peak height or even your peak bone density in your late 20s, early 30s. That metabolism continues on. There's this funny statistic. I actually don't know where this comes from, but there's this statistic floating around that says that we have enough bone metabolism to generate an entirely new skeleton every 10 years. I have no idea if that's true, but I think something like that is probably plausible and, and that's how much bone metabolism is actually happening. There's that much breakdown in buildup and that's why I really think that we need to reconsider accepting bone loss as a part of aging. We hear this all the time, age related bone loss, quote unquote. And I think that we need to reject that and say, hmm, no, if you're losing bone, let's look and see why. What's happening, what's imbalanced.
- [09:49]
B
When I think about the way in which we were trained, the conventional playbook for osteoporosis, it's here's your dcsa. It's really actually two ways. It's you are. Have they changed the age of. When you can. When insurance will cover the first DEXA65. I was hoping that that had changed.
- [10:07]
A
There are a couple of different areas there. But yeah, right now the USPSTF still says 65.
- [10:11]
B
And in our practice in strong medical we recommend, I mean we'll get a baseline dexa. Yeah, there is no. From my Clinical assessment, there is no reason why you wouldn't get it early. And the playbook has taught us 65 and up is when you're even gonna start screening with your first Dexa. And then you will have the opportunity to have a prescription. And those prescriptions I would love for you to just kind of share. You know, I've got, we all remember bisphosphonate, I'm sure that there's others, but that's really the treatment. It's resistance training, which people. The guidelines have just changed about that. And, and that's, that's it. What's wrong with that approach?
- [10:56]
A
So it's a very reactive approach. Right. So let's wait to screen until we're likely to see the disease, which I understand the public health statistical analysis there, I get that. But the way I treat patients, the way you treat patients is we want to prevent chronic disease if at all possible. We want to catch it early because it's so much easier to turn that corner and resolve it early. If we wait until 65, it's not too late, but boy, it gets so much harder the older we get. And so the conventional medical model is what it is. It has been for over 100 years. Diagnose, treat with pharmaceuticals or surgery. That's the system. If you want something different, we need to think about it differently. And that's why you're screening early? That's why I'm screening early. Because we want to prevent disease and the conventional system is not set up for that, or at least not currently yet. It could be right? It could be, let's be hopeful. And the drugs are not ideal and I'd love to get into all the different versions of it, but essentially the drugs have a short term window for the most part. And if you are young, and by young, I mean 50s, 40s, even 60s, honestly, if you are young, then you need to have a really comprehensive understanding of why you're using these drugs. How long are you going to use these drugs? What's the plan if you want to come off of these drugs?
- [12:17]
B
What are the drugs that people typically ask you about?
- [12:23]
A
Yeah, there's basically two classes. So there are the antiresorptive drugs, which is bisphosphonates, and a couple of others I'll get into. And then there's the anabolics, which are the ones that actually really help to build bone. Most doctors will start with an antiresorptive drug. That's what the guidelines have kind of suggested and recommended. They're easy, they're cheap, Bisphosphonates are oral, right. So you know, and covered by insurance. And even if not, they're generic and they're inexpensive. So it kind of makes sense to do that. Except that when we talk about bone metabolism, this breakdown and buildup, and look at treatment with drugs through that lens, the antiresorptives are a bit limited because they essentially slow down bone metabolism, which is potentially beneficial. There's a time and a place for these things. But if you slow down bone metabolism, slow down breakdown, you also slow down buildup. There just isn't a lot of bone turnover. And that's okay. In the short term it will reduce fracture risk, it will increase on average bone mineral density. But what's the long term plan here? The anabolics are an even shorter window though, but they do build up.
- [13:29]
B
What do you mean shorter window?
- [13:31]
A
So they are FDA approved to be used for up to two years. So shorter window. Right. So especially, I mean, if you're, you know, whatever, 60s, 70s, 80s, two years is a really narrow window, narrow opportunity. And generally these will be followed by an antiresorptive drug. I like the Anabolics.
- [13:48]
B
What are the names?
- [13:49]
A
So the anabolics in the US are going to be brand name Forteo, Teriparatide, Tymlos, Abalo, Paratide. Those drugs work with all of our lifestyle things. This is why I like them. So imagine if you're doing the exercise, you're eating the diet, you're taking whatever supplement you think is good for you, you're optimizing hormones and you're still not getting there or you are at high, very high fracture risk. Taking an anabolic drug can help to just push everything forward. So I really like that approach for those at very high fracture risk. But the question is then what do you have to go on this anti resorptive approach? And again, that's the bisphosphonates across the board. Prolia or denostumab is another one. Avenidae, Romosozumab is sort of like in between. It's a little bit of both. But having a very good understanding of what the long term plan is is critical regardless of where you start.
- [14:43]
B
Would you equate it to a type 2 diabetic going on a insulin type medication or a glucose, not glucose removal but some kind of glucose disposal medication that when you come off of it, one would anticipate those levels to just return to?
- [15:08]
A
Sure, yeah. If you don't fix the underlying issue, then the drug is simply suppressing or potentially, you know, improving. But for a short period of time, what was happening naturally. I talk a lot about this concept of quote unquote osteoporosis reversal. And many endocrinologists have given me some, we'll call it strong feedback to say that I shouldn't say that. And the reason why I agree with them to some extent is that they equate it to diabetes, hypertension, where if you treat it with a drug, then you don't fix the underlying issue. Even if their biomarkers, their blood pressure, their A1C, their glucose, whatever is normalized, they still have the chronic condition. Right? They still have diabetes and high blood pressure. Osteoporosis is the same thing. If you go on, let's call it prolia and your T score goes from negative three to negative two, you still have osteoporosis even though you don't meet the criteria for it anymore. But if you flip that script and same thing with that diabetic, that person that has high blood pressure, you look for the underlying cause. It's a different conversation.
- [16:06]
B
Fun fact. I have been using Kettle and Fire, one of the new sponsors of the show for years. Their bone broth has been a staple in my kitchen when I was pregnant with my child. And as a physician I'm always thinking about the quality of the foods that I consume, that we consume. But aside from bone broth, what are we cooking with? And I spend a lot of time trying to secure ingredients. But fat is something that I cook with every day. And one reason I appreciate brands like Kettle and Fire is that their tallow, they have 100% grass fed and grass finished beef tallow, it has one ingredient, no additives, no preservatives, just traditional cooking fat. And it works beautifully with higher heat cooking, roasting, building flavor and their bone broth, for example, I appreciate products that simplify healthy choices, making it easy to make good choices. It doesn't have to over complicate things. And for a limited time you can go to kettleandfire.com drlion and and use the code DoctorLion for 25% off site wide. I love their bone broth and their beef tallow. That's kettleandfire.com DrLion code DrLion the idea that these medications, and I've heard you talk about this, that there's a difference between quantity and quality of bone which is the same for muscle. Sure, these studies had come out saying, well, that people that struggle with obesity or also have a higher bone or a higher muscle mass, but the quality of that tissue, regardless if an individual is Sedentary, regardless of the mass is impaired. Right. There's fat infiltration, the quality is not good. Talk to me a little bit about as we think about these medications, because that's always the first stop is here's the problem here, here's the medication, or we're going to wait until you're bad enough to treat. Highlighting the difference between bone quality and quantity.
- [18:13]
A
Yeah. So ultimately the question is fracture risk. Right. We use bone density to help to understand, or you could call that bone quantity. Right. We use density quantity, same thing to help to predict fracture risk. But really the fracture risk equation is bone quantity plus bone quality equals fracture risk. So it's density and quality, or density and strength is another way to say it. And this is why it gets confusing. There's all these terms, but ultimately it's more than just the quantity. It's more than just the density. It is the quality. So then to get to your question with the drugs, yes, if you use an anti resorptive drug and you suppress bone building and bone breakdown, your bone will continue to calcify, it will continue to mineralize, so, so it will get more dense and in the short term that does decrease fracture risk. But the challenge is what happens in the long term, because if you can't build bone, you inevitably end up with more dense but potentially more fragile bone.
- [19:11]
B
And the outcome, I like always highlighting what is the outcome that we're looking for? And what I'm hearing you say is that the outcome that people are concerned about is actual fracture risk.
- [19:20]
A
Of course.
- [19:21]
B
Is there anyone who should not take see that first line drug treatment?
- [19:26]
A
So there's some research coming out now that I really like the angle of which is looking at the order of these drugs. If you're going to need a drug, look at the order of the drugs that makes the most sense. We know that if you start with an anti resorptive drug and you suppress bone metabolism, then follow it with the drug, the anabolic drug that can build bone. We know that that doesn't work as well because you've already suppressed the metabolism and these drugs stay in the bone for really long time. So again, looking at this through bone metabolism, say, ooh, well, let's start with an anabolic drug, let's actually build up as much bone as possible and then if you have to, then switch to something to maintain those gains. So that's a different way of looking at it. And this is a totally new perspective that endocrinologists are really just now starting to get on board with.
- [20:10]
B
How Sensitive are dexas for when. Let me ask this a different way. When. What is the best test to identify bone quality?
- [20:21]
A
There really isn't a great one, so probably Connecticut.
- [20:25]
B
That's what for. For muscle, it's ct. Yeah.
- [20:28]
A
Which is not a good screening tool and not something we want to do over and over again. Right. So, yes, Connecticut can look at strength and that is good, except that I don't want to expose myself to a CT every, you know, year or couple of years. So outside of ct, DEXA doesn't look at quality at all by itself. There is an add on called TBS Trabecular Bone Score, and that is a software add on. So same input, so questionable output, but it can help to stratify at least poor bone quality. Better bone quality than average. And then there are other imaging modalities altogether. There's an ultrasound device which is kind of making waves in the wellness space and it reports to. And there's a couple of studies supporting the idea of looking at quality with ultrasound, but it's relatively new and I think the data is, let's just call it inconsistent.
- [21:18]
B
We. We definitely should pause on this. Part of what the mission of this podcast is is to have really transparent conversations. What we are seeing with information as it becomes more accessible is that oftentimes things are repeated without really being questioned. When I'm hearing you talk about dexa because. Because DEXA doesn't measure muscle mass directly. It extrapolates lean mass, and a percentage of that lean mass is muscle.
- [21:49]
A
Okay.
- [21:50]
B
Most people don't consider that DEXA does not directly look at skeletal muscle mass. As you were talking, I can't help but think about bone through the lens of how I process muscle. And what I'm hearing you also say is that DEXA seems to look at the amount, but it's not necessarily the total amount that matters. It's the quality. Did I get that right?
- [22:21]
A
So it is both. Right? It is both because we have these tools like frax online Risk Fracture Assessment Tool that has tremendous data behind it using just the density plus other risk factors to help to extrapolate fracture risk. So it is important, but it is missing a big piece of the puzzle, which is quality.
- [22:41]
B
That seems as if it's kind of a big gaping hole.
- [22:45]
A
It's a huge hole. I'll add one more layer to that if you'll let me, which is that one of the challenges around DEXA is the variability from scan to scan. Even using the same machine, the same operator on the machine, there is variability called lsc or at least significant change from scan to scan. And it's essentially the margin of error. Right. And so the LSC is well calculated on different machines and it should be actually reported on the report. And it could be anywhere from a little under 2% all the way up to almost 6%. So now we have this machine that isn't telling us about quality at all and has an up to 6% variability measure from scan to scan, knowing that our bone density is really only changing for most people, 1, 2, maybe 3% per year. So now we can't even say that those gains or losses are real if it's within that margin of error.
- [23:39]
B
This is important to understand. Muscle is not very sensitive to change. Right. The lean tissue. When we look at Adexa, typically you think about an 8 to 10% change over 10 years. It sounds as if they're equivalent. But the data point to data point, the year to year change from a bone perspective doesn't seem that it's as sensitive as it should be. And I'm going somewhere with this is I think, okay, well what is the practical information for people, everyone over the age of 65, they're getting a DEXA. But if we're looking at our younger athletes and our 35 year old moms that potentially need to assess where their bone is at, and you have a list of bone turnover markers and things that I want to cover that baseline score that someone is going to get at 35. Do we have a good algorithm? For example, their T score is that reflective? Do we have a volume or a population number that when that 35 year old goes in, is that 35 year old being compared to the same markers as a 65 year old? And how can we reconcile that?
- [24:50]
A
Yeah, it's a great question. And there's so much confusion around T score and Z score because I get these questions all the time around Z score, people want to use the Z score. If you are over the age of 50, we're going to talk T score because you're comparing with the T score actually to your younger gender and race related self. Right? So you're 20 something year old, you, when you are in your 30s and even 40s, we want to use Z score because Z score is comparing you to your age match population. So what you want to know is where are you compared to others like you? And then you can say, well I'm above average, I'm below average. Knowing that average for that age group is quote unquote. Okay, it is still the general population, but at least you're not, you know, in your 80s or 90s where average is osteoporosis. And this is why we split and start using T score after the age of 50.
- [25:43]
B
Thank you for that clarification. I can't also help but think that if it is, I'm guessing it's based on population data, then that would mean it's sedentary. Correct, A sedentary population.
- [25:58]
A
So I think there's two ways that they do it. So one is you can look at these massive cohort studies who have had dexas, and we know T scores and Z scores and so you can get data that way. But also imagine these companies like hologic, these massive imaging companies that have DEXA scanners, they own all that data, right? So they have all of, they have their own internal database of all of these DEXA scans of different populations because they have all the inputs that go into it too. Right. But that is still the general population. So yes, sedentary, poor nutrition, like all of the things that we would expect to see in the general population.
- [26:33]
B
Take it with a grain of salt. Yes or no, the number, I think
- [26:37]
A
it's more than a grain of salt. I think it's important to understand where you are compared to your population. One of the terms I used to use more than I use it now, but is this concept of aim for optimal, right? Like we don't want to be average, we want to aim for optimal. Meaning it's good to know where you are compared to the population in which you live. But where do you want to be in that? Do you want to be 1 standard deviation above? 2 standard deviations above? I would vote for probably more.
- [27:02]
B
I realize that we didn't close out the conversation of anabolics, the anabolic medications, is that only directed towards bone? Interesting question, bone specific.
- [27:15]
A
So what it is, the mechanism is parathyroid hormone, which is counterintuitive because a parathyroid tumor or elevated parathyroid hormone actually causes bone loss. But if you pulse it, it's a very abnormal way of doing it or non physiologic way of doing it. But if you pulse it, daily injection of parathyroid hormone or these analogs, then you see tremendous bone growth. So it is actually very specific to bone.
- [27:39]
B
Two more questions related to this. The are there off label drugs that can be used for bone? You know you're talking about pulsatile release. I can't help. I don't prescribe growth hormone, but I can't help but think about agents that are used in performance or optimization or quote wellness. However you want to frame that, things like growth hormone or other anabolic and then okay, so it's growth hormone and then what about anabolic agents that affect muscle? And are these medications able to be used off label for a bone?
- [28:14]
A
Yeah. So growth hormone I've not seen good data for. I would think it would be beneficial, but I just haven't seen any data on it as far as other anabolics. You and I have had conversations in the past about other potential tools and there's nothing that I would recommend right now because I just don't think the data supported above. You know what we are currently seeing, we with the exception of the potential benefit of testosterone, but the research, especially in women is still pretty limited. In men it's better. So definitely a tool worth considering, but clearly off label.
- [28:45]
B
The next logical thought would be perimenopause, menopause, decrease in estrogen. Where does that come in with the bone conversation?
- [28:56]
A
It is just running parallel so strongly. And this is why I ended up in my career really talking a lot about hormones in both men and women. You know, right now, clinically, I'm creating protocols for hormone optimization for both men and women because bone is such an related to bone. Yes, through the lens of bone. Now we do it, we have a women's health program that I'm leading. But it's. I love doing it through the lens of bone because bone tells us what's happening with hormones. It is one of the few organ systems that gives us great feedback on levels dosing like we talk about symptoms of menopause perimenopause related to hormones. But those symptoms are can be vague, can be related to other things. It can be challenging to dose just based off of symptoms. But our bones are telling us objectively what's happening.
- [29:46]
B
Okay, talk to me about that. You've now piqued my curiosity. How would you dose hormone replacement therapy to direct it to be directed at bone?
- [29:54]
A
Yeah. So first let's talk about the bone turnover markers because this is going to be really important. So when we look at what's happening in bone, we have an opportunity to use imaging, which we've talked about has its weaknesses and it doesn't change very quickly. Right. So not a great tool from this perspective. The bone turnover markers I talk about often, which are blood markers you can measure as frequently as you want to get your blood drawn, they measure that bone metabolism. So the building of bone and the breakdown of bone. The building side, there's a marker called P1NP.
- [30:26]
B
It's a long P1N.
- [30:28]
A
P1N is a Nancy P long acronym. But it's basically a type of collagen. And so when your osteoblasts, these cells that build bone, are doing that, they release this end of the bloodstream and you can measure it. Osteoclasts, the cells that break down bone, release something called CTX or ctelopeptide. That one's easier to say. And CTX also released in the bloodstream, you can measure it and you can objectify these things. So quantifiably, you can determine are you in more of a bone building dominant mode or more of a breakdown dominant mode? We see this in the phase three trials. For every bone drug that's out there, they're used, they're used in research for nutrition interventions, supplement interventions. I mean, these things are used across the board. They're awesome. And so now we have the opportunity to use them in conjunction with measuring serum or blood levels of hormones to understand what are the hormones doing to your bone turnover. And this is beautiful because, again, it's the only organ system that really gives you this feedback. So for our patients that have, you know, they have bone loss, osteoporosis, they're worried about fractures. We're talking about bone metabolism. Now, if they're on hormones, we can say, okay, well, what is this form of estrogen? Whatever, you know, transdermal gel, cream, patch, whatever you're using. What are those levels of estradiol? I also measure fsh, which we can talk about, which is kind of a feedback loop hormone. And then we also measure CTX and P1 and P. And we should see CTX drop by 40, 50% if it's actually saturating the bone receptors for estrogen. And we could see P1 and P rise, or it'll drop a little bit less than ctx, again changing that ratio so that we're favoring bone builder.
- [32:10]
B
When you are looking at a patient, do you say the target estradiol level is 40 or above? If you look at the literature, they give you a number between. And there's a handful of different picograms per deciliter, but 40 to, say 100. Do you look at that and you say a woman's estradiol number needs to be at least 40 for bone protection?
- [32:37]
A
I used to. And so we had this. We used 60 as sort of our threshold cutoff. There's literature to support that, but what we realized is that I had women who were on very low doses of transdermal estradiol where I would not expect to see much systemic exposure. You wouldn't expect to see high levels and we wouldn't. But yet we would see FSH suppression and I would see CTX come down, meaning that I can't make an argument actually to increase her dose if that's what we're aiming for. So sometimes we see it be effective at less than that, but then the opposite is also true. I have women that hit 60, 80, 100 and their CTX is still 800. Right. It just doesn't seem to have had an effect on the bone yet. And so we will have women who will push that. It gets more challenging. Let's talk about how to protect organs and you know, the uterus and breast tissue, et cetera. But women that have pushed that into the, you know, 100 to 200 range and then you see the CTX drop. So I think there's a receptor challenge that we can't measure effectively. So I've stopped using estradiol alone as a goal.
- [33:38]
B
As a physician, I spend a lot of time talking to patients about healthy aging and one of the most important factors is maintaining skeletal muscle. I know it sounds simple, but simple isn't the same as easy. And many people struggle to consistently consume enough high quality protein to support muscle health, recovery and long term metabolic function. And thank you you to one of the sponsors of the show Perfect Amino. That's one reason why I personally use and recommend Perfect Amino by Body Health. Perfect Amino provides all of the essential amino acids your body needs for protein synthesis and beyond. It is a highly bioavailable form of amino acids. It's easy to take and can be a practical option for individuals looking to support muscle health especially especially when meeting protein goals are difficult. Remember, muscle is the organ of longevity. Whether you're training hard in the gym or simply focused on staying strong and independent as you age, giving your body the building blocks it needs is an absolute non negotiable for your long term health. Go to bodyhealth.com and use the code Lion 2020 for 20% off your first order. That's bodyhealth.com code Lion20 I I absolutely agree with you. In a young woman who is 35 or 30, what would be a normal CTX number?
- [35:13]
A
It's going to depend on the phase of the cycle. So this is one of the really cool things that I learned about starting to treat women in perimenopause, which is if you understand what's happening with the cycle, you can Understand what's happening with bone metabolism really well. Right. So, you know, if we look at the, you know, the, the estrogen levels throughout a woman's monthly cycle, in the follicular phase, you see estrogen rise, right? It goes much higher than any other time and then it drops and then it kind of comes back up in the luteal phase. But the luteal phase is dominated by progesterone. You see very clearly the effect of estrogen, right? It slows down bone loss. And then. And so you'll see ctx. You'll see CTX rise during that time. I'm sorry? You'll see CTX drop during that time. And then during the luteal phase, you'll see it rise and you see this natural push pull of the estrogen and progesterone dominance. And so that is the natural cycle, this push pull, this rhythm that's occurred every month during the cycling years of a woman that as you get into perimenopause, starts to get dysfunctional. These women, especially if they stop ovulating, then you kind of don't have that progesterone rise. And this is where this dysfunction starts.
- [36:19]
B
You said, does progesterone. We talked about estradiol. Estradiol's effect on CTX, P1MP. Is it the same for P1MP?
- [36:28]
A
So it has an effect on both sides of the, of the metabolic equation. So it has the most profound effect on ctx. It does have an impact on osteoblast. It's just not as obvious. So. So we think that it supports osteoblasts, but really progesterone is more supportive of osteoblasts. We see that osteoblasts have progesterone receptors, that natural push pull of the rhythm of the estrogenic progesterone flow that will encourage osteoblasts to either, you know, go away or to come back. Progesterone probably plays a bigger role than does estrogen, but it's not as well studied.
- [37:02]
B
I also really appreciate what you said about the receptors. There is this idea of precision medicine and it's. It's not going to be the right dose for everybody. Likely a receptor issue. It just makes me think about how we target testosterone. I don't know if you've read much about CAG repeats, CAG repeats. It's basically the androgen receptor. The higher the androgen receptor, then it would make sense that the less testosterone one would need.
- [37:34]
A
And does that play out?
- [37:35]
B
It does.
- [37:35]
A
Amazing.
- [37:36]
B
It does. It's called CAG repeats. They're doing a lot of research at Baylor regarding CAG repeats. It's not necessarily the dose of testosterone. It's all about the density of the androgen receptors, which, conversely, you have patients that they feel terrible on 300 milligrams of testosterone, which is you. And I would never prescribe more than that. Sorry, guys. But. But there might be something to say for the fact that it really is the density of these receptors. And I'm. I'm curious as it sounds as if it would be the same for bone, which makes testing blood markers really important to allow for precision. Because what you're saying is that it's not just the symptomatic relief. How fast, Once you lower some of these blood markers, how fast do you anticipate seeing it in a scan or some kind of proof that it's working?
- [38:30]
A
Yeah, this is the frustrating part about bone health, is that it's still a slow journey. DEXA is probably not going to change faster than every 12 months. And even then, when people don't see if they're on, if they're doing all the things and they don't see DEXA improve like we would expect it to, I just tell them, look, it changes slowly. Bone is slow to mineralize. So even if all the good things are happening, it's. You may just not see it yet. Now, the ultrasound device, in theory, is faster, but again, evidence is a little sparse.
- [38:58]
B
I'm sure you've watched closely the conversation around estrogen and bone loss. What does the evidence say in terms of prevention or even treatment?
- [39:07]
A
Oof. Well, first off, let's talk about when this actually happens. Right. We think we, you know, we talk a lot about this idea that in the five to seven years after the onset of menopause, you see up to 20% loss in bone density. Those are real numbers and definitely worth pointing out. But what's interesting is when you look at the graphs that show that it doesn't start at 50, it starts at 45. So we talk about this quote, unquote, at the onset of menopause. But no, it's actually during perimenopause because that's when the back and forth cycling starts to get dysfunctional. That's when you start to lose progesterone. It's when estrogen levels start to not actually reach the peak. So it starts much sooner than that. The opportunity for intervention is also not at 65. My goodness. At 50. Sure. But I would argue actually before that as well. Like, let's Optimize hormones throughout the lifespan, especially midlife for women.
- [39:58]
B
Can you treat bone loss with estrogen?
- [40:02]
A
So eftradiol specifically is actually FDA approved for the prevention of osteoporosis. So I can even say that prevention, yeah, I can even say that out loud. It's amazing. FTC is not going to come knocking on your door. What I will say about estrogen or estradiol specifically is that it is a very powerful lever if a woman chooses to is a candidate for using it both in prevention but also when a woman has osteoporosis. I can't say use it for osteoporosis, but when a woman has osteoporosis to improve bone metabolism, other symptoms of menopause, it will have a big impact on her bone density.
- [40:38]
B
I like the way that you said that. It was said very responsibly.
- [40:40]
A
Thank you.
- [40:41]
B
Well done. Don't know if you practiced it, but you did a great job. It's tricky in medicine because even with, say, Alzheimer's and estrogen, we can't say, well, that there's any treatment with Alzheimer's memory with the use of estrogen. But you can say we have a good understanding of what happens when estrogen is low or removed or suppression therapy. It's tricky.
- [41:11]
A
So I look at this one in two very clear ways and I've had some fun interviews lately that have really driven this home for me. But I think of if you look at women who have their ovaries and uterus removed, they have a hysterectomy and they're young, right? So 30s or 40s. The guidelines clearly state use hormones and optimized levels not just for symptom prevention, but higher levels of hormones to stave off early what Alzheimer's, dementia, heart disease and osteoporosis so that physiology doesn't change as we get older, the risks might change. I had two interviews lately with Dr. Perlmutter. Do you know David Perlmutter? He's awesome. I really enjoy talking to him. And he says very clearly and openly, yes, the literature is not clear. We cannot say that we're using hormone replacement to treat, prevent anything Alzheimer's related. But what we can see clinically is the profound impact that optimized hormones have on cognitive function. I see it same. I'm sure you see it same. Right? It is clear as day. But we have to be careful what we promise.
- [42:15]
B
You also talk about finding the root cause. You have a I, I really like frameworks. And you have a 4R method. First one is Recognize why are people having bone loss. And I'm going to just leave it at that. And then selfishly, I want to hear about the nutritional aspects.
- [42:35]
A
Yes, of course. So again, I don't believe that we should accept bone loss as a normal part of aging. It's going to happen at some point, but how long can we stave it off? So again, if you're losing bones, something's wrong. Let's figure out what it is. And this is why we created the 4R framework. Because most people, especially with a diagnosis, are told this is age related. You know, it's due to hormone. They actually say, like, it's due to hormone decline and there's nothing you can do about it, which is a clear contradiction in terms. But even more so than that, I feel like there are so many different levers. When you start looking under the hood. There's so many things that you could potentially address when it comes to bone loss. Nutrition certainly being one of them. So we created this framework to help people to understand this concept of root cause medicine. That's what we're talking about. So the 4R framework is recognize why you're losing bone. Right. And then, which then leads to the second R, which is reverse those causes of bone loss. So again, identify why you're likely losing bone. Let's pick a couple of levers and then let's do something about it.
- [43:34]
B
Talk to me about why, why are we losing bone? And specifically, selfishly, I want to know how much this has been very controversial. Calcium.
- [43:45]
A
Oh, my gosh.
- [43:45]
B
Yeah, I want to hear about calcium.
- [43:47]
A
Yeah. So I think, no surprise to you that most cases of osteoporosis are not a calcium deficiency issue. Right. If you look across the board, most Americans are eating 700 to 800 milligrams of calcium A day from all sources. That is probably enough to support bone metabolism. The recommendations for over the age of 50 are up to 1200 milligrams of calcium. But that, I feel, is a little bit of a surplus to help to build bone. If you think that it helps to build bone, but we don't really live in a calcium deficient society.
- [44:16]
B
We do not. And I haven't been able to reconcile the fact that we have some of the highest rates of osteoporosis, but we have and are eating a ton of dairy. Talk to me about the role of calcium. Is that something that people should take from a supplement standpoint? Is it calcium? Is it vitamin D? Where, where are, is it, are we supposed to be eating leafy greens I mean, when I was in fellowship, there was a osteoporosis screening. From a nutritional standpoint, it was dark, leafy greens. How much caffeine, how much alcohol are you drinking? Do you smoke?
- [44:53]
A
It's. This is really tough when you start talking about nutrition and bone health because we get into the bias of the last, you know, 40 years. Right. So if you were to paint a bone health picture through nutrition and do it from, you know, the time of Ancel Keys on, you have this really conflicted, like, you know, don't eat too much protein because it's bad for you. Watch out for dietary fats. You know, certainly don't consume dairy because it has saturated fat and it's inflammatory. And then get your calcium through leafy greens. And you're kind of like, whoa, whoa, whoa, whoa. Like that doesn't actually make a lot of sense. And so I was just reading a book, prepping for an interview, and I'm not going to say what it is, but that was the nutrition advice and it literally said red meat is inflammatory and Americans eat too much protein. I was like, like my population, because I have them all track what they eat. They do not eat too much protein. They under eat protein significantly and most of them are actually getting adequate calcium. So what we've been told over the last several decades just doesn't jive with where people with osteoporosis and bone loss are now.
- [45:54]
B
Is calcium something that is important? Do you recommend supplementing with calcium?
- [46:00]
A
I recommend everybody track what they eat for at least a short period of time. I know it's a pain, but track what you eat and be honest about it so you can understand how much calcium you're getting through diet. If you're under 800 in theory, I should say a thousand. But if you're under 800 to 1,000, then yeah, you should probably add some. But don't add too much because it's not a calcium only problem. It is a mineral problem. Right, but that means you need all of the minerals, not just calcium.
- [46:25]
B
What else is another big. Or what are other minerals or vitamins and minerals that are really important for bone?
- [46:32]
A
Yeah, I mean, the supplement stack can be really long. But let's just start with the basics. Right, so yes, potentially calcium, but you also need magnesium. You also need phosphorus. You also need potassium. And that's why the products that we talk about generally are going to have, you know, at least trace minerals or other minerals that go along with it. From a vitamin perspective, vitamin D is critical. If you're Going to consume calcium and minerals. You need vitamin D. You should also be measuring that one know what your levels are. Vitamin K in various forms have different reasons to use one or another. But vitamin K is also really important and I think vitamin E is coming out as a bigger player. Vitamin E in again different forms than what's traditionally been available. Also becoming a bigger player in the bone health space. So minerals, vitamins, and then you start getting into all the other things that could potentially impact bone metabolism.
- [47:22]
B
We don't want potential, we want. What do we know? Is there one superfood for. I mean cause for muscle? I think lean red meat.
- [47:32]
A
Yeah.
- [47:33]
B
For me, if I had to pick one food, it would be lean red meat. When I think about muscle health, I
- [47:40]
A
think for bone health it's the same. So you and I are on the same page. Lean red meat or if you can tolerate the saturated fat, fattier red meat. I will say there is a standout though for bone when it comes to small fish.
- [47:51]
B
Please don't say sardines. You're going to say sardines.
- [47:53]
A
I know, I know. But so powerful, right? Protein, omega 3s, calcium and minerals. It is just a superfood.
- [48:03]
B
I agree with you. And it makes you very unpopular when you're on the plane.
- [48:09]
A
True.
- [48:10]
B
The sardines, for a superfood, you eat the little bones. Do you think that there's any utility in eating? I mean, I don't even know how else to say it. Eating bone having. When you're stewing broth, are you extracting some of those nutrients? Because. And this might be outside your scope. I know it's kind of outside my scope. I'm not stewing bones. But I can't help but think, man, the nutrients, when you open that is probably nutrients that are viable and important. And in the west we typically just eat muscle meat or not eating a ton of organs or bones. Do you think that that would be something that you add in once a week? Have you thought about it?
- [48:50]
A
It totally makes sense. Again, there's no good data, but yes, it makes sense.
- [48:54]
B
Are there conversely things that would affect negatively affect bone loss? Diet soda, sparkling water. I love bubble drinks.
- [49:04]
A
I looked up this one because I love sparkling water. I stopped drinking alcohol about six years ago. So now like my go to happy hour drink is sparkling water. So I needed to look this up. And I'm happy to say there's zero evidence to suggest that sparkling water is bad. Now if you talk about colas, like sodas, like if you have a phosphate rich soda, then that actually could be an issue.
- [49:25]
B
When you say phosphate rich. What? What? I again, I'm not a soda expert. There's added phosphate in phosphoric acid.
- [49:33]
A
Right. So generally your, your dark colored sodas,
- [49:36]
B
what that means energy drinks too.
- [49:38]
A
I don't know that that's true.
- [49:40]
B
Okay, we're gonna look it up. Yeah, because I'm asking for a friend. Mostly me. So sparkling water, you're okay with the effervescence? What else is it? An absolute. If you want to destroy bone, here's your playbook.
- [49:53]
A
Yeah, if you want to destroy a bone under, eat protein. Right. Eat an inflammatory diet. High, you know, ultra processed foods, high quantities, get poor sleep, live in chronic stress.
- [50:04]
B
Okay, well, the sleep part bothers me, but do you think that, you know, when we were in training there, we talked about the brittle bones, diabetic, brittle bone.
- [50:17]
A
Metabolic health is big.
- [50:19]
B
How does metabolic health and bone go hand in hand?
- [50:22]
A
Yeah, it's chronic inflammatory state. I mean, it's a simple way to say it.
- [50:27]
B
All right, well, friends, you heard it here. Is there anything that people can do to improve their nutrient absorbent? Is there anything that people can do specifically to improve nutrient absorption? With bone being the endpoint? Anti fracture diet.
- [50:50]
A
Yeah. So from a dietary perspective, we need to make sure that the gut works right. So you can eat the best diet in the world and you can have $1,000 a month supplement stack. But if your gut doesn't work and it's not absorbing it, that's a problem. So we do a lot of, you know, in the functional testing space, dual studies looking at function and then creating a plan around treating that. It's a challenging space to live in, but at least improving gut function or understanding if you need hydrochloric acid or enzymes or whatever to help with absorption. So definitely worth testing. And then from there, eating a protein forward diet that is micronutrient dense and not too calorically dense.
- [51:25]
B
One of the biggest misconceptions that we have heard over the years is that protein is bad for bone. And when I was in fellowship, geriatric fellowship, those individuals that had the lowest protein diet had the greatest risk for of course, fracture. It is not. It's a complete myth. It should die and be dead and be buried. Bone is made from protein. When you think about people or populations that are at risk are those individuals with celiac with gluten intolerance. Who do you go? Okay, here are the three people again. Pre existing or comorbid conditions.
- [52:04]
A
Yeah. So celiac is a super common one. Right. And we actually diagnose a lot of celiac because they come in with osteoporosis, and that's one of the things we check. They just didn't know. And so, yeah, if you can't, if your gut doesn't work, it can't absorb.
- [52:16]
B
And celiac is, is an autoimmune response to gluten or, or gliadin.
- [52:22]
A
Yeah. So then the question is, you mentioned, you know, non celiac gluten intolerance. So then how likely are they to have bone loss and osteoporosis? And the answer is, we don't really know because it's a spectrum. Right. But, you know, I, I, I don't eat a lot of grains. I discourage the use of consumption of a lot of gluten or any gluten across the board almost, because I just see it so commonly. So I think it probably is having an impact. Does it actually cause osteoporosis? I don't know. I wonder if you'd give me two minutes on the, the ph thing, the muscle thing. Can't wait. Oh, my gosh. So I talk about this every time I get an opportunity because it is one of these things, and you mentioned these dogmas earlier. It's one of these things that gets repeated over and over again that you want to alkalize your body for your bones. You learned it. I learned it.
- [53:08]
B
I heard it. I would say I never learned it.
- [53:10]
A
Right. Because it didn't make sense.
- [53:11]
B
No.
- [53:12]
A
Yeah. And so I had to look into this because it just doesn't intuitively make sense to me. And yet, even in authors that I really respect, doctors when it comes to talking about bone, it just comes out of their mouth like, but you need to make sure you alkalize your diet for your bones. Like, what? That doesn't make any sense. Because if you do that, then, like you just said, protein is, quote, unquote, acidifying. It's the opposite of what this principle would suggest. But yet protein is the most important component from a nutritional perspective for bone health. So it just doesn't make sense. The literature. There actually are many studies looking at an alkaline approach, some kind of intervention, and it always fails. Except one study where they control for protein first.
- [53:57]
B
You guys heard it here first. If someone is trying to sell you or talk to you about a ph diet, next, what is it? Swipe right or swipe left? Swipe in one of those directions. Talk to me about medications that we don't think about. Medications are pervasive. Are there a Handful of medications that people take routinely that affect bone.
- [54:22]
A
I mean, the first one hopefully is not routine, but if you are using systemic, either oral or any other form of steroid.
- [54:30]
B
Meaning like a metal dose pack.
- [54:32]
A
Exactly. Yes.
- [54:33]
B
For asthma or something like that.
- [54:34]
A
Yeah. Including inhaled ones. If you're using them frequently and consistently, definitely check and see what's happening with your bone. That is a public service announcement. Outside of that. Because everyone usually pretty well known outside of that. The ones that I would say that surprise people would be like your. Your PPI drugs. Right. The drugs that you're going to use, the Nexium. I always forget the brand names, but like Nexium, things that are now over the counter. Yeah. That suppress stomach acid in an attempt to reduce symptoms of acid reflux. Those drugs are associated with increased fracture risk, ironically not with decreased bone density though, which I can kind of explain. But ultimately, if you're having to take these things for a long period of time, try to understand why there is a time and a place for that, but should not be for chronic acid reflux without a reason. And then another really common group that's concerning are the SSRIs. So SSRI is antidepressants, anxiety drugs. These are also associated with osteoporosis. I don't actually understand the mechanism there.
- [55:37]
B
Associated but not causative with no underlying mechanism.
- [55:40]
A
I don't know the mechanism. Correct, Correct. But we do see the association and it's pretty strong.
- [55:44]
B
Are you like me watching your skin age? It kind of sucks. But as science continues to evolve, we have options. We've heard a lot about peptides lately. And speaking of peptides, thank you to One Skin for sponsoring the show. Now, I have used these products long before they became a sponsor. There is normal skin aging and then there is skin health. That's why I use One Skin. It's founded by female PhD scientists and it's rooted in rigorous research. I use OS One Face topical supplement and it's completely changed how my skin texture looks and feels. Even my husband Shane is happy because it replaces my old messy skin routine with one simple step. At its core is the the OSO1 peptide. And it's clinically proven to target a leading driver of aging skin so you can have healthier skin over time. It's born from over a decade of longevity research. And this targets the visible signs of aging, helping you get better skin. And for a limited time only try one skin for 15% off using the code. Dr. Lyon. That's one skin co use the code DrLion for 15 off the PPIs, I think surprise a lot of people. Probably 15 years ago there was a maybe mid 50 year old woman that she had fractured something. It was weird. She was super fit. And I remember talking to her physical therapist. I will never forget this talking to her physical therapist. And I told this patient that she had to come off these PPIs, that I believed at the time that it was affecting her vitamin mineral absorption. That physical therapist called me screaming at me, how dare I tell this patient that the reason that they may or something that contributed to this fracture was the use of these PPIs.
- [57:49]
A
It's odd coming from a physical therapist.
- [57:50]
B
I understand, but there's. Yes, it was odd. And now I think fast forward that one of the things interesting in medicine is that we see things in patterns over time that we might not be able to exactly explain the mechanism or it takes time for the mechanism to come out. What about the use of Advil or things that affect potentially gut integrity or birth control? I understand they're two separate, but do those, either of those play a role?
- [58:19]
A
So gut integrity does play a role for sure because it relates to the inflammatory component, the immune system. Absolutely. The effect of NSAIDs like ibuprofen and aproxen. I've not seen a direct causative or correlation there. It makes sense to me again and I discourage the use unless somebody really needs it. Birth control is an interesting topic because my gut told me that birth control is bad for bones. But when I looked into this to try to create this again public service announcement, what I found is that because the progestins, the synthetic progesterones in birth control tend to be anabolic. There's a couple of exceptions there, but they tend to be anabolic and actually push on androgen receptors. Likely because of that they do not seem to be associated with bone loss. There are some that are though and I actually don't remember the names off the top of my head, so I'm not going to say any out loud, but definitely for a woman who is suppressing her cycle using birth control, understand
- [59:18]
B
what's happening with your bum and test early.
- [59:22]
A
Test early.
- [59:23]
B
Exercise. I have a patient that she was an ultra Runner. She's 60. This woman puts me to shame. She out trains me. She is three times stronger than I am and she's been a lifelong athlete. When she came to see us, she was osteoporotic. Wow, crazy. Higher protein diet makes sense. She's running ultras. Like that's kind of crazy. We changed her training to now she's pulled back on the ultra and she's lifting. She's osteopenic, which I was surprised. I mean, yes, we've obviously, we're improving her bone density, but still osteopenic. And as I was thinking about, okay, what is our net? Her hormones are optimized. We have not done ctx. I am going to get that and a handful of other lab values. It just makes me think, and I had this aha moment, which you can tell me this is totally wrong, is that we have her on a resistance training protocol. She is doing her cardiovascular activity. She has a higher protein diet. She's on hormone replacement. She's doing no high impact jumping, plyometric, broad jump, any of those activities.
- [60:41]
A
So the first thing I would say is, how long has it been? And how long have you been working with her to see that?
- [60:46]
B
Two years.
- [60:46]
A
Yeah. So two years, still relatively short. Right? You are seeing improvement in two years, which is great. So the first thing I would say is let's be patient because it's probably all working anyway. But if you wanted to optimize exercise, yes, resistance is great, and we should continue to do resistance. And. But the bones really do respond to impact. And the challenge then is how do you do impact in a way that doesn't hurt the body? I love the concept of plyometrics and jumping, but it's really hard to recreate in studies. Like how I jump and how you jump and how you land is going to look very different. So how do we recreate that intervention? There are some studies on some very simple things, like heel drops. Not sexy.
- [61:24]
B
I hate those.
- [61:25]
A
I know they're not sexy and they actually don't feel very good. But that's kind of the point, is that you can generate over four multiples of body weight just by doing a
- [61:32]
B
simple heel drop, basically standing on a bench. I'll do a video on this. J.J. thomas, my physical therapist, has had me do heel drops because we're on a return to run program. For whatever reason, she has me doing it. I stand on a bench, I put my. How should we describe it? My one foot as if you're stepping off of a stair.
- [61:52]
A
So maybe we're thinking about different things. Okay, so when I think of a heel drop, at least the study I'm. I'm referring is essentially standing on flat ground. And the advanced version is barefoot on concrete. Don't start there, but barefoot on concrete, if you want to get the maximum effect, rise up onto the balls of your foot and then just let your Body weight fall with your knees essentially locked out. Now, everybody listening, please don't go do this.
- [62:17]
B
Right. Well, we'll do a video of it, but, yeah, we're talking about two separate things. That seems as if that's almost no impact.
- [62:24]
A
So we're gonna try it, and you'll be shocked at how much impact it is.
- [62:30]
B
Heel drop. What else do you as when you see patients, do you say you do need? Is it jump rope or how do we begin to challenge? One of the other things I'm sure that you've heard is that people are afraid to fracture their bone.
- [62:43]
A
Of course.
- [62:44]
B
How do they do activity that is meaningful to bone that's already compromised?
- [62:49]
A
It's a very difficult position to be in. And this is why early intervention is so important. Because when I get those questions from women in their 60s and 70s with a T score of negative 3 and negative 4, inevitably they're asking, well, will this cause a fracture? And the answer is, I have no idea. I can't tell you if it will or if it won't. But what I can tell you is that if you do nothing, I know what that trajectory looks like. Right. It will get worse. So we have to pick a starting point that you're comfortable with. And I would say start low, go slow.
- [63:18]
B
But basically, there's no data to say. This is the.
- [63:20]
A
There's no way to know. There's no way to know.
- [63:23]
B
Vibration plate.
- [63:25]
A
Fun, and I like them. It's an oddly controversial space. So there's essentially three different types of vibration plates. One of them is good for bone, both in the hip and the spine. But of the three versions, that's not the most common out there. So I'll just run through them real quick. If you go on Amazon, you type in whole body vibration, you'll get all these different things. Usually they are $100 to $200. They kind of go side to side, right? That's not a device that I would recommend for your bones. And then there are a couple of devices on the market. I'm not going to name any names that have what's called ultra low displacement or micro displacement, meaning that they don't move up and down very much. And they market not making direct claims for bone, but they kind of mark it in the bone space. And the literature does not support that. These devices will increase bone density at the hip and the spine. And then there's the devices that I do personally use or recommend, which have a displacement of between 2 and 4 millimeters, meaning they go up and down 2 and 4 millimeters. They're vertical, so they're not going side to side. They're just moving up and down between 30 and 40 hertz. That's the frequency. So that's how many times per second. Those devices actually have a ton of data supporting that they can either slow down or increase bone density.
- [64:40]
B
And where do you get those devices? Those medical. Are those medical devices.
- [64:45]
A
So direct to consumer. The company that we use is Power Plate. And so their. Their home devices. Yeah, the Personal and the Move have the. Exactly the requirements that I look for from the research.
- [64:57]
B
How often? Because, I mean, there's no reason why. I mean, I'll check to see if it's cost prohibitive, but there's no reason why we shouldn't be doing that.
- [65:07]
A
They are pretty expensive. So the Power Plate Mood, which is the version I have, I think is close to $3,000. So, yeah, it can be a issue. Their Personal is a little bit less, but it's still probably around $2,000. So, yeah, it's expensive, but it is a passive tool. Not everybody can use it. There's a few contraindications, especially like eye, ear things, but most people can use it. It's passive. You literally stand on it and that's all you need to do for ten minutes a day, five days a week.
- [65:36]
B
Ten minutes a day, five days a week. And gyms have it. Right? It's something that.
- [65:40]
A
Yes. I'll say a caveat about the professional versions because they have commercial for gyms, they also have healthcare versions. Those versions go up higher than the thresholds that I just mentioned. So they do move up and down potentially more and potentially faster. So more is not better. Right. If you go more, then you could potentially get to a point where you don't want to stand on it. It's too much. And faster actually decreases the benefit. So stick with those thresholds.
- [66:07]
B
Hmm. What else are we missing in that story?
- [66:11]
A
Anything else from an impact perspective? So there's. There are devices that are very popular or kind of popular that use this concept of osteogenic loading. Are you familiar?
- [66:22]
B
I believe so, but I'd like to hear.
- [66:27]
A
So the. The franchise name out there is osteostrong. It was another company.
- [66:31]
B
That's what I was thinking.
- [66:32]
A
Biodensity. Yeah. So these are really interesting devices. The initial research, I think, again was interesting. It was not well done. No big studies. But the principle is there. And the whole concept here is that can we create at a certain range of motion which is nearly, you know, nearly straight with your legs and with your arms, because you can generate so much more force there. Can you generate that over four multiples of body weight, which is potentially the, the trigger for bone growth, just by pushing on an immovable object. So the early research was promising. The franchise took off. So osteostrong available around the globe biodensity, kind of a different business model, but also available very similar devices. But the research that's come out over the last 18 months has not been convincing. There was a long period of time where these companies grew without any good randomized control trials. They started to ask almost the right question. Now we have some randomized control trials. There are four that have come out over the last 18 months. None of them showed any benefit of using these devices. Now that doesn't mean.
- [67:37]
B
But it's only four months.
- [67:38]
A
Well, so only four months of what?
- [67:41]
B
Randomized controlled trials. If a randomized control trial is four month trial.
- [67:46]
A
No, there's four randomized controlled trials.
- [67:48]
B
Oh, and how long was each trial?
- [67:50]
A
There were different lengths, but usually 10 months to 12 months, I think if I remember off the top of my head. But the challenge is that these trials were not asking the right questions. I said close to the right question. They did not ask the right question. So the question that we need to answer with these devices is who is the right population? Right. Is this women who are perimenopausal in their 40s? Is this women who are frail in their 80s? Which group? They're very different. HRT plus minus, if you're on bone drugs, plus minus. So we've started to ask close to the right questions. The data don't support using them according to these studies. But again, these were not good studies. They were poorly controlled, in my opinion, poorly done. I have a video on each one in our YouTube channel and basically we'll
- [68:33]
B
link it, we'll link it below.
- [68:34]
A
Yeah, I just rip apart the methodology because I'm so frustrated because I have so many people who have a lot of hope with these machines and I think it does make sense, but I can't say for whom it is the right person to do this with.
- [68:47]
B
What is the minimum effective dose that we know of and the load necessary to impact bone density? And I know it's a really hard question, but what I liked about those machines is it basically it used AI and it worked off of your resistance, the amount of force that you were applying.
- [69:09]
A
Yeah, I love the concept. Right. So the machine doesn't push on you, you push on it. So as a result like this feels like it's relatively safe and you can generate a tremendous amount of force, but
- [69:20]
B
that doesn't mean it affects bone.
- [69:23]
A
Yes.
- [69:24]
B
And I want to know what is the minimum effective dose? If you were to say, here are the exercises that again, people should do for. Because the areas of concern for you are the spine and the hip. Are there other areas that you are concerned about?
- [69:38]
A
I mean, I'm concerned about the whole body. Right. But the hip fracture in particular is the one that you want to avoid at all costs. Those are, I don't know how many, hundreds or even thousands potentially of these things I have operated on and quote, unquote fixed. And the outcomes, even if the surgery is perfect, the outcomes are abysmal.
- [69:53]
B
Talk to me about again, what we're really, we are talking about the activity to impact bone and hip fractures. You don't really hear a lot about back fractures, do you?
- [70:07]
A
I mean, they are problematic, right? They cause a significant amount of pain, they can cause deformity. I mean, they can be a very big deal. But no, they're not. They're just not sexy to talk about because the statistics aren't as robust as the hip.
- [70:18]
B
And also we see when someone falls and is it that they fall and break a hip or does the hip fracture and then they fall?
- [70:25]
A
It can be both. Yeah, I surprisingly hear more of the latter. The other one I want to point out that isn't talked about often is the top of the arm right around the shoulder. If you break the top of your humerus bone, the top of the shoulder itself, you will likely lose a significant amount of range of motion that has tremendous impact on your life. So especially for women, imagine men, maybe they care too. But for me, I don't care if I can brush the back of my head, but I have so many patients who can't get their hair brushed to the back of their head. And it really bothers them. They can't reach up and grab something off the top shelf because they have a restricted range of motion of their shoulder. After these things heal in surgery doesn't necessarily make that better. So again, these are just fractures we want to avoid.
- [71:06]
B
We did, we really did frame this conversation around women. From my perspective, we have. It's very rare to see, at least in our practice, to see osteopenia, osteoporosis. The time that we have seen it is when we've gotten patients that have been on long term anastrozole, long term estrogen blockers. Are men and women, do they have the same risk factor?
- [71:31]
A
Well, estrogen is the primary sex hormone driver for bone in both men and women. And I actually was thinking about this today because I just had a patient who went and got a consult from some longevity doc in Miami, and he said, hey, you should go on testosterone and anastrozole and AI. And I said, for bone, it doesn't make any sense at all. You need the estrogen level. Right. You want your estradiol to be, you know, upper end of normal. And so, yeah, I think it's a big concern, especially for men who are in that zone of treatment. Right. It's really common to use anastrozole. I'm concerned about all of the men that have been doing that at high doses for years, because I bet that we're going to see again this landslide of osteoporosis as a result. Is
- [72:18]
B
osteopenia, osteoporosis as common in men in general?
- [72:21]
A
Certainly not.
- [72:22]
B
It's not.
- [72:23]
A
Not because they don't lose bone. They do. But if you think about what happens with sex hormones, right, Testosterone levels decline more gradually. There is no, like, andropause is not as sudden as men.
- [72:33]
B
Not even a thing. Right. You could potentially not have men, potentially might not even ever get a decrease in testosterone, which is really fascinating.
- [72:43]
A
Yeah. I mean, in your world, I see it all the time. Yes. Right. You have optimized patients. So I. I am worried, though, about low testosterone levels out of the gate for men. I am worried if they're on AIs. I am. I'm worried if they're doing other things that are bad for their bum that they don't know, but they have a higher starting point. And this is the difference. If you look at the graph, you know, women hit a certain threshold on average. Men are another standard deviation or two above that. They just have more room to fall before they hit it.
- [73:11]
B
And when he says AI, he's talking about aromatase inhibitors. I have a question, and this is kind of a scientific question, but this is really a personal opinion question. As you're talking, I'm thinking, okay, men have higher levels of muscle mass and testosterone. People will be like, oh, well, it's relative, all this other stuff. But I'm curious, do you think. Again, I don't really know how to frame this, but do you think that there is an inherent sex difference or is that we are not having women out there pounding weight in the same way? I mean, just think about it. Women are not. They're just not out there pounding weights in the same way, and they're just not you know, I look at my son Leonidas who, you know, he's five, he's out there, he's mom, where's the kettlebell? Mom, where's the kettlebell? And my daughter's over there dancing, she's like mom, did you see zombies? Right? And, and she said put on this song.
- [74:16]
A
Yeah.
- [74:17]
B
And I, I realized that over time that just their, their physical nature is different. What do you, what do you think?
- [74:23]
A
I mean so similarly I have two boys and I have a seven year old girl and yes, they are doing wildly different activities just naturally. Now I do think it's interesting my, my daughter is into gymnastics which actually is a, like a profound bone building exercise. But yeah, I mean in general my boys are, they're just, they're wrestling, they're falling off stuff like they're impacting their bones. You know. My oldest is, is already into lifting weights and so it like I do think there is going to be a natural split there. But there's also genetic changes. Testosterone levels rise faster. I think in young boys there's hormone, other hormone changes, there's dietary changes. So boys just eat constantly, just machines. Whereas my daughter is still a pretty picky eater and really struggling to get adequate protein in there for her. So it's a combination of all of it.
- [75:15]
B
Yeah, it reminds me of the athletes triad for the girls. They lose their period, they're under eating and you know, I don't see those same behaviors I think in the guys doesn't mean that they don't exist. But I also wondered, is that setting us up for a milieu of bone mistakes?
- [75:39]
A
Well, I think what's happening in young men especially is I do see some of the same risk factors, factors we don't have a cycle to go off of for men. And so I'd see some of these same risk factors. Sedentary lifestyle, video games, poor nutrition, ultra processed food. I watch it in my boy's classmates early on they get away with it, they eat this garbage diet, they're playing Fortnite all the time and yet they're still pretty active, healthy looking kids. That's going to change as they start to go through adolescence and early adulthood. That's going to change and it's going to look more like what women on average are doing. Of course there are exceptions on both ends of that.
- [76:19]
B
The minimum effective dose for what you would like to see and the amount of weight. For example, women will go to a class and lift lighter weights. More repetition. Do we know if there's a particular stimulus required for bone.
- [76:35]
A
I think it's going to vary from person to person. There are studies looking at a certain amount of exercise, right? Is it two days a week of resistance? Is it three days a week of resistance, one day a week of impact? Like those studies exist, but exercise is kind of hard to study. Populations are different, hormone levels are different, like all this stuff. So I have had patients in their 70s and 80s who can do no more than like two days of resistance training at pretty light weights and still see improvement in bone. In bone. But they're not pulling that lever very hard, right? They're pulling other levers harder. For my women and men who are more active, more capable, harder, better, you can certainly overtrain, but generally we're coming from a sedentary background, so harder, better. But I don't go more than three, maybe four days of resistance training. They have to be able to recover. And then if you're doing that much resistance, it's going to pull back on whatever else you think might be important for you. Is it high intensity interval training or cardiorespiratory work or whatever. So just finding that balance based off of your goals.
- [77:40]
B
It is complicated to study. And I think, again, what is probably good for muscle is good for bone. If you're building, is it fair to say that if you're building and maintaining muscle, you are impacting bone?
- [77:57]
A
I think if you're spending enough time in an anabolic mode where you can actually put on muscle, my guess is you're probably putting on bone.
- [78:05]
B
Dr. Doug Lucas, any last words?
- [78:09]
A
The biggest thing for me is know your starting point. We all have risk factors for bone loss, so please get a dexa. If you want to get a rems, get a rems, but get a dexa. Know what your starting T score is and Z score depending on your age, so that you know what that trajectory looks like. And if you're losing bone, figure out what it is.
- [78:28]
B
All right, well, great to have you on.
- [78:30]
A
Happy to be here. Thank you.