5 Hidden Causes of Bone Loss (#4 Is a Shock) - Dr. Douglas Lucas

23:38Dr. Gabrielle Lyon:This is important to understand. Muscle is not very sensitive to change, right? The lean tissue, when we look at a DEXA, 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?

24:36Dr. Gabrielle Lyon: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? 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 if people want to use the Z-score. If you are over the age of 50, we're going to talk T-score, right? Because you're comparing with the T score actually to your younger gender and race-related self. So you're 20-something-year-old you.

25:13When you are in your 30s and even 40s, we want to use Z score because Z score is comparing you to your age-matched 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 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.

25:43Dr. Gabrielle Lyon: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. 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 Whole Logic, these massive imaging companies that have DEXA scanners, they own all that data, right? So 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?

26:24But 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.

26:33Dr. Gabrielle Lyon:Take it with a grain of salt, yes or no? The number? I think 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 it's 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 one standard deviation above, two standard deviations above? I would vote for probably more. I want to, I realized that we didn't close out the conversation of anabolics.

27:07Dr. Gabrielle Lyon:The anabolic medications, is that only directed towards bone? Interesting question. Bone specific? 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. Two more questions related to this. Are there off-label drugs that can be used for bone?

27:45Dr. Gabrielle Lyon: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? 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 is supported above what we are currently seeing, with the exception of the potential benefit of testosterone.

28:35But the research, especially in women, is still pretty limited. In men, it's better. So definitely a tool worth considering, but clearly off-label.

28:44Dr. Gabrielle Lyon:The next logical thought would be perimenopause, menopause, decrease in estrogen. Where does that come in with the bone conversation? 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. 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 I love doing it through the lens of bone because bone tells us what's happening with hormones.

29:24It is one of the few organ systems that gives us great feedback on levels, dosing. We talk about symptoms of menopause, perimenopause related to hormones, but those symptoms can be bagged, 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.

29:45Dr. Gabrielle Lyon:Okay. Talk to me about that. You've now piqued my curiosity. How would you dose hormone replacement therapy to be directed at bone? 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.

30:19So the building of bone and the breakdown of bone. The building side, there's a marker called P1NP. It's a long... P1N. 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 C-tellopepta. 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.

30:59We see this in the phase three trials for every bone drug that's out there. 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.

31:33We'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 P1NP. 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.

32:09Dr. Gabrielle Lyon: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? 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.

32:54But 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. We have to talk about how to protect organs and the uterus and breast tissue, et cetera. But women that have pushed that into the 100 to 200 range, and then you see the CTX drop.

33:30So I think there's a receptor challenge that we can't measure effectively. So I've stopped using estradiol alone as a goal.

33:37Dr. Gabrielle Lyon: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's unsimple, 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 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.

34:18Dr. Gabrielle Lyon: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 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 LION20 for 20 % off your first order. That's bodyhealth.com, code LION20. I absolutely agree with you. In a young woman who is 35 or 30, what would be a normal CTX number?

35:13It'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 metabolism really well, right? So you know, if we look at the, you know, the estrogen levels throughout a women'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.

35:41You 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.

36:17And this is where this dysfunction starts.

36:18Dr. Gabrielle Lyon:You said, does progesterone, we talked about estradiol, estradiol's effect on CTX, P1MP, is it the same for P1MP? So it has an effect on both sides 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 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 estrogen and progesterone flow, that will encourage osteoblasts to either go away or to come back. Progesterone probably plays a bigger role than does estrogen, but it's not as well studied.

37:02Dr. Gabrielle Lyon:I also really appreciate what you said about the receptors. There is this idea of precision medicine, and it's not going to be the right dose for everybody. It's 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. And does that play out? It does. 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.

37:43Dr. Gabrielle Lyon: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 there might be something to say for the fact that it really is the density of these receptors. And I'm curious, 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?

38:30Yeah, 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, you may just not see it yet. Now, the ultrasound device in theory is faster, but again, evidence is a little sparse.

38:58Dr. Gabrielle Lyon: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? Well, first off, let's talk about when this actually happens, right? We think we, you know, we've talked 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, you know, 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.

39:38That'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.

39:57Dr. Gabrielle Lyon:Can you treat bone loss with estrogen? So, estradiol specifically is actually FDA approved for the prevention of osteoporosis. So, I can even say that out loud. Prevention, yeah. I can even say that out loud. It's amazing. FTC is not going to come knocking on your door. What I would 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.

40:37Dr. Gabrielle Lyon:I like the way that you said that. It was said very responsibly. Thank you. 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. 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 in their young, right?

41:24So 30s or 40s. The guidelines clearly state use hormones and optimize 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.

42:08I 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.

42:14Dr. Gabrielle Lyon:You also talk about finding the root cause. You have a, 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. 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.

42:56They 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 four-hour 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.

43:28So again, identify why you're likely losing bone. Let's pick a couple of levers and then let's do something about it.

43:34Dr. Gabrielle Lyon: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. Oh, my gosh. Yeah. I want to hear about calcium. 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 1 ,200 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.

44:13But we don't really live in a calcium-deficient society.

44:16Dr. Gabrielle Lyon: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 it 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? 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.

45:00Right. So if you were to paint a bone health picture through nutrition and do it from the time of Ansel Keys on, you have this really conflicted, don't eat too much protein because it's bad for you. Watch out for dietary fats. 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. 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.

45:34I was like, ah, 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. Is calcium something that is important?

45:56Dr. Gabrielle Lyon:Do you recommend supplementing with calcium? 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 1 ,000, 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. What else is another big or what are other minerals or vitamins and minerals that are really important for bone?

46:32Yeah, 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 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.

47:05And I think vitamin E is coming out as a bigger player. Vitamin E, you know, 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 like all the other things that could potentially impact bone metabolism.

47:21Dr. Gabrielle Lyon:We don't want potential. We want what do we know? Is there one superfood for, I mean, because for muscle, I think lean red meat. Yeah. For me, if I had to pick one food, it would be lean red meat when I think about muscle health. I 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, you know, fattier red meat. I will say there is a standout, though, for bone when it comes to small fish. Please don't say sardines. You're going to say sardines. I know. I know. But so powerful, right? Protein, omega-3s, calcium and minerals.

48:00It is just a superfood.

48:03Dr. Gabrielle Lyon:I agree with you. And it makes you very unpopular when you're on the plane. True. 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.

48:44Dr. Gabrielle Lyon:Do you think that that would be something that you add in once a week? Have you thought about it? It totally makes sense. Again, there's no good data, but yes, it makes sense. Are there conversely things that would negatively affect bone loss? Diet soda, sparkling water. I love bubble drinks. I looked up this one because I love sparkling water. I stopped drinking alcohol about six years ago. So now 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.

49:25Dr. Gabrielle Lyon:When you say phosphate rich, what would I again, I'm not a soda expert. There's added phosphate in. Phosphoric acid, right? So generally you're dark colored sodas. What if that means energy drinks too? I don't know that that's true. Okay. We're going to look it up. Yeah. Because I'm asking for a friend, mostly me. Um, sparkling water, you're okay with the effervescence. What else is an absolute, if you want to destroy bone, here's your playbook. Yeah. If you want to destroy bone, under eat protein, right? Eat an inflammatory diet, high, you know, ultra processed foods, high quantities, um, get poor sleep, live in chronic stress.

50:03Dr. Gabrielle Lyon:Okay. Well, the sleep part bothers me, but, um, do you think that, you know, when we were in training there. We talk about the brittle bones, diabetic brittle bone. Metabolic health is big. How does metabolic health and bone go hand in hand? Yeah. It's a chronic inflammatory state. I mean, it's a simple way to say it. 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? Yeah. So from a dietary perspective, we need to make sure that the gut works, right?

50:53So you can eat the best diet in the world and you can have a thousand dollar 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, stool 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.

51:24Dr. Gabrielle Lyon:One of the biggest misconceptions that we have heard over the years is that protein is bad for bone. When I was in fellowship, geriatric fellowship, those individuals that had the lowest protein diet had the greatest risk for cortisol fracture. 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? So celiac is a super common one, right? And we actually diagnose a lot of celiac because they come in with osteoporosis.

52:11And 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, you can't absorb.

52:16Dr. Gabrielle Lyon:And celiac is an autoimmune response to gluten or glidin. 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 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 give me two minutes on the pH thing. The muscle thing.

52:53Oh 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.

53:07Dr. Gabrielle Lyon:I heard it. I would say I never learned it. Right. Because it didn't make sense. No. 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. I'm like, what? If it 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.

53:41So 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.

53:56Dr. Gabrielle Lyon: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 bones? I mean, the first one hopefully is not routine. But if you are using systemic, either oral or any other form of steroid. Meaning like a metarol dose pack. Exactly. Yes. For asthma or something like that. Yeah. Including inhaled ones. If you're using them frequently and consistently, definitely check and see what's happening with your bone.

54:41That is a public service announcement. Outside of that, because everyone's usually pretty well known, outside of that, the ones that I would say that surprise people would be like 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.

54:58Dr. Gabrielle Lyon:Pylosec. 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 SSRIs, antidepressants, anxiety drugs. These are also associated with osteoporosis. I don't actually understand the mechanism there.

55:37Associated but not causative with no underlying mechanism. I don't know the mechanism, correct. but we do see the association and it's pretty strong.

55:43Dr. Gabrielle Lyon: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 OS1 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.

56:30Dr. Gabrielle Lyon:At its core is the OS01 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 DRLYON. That's oneskin.co. Use the code DRLYON 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 i will never forget this talking to a 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 That physical therapist called me screaming at me.

57:37Dr. Gabrielle Lyon: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. It's odd coming from a physical therapist. 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?

58:19So 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, like, again, public service announcement, what I found is that because the progestins, the synthetic progesterones in birth control tend to be anabolic.

58:57There'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 what's happening with your bum.

59:20Dr. Gabrielle Lyon:And test early. Test early. Exercise. I have a patient that she was an ultra runner. She's 60. This woman puts me into 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. 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, obviously we're improving her bone density, but still osteopenic. And as I was thinking about, okay, what is our net?

1:00:08Dr. Gabrielle Lyon: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 height. She's on hormone replacement. She's doing no high-impact jumping. plyometric broad jump any of those activities so uh the first thing i would say is how long has it been and how long have you been working with her to see that two years 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 but the bones really do respond to impact.

1:01:03And 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.

1:01:23Dr. Gabrielle Lyon:I hate that. 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 simple heel drop? Basically, standing on a bench, you... I'll do a video on this. JJ 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? It's my one foot as if you're stepping off of a stair. So maybe we're thinking about different things. Okay. So when I think of a heel drop, at least the study I'm referring, is essentially standing on flat ground and the advanced version is barefoot on concrete.

1:02:02Don'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 through this.

1:02:16Dr. Gabrielle Lyon: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. So we're going to try it and you'd be shocked at how much impact it is. So 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. Of course. How do they do activity that is meaningful to bone that's already compromised? It's a very difficult position to be in. And this is why early intervention is so important.

1:02:53Because when I do get those questions from women in their 60s and 70s with a T score a negative three, a negative four. And 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.

1:03:17Dr. Gabrielle Lyon:But basically there's no data to say this is the amount. There's no way to know. There's no way to know. Vibration plate. 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 that kind of go side to side, right? That's not a device that I would recommend for your bones.

1:03:54And 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 market 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 two and four millimeters. I mean, they go up and down two and four millimeters. They're vertical, so they're not going side to side.

1:04:27They'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.

1:04:40Dr. Gabrielle Lyon:And where do you get those devices? Are those medical devices? So direct-to-consumer, the company that we use is Powerplate. And so their home devices, Yeah, the personal and the move have exactly the requirements that I look for from the research. 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. They are pretty expensive. So the PowerPlate Move, which is the version I have, I think is close to$3 ,000. So, yeah, it can be a cost issue. Their personal is a little bit less, but it's still probably around$2 ,000.

1:05:19So, 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 10 minutes a day, five days a week.

1:05:36Dr. Gabrielle Lyon:10 minutes a day, five days a week. And gyms have it, right? It's something that... 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. What else are we missing in that story?

1:06:10Dr. Gabrielle Lyon:Anything else? From an impact perspective? So there are devices that are very popular or kind of popular that use this concept of osteogenic leading. Are you familiar? I believe so, but I'd like to hear. So the franchise name out there is OsteoStrong. It was another company. That's what I was thinking. 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.

1:06:54Can you generate that over four multiples of body weight, which is potentially 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.

1:07:29There 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... But it's only four months. Well, so only four months of what?

1:07:41Dr. Gabrielle Lyon:Randomized control trial. If a randomized control trial is a four-month trial? No, there's four randomized control trials. Oh, and how long was each trial? 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? Is this women who are perimenopausal in their 40s? Is this women who are frail in their 80s?

1:08:12Which 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 link it. We'll link it below. 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.

1:08:46Dr. Gabrielle Lyon: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 that it basically used AI and it worked off of your resistance, the amount of force that you were applying. 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 that doesn't mean it affects bone. Yes. 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.

1:09:34Dr. Gabrielle Lyon:Are there other areas that you are concerned about? 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. 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? I mean, they are problematic, right?

1:10:08They 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.

1:10:17Dr. Gabrielle Lyon:Robust is it. And also we see when someone falls. Is it that they fall and break a hip or does the hip fracture and then they fall? 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.

1:10:49But 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, it doesn't necessarily make that better. So, again, these are just fractures we want to avoid.

1:11:06Dr. Gabrielle Lyon:We really did frame this conversation around women. From my perspective, 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? 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, an AI.

1:11:46And I said, for bone, that 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 an astrazole. 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.

1:12:15Dr. Gabrielle Lyon:So is osteopenia, osteoporosis as common in men in general? Certainly not. It's not. 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 menopause. It's 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. Yeah. I mean, in your world, I see it all the time. Yes. Right. You have optimized patients. So I am worried, though, about low testosterone levels out of the gate for men.

1:12:52I am worried if they're on AIs. I'm worried if they're doing other things that are bad for their bone 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, you know, standard deviation or two above that. They just have more room to fall before they hit it.

1:13:10Dr. Gabrielle Lyon: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 are 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's an inherent sex difference or is that we're not having women out there pounding 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.

1:14:03Dr. Gabrielle Lyon: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 she's put on this song. Yeah. And I realized that over time that just their physical nature is different. What do you think? 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. saying my daughter is into gymnastics, which actually is a profound bone building exercise.

1:14:38But yeah, I mean, in general, my boys, they're just wrestling, they're falling off stuff, like they're impacting their bones. My oldest is already into lifting weights. And so 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 other hormone changes, there's dietary changes, So like boys just eat constantly, just machines. Whereas my daughter is like still a pretty picky eater and like really struggling to get adequate protein in there for her. So it's a combination of all of it.

1:15:14Dr. Gabrielle Lyon:Yeah. It reminds me of the athlete's 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. It doesn't mean that they don't exist. But I also wondered, is that setting us up for a milieu of bone mistakes? Well, I think what's happening in young men especially is I do see some of the same risk factors, right? Like we don't have a cycle to go up for men. And so like I see some of these same risk factors, sedentary lifestyle, video games, poor nutrition, ultra processed food. Like I watch it in in my boys classmates.

1:15:59Early on, they get away with it. Right. They eat this garbage diet. They're playing Fortnite all the time. And yet they're still like pretty active, healthy looking kids. That's going to change. Right. 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.

1:16:18Dr. Gabrielle Lyon: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? 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. 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 two days of resistance training at pretty light weights and still see improvement.

1:17:03In bone. In bone. Wow. 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, like harder, better, right? You can certainly overtrain, but generally we're coming from a sedentary background. So harder, better, but I don't go more than, you know, 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 like whatever else you think you might be important for you. Like, is it high intensity interval training or cardiorespiratory work or whatever?

1:17:36So just finding that balance based off of your goals.

1:17:39Dr. Gabrielle Lyon: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? 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. Dr. Doug Lucas, any last words? 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.

1:18:24And if you're losing bone, figure out what it is.

1:18:27Dr. Gabrielle Lyon:All right. Well, great to have you on. Happy to be here. Thank you. .