How Dr. Doug Lucas Reverses Osteoporosis Naturally in Women

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I hear over and over again, I cannot hit my protein goals. When I see people say I can't hit my protein goals, but they don't start eating until 1 PM, I'm like, well, look, you're missing an opportunity to stimulate muscle protein synthesis as early as possible. Calcium alone has been shown to increase the risk of heart attack. And the good news is it turns out that even like a whiff of vitamin D brings that risk back down to baseline.

If your DEXA is normal, you're safe.

No. In fact, over 50% of fragility fractures occur in women without a diagnosis of 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, and by definition, you don't have osteoporosis. To me, that's reversal of osteoporosis.

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How about that? I like that. Welcome to the show. Happy to be here. Welcome back, actually, to the show. We are going to dig into bone health today because since you were on, I've been getting so many questions and I thought what would be fun, because this is an area where there's a lot of urban legends and fairy tales. So we're going to dig into those first, if that's okay.

Let's go.

First of all, calcium alone 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?

I mean, I'm bearing it. We're sitting on our tailbone, right? Like, this is— is this weight-bearing exercise? 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.

So, 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 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. And it's 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. 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 going to want to be more proactive about your bone than potentially later. But also, if you're seeing a decline even from normal bone density 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 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 going to 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.

But a 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 of 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. Boo.

This is something that I, um, 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 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 Reclast, 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 Virgin, 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 is 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.

Well, so let's figure out why. What are those root causes of bone loss?

The fun thing is we actually have a complete list because it's the same list as those risk factors for osteoporosis in the first place. Right. So if it's genetic, okay, well, you can't change your genetics, but you can certainly be more aggressive about how you're treating your bones. But let's run down the list, right? So hormone dysfunction, premenopausal, perimenopausal, postmenopause, not on HRT. Look at medications that cause bone loss. Steroids are the biggest one here. How many people are on, you know, they take up an oral prednisone taper. Now it takes more than just one prednisone dose pack, right? It takes more than one of those to result in bone loss. But so many people are put on steroids and that has a massively detrimental impact on—

Well, that is a very common one. So how, how many rounds of that would lead to a problem?

I don't remember the number off the top of my head, but it's way less than you would think, right? And we're talking like probably 2. It's not much. And of course, I mean, you're going to see a dip in bone health, but if you're not in a bad situation, like, that's not— that's fine. Right? Like we can all accept a little bit of bone loss because hopefully you needed that thing in the first place. Hopefully you didn't not need it and you were taking it. But that's not the only one. You know, there are other drugs that have less strong associations. Some of the most popular would be like SSRIs, right? Antidepressants. SSRIs cause bone loss? Associated with bone loss, to be clear. Oh, why? I actually don't know the mechanism behind that one. Another really common one are PPIs.

That makes sense.

But I want to just double-click on it because So many people take these PPI drugs for acid reflux and they don't understand that there's risks.

I mean, it seems like bone and muscle would be huge risks for taking those.

For me, if you, if you're blocking the stomach acid, yeah, people say like, oh, possibly going wrong. Yeah. Like I don't need stomach acid. No. I mean, there's a reason why I think you have this pot of, you know, pH 1 liquid in your stomach at all time. I mean, it's there for a reason. And so if you block that because you're having symptoms, now there is a time and a place for these things, but so many people take them unnecessarily. You can't digest protein adequately. You can't absorb minerals, especially calcium adequately. It's going to impact vitamin D absorption. Like all of these things happen in a low acid environment or a, you know, higher pH environment.

We have to look at these things so much deeper. It's the same with muscle. When you look at muscle and you have to do a proxy on fat-free mass to skeletal muscle, if you don't look at quality, So you got a lot of fat-free mass, but you can't do lowest quartile of grip strength. Mm-hmm. It's, it feels the same to me. Okay. What else?

So diet, I think, is one of the biggest ones. And this is hard because if you were to ask me what I ate yesterday, like, I don't even know, like ask most people what they ate yesterday. They're not going to know. Ask them what they ate a year ago. They're really not going to know. And so it's hard to look back historically and say, like, is my diet deficient in even something as simple as protein? People don't know because they don't track. And so looking at a, you know, a ultra-processed, maybe potentially even calorie-rich but nutrient-poor diet, protein-poor diet, that is one of the biggest risk factors we see. Sedentary lifestyle, massive risk factor, right? If you're not stressing your body, you'll lose bone and muscle. If you are an athlete, but you're more of an ultra-endurance athlete, right? Like if you're a marathon runner, it just makes sense. Your body's going to adapt to these things, right? If you were to want to tell your body to run 100 miles, what's it going to do? It's going to offload anything that it doesn't need. To run 100 miles. I mean, it is in survival mode at that point, right? And so all of these things are potential risk factors. And this is why I say that, you know, all midlife women should be screened because you all have risk factors.

If you were going to design an ideal day of eating, what would it look like?

Well, the first thing is don't forget to eat in the morning. So I—

Oh, let's talk about that because that is so— that's— oh, that biggie.

I was a big fan of fasting for a while, and I think a lot of us, You know, gone through this cycle of like, wow, fasting is amazing. And it does have some potential benefits. And I think for metabolic health, it is, if you have poor metabolic health, it is one of the most powerful tools. But I mostly in my patient population, in our community, I hear over and over again, even in my own household, I cannot hit my protein goals. So then when I see people say, I can't hit my protein goals, but they don't start eating until 1:00 PM. I'm like, Well, look, you're missing an opportunity to stimulate muscle protein synthesis as early as possible, right? Like if you need 4 meals a day to do that, that's fine, but you have to start early. Right. And so, yeah, I think we need to get up and as soon as is reasonable for you, we need to eat a meal that has enough protein in it, which is going to be around 30 grams for most adults, 30 grams of protein. So you can spike muscle protein synthesis out of the gate. Other benefits too, but that's the start. For me, that's going to be 5 eggs because I love eggs. They feel good in my body. It's Mother Nature's multivitamin. Like, I love animals. And so, yeah, so my chickens lay eggs. I eat a lot of eggs. My kids eat a lot of— well, one of my kids eats a lot of eggs right now. And I think it's a great way to start the day. Now, not everybody can tolerate eggs. Not everybody wants to eat eggs. That's fine. I think another great option, if you can tolerate dairy, is whole fat Greek-style yogurt. So dense minerals, dietary fat, protein. Amazing. Put some berries, some honey, nuts if you tolerate them. Oof, that's a great way to start the day. So I would say one of those two things, at least as at a minimum. And then for me, my workout comes in shortly after that. So then I'm going to do some kind of training in my mostly protein breakfast. I mean, honestly, even halfway through my workout, like I'm ready for my next hit of some kind of nutrient. So I'll usually finish my workout and that's if I'm going to take a shake, like if I'm in more of an anabolic mode. That's when I would do something like a protein shake. I don't always do it, but if I'm pushing to really, for me, push, you know, 200, 250 grams of protein, I have to get that in there. I can't absorb it otherwise. So that's when I would do that immediately in that sort of like window right after the workout. And then I'm going to eat relatively quickly after that another meal. So what, what's crazy to me is that by the time I hit 1:00 PM, I've probably already consumed 100 to 150 grams of protein.

That's usually where I am too. Yeah. I'm always over 100 grams of protein by the time I'm done with lunch.

And the great thing about that is, is then like if your day gets away from you, you know, like if you're like, oh, I'm too busy, I can't do this or that, like I'm always going to have an evening meal with my family, assuming I'm home. So if I hit 150 by 1, I'm going to be able to hit 200 by the end of the day.

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I just think starting early is the way to do it, 'cause right now I hear this story over and over and over again. I just can't eat in the morning. I'm not hungry. And then they end up sort of the day gets away from them and then it's 3, 4:00 PM and they haven't eaten anything or they haven't eaten any protein whatsoever and they're famished. But then their stomach is so like reactive to that dense animal protein, they can only get in 20 grams. And I literally have people in our community that eat 40 grams of protein a day and they wonder, wow, why am I still losing bone?

Wow. That's where I use this. Well, my two things are I use essential amino acids. I have them eat protein first.

Now, do you count the essential amino acids as protein? Is this— is this in your numbers?

Technically, technically it counts. But what I do is I have them if they're hitting a wimpy amount. So let's say they got maybe 30 grams. What was all plant or 20 grams or less. Right. But, but I consider if you're doing plant, I push it up to 40 to make sure we're getting what you need in terms of amino acids. So if they're either skipping a meal in the morning, I do a double hit of aminos to make sure they got what they needed and they have at least like 2.5 to 3 grams of leucine. And same with the evening, because I'll just do a little hit because I'm not worried about the midday. Yeah. So that's how I use it. Well, let's talk exercise because, you know, the, the other thing I get asked all the time is, you know, jumping and is Pilates enough and, you know, what about walking and what about the Power Plate and all these different things. So, yeah.

And weighted vest.

So let's go through it. Well, let's start with the jumping.

So I have seen this trend now on social media that, I mean, everybody's jumping, right? Jumping for bone, jumping for bone. And I'm like, cool. Like, this is— I like to see the conversation. It's good. I want to see it continue to like really blossom. I want everybody talking about bone health. And let's be careful jumping. Yes. Yeah. I mean, I don't know. I've got some arthritis. I know you've got some arthritis. Like, Jumping is not a good thing for me to do on a regular basis, so I do alternatives. We can talk about that. Jumping does have some research behind it, but the problem with jumping research is that there is tremendous variability in what—

like, what is a jump? Unless we had a force plate, right? Like, how would we really know?

I'm glad you brought that up because my feeling with jumping is—

and in graduate school I did a whole project on plyometrics. It was funny because at the time we were, we were creating a class at an exercise studio, a plyometric training class, but we couldn't make it work because everyone was dead in 10 minutes and the classes had to be 45 minutes or longer.

And I'm like, that's a lot of plyometrics.

We can't do it like this.

It's 10 minutes and we're done.

My feeling with this is you must build the foundation before you do this and that a lot of it might just be hopping.

I mean, I look at the research on, quote unquote, impact. This is the point, right? We want— we want impact to stimulate the bone because resistance training alone is not enough. To actually stimulate progress.

Which is important for people to hear because they've heard that walking is enough. I'm like, great.

Well, and there's, there's research that kind of refutes this, but I can get into the details of that. But if we're talking about impact, we need to be very clear on the mechanism. But something as simple as a heel drop, right? Standing straight legged, rise up onto your toes, drop onto your heels. Now, if you are new to this, please be careful because you will blow your mind about how much force you can generate just by doing a heel drop. So you can actually generate over 4 multiples of body weight just by doing a heel drop. That's actually all you need to do for impact. It's cheap, it's free, and it's a lot of force. So please be careful. Yeah, but people get bored. So then like, what are the other things? Well, there's a study, the LIIFT-MORE trial, if you're familiar with Belinda Beck's work. The LIIFT-MORE trial used an impact exercise where they did an assisted pull-up and then they dropped off the chin-up bar. Now, Careful, right? Like another one, please be careful. And this was done under supervision, obviously. But that study did show a significant increase, especially in the spine, even in an 8-month interval, which I mean, it's a really short intervention, right?

How many times a week were they doing this and how many—

I think I might misquote this. It was either 2 or 3. So it wasn't that often, but they were also doing high-intensity resistance. They called it the HIIT intervention. So high-intensity resistance and impact training. And so this is a big issue and I've spoken out in a negative way. Belinda, I mean, these are some of the best studies on resistance training, so I'm not trying to be negative, but she chose these interventions very intentionally because the resistance training that she was teaching are full-body exercises that load the spine. So she chose 3 exercises, simple, great. So it's a barbell deadlift, a barbell back squat, and a barbell overhead press. Simple, right? You can do these. I can do these. But if you—

see, I hate a barbell overhead press because you're—

and you know, you're an orthopedic surgeon. I'm like, do them this way.

Don't ever do them this way.

I don't do them, right? Or if I do, I'm like trying to do it in front of my—

yeah, like it's, it's awkward. I just do it this, you know, it's like, let's go this way.

Yeah. I'm only dumbbell with overhead press anyway, because I've had an AC resection, like, yeah, shoulders, the whole thing. But my concern is if You've never lifted a weight before.

You're gonna do deadlifts.

Please don't. Please don't. And Belinda knows this too. So she actually, she, the LIIFT MORE trials were very, they're very popular people, you know, they know them by name. She's done 3 different publications about these exercises. And then she created a licensed program called ONERO. And, and so this is more popular in like Australia and Europe. In the US it's been slow because she wants it to be with exercise physiologists and physical therapists and not trainers. But in the US trainers are doing the bulk of the training.

So I mean, all the extra— when I was in exercise phys school, everything was to become a professor. None of them would ever be based.

And it's different in different countries, right? And so she's in Australia, so it just like, it isn't taking off here. So she has created a model to help people learn how to do this, but in the US it just isn't available. And so what we did when we created our program for exercise is to say, look, you never have to do those 3 exercises. Resistance training is resistance training. It doesn't matter if all you have is body weight or bands or dumbbells.

It doesn't matter. You just have to challenge your muscles.

Yes. So whatever— that's what I tell people, like, because they're, how much should I weigh? I go, wait, how much should I lift?

I'm like, the heaviest weight you can handle in good form. And that can be your body weight. That could be a water bottle.

I go, I don't care. And you never have to be able to do a barbell deadlift. Like, I don't even do barbell deadlifts, right? Like, I have a hex bar because I don't— just like, it's a lot of force out there. So you don't have to do those things. Resistance training is beneficial, not necessarily for your bones. I mean, it's, it's good. It can slow down bone loss if you just look at that, but we gotta build muscle too. We gotta build balance. It's about fall prevention as well.

Okay. Vibration plates. Yeah.

I'm a fan. So I did a deep dive on this and this is one of the first areas of controversy where I was just blown away by how controversial this topic is. So in the whole body vibration space, there are a lot of claims. I think there's some crummy research, but my conclusion is this: after like 4 different— there's 2 interviews, 4 different long-form videos on the topic, and dozens and dozens of studies— I think whole body vibration with the right displacement, the right frequency, can be beneficial for bone. The research would support that you can increase bone density of both the spine and the hip. By simply standing on this thing for 10 minutes a day.

It's pretty wild. Yeah. But why would you just stand on it? Why wouldn't you do some stuff? Well, here's the thing.

So if anybody has something like, we'll just like use the name Power Plate just so, cause it's clear, like all of their devices meet these criteria. So if you're standing on a Power Plate, you know that if you stand in a certain position, you can feel it in your eyeballs. Right. So probably don't do that. The thing I have with exercising, cause I do that too. But it's not the same thing. I don't think you're going to get the same bone benefit because once you start moving your, your, your body around and you start getting into your joints, that energy's dissipated. You really want that energy to go through your skeleton. So what I tell people to do is if you can tolerate it, stand on a PowerPlate device, either like either home devices, professional, doesn't matter. They all start on the low end at the same level. If you can stand on it with your knees slightly bent, most of your weight in the front of your foot. That's what's been studied. And at the displacement that those things are moving, that, that 2 to 3 or 2 to 4 millimeters, depending on the device, that amount of displacement is going to generate enough force that you will actually see benefit your bones. It's super simple. The studies are variable anywhere from 3 to 5. I just tell them to do it 5 days a week.

5 days a week. Stand up for 10 minutes.

Stand on it for 10 minutes. Now, the Power Plate Move, which is the one that I have, runs for 9 minutes. I don't add another minute. So somewhere 9, 10 minutes.

I just have to put my red light panels in front of my power plate. I just did this.

So I now have, I have a red light, full body red light panel on both sides of my power plate. Yeah. So now I'm, I'm just standing there and I'm sort of like, I'm kind of meditating. I'm red lighting. Like, I love it.

So we've got DEXA. Are there, are there blood tests?

Like what else can we be doing to look at?

What are the— Yeah, there's, there's 3 things I talk about here. So we, we have to use DEXA. We're not gonna get away from DEXA. It is imperfect because it is an older technology. It's an X-ray essentially, right? So it's a two-dimensional image and it only really looks at density. So it's not perfect, but everybody has access to it. So let's use it. The biggest issue with DEXA is that there is a pretty wide margin of error. And when we talk about changes in bone density, we're generally talking like 1-2%, but that's within the margin of error. So this is the issue with like a single DEXA or even like 2 DEXAs back to back is you really need longitudinal data. You need to see trends over time because some people would put that margin of error in a DEXA, it's called LSC, but some people put that margin of error closer to 6%. Like if it's 6%, I really need to see 3, 5, 7 years of data to know if that trend is real or not. Okay.

But here's the other challenge then, because from what I've heard with DEXA, the technician matters, the time of day matters. I would assume that would matter much more for fat-free mass, fat mass than it would for bone. Bone's not going to be influenced by that, but does the technician matter?

Yes. Yeah, definitely for fat-free mass. I remember the first one I did for body composition, I drank like a liter of water before. Sure. And my, yeah, my body fat was like 4%, right? I was like, please. So you can definitely, you can game a DEXA with, with lean mass. Now with bone, you're right, that's not going to impact it. Like unless you take like minerals the day of or the day before, right? If you take strontium or calcium the day of your DEXA, your spine is going to look more dense because it's in your GI tract. Interesting. Yeah. So don't do that. The technician matters. The positioning is critical. And technicians aren't— let's face it, some are well-trained, some are not.

God, I never get into like the position.

They're like, just lie down there.

So you have to internally rotate the hip because you need to see the way that the femur is made. You need to—

never had someone say that.

You need to rotate so that you're seeing the long axis of the femoral neck. If you're like this, like if you're laying like this with your leg externally rotated, you're going to be looking essentially down the tube in your— the density will be much higher because you're looking for—

I've always been externally rotated.

Like, no one's ever told me to do that ever.

All the DEXAs I've done. It's so important. So, yeah, so you should probably check your femoral neck. Spine is also affected by position, but this is going to be more internally, right? So if you have scoliosis, if you have arthritis, like these are the things that throw off a DEXA. Okay.

What about any bone turnover markers? Blood tests?

Yes. So there's one more imaging modality that is getting more popular, and I think it's important we talk about it because it can also be misleading. There is something called REMS by the company Echolite, and it's essentially an ultrasound, right? Looks like the same ultrasound wand you would see at your OB-GYN office, but it's backed up by an algorithm that has a large database in it. In theory, will give you density just like DEXA, gives you a T-score, and it also gives you a fragility score. I already mentioned earlier that fracture risk is a combination of a bunch of things. But density and fragility are two of the biggest pieces. So if we could understand our fragility, we could better predict fracture risk.

What's it basing that fragility score on?

So it's basing it off of the database of patients followed longitudinally who fractured that they had data on. Right. So like you follow a big enough group, 50,000 people, you follow them, you see who fractures, you see what their data looks like. But recently there's been a couple of papers that have been published which are controversial, but they're basically suggesting that the inputs, meaning your age, your weight, your height, that those have a bigger— those are bigger variables than is the actual input from the ultrasound. So essentially it's a calculator. Now, Echolight, I've not seen anything public. I know people in the space and everybody disagree. They're like, that can't be true because people that have these devices know that if they measure the exact same looking person on paper, they will get different measurements. But it still makes me pause on this technology to say, well, do we really know what we're looking at? So I still like them. I still think it's helpful. I don't, I've never said don't use DEXA. I've said use both if you have access to both. I just don't know what REMS is showing us right now. I want to see more data.

So I did a DEXA, I did REMS. REMS showed that both Tim and I had osteopenia in our spine. Never seen anything like that on DEXA.

I think there's, again, there's value in both. Where I see it to be very valuable is in my, my short, petite, small-framed women who we know are on the outside of the bell curve on DEXA. So they are very frequently diagnosed with osteoporosis, very low T-scores, but they've had no fractures. They're otherwise healthy. Like, it doesn't really jive. And then you put them on a REMS and their bone density might look the same, their T-score might look the same, but their bone quality looks great. And so I would not tell that woman, oh, don't worry about it. I would say, hey, we still need to work on our bone. And you're probably not as at an elevated fracture risk as the DEXA would suggest. Now, I don't— again, I can't put a number on it, but it helps them to again, reduce that fear and anxiety around the diagnosis.

Got it. Okay. So that makes sense. What about any blood tests?

Let's talk about the blood test. I love this topic. So the challenge with all of the imaging is that it takes forever. It's a 12-month, 24-month in-between, right? And we just said DEXA, you might need 5, 7 years to know if this is working.

It's like grass growing.

Oh my gosh. It's paint drying, right? It's terrible. And so the challenge here is if you are doing some kind of an intervention, whether it be exercise, sleep, supplement, hormones, drugs, whatever, it takes forever to know if it's working. And if you're doing something that is lifestyle-driven, that takes daily effort, boy, it's really hard to keep going if you don't know that it's working. So there are these bone turnover markers. I got really interested in this as I was trying to build a program to help demonstrate that people are, you know, being successful at improving their bone density without having to wait for Edexa because it's challenging. Again, month after month, you're paying for a membership, you're doing all these things, you know, is it working? The bone turnover markers have been used in the pharmacologic space for years. So we know actually that these things are valid. We can see what's happening with the drugs based off of these things. And as I started looking into this, I realized that they've been used in research for years, the same ones. With different interventions, whether it be dietary supplement, whatever. So now there's a, there's a ton of data, but nobody's really ever put it together to say, well, let's use these on a regular basis clinically to understand what's happening with bone metabolism. We know that bone metabolism, ultimately a disorder of bone metabolism, it's what results in osteoporosis in the first place. How much bone are you breaking down? How much bone are you building up? And if you can build up more than you're breaking down, Eventually you'll build bone, right? So you can measure the buildup and you can measure the breakdown. That's what's beautiful.

These are available clinically. Yes. What are they called?

So the breakdown marker is called CTX or C-telopeptide. And you can order this LabCorp Quest, both have it. Sometimes it's on their direct-to-consumer, sometimes it's not. But there's plenty of panels that, that utilize it, or your doctor can order it if they're willing to. But CTX is measuring the, the function of the osteoclasts. So as they break down bone, they release this, this thing into blood and you can measure it. So you can see exactly what's happening.

But you'd want to do that with the other one.

You need them both. And this is, this is the challenge is sometimes doctors will say, oh, I'll just order a CTX and that'll tell you how much bone you're breaking down. But that's not the complete picture. You want to know how much bone you're building up too. That one called P1NP and it stands for kind of a long series of words. So we'll just call it P1NP. You can look it up like that. And P1NP is the other side. It's the bone building side. So osteoblasts, as they're building bone, are releasing this thing that you can measure in blood. So now we can actually compare the two. And especially if you're doing data over time, this is why tracking is so amazing. If you're doing data over time, you can look at what I calculate as this ratio between the two. So I'll, I'll describe it. You might need to write it down, but I'll describe it because this is the most important point. It's P1NP over CTX. There's more data behind this than anything else. There's P1 and P over CTX adjusted for units. And this is where it gets confusing, but it's actually pretty simple. P1 and P is generally a 2-digit number, so you don't even need to know what the units are. It's a 2-digit number in the US. CTX is a 3-digit number, but you need to move the decimal point over 3 times. So move it 3 spaces so that it is a 0.3-digit number. So it's a 2-digit number over a 0.3-digit number, and that'll give you a number between usually 100 and 300. And higher is better. Right in the middle of that range, around 150, is the threshold that the evidence supports is sort of the shifting point between breaking down and building up bone.

Why are we not doing this?

Doctors are afraid to order it. Insurance often won't pay for it unless you're on a drug. How expensive are the labs? They're a couple hundred bucks. They're not cheap, but a hip fracture is not cheap. A change in your life is that cheap. So again, I, you know, we've built this into our programs. People have access to these things. I think it's going to become more and more readily available just by demand.

Would you see the interventions like exercise, diet, hormones, vitamin D3, K2, would those shift that equation? Yes. This is, this is fantastic. Yes. Amazing. Yeah, it's super powerful. Wow. That is super powerful. So you'd want to, I mean, these, I can't believe that I've never even heard of these.

I wonder if they're, are they on Function Health? Can you order them through Function Health?

The endocrinologists push back against this because they will say that this has not been studied clinically. And that's not true because they've been studied again for the drugs extensively. And then there are, again, there's a couple of little studies around supplements and dietary interventions that use these same biomarkers. So it totally makes sense. Now, is this the only thing I go off of? No, but it at least gives you some guidance clinically. It is so helpful. Wow, this is amazing.

And then I'm assuming here, you know, you would do estradiol, testosterone, progesterone.

Well, and so, so check this out. This is— is I— when I have conversations around hormones, I get in trouble because I talk about testing and I talk about optimization and people yell at me. Oh boy. But when it comes to bone health, again, you can measure this stuff. So when people ask me, oh, like women love to ask me this question, what's the optimal level of estradiol? And the answer is there isn't one. And if you measure estradiol and FSH and CTX and P1NP, then you have a complete picture of what's happening with estradiol and bone health. And it's very predictable. If your estradiol level is whatever it is, but your FSH is dropping from 100 to 30, your CTX will drop from 1,000 to 250. Your P1NP will likely even go the other way, which is amazing that we can do this. It'll go from, you know, low double digits to high double digits. And when you're in that metabolic state, I guarantee you you're volume prone.

Where do progesterone and testosterone come into play here? Less well studied.

When we are optimizing hormones, I recommend estrogen, progesterone, testosterone, depending on whether or not they meet the criteria for it. But what do you mean they meet the criteria? Well, let me finish progesterone first. So progesterone, for me, this is something that I— gosh, I just can't say it enough. The current indications are only for women with a uterus intact.

Ridiculous.

But we know that there's progesterone receptors all over the body, including in the bones. Never been studied independently for bones as an intervention. But we know that for women who are still cycling, if they're not ovulating at least 5 times a year, meaning that they'll have a rise of progesterone in their luteal phase, If they don't have that at least 5 times a year, they're losing bone even with normal estrogen levels. So we know that it's doing something. I just can't tell you by how much. So that's progesterone. Testosterone is frustrating. I love it. I'm on testosterone, huge advocate for both women and for men, for, for those that need it. But the thing with women about testosterone is that for women, I see women who go through menopause, they have the expected low levels of estrogen and progesterone. But they still have optimal testosterone. So not all women are going to need testosterone replacement. This is why we have to test it. And this is why the cognitive dissonance around the recommendations for not testing hormones for women drives us bonkers, because we can't recommend testosterone unless we test it. And if you don't test it, then you can't recommend it. So just super frustrating for me that we're not even having that conversation.

Yeah, hopefully that's starting to change. I think Dr.

Kelly Caspersen is getting getting everything. She's got enough feathers ruffled. I think she's, you know, she's, she's making some progress.

It's great. Yeah. All right. I'm going to give you a big final question here, please, because we could go on for hours on this. This is fantastic. If you could give every woman over 40 a prescription for stronger bones, what would it be?

Start with a whole foods, nutrient-dense, protein-forward diet. Get daily movement. That includes at least 3 days a week of resistance training. And impact training. Optimize your sleep, optimize your mindset, optimize your hormones to the best of your ability. And if you can do those things, you probably don't have anything to worry about. Beautiful.

That's one thing to run on.

That was like just a clear, very clear sentence. For people who would love to go deeper with you, where do they go?

How do they find you? Yeah.

The easiest place is to find me on YouTube, the Dr. Doug Show. It's all about bone health. It's all about hormones and the impact on bone. So all of our information is on there, free available, 300 and whatever, 70 videos at this point. From there you can access all the other things, including our community, the Osteo Collective, all of our other social things and so forth. Cool.

We'll put that all in the show notes at JJVirgin.com/DrDoug, plus our last episode.

So we'll get all of that stuff included. As I appreciate you jumping in here.

Thank you. I appreciate the opportunity.

Be sure to join me next time for more tools, tips, and techniques you can use to look and feel your best and be built to last. Also, I'd love to connect with you and hear your thoughts on the podcast. Here's how. First, subscribe to the podcast and leave an honest review. Second, take a screenshot screenshot of your review. And third, text it to 813-565-2627. That's 813-565-2627. When you do, I'll reply using my brand new Virtual JJ Virgin. It's my on-demand virtual self built from my books, talks, and years of experience so I can interact with you directly. You'll make my day and I can't wait to hear from you. Thanks for tuning in and I'll catch you on the next episode. Hey, JJ here. And just a reminder that the Well Beyond 40 Podcast offers health, wellness, fitness, and nutritional information that's designed for educational and entertainment purposes only. You should not rely on this information as a substitute for, nor does it replace professional medical advice, diagnosis, or treatment. If you have any concerns or questions about your health, you should always consult with a physician or other healthcare professional. Make sure that you do not disregard, avoid, or delay obtaining medical or health-related advice from your healthcare professional because of something you may have heard on the show or read in our show notes. The use of any information provided on the show is solely at your own risk.

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