In this episode of the Real Health Podcast, Riordan Clinic’s Chief Medical Officer Dr. Ron Hunninghake, MD, is joined by Dr. John Neustadt, ND. They discuss Dr. Neustadt’s book “Fracture-Proof Your Bones: A Comprehensive Approach to Osteoporosis” and how to identify and correct the factors that contribute to osteoporosis and fractures.

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Intro: This is the Real Health Podcast, brought to you by Riordan Clinic. Our mission is to bring you the latest information and top experts in functional and integrative medicine to help you make informed decisions on your path to real health.

Dr. Ron Hunninghake: Well, welcome, everyone. It’s Dr. Ron Hunninghake, and I’m here again with the Riordan Clinic Real Health Podcast. And it’s my pleasure today to have as my guest Dr. John Neustadt. And Dr. John is a naturopathic doctor, and he’s written a wonderful small book, not too big, but enough to really give you a good foundation in how to fracture-proof your bones. And so, John, welcome to our show.

Dr. John Neustadt: Thank you.

Dr. Ron Hunninghake: I’m curious, I always like to ask people, how did you get so interested in bones and healthy bones?

Dr. John Neustadt: The topic really found me. I never would’ve anticipated, when I started my career, that this would be what I ended up specializing in. But I was getting patients into my clinic with osteoporosis and I thought I was doing a great job. Their bone density was improving using integrative and natural methods. So I was happy and they were happy. My mother-in-law, who has osteoporosis, that she was working with her conventional doctor and taking Fosamax, taking the medication, and her bone density was going up. So she was happy, her doctor was happy, I was happy. And then she fell and broke her leg, broke her hip. And I started thinking, “Something’s not right here. Something’s wrong.” And I started researching and looking at bone density and really how valuable it is. Are we doing the best jobs to protect our patients? Because if you have osteoporosis and fracture a hip, there’s up to a 36% chance that you’re going to be dead within a year. And up to 60% of those people, never regained their full pain-free mobility that they had before their fracture.

And as I was looking through the research and started learning more and more, what I realized is we’ve known since the 1990s that a bone density test predicts less than half of the people who will break a bone. In fact, a bone density test only predicts 44% of women with osteoporosis who will break a bone and only 21% of men. Different organizations, the World Health Organization, the North American Menopause Society, the Bone Health and Osteoporosis Foundation, anybody who’s looked at the research has correctly concluded that fracture risk depends on things largely other than bone density. It’s only one piece of the puzzle, and yet clinicians and patients, even still to this day, almost exclusively focus on that number on that test. And I’m proving that bone density.

Dr. Ron Hunninghake: So what you’re talking about is what I is good for the bone and what is bad for the bone. The number alerts you that there may be a risk, but fixing the number itself doesn’t always get you to where you need to be.

Dr. John Neustadt: Correct.

Dr. Ron Hunninghake: And fixing the number itself is not always that easy. And I’ve found that a lot of people get discouraged chasing the number, and I try to get them thinking about, what in your lifestyle can make the biggest difference to lower your risk for having a fracture? So I don’t know, how do you approach that with your patients?

Dr. John Neustadt: Great question. The biggest predictor, most consistent predictor of fracture risk is somebody’s gait and mobility. So is their balance good? Is their muscle strength good? Because 95% of fractures occur because somebody falls. So anything we can do to prevent falling, can prevent fractures. So that’s really important. And understanding the value of movement and exercise and doing it safely is important. Diet, also very important. The Mediterranean-style diet has been associated with a 21% reduced risk for hip fractures and improve recovery if someone were to fracture. So optimizing somebody’s diet, also very important.

Dr. Ron Hunninghake: But calcium alone in the diet is not the whole story. A lot of people think that they would just drink milk and eat other high calcium foods if that’s going to solve the problem, but evidently, you need more of a diversified whole foods diet.

Dr. John Neustadt: The bone is a tissue, and tissues are complex. It’s not just one thing. It’s not just the minerals like calcium and magnesium that are in bone, but there’s lots of proteins in bone. There’s collagen, which is a big component of bone, but there are 180 to 200 other proteins besides collagen in bone. And they need B vitamins to work your biochemistry, and protein, and minerals, and other vitamins. So just focusing on just calcium and saying, “I need to get enough calcium in my diet” is missing the bigger picture of giving the body a well-rounded diet of different nutrients is important, and specifically getting enough protein, which is where a lot of people seem to fall a bit short.

Dr. Ron Hunninghake: Yeah. What are the negatives? What are the things that are common in the modern lifestyle that is really bad for your bones?

Dr. John Neustadt: One of the most common things now that I see are medications. There are a lot of over-the-counter and prescription medications that destroy bone or decrease balance. And some of the most common ones are the acid blocking medications. If you’re on an acid blocker or proton pump inhibitor, like Prilosec for example, for four years or up to a 60% increase risk of hip fractures. Antidepressant medications, the SSRIs, anything that increases serotonin, like Prozac, that increases the risk for fractures. Now, a couple studies have come out and we now know that for every 19 people taking it, we expect that there may be one additional fracture caused by it.

And those are things that most doctors don’t know. They’re prescribing these medications unwittingly and harming bone in increasing fractures. So really understanding. There’s a whole chapter in my book on medication-induced osteoporosis, making sure you look at the list of medications and talk to your doctor about them if any of those medications that are in there that you’re taking.

Dr. Ron Hunninghake: And most patients, when they see their doctor and they have a bone mineral test done and it comes back low, there’s usually some medication that will be prescribed. What’s the good, the bad, and the ugly regarding these osteoporosis medications?

Dr. John Neustadt: The most important thing is, do they reduce fracture risk and somebody with your diagnosis and your medical history? If you’ve never broken a bone before, there are very few medications that are effective at reducing both vertebral and non-vertebral fractures. Fractures in your spine and fractures in your hip both. The only one that does both is intravenous Zometa. The oral bisphosphonates like Fosamax, they do not prevent a hip fracture from happening if you’ve never had one before, an osteoporosis hip fracture before. If you’ve had one, then it’s called secondary prevention. We’re trying to prevent a fracture, an osteoporosis fracture from happening again, and the medications are much more effective at doing that. There are a lot more options available that do reduce the risk.

And there are risks, though, of taking all medications. So understanding the potential side effects and that you’re willing to commit to taking it long term is important. There’s a chapter in the book also all about the medications and questions people should ask their doctor, but it takes 70 to 80% of the medication needs to be taken over that period of time of years in order to get the benefit. So you really have to be willing to commit.

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Dr. John Neustadt: What about the effect of Fosamax on jaw bones and some issues like that? So that’s called osteonecrosis of the jaw. It’s a big challenge. Dentists will frequently have people stop their medication before doing any procedures, even as simple as pulling a tooth, because the Fosamax, the bisphosphonate category of medications, what that does is it creates a situation where your jaw bone literally can just start to disintegrate. There was an article that came out that looked at this issue some years ago, and up to 8% of the people who have are on these medications who then go and have a dental procedure are at risk of that. So it’s a big thing, challenge and something to be aware of.

Dr. Ron Hunninghake: So looking at what patients can do for strengthening their bones, tell me a little bit about, in terms of exercise, where does strength building come in? Where does aerobic exercise come in? Where does sleep and other health-enhancing modalities come in as far as your bone health?

Dr. John Neustadt: With respect to exercise, there is excellent research looking at how somebody can improve their balance to reduce falls. And again, I go back to that. That’s very important. You don’t have to go into a gym necessarily. You can work things into your daily life. You can stand on one foot called the stork exercise while you brush your teeth twice a day and then switch feet to improve that balance a little bit. Even walking. Walking 7,000 to 7,500 steps per day on average has been associated with up to a 70% reduction in all-cause mortality, which means death from any cause, including osteoporosis, including a fracture. Weight bearing exercises are important also for building muscle, but you don’t have to go into a gym, you can use your own body weight. Ensuring though you have adequate protein to build muscle though is also important. So there’s a calculation in the book, very simple of what to do to make sure you’re getting enough of that protein.

In terms of sleep, sleeping less than five hours a night is associated with an increased risk for osteoporosis. There are lots of things people can do to help improve their sleep and including using white noise machine, getting off their phone, screens an hour before they go to sleep, making sure the temperature is the optimal temperature, taking melatonin or some sleep aid dietary supplements that have combinations of nutrients. All of those can be helpful for improving sleep.

Dr. Ron Hunninghake: Is there a limit to how much calcium people should take? I mean, in terms of supplemental calcium, there’s got to be an amount that people need to get in their diet, but when they go above that, there’s all kinds of additional concerns that can occur. What’s your thoughts on that?

Dr. John Neustadt: Correct. The American Academy of Preventive Cardiology and the Bone Health and Osteoporosis Foundation’s current published position statement on this is that people should not consume more than what the National Academy of Medicine and Sciences recommends as the tolerable upper limit, which is the most you can take without there being risk, which is 2,000 to 2,500 milligrams per day of calcium. Now, that’s from all sources, diet and dietary supplements.

Most people, the average American woman gets about 800 milligrams of calcium from their diet. And the USRDA for calcium, it’s recommended that they get about 1,200 milligrams to 1,500 milligrams per day of calcium, again, from all sources. So taking a dietary supplement that has 800 milligrams or even up to 1,000 milligrams of calcium is considered safe.

But there are other nutrients that are actually more important than calcium. Vitamin D is important. Make sure you get your vitamin D into a healthy range. So I do recommend people get their vitamin D tested. And we want to get it at least to 33 to 44, that number, for fracture reduction that’s been associated with fracture reduction. And then there’s a form of vitamin K2 called MK4 in the amount of 45 milligrams per day. That’s the only form of vitamin K2 shown in studies, in clinical trials, not only to promote healthy bone density, but to maintain bone strength as indicated by over 70% fewer fractures in clinical trials.

And it’s because of that research and because of me diving into the literature and the research decade over a decade ago, 15, 16 years ago, because of my mother-in-law, because my patients and I discovered the research, that product, that nutrient did not exist in the clinical dose with calcium and vitamin D at the time, so I created it. And that’s my Osteo-K and Osteo-K Minis products that I launched under the market in 2007. And I’m so convinced by the research and my experience with it, that in fact, just this last year, we rolled out a new guarantee that we guarantee that people taking those products will see their bone density stabilize or improve within six months, but more importantly, they will maintain strong bones. So if they break a bone, we will refund their money for all qualifying purchases.

Dr. Ron Hunninghake: And also, by taking vitamin K2, you also do not have to worry so much about vitamin D toxicity because the only thing that vitamin D toxicity will do is give you excessively high calcium level. And so, this will help you maintain it into the normal range if you are taking extra vitamin D. So that’s one other benefit of it as well.

So for the women that are going in to get their DEXA scans, it’s always been confusing about the T-score and the Z-score. How do you advocate women use that information?

Dr. John Neustadt: Great question. If you’re post-menopausal woman, then a T-score is applicable to you. A T-score of minus 1 to minus 2.5 means that you have osteopenia or pre-osteoporosis. You’ve got some bone loss, but it’s not all the way to osteoporosis. And a T-score of minus 2.5 or lower, minus 2.8, minus 3.80, et cetera, means you have osteoporosis. What that number is doing is it’s comparing your bone density, which is only the amount of minerals in bone, not the amount of proteins or collagen or other things we’re talking about. Only the minerals. And it compares that amount of minerals in your bone to a woman in her 20s of the same race, 20 to 29 years old. A Z-score, which most clinicians frankly don’t really understand how to interpret, compares your bone density to someone your own age and your own sex. And that is really helpful for identifying potential secondary causes of osteoporosis.

A secondary cause of osteoporosis means that the bone losses cause not simply by the drop in estrogen that occurs with menopause. During menopause and for 10 years after, that’s the fastest time in a woman’s life where she’s losing bone. But secondary causes of osteoporosis are those medications I was talking about, other diseases, autoimmune diseases, inflammatory bowel diseases, things that can cause bone loss to occur.

If a Z-score is less than negative 2.5, anybody of any age who has that number, they should be looking at secondary causes of osteoporosis. If you are a premenopausal woman and that Z-score is lower, then you should be looking at secondary causes as well. Doesn’t have to be all the way down to negative 2.5, but if it’s starting to go down and starting to be low, you want to look at secondary causes.

Dr. Ron Hunninghake: So, hopefully, women won’t fall into the trap of just trying to make the number better. The number is really just to alert women and men that they need to be looking at these secondary causes, which gets into all your lifestyle issues, your exercise, your sleep, your diet, stress. All these things can set you up. Stress can set you up for fault if you’re older. So you want to manage stress for a number of reasons.

This information, by the way, that John is talking about is in his book, and it’s a very readable book. And I strongly recommend the “Fracture-Proof Your Bones book, A Comprehensive Guide to Osteoporosis.”

And John, I really want to thank you because I’ll be honest with you, I’m a family physician and I certainly do promote the whole improved lifestyle, nutrition, and everything that we’ve talked about, but sometimes connecting that to the scores, it’s a little hard for people. And I think your book does a nice job of helping people understand that it’s more than just a number that reflects the health of your bones.

Dr. John Neustadt: Thank you. Yeah. Writing this book and researching it was really a labor of love. And it’s so rewarding to me that, especially from colleagues to get this feedback, but also from people who read it and are writing in and letting me know how much it’s changed their life and how they’re now have the questions, the right questions to ask their doctors and speak to their doctors about to make sure they’re getting the best care for themselves.

Dr. Ron Hunninghake: So Dr. John Neustadt, thank you very much for being on the Real Health Podcast.

Dr. John Neustadt: Thank you.

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