EP 161 WTH?!?: Understanding Osteoporosis with Dr. John Neustadt

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Welcome back everybody. Dr. Greg Eckel. This is what the health Our topic today is the brain gut bone connection with my friend and author Dr. John Neustat. He's an international reputation as a researcher, a doctor and integrative medical expert. Became renowned in the field through his nutritional medicine research, his clinical work and the books he wrote. His work with the FDA on evaluating the use of natural products for the potential treatment of rare diseases, developing million dooll businesses, educating physicians on improving patient outcomes and the general public on how to make sure they're getting the care they need and the results they want. And as a medical expert advising businesses on product development and how to create super fans. He's published more than a hundred medical articles written for health and wellness books. Now a number one Amazon best selling author in the field of osteoporosis. Right here it is, Fracture Proof your Bones A comprehensive Guide to Osteoporosis. Dr. Neustadt is also an editor of the textbook Laboratory Evaluations of Integrative and Functional Medicine which is used across the US to train and educate physicians on using functional medicine with their patients. Welcome aboard. Dr.

Thank you.

And I I love having a colleague, another naturopathic doc on on the show and just one of your stature and caliber. Thank you for writing this book. You know, with our aging population, I asked you why was this a passion project for you? And I'm just going to open it up to you on how did you get into I obviously bone health is important, but what does it mean to you?

Well, I never thought I would spend, you know, 15 years of my life and continue to do so researching bone health and osteoporosis and doing such a deep dive in the topic. But one of my professors and the founder of my university, Bill Mitchell, before he passed away, I had him in an advanced therapeutics class and he very wisely said to us, your patients are going to tell you what they need and if you listen well enough, you will hear it. I was in clinical practice and I had patients coming to me with osteoporosis and I thought I was doing a good job. Their bone density was going up. I was essentially practicing how I was taught and how most doctors are taught to approach and treat osteoporosis, that is improve the number on the test, the bone density test results. My mother in law who's now 93, she has osteoporosis and she did at the time. This was back in 2006, 2007. I was working with her nutritionally, some supplementation Dietary recommendations. And she had her medical doctor, who she was working with, who had her on Fosamax, and her bone density was going up. So her doctor was happy, she was happy, I was happy. And then she tripped on a throw rug in her house and broke her hip. I thought to myself, something's wrong with this picture. What's going on? And I started looking deeper into the research and understanding the value and the limitations of the tests and really what are the most predictive factors for fractures and fracture risk with osteoporosis. And a bone density test is not a major predictor. In fact, what I discovered was that we've known all the way since the 1990s in the research that a bone density test predicts less than half of people with osteoporosis who will break a bone. And in 2008, a study quantify that even further came out and concluded that women with us. For women with osteoporosis, a bone density test predicts only 44% of them who will get a fracture and only 21% of men. And the organizations, national organizations like the North American Menopause Society, the Bone Health and Osteoporosis foundation, all correctly concluded that fracture risk depends largely on factors other than bone density. Huh.

And that is the number one screening for really the population on their bone health.

And it still is the gold standard. And I do recommend people get a bone density test because a it's required for the diagnosis. Also, we do want to track it. It's one piece of a larger puzzle, but it shouldn't be overemphasized. And one of the big mistakes that clinicians are making is that they're treating the number on a test and not the patient sitting in front of them. What we know is that 95% of fractures occur because somebody falls. And so anything we can do to prevent somebody from falling is necessarily going to prevent fractures and other fall related injuries. But in my book, I walk people through chapter by chapter, what are the risks for osteoporosis? And once you're diagnosed, what you can do and what you can do to prevent it as well, to create a holistic plan for themselves. Because unfortunately, most clinicians and the research shows this are confused when it comes to osteoporosis. How to interpret the test results, what are the value of the medications, which medications to use in which situations, and actually how to treat somebody and have these more nuanced in depth and important conversations around bone health that are necessary to, to PR to prevent fractures and protect Somebody as best we can.

It comes up a couple different routes that I want to go with you. One I want to follow that track on. So what are, where are the areas that should be focused on rather than just from the imaging? While the imaging is important and I think everybody should get screened. There are. You're saying we've got to prevent falls. And so I'm. Where, where do you want to go with that?

So first of all I look at this from two sides of the puzzle. So one is are things as somebody doing activities or are there things in people's lives that are increasing their risk for osteoporosis and fractures that are damaging reducing their, their strength and vitality that increases their risk. We want to identify those and remove those from their life or, or, or reduce them as much as possible. And the other side of that puzzle is okay then what can we do to strengthen bones and prevent falls and if somebody does fall, improve the health of the bone so that if somebody does fall that the bone is stronger, the quality of the bone is, is healthier and better and they're able to fall and the bone is not brittle and does not break and on. Because no matter what we do on the, on the side of trying to strengthen somebody and improve their bone health, if we're giving toxic substances or things that are continually damaging bone, we're going to. It's like pushing a boulder uphill.

Yeah. The age of Ziza first is done. We're done with that. We want more ease and flow in our life.

Absolutely.

So on the preventative, like when, how so number one, let's back up a little bit. How dangerous is osteoporosis? And then I'm going to ask you after that it's a non sequitur. But that's just how my brain works. When do we need to start preventing bone loss?

Osteoporosis is extremely deadly. If you are a woman with osteoporosis and break a hip, there's up to a 36% chance that you'll be dead within a year. And if you survive that, about half of the people who survive an osteoporotic fracture never regain their full pre fracture level of pain free life and mobility and enjoyment they had in about 20% of them need continued care for just basic activities of daily living like getting dressed, going to the bathroom, those sorts of things. The older somebody gets, the older they are when they fracture, the greater the risk. But for women, their risk of an osteoporotic fracture for a woman who's 45 years or older. Her risk for an osteoporotic fracture is equal to her combined risk of breast cancer, uterine cancer and ovarian cancer. And in fact, osteoporosis is, accounts for or causes more days spent in a hospital than other diseases like diabetes, heart disease and breast cancer. And globally it's second only to cardiovascular disease as a health concern.

Wow. Wow. That's a pretty amazing, fun fact for the dinner table.

Hopefully it wakes people up a little bit.

Heck yeah, that woke me up.

Nobody's walking around with pink ribbons and there is an osteoporosis awareness month, but there's not this, this huge PR campaign. People aren't getting excited about it. There aren't marathons or. Yeah, you know, those sorts, the awareness campaigns.

And it is such a massive, it's, it's kind of what takes people out at the end of their life secondary to heart disease is what you just said.

That's correct.

So when do we need to start preventing that bone loss? Because you know, we can't wait until our 90s or to a diagnosis of osteoporosis. So I guess, you know, what are those risk factors that lead into it? You said we got to minimize, reduce, remove or minimize them at the very least. And then what activities will help maintain that health of our bones?

The good news is that bone is a living tissue. And so almost all the way throughout life and almost every case, there are ways to strengthen and improve bone health. It's not this static, you know, column of minerals that once you hit peak bone density, there's nothing else you can do. Now peak bone density occurs in our 20s, between 20 and 29, a little later in men than in women. And it's sometimes discussed as a pediatric disease with geriatric consequences, meaning that diet and lifestyle as children, as you're going through and growing bone and getting to that peak bone density, the greater we can make that peak bone density when we're younger, the better it's going to be when we're older. Because once you hit the peak bone density, people start to lose bone mass between about, you know, about a half percent to 2% per, per year. Now that is not just a one way street, though it's often talked about it, it's often discussed in that, in that way that, you know, once, it's just inevitable. But it's not inevit. Not everybody gets osteoporosis, not everybody has a low bone density test result even, even when they're quite old. And so There are many things that you can do as you age to maintain your bone health and bone strength. I am a big fan of starting the awareness. When people are younger with diet, it can be challenging. I have kids, you're a parent, so you know what it's like to have a child and try and talk to them about healthy diet and lifestyle. It's like talking to a brick wall. But it's an important message and hopefully as people help people will gain awareness and an interest in that at a, at a young age. However, that said, one of the major things that I'm most worried about now when it comes especially to women in their 20s, 30s and 40s, is the, the prescription of antidepressant medications and other medications as people age. The ser. Anything that artificially increases serotonin, the selective serotonin reuptake inhibitors or the serotonin norepinephrine reuptake inhibitors like, you know, Wellbutrin and Prozac, those sorts of things. Sertraline, they damage bone. Serotonin. Most people think of serotonin, I think as a brain chemical and it is, it helps promote mood and improve mood. But over 90% of the serotonin is not produced in the brain at all. It's produced in the intestines by a type of cell called an enterochromophen cell in the intestine. And the cells in the bones, the osteoblasts and osteoclasts in the bone, those are the two major cells. The osteoblasts build new bone up and the osteoclasts break down old, worn out bone. And that process is called remodeling. And it's constantly going on and we need it. When, when there's more osteoblast activity going on, we've got, bone is increasing, we're growing new bone. When there's more osteoclast activity, you're, you're breaking down bone and you're losing bone. And so osteoporosis is really a disease and a condition of imbalance. Something's out of balance. Those medications and other things that we'll talk about, but those medications change that balance. They decrease the osteoblast activity and increase the bone breaking osteoclast activity. So you're losing bones. So much so that research has been done, meta analyses have been conducted that for a woman taking an SSRI medication for one to five years, we expect for every 19 women taking them, one will break a bone. And even prior to just one year you start to see bone loss and increased fracture risk. So that's a huge concern for me.

Now a question in that. So what one will break a bone with the use of that medication? One to five years, but that's later in life. Or is that, was there a time frame on that or did for one to five years.

So somebody taking them for one to five years.

Yes.

So it doesn't really matter in their.

Lifetime they'll break, break a bone. No.

While they're taking, if they're taking it for one to women taking it for one to five years during that time period, 19 of them, one of them should they estimate will break a bone.

Wow. Wow. Those are pretty ubiquitous in our society these days.

Yeah. And, and it's often thought that the, this s serotonin and norepinephrine reuptake inhibitors are, are, are not damaging to, to bone. And I've had conversations with other doctors. In fact, I had to send somebody's doctor, you know, PDF studies, you know, showing them. Wait a minute, you're, you're wrong. There's a 10 year Canadian study that was done that actually that did show anything essentially that artificially raises that serotonin.

Wow.

Creates these problems, huh?

Yeah. That's massive. That is a massive find.

Other categories of antidepressants like tricyclic antidepressants do not have that side effect. They have other side effects. But if somebody does have to be on an antidepressant, that seems to be a safer category of antidepressants. And fortunately, as you know, from, from an integrative or naturopathic or functional medicine perspective, there's a lot we can do for mood disorders and depression. I've gotten a lot of people off their antidepressant medications over the years and there's different ways to approach it besides just pharmacology for sure.

What is there another big class of drugs that we might be surprised about there?

Yes, the, the acid blocking medication. So the other, you know, commonly known one are the prednisone glucocorticoids. Those are, those are common, so I'm not going to really talk about that. Yeah, but the acid blocking medications, specifically the proton pump inhibitors have been shown to increase bone loss and hip fracture risk, the most dangerous type of fracture, by 60% in people who take them for four years. So it does, it's not like you take it for three years and zero risk and then suddenly it jumps to 60%. It's, it's going up. In fact, the FDA issued its first warning Letter about protein proton pump inhibitors and osteo causing osteoporosis and increasing fracture risk in 2010. So this is not new information. And now people are just taking them over the counter. They were never approved for long term and doctors aren't typically aware of this issue. In fact, 50% of all acid blocking medication prescriptions are for just one condition, which is acid reflux. And that can be well controlled and often fixed by just simple dietary changes. And those who are taking the acid blocking medication for acid reflux, their risk for osteoporosis and fractures is higher than people taking that for other indications. And. Yeah. And then what happens? And this is a fascinating story of, of, of how the medical system works and how doctors think. So the, the first line therapy for postmenopausal osteoporosis is bis, oral bisphosphonates, Fosamax. So for many years the assumption was, well, if we use it for postmenopausal osteoporosis, somebody has osteoporosis because of another reason, like taking a medication. Let's give it for that as well. Well, they decided to test this. They were just prescribing them without, you know, having run clinical trials yet. So multiple clinical trials have now been run where they combine Fosamax with a proton pump inhibitor or an acid blocking medication. And what they discovered was that people who took the combination of Fosamax with a proton pump inhibitor, their risk for fracture was higher than people who just took the proton pump inhibitor alone.

Now the way. Were they trying to like purposefully injure people with the combination of the two?

No, no, not at all. I think they were the way that.

You, the way that that comes across is like, okay, we know this one's bad, we know this one's bad. Let's put them together and see if it's even worse.

Well, Fosamact, you know, to Fosamax credit, there are clinical trials and postmenopausal osteoporosis showing that it can prevent fractures. Yeah. And improve bone density. Now that's a whole story unto itself and a whole chapter in my book on the medications.

Yeah.

I'm not a fan of the medication. 70% of people who start the osteoporosis medications stop taking them within a year because they. Of the, of the side effects. In fact, those oral bisphosphonates, you know, several studies have been done, meta analyses.

Yeah.

Showing in that that they actually don't. They don't reduce the risk, they don't prevent both vertebral and hip fractures. Only hip fractures. I mean only vertebral fractures. I'm sorry, not hip fractures. For somebody for what's called primary prevention if you've never had one before.

Got it.

And so they're better for secondary prevention if you've already had a fracture. I think the utility and the usefulness of them is very limited. The side, if there's a lot of side effects. I think there are better medications if somebody needs one than the bisphosphonates. I'm not a fan of them.

Yeah.

But there is research showing some benefit as well as a lot of risks.

Yeah. A lot of docs use those first, first line. And then isn't there a component with the, the jaw weakening osteonecrosis of the gy.

Yes.

Yeah. So the. You have a whole chapter in your book on that. I think what I want to do. Let's talk about what you can do now as a, maybe as a preventative component. Because I think the prevention is probably also the treatment. But just in, in the beginnings of like how do we prevent that from happening in the first place? Are there things that we should be incorporating into our day to day.

The, the general recommendations. You're right. For preventing osteoporosis are very similar to the recommendations for once you, once you have it. So we want to first of all give our body the raw materials and the right environment to grow bone. And we've been focusing on bone minerals in this conversation.

Yeah.

Primarily with the bone density. A bone density test only predicts, only measures the mineral content of bone. But bone is a tissue. So there's a lot more, there are a lot more things in bone than just the minerals. The other major component of bone is protein and specifically collagen. So collagen is what gives bone its ultimate quality. It's very flexible, it's stronger than steel. And if somebody falls, it's what allows the bone to absorb the impact of that and not break, but, but, but deform a little bit. Now why I mentioned that is because a. The dietary pattern, the standard American diet, which is very high in packaged foods, high in processed foods, high in foods that are nutritionally deficient and promote inflammation, destroys bone. So over the years, 70 years or more, dietary patterns around the world have been evaluated. And over and over, the Mediterranean dietary pattern has been shown to be the healthiest. And not just with respect to bone health, but reducing cardiovascular disease risk, cancer risk, death from cancer, all cause mortality, diabetes risk, obesity risk, on and on. With respect to osteoporosis it's associated with a 20% reduction in osteoporosis risk and most importantly a 21% reduction in hip fracture risk. Now one of the important things with that is it's a plant forward diet. So we're giving the body the vitamins, the nutrients, the other plant antioxidants that we need to thrive. But one of the things that even when people are following that or I do an intake and they say they're eating a great diet and by and large they're eating, you know, a good healthy amounts of whole foods, they're not getting enough protein. Protein alone can account for 2 to 4% of bone mineral density. See the collagen, not just, just doesn't give strength. It's also the scaffolding on which the minerals bind. So you've got to have that extracellular matrix in the bone to have healthy bone density as well to have healthy bone mineral content. So eating enough protein in the USRDA for protein as people get older is insufficient. It's not high enough to maintain muscle mass and bone density. So I've got a whole chapter in my book on diet that people can calculate how much protein should they be eating as a target. So that to me is the foundation. Diet, lifestyle. The beautiful thing is all of these recommendations, not only do they help with bone health, but will also reduce other disease risks as well, like cardiovascular disease, cancer risk and all of that. Exercise, super important movement. I think everybody already knows that, so I'm not gonna, you know, belabor that point, go into much detail.

But that's, that's crucially how, how important is weight lifting?

It's not, it's not. No. I mean you don't have to go into a gym if you're walking up a stair stairs. Technically you're doing weight bearing exercise because.

Body weight bearing exercises.

Yes. You don't have. So Even just walking 7,000 to 7,500 steps a day on average is associated with a 50 to 70% reduction in all cause mortality. That's death from osteoporosis. Gardening. The best exercise, I tell people, is the one that you're going to do. Right, right. I don't love to go into a gym. So there's lots of, lots of options.

Yeah.

The other thing that there's a couple other really important fundamental components that are, that are not talked about and are missing most of the time. One is sleep and stress. Not getting enough sleep is associated with increased osteoporosis risk. And in fact there's melatonin receptors in the bone. So people probably understand melatonin for helping to regulate sleep, but it's also important systemically. It's an antioxidant, but it also. There are melatonin receptors in bone. And when you're not getting enough adequate sleep, maybe you don't have adequate melatonin or you're not getting that deep restorative quality of sleep. It can destroy bone. People who are under high amounts of chronic stress lose bone faster. But you don't have to have pathologically high cortisol. Cortisol is a stress hormone for people who aren't aware. And when you're, when you're under stress, cortisol will go up. There are diseases like Cushing's disease, which is a pathologically high, very high level of cortisol that's secreted by the adrenal gland. And that's a, that's a disease. That's a, that's a major health concern that needs to be dealt with medically. But even one study looked at healthy people and their cortisol was in the normal range. Those who were in the high normal. They had faster bone loss. They were at a higher risk for osteoporosis. So just not living your life, as I would say, out of balance, not managing stress well is a risk factor for osteoporosis. The other thing too is connection. Making sure community connection is actually associated with a faster recovery from fractures and osteoporosis fracture if somebody has one and increased longevity decrease all cause mortality. Studies looked at this, you know, social networks. How many friends do people have to have, you know, to be. Opt for optimal health? Is it 3, 4, 5? It was only 3. But the catch is you've got to do something with them. You've got to reach out to them. You've got to do, you've got to connect. Being connected with your community is re. Is, is, is important. That's what everybody can do just with their lifestyle and diet. You've got to eat anyway. So I recommend people eat to, to promote their health instead of feeding their disease and live in a way that's going to improve your vitality and your lifespan and your health span and help you feel better. And then there's a whole area of dietary supplements and supplementation that people can also explore that there are clinical trials on certain nutrients that are shown to promote healthy bone density and maintain strong bones that I think are, are very important to consider and take in people who are concerned about their bone health.

Got it. Wow. Dr. Neustadt, the, the book. Everybody, for amazing information and a plan. We're going to put the link there. Any closing remarks that you'd like to share with our listeners or viewers?

Yes, that basically if you're concerned about your bone health, you don't have to be scared. One of the things that I see over and over is people come to me, they got their bone density test results and they're frightened. And I understand because it is, it can be a scary diagnosis. And the first thing that I tell people is I tell them about the bone density test and the limitations of it and I have them take a breath. Just take a deep breath. This is not an emergency. There is time to learn and educate yourself and put together a holistic plan that make sense for you. And that's what my book helps people do as well as gives them questions to ask their doctors to make sure they're getting the best possible possible recommendations and making the best choices for their own health care.

Oh, I love it. Way to, way to wrap it there, doc. Everybody, if you liked today's show, get out there, give us a five star review and put an action item of what you learned today because it could save a life. Thank you.

Dr. John, one more thing. It's, it's, there's, there's tons of these resources and information on my website, nbi health.com awesome.

And we're going to put all of that in the show notes for sure. How to connect on social, all of that jazz. So awesome. Yes indeedy.