In this podcast episode, host JJ Virgin and a medical expert discuss common misconceptions and emerging insights about bone health after menopause. They debunk the idea that calcium alone is protective, explaining that high‑dose calcium without vitamin D raises heart‑attack risk, while modest vitamin D (≈400 IU) mitigates it. They clarify that walking, though weight‑bearing, does not reverse osteoporosis and that the term “weight‑bearing exercise” is often misunderstood. The conversation expands the risk profile beyond thin, elderly women to include young men with celiac disease, sarcopenic women, and even obese women, especially those undergoing rapid weight loss from high‑dose GLP‑1 therapies. The experts explain that GLP‑1 drugs themselves are not inherently harmful to bone; rather, severe caloric restriction leading to inadequate protein intake drives bone loss. They highlight that over half of fragility fractures occur in women without an osteoporosis diagnosis, underscoring that bone density is only part of fracture risk. Risk assessment should consider family history, prior fractures, steroid use, genetics, and trends in bone density over time. A clear definition of fragility fracture is provided, emphasizing low‑impact mechanisms (e.g., standing height falls) that should not cause fractures in healthy bone. The role of osteoporosis drugs is examined: while useful for high‑risk, older patients, they are overprescribed because clinicians lack alternative tools, and they may not address underlying metabolic health. The episode challenges the belief that bone loss is irreversible, citing endocrinology literature and arguing that lifestyle changes—nutrition, sleep, weight management—can halt and even reverse bone loss, allowing T‑scores to improve past the osteoporosis threshold. The discussion concludes that bone health can serve as a biomarker of overall healthspan, but ongoing vigilance is needed to prevent recurrence.
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So good, so good, so good.
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Calcium alone. Hmm. Prevents fractures?
No. The reason why this is dangerous is calcium alone has been shown in big studies to increase the risk of heart attack. Now, fortunately, not a lot of people are taking it alone anymore because generally you can't say the word calcium without saying the word vitamin D after it. And the good news is it turns out that even like a whiff of vitamin D brings that risk back down to baseline. So I don't think anybody's taking 1,000 milligrams of calcium alone. If you are, please don't. But just a little bit of vitamin D, I mean, 400 IU of vitamin D will bring that risk back down to zero.
Walking is enough to build bone.
False. We hear people go to their doctor, their doctor says, hey, you should consider taking this drug and calcium and vitamin D and do weight-bearing exercise. I really don't like that term weight-bearing exercise because I don't even know what that means.
I mean, I've got weight on me, right? And I'm bearing it.
We're sitting on our tailbone, right? Like, this is— is this weight-bearing exercise? Guys, no. And so people don't know what that means, and I think they're misled by it. And yes, walking can potentially slow down bone loss. That actually has been shown in research, but will it reverse osteoporosis? Not a chance.
Okay. Only thin elderly women are at risk for osteoporosis.
Absolutely not. Some people you've worked with, young men with certain risk factors like celiac disease. But honestly, we see a large spectrum right now, especially of certainly thin frail-looking sarcopenic women are at risk. Absolutely. But with the obesity epidemic, we're now also seeing this interesting obese women, especially that also have osteoporosis, even if they haven't lost weight yet. If they have lost weight, then we're really concerned because rapid weight loss, especially with the advent of GLP-1s and the ability to really be on a restricted calorie diet, we're seeing tremendous loss of bone density and quality. So now we have— a whole spectrum of people who you would not think are at risk, they're at risk.
So is it the GLP-1 that's causing the bone loss, or is it the rapid weight loss due to the high dose of the GLP-1 causing the bone loss?
Yeah, I, I hope I said it clearly, which is people on GLP-1s who are severely calorically restricted, right? Because it's not the GLP-1s. In fact, there is philosophy theory that GLP-1s should actually be protective of bone. And there's some recent literature to support that you can at least maintain bone while you're losing weight on a GLP-1, which is really great news. But if you take especially the larger pharmacologic doses, it's really difficult to eat adequate protein. And so this is where we need to help steer people, people who are on GLP-1s to avoid that excess lean mass loss.
I wanted to make sure we really hit that because the latest crazy fear all over Instagram is of course GLP-1s cause bone loss. Seems like You know, it's crazy. If your DEXA is normal, you're safe.
No. In fact, over 50% of fragility fractures occur in women without a diagnosis of osteoporosis. In other words, they do not meet the diagnostic criteria on T-score of osteoporosis, and yet they are having fragility fractures. Bone density is just one part of that equation. Wow.
How can we look at all of it to figure out what— if they're at risk then? Is there a real way to do it?
It's challenging. So this is something that I don't have a clear answer to other than I think that we can look at trajectory of bone density over time if that's all we can measure. Uh, you and I have talked about this before where the ideal time to start measuring density is in early adult life. And so depending on your starting point, you're gonna want to be more proactive about your bone than potentially later. But also if you're seeing a decline even from normal bone density, you and you're seeing a decline and you have other risk factors for fracture, let's call it genetics, family history, history of steroid use, these things that are going to degrade bone quality, even without measuring bone quality, which you can kind of do, but even without that, you should be more alert to the— your increased fracture risk.
So those risk factors again, let's go through them.
Yeah, there's a, there's a ton, but just off the top of my head, family history is one of the easiest ones to ask, right? Did your mom have a hip fracture? Did your grandmother have a hip fracture? If so, you really need to pay attention. There are some genetic studies that you can do that are gonna show you and really objectify that risk, but ultimately just ask your family history if you know it. So family history is a huge one. History of fracture is another big one, right? So if you've already had a fragility fracture, you are at high risk of another one.
Fragility fracture versus the other— Yeah.
Let's define.
Yes.
If you were in a car accident and you were going 75 miles an hour and you rolled over your car and you had a hip fracture, That's not a fragility fracture. Fragility fracture is defined as a fracture of, and there's a couple different definitions, but generally it's the hip, it's the pelvis, it's the wrist, it's the upper arm. These are the bones that can fracture with a very minimal mechanism if you are fragile. And that mechanism could be something as simple as turning, you know, literally turning in a chair and you could actually hear a pop, right? Standing up, reaching over and getting your keys. You break, and then you fall to the ground. That's the most extreme example of a hip fracture from a fragility fracture. But also, a fall from standing height shouldn't break a hip, right? If you were to just trip going over to pick up your bag, you should not break a hip. And if you do, then we need to look deeper at your bone quality. Same thing with the wrist. If you were to, you know, gently fall over and put your hand down, you should not break a wrist. If you fall down a flight of stairs, different story. And it's not obvious, it's not black and white, but if there's suspicion, like, hey, that mechanism didn't really make sense for this injury, that's when we need to be concerned.
If you have osteoporosis, drugs are the only solution.
Boof. This is something that I, I used to be actually really aggressive about. I've backed off quite a bit because there is a time and a place for drugs. I'm not anti-drug, but the challenge I see with the drugs is that they are overprescribed And not because doctors are bad people or they're mean or they wish you poor. They're overprescribed because it's the only tool they have. If you go to a doctor in the conventional medical system, they are not a bone health specialist. They're a— potentially— a bone drug specialist, right? Like they only have one tool to help you prevent fracture. So they're going to use that tool if you're at high risk for fracture. But the drugs have a limited time span in which you can use them. They have some risks. They have some potentially severe risks, but the biggest thing for me is that they don't really work with metabolism of bone. If your goal is to not need a drug ever or in the future, if your goal is to do this naturally, the drugs can potentially work against you. And especially if you're young, and this is one of the things we do is to help people to understand how much bandwidth or runway is another way to say it. How much runway do you have to do this naturally before a fracture? Obviously I can't put a number on that, but I'll give you some extreme examples. So if you are 85 and you are in relatively poor health and you have a diagnosis of osteoporosis, you know, let's say you can't really exercise very well, you have limited capacity to change what you eat. Let's face it, a drug is probably in your best interest. But if you're 45 and you went through an early menopause and you're also diagnosed with osteoporosis simultaneously, and that same drug that was offered to the 85-year-old is then offered to you at 45. Does this make sense? Not a chance. But again, the doctors don't have any other tools. So if you meet criteria at 45, you're still likely to be prescribed that exact same drug. And so this is when we say, what kind of runway do you have? A 45-year-old woman who is otherwise healthy likely has a very long runway before a fracture, and she can at least give this a trial to see if she can improve her bone density and quality without a pharmaceutical.
Which then comes to the— can bone loss— because the big, The big myth is bone loss cannot be reversed.
Yes. I think this comes mostly from the endocrinology side. There's a paper that I quote from Dr. Lewicki, who's an endocrinologist in, I think somewhere in New Mexico. And he's a super smart guy. Lots of papers, respect his work. I think the title of this paper is Treated Osteoporosis is Still Osteoporosis. And a lot of doctors will take that to say, we should not say that you can reverse osteoporosis. And I understand his perspective, which is, look, if you have diabetes or high blood pressure and we put you on medication for those things and your, you know, biomarkers for diabetes normalize, your blood pressure normalizes, but you're treated, you're on medication. Do you still have those diseases? The answer is yeah, you do. Right. So then with osteoporosis, in theory, this is the same thing. If you have a T-score of -3 and I put you on reclassed to this phosphonate drug for osteoporosis, which will reliably increase your bone density, it goes to -2. By definition, you don't meet the diagnostic criteria of osteoporosis, but you're treated and your risk factors remain the same. So you should not say that it's reversible under those circumstances. But I love the way that he puts this in this paper because it gives me the opportunity to point out the other side, which is if that person who is obese, diabetic, and hypertensive high blood pressure, figures out what the underlying cause is, changes the way that they eat, the way they sleep, all the things that you talk about, JJ, and their weight comes down, their blood pressure comes down, their blood glucose, their A1C, and their insulin all normalize, and they are not on a medication. Did they reverse their high blood pressure and their diabetes? Yes. So the same thing's true with osteoporosis. If we can treat that thing, you should be able to see bone loss plateau. bone loss start to go the other direction. You should be able to build bone density and quality, assuming you're able to execute on it. And then eventually your T-score will cross over that -2.5 line. And by definition, you don't have osteoporosis. To me, that's reversal of osteoporosis. I've had lots of endocrinologists reach out to me and tell me that I'm, you know, potentially putting people at risk. But my point is, is that you should be able to improve bone density if you can act on it. You should be able to reduce fracture risk if you can act on it. And if you can, then I don't think that we need to consider you as still having the disease. Now, are you at risk of it coming back? Of course. Same thing's true with the obese diabetic hypertensive patient, right? They were predisposed to it. They are still predisposed to it. But if you continue with the lifestyle intervention, the things that you did to reverse it, then you should be able to continue down that path.
Osteoporosis is inevitable with aging.
One of the things I show, and I'll show it in my talk here tomorrow, is this graph of predictable bone loss as we age. And it's, it's predictable, right? You see in both men and women, we peak in, you know, late 20s, early 30s, and then there is a predictable decline. You want to put a number on it, it's around 0.5 to 1% per year over the course of a lifespan. Now, women, there's this dip around menopause where you can lose up to 20% of your bone density over the 5 to 7 years after menopause. That's a really big deal. But I remember looking at this after starting the practice, after seeing reversal over and over again in age ranges from 20s all the way through 80s and realizing, wait a minute, if my patients can reverse their bone loss and we see their bone density increasing without pharmaceuticals, do we really need to accept that bone loss is a mandatory part of aging? I think the answer is no. In fact, I've gone so far as to say that really, if you're losing bone, I think we need to consider that something is wrong, right? Like, why are you losing bone? And then now we look at bone health in a totally different way because we can track it. It's one of the coolest chronic diseases that you can track, right? It's hard to know what's happening with your heart or with your brain, but with bones, we can look at the metabolism day by day. We can look at imaging over time. So now I say, look, bone health, it actually should be considered a biomarker of longevity. It's a biomarker of healthspan. If you're losing bone, better figure out why.
