 A few months ago, I presented a webinar on osteoporosis. All the videos will eventually be up on NutritionFacts.org, but I wanted to share the full recording with you now. Stay tuned for the end for lots of great Q&A. Enjoy. Everyone, and welcome. I'm Dr. Michael Greger, coming to you live from my treadmill for our very first CME-approved webinar, continuing medical education for doctors and other healthcare professionals as such. I'm proud to declare that I have no relevant financial relationships with ineligible companies to disclose that kind of declaration statement is necessary given a long checkered past of big pharma and medical instrument companies secretly propping up paid shills to push their products. So now they just non-secretly prop up paid shills to push their products, but at least a little hard for them to hide, but no commercial bias here. Before I cover the pros and cons of drugs used to treat osteoporosis, let me start us off today covering drugs that may cause it. Product fractures for 50-year-old white... Let me start that at the beginning. Nearly 1 in 5 adults in the world may have osteoporosis. That's hundreds of millions of people. The word osteoporosis literally means porous bone. Now most of our bone is actually porous to begin with. This is what normal bone looks like inside, but this is osteoporosis. Bone mineral density is considered to be the standard measure for the diagnosis of osteoporosis. Although the bone mineral density cut off for an osteoporosis diagnosis kind of arbitrary, using the standard definition, osteoporosis may affect about 1 in 10 women by age 60, 2 in 10 by age 74 and 10 by age 80 and 6 or 7 out of 10 by 90. Osteoporosis is typically thought of as a disease in women, but one-third of hip fractures occur in men. The lifetime risk for osteoporotic fractures for 50-year-old white women and men are 40% and 13% respectively. The good news is that osteoporosis need not occur. Based on a study of the largest twin registry in the world, less than 30% of osteoporotic fracture risk is heritable, leading the researchers to conclude prevention of fractures even in the oldest elderly should focus on lifestyle interventions. This is consistent with the enormous variation of hip fracture rates around the world, with the incidence of hip fracture varying 10-fold or even 100-fold between countries suggesting that excessive bone loss is not just an inevitable consequence of aging. The United States Preventive Services Task Force, an independent scientific panel that sets evidence-based clinical prevention guidelines, recommends osteoporosis screening, such as dexabone mineral density scan, for all women aged 65 and older, and potentially starting even earlier than 65 for women at increased risk, such as having a parental history of hip fracture, being a smoker or an excessive alcohol consumer, or having low body weight. What should you do if you're diagnosed? Or more importantly, what should you do to never be diagnosed? Before exploring the drugs on offering to treat osteoporosis, there are some drugs that may cause it. So let's start there. Stomach acid-blocking proton-pump inhibitor drugs, so-called PPIs, with brand names like prilosec, previsid, nexium, protonics, and as effects, are among the most popular drugs in the world, raking in billions of dollars a year. But then, in 2006, two observational studies out of Europe suggested an association between intake of this class of drugs and increased risk of hip fracture. And by 2010, the growing evidence forced the US Food and Drug Administration to issue a safety alert implicating PPI use with fractures of the hip, wrist, and spine. By now, there's been dozens such studies involving more than 2 million people that overall show higher hip fracture rates among both long and short-term users at all dose levels. The irony is that most people taking these drugs shouldn't even be on them in the first place. These PPIs are only FDA approved for 10 days of use for the treatment of H. pylori, up to two weeks for heartburn, up to eight weeks for acid reflux disease, and for two to six months for ulcers. Yet, in a community survey, most users remained on these drugs for more than a year, and more than 60% of patients were taking them for inappropriate reasons, often wrongly prescribed for quote-unquote indigestion, for instance. Calls to stop this massive overuse from regulatory authorities have fallen on deaf doctor ears. And now that they're available over-the-counter, the problem of overuse may have just gotten even worse. They can be hard to stop taking, since many patients experience withdrawal symptoms that can last for weeks. In fact, if you take normal, healthy volunteers without any symptoms and put them on these drugs for two months, and then covertly switch them to a placebo without their knowledge, all of a sudden they can develop acid-related symptoms, such as heartburn or acid regurgitation, so ending up worse off than they were before they even started taking the drugs. In addition to bone fractures, this class of drugs has also been linked to increased risk of other possible long-term adverse effects, such as pneumonia, intestinal infections, kidney failure, stomach cancer, and cardiovascular disease. In fact, the blood vessel effects could explain the case report abrupt onset, profound erectile dysfunction in a healthy young man after initiating over-the-counter pylosac. Oh, and also premature death. There are individuals with conditions like Zollinger-Ellison syndrome, stricken with tumors that can cause excess stomach acid secretion, for whom the risk versus benefit of long-term use may be acceptable. But that's a far cry from the 100 million PPI's prescribed annually in the United States alone. To deal with acid reflux without drugs, recommendations include weight loss, smoking cessation, avoiding fatty meals, especially within two to three hours of bedtime, increased fiber consumption, and overall a more plant-based diet, because non-vegetarianism is associated with twice the odds of acid reflux-induced inflammation. Other classes of drugs that have been associated with hip fracture risk include antidepressants, anti-Parkinson's drugs, anti-psychotics, anti-anxiety drugs, oral corticosteroids, and the other major class of heartburn drugs, the H2 blockers, such as Pepsid, Zantac, Tagamet, and Acid. OK, so excessive bone loss is not just an inevitable consequence of aging. And one of the things we can do to lower our risk, and that of our patients, is to take into account the potential skeletal side effects of the drugs we take and prescribe. OK, what about the drugs prescribed to treat osteoporosis? First, let me address efficacy. Drug therapy for osteoporosis is recommended for those 15 older with a history of past hip or spine fractures, those with hip or spine T scores of negative 2.5 or less, and postmenopausal women or men 15 older who don't make that cutoff, but have an estimated 20% or higher risk of major osteoporotic fracture of the subsequent decade, or an estimated 3% or greater risk of hip fracture specifically. A T score is a measure of how dense your bones are compared to a 30-year-old white woman. Since that's the standard and we tend to lose bone as we age, you can be labeled as having osteoporosis, even if you have completely normal bone density for your age. Of course, just because your bone density may be normal doesn't mean it's necessarily optimal, which is why the National Osteoporosis Foundation set out these guidelines for drug treatment. Though another reason perhaps is because it gets substantial funding from the drug industry, which reeks in literally billions of dollars in profits from osteoporosis drugs. What does the science say? The primary drug class used to treat osteoporosis is the bisphosphonate, sold as such brands as Phosomax, Actinel, Boniva, and Reclast. They're most effective at reducing vertebral fractures, cutting the risk in postmenopausal women from 2.8% down to 1.4%. That's a relative risk reduction of 50%, but an absolute risk reduction of only 1.4%, meaning you'd have to treat 71 women to prevent just one woman from getting a vertebral fracture. Unfortunately, the diagnosis of vertebral fractures is kind of wishy-washy. Depending on how you define the changes on x-ray, the prevalence of vertebral fractures can vary as much as 3% to 90% in the same elderly population, almost none to almost all. They're also poorly predictive of back pain or disability. Vertebral fractures can certainly lead to back pain, reduce physical function, but only about a third are symptomatic at all. The most harmful fractures are hip fractures. Despite most of the clinical trials for osteoporosis treatment being funded by the drug companies themselves, no primary prevention benefit from dysphosphonates has been found for hip fractures. In other words, taking these drugs has not been convincingly shown to prevent fracturing your hip in the first place. However, having a prior fracture doubles your risk of breaking another bone, so for those at high risk, dysphosphonate drugs may decrease the odds of hip fracture by 25%, though the absolute risk reduction isn't again only about 1%, it may take treating 91 people for three years to prevent one hip fracture. In overconfidence in the power of pills and procedures for disease prevention, maybe one of the reasons doctors and patients alike may undervalue diet and lifestyle approaches. In this study, patients were asked to estimate the number of fractures or deaths prevented in a group of 5,000 patients undergoing each drug intervention over a period of 10 years. The vast majority of people tended to wildly overestimate the ability of mammograms and colonoscopies to prevent cancer deaths, the power of drugs like Fosomax to prevent hip fractures, and drugs like Lipitor to prevent fatal heart attacks. No wonder most people continued to rely on drugs to save them. But the dirty little secret is that most people said they wouldn't be willing to take many of these drugs if they knew how little benefit these products actually offered. In a study of those undergoing bone density scans, the average five-year fracture risk that would motivate most participants to consider preventive medicine was 50 to 60 percent, much higher than their actual risk. Most patients want to be told the truth. They want to be told what the chances are that the drugs will actually benefit them. But there's a tension between the patient's right to know and the likely reduction in their willingness to take the drug if they knew the truth. In the Bone Density Scan Survey, participants greatly overestimated their own personal risk for hip fracture, thinking it was around 19% of the next five years, which is more than 10 times higher than their actual risk of 1.4%. Rather than disabusing them of this overestimate, some suggest physicians should do the opposite. Stoke fear in patients who refuse to comply with medication recommendations by increasing their perceived susceptibility to fragility fractures, as well as their perceived severity of suffering from a fragility fracture. Since emotion can be more motivating than reason, and anecdotal evidence can be more effective than evidence evidence, a graphic scenario of suffering and incapacitation after hip fracture will enhance emotional perception of this threat. But hip fractures can indeed be devastating and are associated with a significant risk of ensuing deaths. So what about all the lives these drugs must be saving? Well, only about a quarter of the deaths following fractures may be attributable to the fracture itself. So most of the mortality risk may just be a consequence of the comorbidities, that is, the other diseases and poor health status of people who tend to fracture their hips. So they might have died anyway in that same timeframe, even if they hadn't broken any bones. This may help explain why there are no saved lives. Osteoporosis drug treatments, particularly by phosphonates, fail to significantly reduce overall mortality. Okay, so the efficacy of the primary drug class used to treat osteoporosis is so slight on an individual basis that most patients, if truly fully informed, likely would not take them. And that's before even talking about the side effects, which I'll turn to right now. Potential lack of efficacy is not the only reason why most people prescribe bisphosphonate drugs for osteoporosis, like Fosamax, Actinel, Boniva reclass, may stop taking them within a year. There are two rare but devastating side effects, osteonecrosis of the jaw, and atypical femur fractures that contributed to around a 50% drop in the use of this class of drugs when they came to light. The New York Times article noting the decline explained the reasoning. Reports of the drugs causing jaw bones to rot and thigh bones to snap in to have shaken many osteoporosis so much that they say they would rather take their chances with the disease. The jaw rot syndrome that prevents many from initiating treatment for fear of their jaw falling off can severely impact many aspects of quality of life, but is exceedingly rare, affecting most 1,000 patients treated for osteoporosis. Atypical femur fractures can occur more frequently though as many as 1 in 300 users treated for three years. They're called atypical because they occur not after a fall or trauma, but just during routine activities like walking, twisting at the waist, or even just standing still. Your femur, your thigh bone, the biggest bone in your body just breaks in half. Too cruel an irony from a drug that's supposed to protect your bones. This is what it looks like on X-ray. Ouch! This phosphonates work by inhibiting the action of a type of bone cell called osteoclast. Your entire skeleton is constantly being remodeled with bone added in some spots and taken away in others to conform to changing demands. The cells that are continually laying down new bone are called osteoblasts and the ones that chisel away old bone are called osteoclasts. It makes sense then that curbing the class could prevent bone loss, but by reducing the active remodeling process, this phosphonates can freeze the skeleton, allowing for the accumulation of micro cracks over time resulting in stress fractures. Other osteoporosis drugs like dinosumab, sold as polio, prevent the same formation of osteoclasts in the first place and have been plagued by the same kinds of rare but disturbing side effects. As with anything in life, it all comes down to risks versus benefits. I mean, how many hip fractures are prevented for every femur that snaps? It depends on your race and how long you're on these drugs. After five years in white women, 36 hip fractures are prevented for every atypical femur fracture. Hispanic women only get half the benefit, about 18 to 1. And for Asian women, it's only about five hip fractures prevented for every femur fracture caused. The study claims it failed to accrue enough data on black women. At 10 years of drug exposure, the ratios get worse. 16 to 1 for white women, 5 to 1 for Hispanic women, and only 1.5 to 1 for Asian women, meaning that the devastating fractures prevented and caused in Asian women are nearly comparable. A nationwide survey of resident physicians found that knowledge regarding osteoporosis diagnosis and treatment was poor, with a particularly striking lack of knowledge regarding the two serious drug side effects. The good news is that after stopping the drugs, the risk of femur fracture rapidly drops by 70% within a year, leading to the suggestion that a drug holiday be considered after a few years in the drug to help mediate the risk. How crazy is that atypical femur fracture data, right? I just cannot get over the irony of it all. Okay, so between the lack of sufficient efficacy and these rare but devastating side effects, what can we do personally and how can we counsel our patients to protect their skeletons? Well, before I get to lifestyle approaches, let me first cover supplements, calcium and vitamin D supplements. In 12 short years, government panels have gone from suggesting widespread calcium supplementation may be necessary to protect our bones to do not supplement. What happened? It all started with a 2008 study in New Zealand. Short-term studies have shown that calcium supplementation may drop blood pressures by about a point, though the effect appears transient, disappearing after a few months, better than nothing. And excess calcium in the gut can cause fat malabsorption by forming soap fat, reducing saturated fat absorption, and increasing fecal saturated fat content. And indeed, if you take a couple of tons, along with your half bucket of KFC, up to twice as much fat could end up in your stool. And with less saturated fat absorbed into your system, your cholesterol might drop. So the New Zealand researchers were expecting to lower heart attack rates by giving women calcium supplements. To their surprise, there appeared to be more heart attacks in the calcium supplement group. Was this just a fluke? All eyes turned to the Women's Health Initiative, the largest and longest randomized controlled trial of calcium supplementation. The name might sound familiar. That's the study that uncovered how dangerous hormone replacement therapy was. Would it do the same for calcium supplements? The Women's Health Initiative reported no adverse effects. However, the majority of participants were already taking calcium supplements before the study started. So effectively, the study was just comparing higher versus lower dose calcium supplementation, not calcium supplements versus no calcium supplements. What if you go back and just see what happened to the women who started out not taking supplements and then were randomized to the supplement group? Those who started calcium supplements suffered significantly more heart attacks or strokes. Thus, high dose or low dose any calcium supplementation seems to increase cardiovascular disease risk. So researchers went back digging through other trial data for heart attack and stroke rates in women randomized to calcium supplements with or without vitamin D added and confirmed the danger. And most of the population studies agreed users of calcium supplements tended to have increased rates of heart disease, stroke, and death. The supplement industry was not happy, accusing the researchers of relying in part on self-reported data, like they just asked people if they had a heart attack or not, rather than verifying it. Indeed, long-term calcium supplementation causes all sorts of gastrointestinal distress, including twice the risk of being hospitalized with acute symptoms that may have been confused with a heart attack, but no. The increased risk was seen consistently across the trials whether the heart attacks were verified or not. Okay, but why do calcium supplements increase heart attack risk, but not calcium you get in your diet? Perhaps because when you take calcium pills you get a spike of calcium in your bloodstream that you don't get just eating calcium-rich foods. Within hours of taking supplemental calcium, the calcium levels in the blood shoot up and can stay up as long as eight hours. This evidently produces what's called a hypercoagulable state, your blood clots more easily, which could increase the risk of clots in the heart and brain. And indeed, higher calcium blood levels are tied to higher heart attack and stroke rates, so the mechanism may be calcium supplements leading to unnaturally large, rapid, and sustained calcium levels in the blood, which can have a variety of potentially problematic effects. Calcium supplements have been widely embraced on the grounds that they are natural and therefore safe way of preventing osteoporotic fractures. But it's now becoming clear that taking calcium in one or two daily doses is not natural, and that it does not reproduce the same metabolic effects as calcium in food the way nature intended. And furthermore, the evidence is also becoming steadily stronger that calcium supplementation may not be safe. That's why most organizations providing advice regarding bone health now recommend that individuals should obtain their calcium requirement from diet in preference to supplements. But if we can't reach it through diet alone, would the benefits to the bones outweigh the risks to the heart? We'll find out next. So, we'd still need to get enough calcium, but it should be through foods the way nature intended, not through toms. Let's now turn to calcium from calcium supplement safety to calcium supplement efficacy. There has been an assumption for decades that as a natural element, calcium supplements must intrinsically be safe. But calcium supplementation is neither natural nor risk-free, but the same could be said for every medication on the planet. Yet, doctors continue to write billions of prescriptions for drugs every year, because the hope at least is that the benefits outweigh the risks. So, what about the benefits of calcium supplements? Yes, heart attacks and strokes can be devastating, but so can hip fractures. The risk of dying shoots up in the months following a hip fracture about 1 in 5 women don't last a year after hip fracture, and it may be even worse for men. On average, apparently cutting one's lifespan short by 4 or 5 years. And unfortunately, these dismal statistics don't seem to be getting much better. So, even if calcium supplements caused a few heart attacks and strokes, if they prevented many more hip fractures, then it might result in a favorable risk-benefit ratio. So, how effective are calcium supplements in preventing hip fractures? We've known that milk intake doesn't appear to help, but maybe that's because any potential benefit of the calcium in milk may be overshadowed by the increased risk of fracture and death associated with the galactose sugar in milk. But what about just the calcium in a calcium supplement alone? Calcium intake in general does not seem to be related to hip fracture risk at all. And when people have been given calcium supplements, not only was there no reduction in hip fracture risk, an increased risk is possible. The randomized controlled trial suggests that 64% greater risk of hip fractures with calcium supplementation compared to just like getting a placebo sugar pill. Where did they even get this idea than that calcium supplements might help our bones? It was this influential study in 1992 that found a combination of vitamin D in calcium supplements could reduce hip fracture risk 43%. But this was done on institutionalized women, like in a nursing home, who were vitamin D deficient. They weren't getting sufficient sun exposure. And so, if you're vitamin D deficient and you take vitamin D in calcium, no surprise, your bones get better. But for women living independently out in the community, the latest official recommendations for calcium and vitamin D supplementation to prevent osteoporosis is unambiguous. Do not supplement. Why? Because in the absence of compelling evidence for benefit, taking supplements is not worth any risk, no matter how small. Now, this is not to say these supplements don't play a role in treating osteoporosis, or that vitamin D supplements might not be good for other things. But if you're just trying to prevent fractures, women living outside of institutions should not take them. And perhaps even in institutions. In this study, instead of giving nursing home residents vitamin D and calcium supplements, they randomized them to sunlight exposure and calcium supplements. And those that got the calcium pills had significantly increased mortality, lived shorter lives than the sunshine only group. Although calcium supplements don't appear to prevent hip fractures, they may reduce overall fracture risk by like 10%. So here's how the risk benefit shakes out. If a thousand people took calcium supplements for five years, we would expect 14 excess heart attacks, meaning 14 people would have a heart attack that they would not have had if they had not started the calcium supplements. So they were effectively going to the store and buying something that gave them a heart attack. Plus 10 strokes that otherwise would not have happened. And 13 deaths. People would have been alive had they not started the supplements. But that's all balanced against the 26 fractures that would be prevented. Now it's no fun falling down, breaking a wrist or something, but I think most people would look at that risk benefit analysis and conclude that calcium supplements are doing more harm than good. Given these findings, the use of these supplements should be discouraged. And individuals advised to attain calcium from their diet instead. Calcium supplements have been associated with elevated risk of myocardial infarction, heart attacks, whereas dietary calcium intake has not. How much calcium should we shoot for? Interestingly, unlike most other nutrients, there's no international consensus. For example, in the UK, the recommendation for adults is 700 mg a day. But across the pond in the US, it's up to 1200 a day. Whenever I see that kind of huge discrepancy between government panels, I immediately think scientific uncertainty, political maneuverings, or both. Newer data based on calcium balance studies, in which researchers make detailed measurements of the calcium going in and out of people, suggests that the calcium requirements for men and women is lower than previously estimated. They found calcium balance was highly resistant to change across a broad range of intakes, meaning our body is not stupid. If we eat less calcium, our body absorbs more and excretes less. And if we eat more calcium, we absorb less and excrete more to stay in balance. Therefore, current evidence suggests that dietary calcium intake is not something most people need to worry about. This may explain why in most studies no relationship was found between calcium intake and bone loss anywhere in the skeleton, because the body just kind of takes care of it. Don't push it too far, though. I mean, once you get down to just a few hundred milligrams a day, you may significantly get more bone loss. Though there may not be great evidence for the US recommendations, the UK may have the right idea, shooting for between 500 and 1,000 milligrams a day from dietary sources, unless you've had gastric bypass surgery or something and need to take supplements. For most people, though, calcium supplements cannot be considered safe or effective for preventing bone fractures. Okay, so calcium supplements appear to do more harm than good. What about taking vitamin D supplements? Let's find out. We've known for over 400 years that muscle weakness was a common presenting symptom of vitamin D deficiency. Bones aren't the only organs that respond to vitamin D muscles do, too. But as we age, our muscles lose vitamin D receptors, perhaps helping to explain the loss in muscle strength as we age. And indeed, vitamin D status does appear to predict the decline in physical performance as we age, with lower vitamin D levels linked to poorer performance. But maybe the vitamin D didn't lead to weakness. Maybe the weakness led to low vitamin D. Vitamin D is the sunshine vitamin, and so if you're too weak to run around outside, that could explain the correlation with lower levels. To see if it's caused an effect, you have to put it to the test. There's been about a dozen randomized control trials, vitamin D supplements versus sugar pills. Put all the studies together, and older men and women do get significant protection from falls with vitamin D, especially among those who start out with relatively low levels. Leading the conservative USPSTF, the US Preventive Services Task Force, the Official Prevention Guidelines Setting Body, and the American Geriatric Society, to recommend vitamin D supplementation for those at high risk for falls. We're not quite sure of the mechanism, though. Randomized controlled trials have found that vitamin D boosts global muscle strength, particularly in the quads, which are important for fall prevention. Though vitamin D supplements have also been shown to improve balance, so it may also be a neurological effect, or even a cognitive effect. We've known for about 20 years that older men and women who stop walking when a conversation starts are at particularly high risk of falling. Over a six-month time frame, few of those who could walk and talk at the same time would go on to fall, but 80% of those who stopped when a conversation is initiated ended up falling. Other high-risk groups that should supplement include those who've already fallen once or are unsteady or on a variety of heart, brain, and blood pressure drugs that can increase fall risk. There's also a test called Get Up and Go, which anyone can do at home. You time how long it takes you to get up from an armchair, walk 10 feet, turn around, walk back, and sit down. If it takes you longer than 10 seconds, then you may be at high risk. So how much vitamin D should you take? Seems to take at least 700 to 1,000 units a day. The American Geriatric Society recommends a total of 4,000 a day, though. Based on the rationale that this should get about 90% of people up to the target vitamin D blood level of 75 nanomoles per liter. 1,000 should do it for the majority of people, 51%, but they recommend 4,000 to capture 92% of the population. Then you don't have to routinely test levels, since you would get most people up there, and it's considerably below the proposed upper tolerable intake of 10,000 a day. They do not recommend periodic mega doses. Because it's hard to get patients to comply with pills, why not just give people one mega dose, like 500,000 units once a year? Like when you come in for a flu shot or something. So every year you can at least guarantee everyone gets an annual spike in D levels that lasts a few months. It's unnatural, but certainly convenient for the doctor at least. The problem is that it actually increases fall risk, 30% increase in falls in those first three months of the spike. Similar results were found in other mega dose trials. It may be a matter of too much of a good thing. See, vitamin D may improve physical performance, reduce chronic pain, and improve mood so much that you start moving around more and thereby increase fall risk. You give people a whopping dose of D and you get a burst in physical, mental, and social functioning, and it may take time for your motor control to catch up with your improved muscle function. It would be like giving someone a sports car all of a sudden when they've been used to driving some beater. You gotta take it slow. It's possible, though, that such unnaturally high doses may actually damage the muscles. The evidence they cite in support is a meat industry study showing you can improve the tenderness of steaks by feeding steers of a few million units of vitamin D, so the concern is that such high doses may be over 10 derising our own muscles as well. So yeah, higher D levels are associated with a progressive drop in fracture risk, but too much vitamin D may be harmful. The bottom line is that vitamin D supplementation appears to help, but the strongest and most consistent evidence for prevention of serious falls is exercise. If you compare the two, yes, taking vitamin D may lower your fall risk compared to placebo, but strength and balance training with or without vitamin D may be even more powerful. It's so interesting watching those old videos. Sorry if I made anyone seasick with those tilting PDFs, but it's kind of a neat blast from the past there. All right, anyway, so periodic annual or even monthly mega doses of vitamin D may increase risk. What's the best daily dose? And well, let me share a study with you that came out after I finished that video, which I think is really enlightening. I wish it was around when the video was made so I could include it. Okay, so I'm what I'm going to do is I'm going to share this PDF here and let's see how this works. Okay, hopefully before you, you should see a PDF. All right, I'm going to zoom in a little bit here to the blue quote. Hopefully you can read it. Okay, so what we're looking at here, this is a year-long randomized double blind placebo-controlled trial of seven different daily doses of vitamin D for elderly women who started out low in D. Okay, and what they found, sorry, I'm going to scroll quick speaking of making people sick. And so looking at the green quote here, you can see that which found that the low doses appeared to be useless, 400 or 800 international units a day, but there was a significant reduction in fall rates among those taking the medium doses, 1600, 2400, or 3200 units a day, and significantly higher fall rate for taking 4,000 a day or 10,000 a day compared to the medium doses. So you'll remember back in the video, I talked about some authorities suggesting 4,000. After this study, I would suggest that's too much unless you have some reason to think otherwise. All right, I'm going to switch over to another study here. This is a three-year study. You can close your eyes till I finish. I'm looking for a green quote. Is there no green quote in here? All right, well, let me maybe blue quote, mess that up. All right, I'm going to zoom in here. Whoa, what just happened? I just started printing it. All right, zoom in. Okay, a three-year study found higher doses, 4,000 or 10,000 a day may also lower bone mineral density. Oh, look, can I make it, check it out, lower bone mineral density. Can I make pretty colors? I don't know. Anyway, I'm getting to PDF happy. But so that may help explain the increased fracture risk. Okay, moving on to the next PDF. Okay, what's the average effects, didn't we just talk about? May also lower bone mineral density. Oh, oh, and I was just, it turns out that action may be worse for women than in men. I guess that was the only point I was making this. All right, let's go back to the videos here. When I say it's better to get calcium from foods, most people immediately think dairy, right? But two videos ago in this webinar, you know, I talked to, very briefly, you know, mentioned and kind of flashed by, remember, you're going to get all these videos, so you can watch it slow and pause, and you know, I know this, everything flies by quick. I'm just obviously trying to pack a huge amount of information into every second here. But you know, I talked about how milk intake doesn't appear to help, but maybe because any potential benefit of counseling may be overshadowed by the increased risk of fracture and death associated with the galactose, sugar, and milk. You say, wait a second, increased risk of fracture and death, let us definitely address that next. In adolescence, Harvard researchers decided to put it to the test. Studies have shown that greater milk consumption during childhood and adolescence contributes to peak bone masses, therefore expected to help avoid osteoporosis and bone fractures in later life. But that's not what they found. Milk consumption during teenage years was not association with a lower risk of hip fracture, and if anything, milk consumption was associated with a borderline increase in fracture risk in men. It appears that the extra boost in total body bone mineral density you get from getting extra calcium is lost within a few years, even if you keep the calcium supplementation up. This suggests a partial explanation for the long-standing enigma that hip fracture rates are highest in populations with the greatest milk consumption. Maybe an explanation why they're not lower, but why would they be higher? This enigma irked a Swedish research team puzzled because studies, again and again, had shown a tendency of higher risk of fracture with a higher intake of milk. Well, there is a rare birth defect called galactosemia, where babies are born without the enzymes needed to detoxify the galactose found in milk. So they end up with elevated levels of galactose in their blood, which can cause bone loss, even as kids. So maybe the Swedish researchers figured, even in normal people that can detoxify the stuff, it might not be good for the bones to be drinking it every day. And galactose doesn't just hurt the bones, that's what scientists use to cause premature aging in lab animals. They slip them a little galactose, and you can shorten their lifespan, cause oxidative stress, inflammation, brain degeneration, just with the equivalent of one to two glasses of milk worth of galactose a day. We're not rats, though, but given the high amount of galactose in milk, recommendations to increase milk intake for prevention of fractures could be a conceivable contradiction. So they decided to put it to the test, looking at milk intake and mortality, as well as fracture risk, to test their theory. 100,000 men and women fall for up to 20 years. What did they find? Milk drinking women had higher rates of death, more heart disease, significantly more cancer for each glass of milk. Three glasses a day was associated with nearly twice the risk of death, and they had significantly more bone and hip fractures too. Men in a separate study also had a higher rate of death with higher milk consumption, but at least they didn't have higher fracture rates. So a dose-dependent high rate of both mortality in fracture in women, and a high rate of mortality in men with milk intake. But the opposite for other dairy products like soured milk and yogurt, which would go along with the lactose theory, since bacteria can ferment away some of the lactose. To prove it though, we need a randomized controlled trial to examine the effect of milk intake on mortality in fractures. As the accompanying editorial pointed out, we better figure this out soon, as milk consumption is on the rise around the world. darn right, we better figure this out. Thankfully we do have some new data, which we can look at. Obviously you can imagine how that freaked out the scientific community, and so they pulled out the big guns. And so let me pull that PDF up for you. All right, with the then largest ever study on milk intake and mortality, showing such adverse effects Harvard researchers stepped in with their three famous cohorts. The former study twice as big to see if the Swedish findings were a fluke, falling more than 200,000 men and women for up to three decades. And in 2019, they confirmed the bad news. Those who consumed more dairy lived significantly shorter lives. Every half serving more of regular milk a day was associated with a 9% increased risk of dying from cardiovascular causes, 11% increased risk of dying from cancer, and an 11% increased risk of dying from all causes put together. Okay, but wait a second. We have influential influential organization, advocacy organization, such as the U.S. National Osteoporosis Foundation and the Europe-based International Osteoporosis Foundation, which continue to push dairy, drugs, and calcium supplements. Well, perhaps it's because their objectivity is compromised by the influence of their commercial sponsors, which include companies that market, you guessed it, dairy, drugs, and stuff. Okay, so what foods out there may help our bones? Well, let's turn to that next. Even just a single extra serving of fruits and vegetables per day is associated with lower bone fracture risk. Why? Well, osteoporotic fracture risk is associated with higher levels of inflammation in your blood, for example, C-reactive protein, and specifically a more pro-inflammatory diet. Those eating higher on the dietary inflammatory index have about 30% greater risk of osteoporosis and fracture than those eating more anti-inflammatory diets. And a higher intake of fruits and vegetables decreases inflammation. So that's one possible reason. Free radicals may also play a role in eating away at your bones, suggesting that pro-oxidant stress may contribute to osteoporosis. Both the total antioxidant power and capacity of people's bloodstreams and diets are significantly lower in those with osteoporosis. And how do we squash free radicals and improve antioxidant status with fruits and vegetables? For example, consumption of vitamin C-rich foods is associated with lower risk of hip fracture, osteoporosis, and bone loss. Every additional increase of 50 milligrams of dietary vitamin C a day, which is about the equivalent of one orange, may lower the risk of hip fracture by 5%. The third way fruits and vegetables may help our bones are through acid-based balance. As we grow older, there's a slight drop in the pH of our blood as our blood becomes more acidic with age. This is thought to be due to the waning ability of our kidneys to excrete excess acid. In vitreous studies, suggests a drop in pH may lead to activation of the cells that break down bone and an inhibition of cells that build bone back up. So how about eating alkaline-forming foods? The most acid-forming foods are meat and cheese, especially fish, and the most alkaline or base-forming foods are fruits and vegetables. This may help explain why, if you experimentally remove fruits and vegetables from people's diets, a mark of bone formation significantly drops, and a mark of bone loss shoots up, and vice versa when you add fruits and vegetables back into their daily diets. The greater the estimated ratio between acid-forming foods and alkaline-forming foods, the greater the risk of hip fracture. Supporting the rationality, less acidic diets, but this was based on observational data to prove cause and effect, two-year double-blind randomized controlled trials were performed in which the three added servings of fruits and vegetables or the equivalent of six extra servings failed to have an effect, but randomized people did the equivalent of nine daily servings of fruits and vegetables worth of an alkaline-forming compound, and you do see a significant increase in bone volume and density in the spine, hip, and throughout the whole body. Are there any fruits and vegetables that are particularly good? That's the question I'll address next. Okay, so observational studies suggest that fruit and vegetable consumption may help protect our bones, and an interventional trial of an alkaline load equivalent to nine daily servings improved bone volume and density. Have any specific fruits and vegetables been tested? Yes, check it out. Feeding rats dozens of different foods, the fruit found to preserve their bones the best was the prune, and the leading vegetable was the onion. I've talked already about prunes, what about onions? The country with apparently the highest per capita consumption of onions in the world is Turkey, which also has one of the lowest rates of osteoporotic bone fractures. Turkey may have four times greater daily per capita onion intake than the United States, and four times lower hip fracture probabilities. Is that just a coincidence, though? The problem with trying to correlate country-by-country comparisons is that you don't know if the people within those countries who are actually eating those onions are the ones who are actually avoiding fractures. But in 2017, a prospective study was published in which the fruit and vegetable intake of about 1,500 older women was followed for nearly 15 years. And of all the classes of vegetables, the intake of allium family veggies, such as onions, leeks, and garlic, were the ones most associated with lower risk of bone fractures. Based on a study of non-Hispanic white women, 50 years and older, those who ate onions on a daily basis had an overall bone density, 5% greater than those who rarely ate them. This may not sound like a lot, but could potentially translate into reducing the risk of hip fracture by more than 20%. Why onions? Maybe it's the quercetin. Onions are one of the most concentrated sources of this phytonutrient, which can stimulate the activity of our bone-building cells, at least in petri dish. This is also a potent inhibitor of the formation of new bone-eating cells. Or could it be the fructan fiber prebiotics in onions? Experimentally infused into the rectum, the short-chain fatty acids created by our fiber-eating gut floor have been shown to stimulate calcium absorption, so much so that adolescents randomized to the type of fiber found in onions about an onion in a day's worth for a year significantly increase their bone mineral density over the placebo group. In the rodent bone preservation study, a number of spices beat out prunes and onions, with a top dog being another allium, garlic. And in the prospective human study, cruciferous vegetables like broccoli came in at a close second to the allium family. Although there are some petri dish data supporting the potential bone benefits of the sulforaphane and cruciferous veggies inhibiting the formation of bone-eating cells and appears to protect bone health and mice, the reason I'm singling out onions is that it's one of only two vegetables that have actually been put to the test in clinical trials. But how are you going to come up with a placebo onion for the control group? That's why a group of innovative Chinese researchers gave people onion juice versus a fake onion juice. I don't know which sounds worse, but anything for science. And those randomized to the real onion group experienced an improvement in a marker of bone loss of a placebo, but the study didn't last long enough to see if this translated into tangible bone benefits. But a clinical trial on the other vegetable put to the test did. The tomato story starts out like the onion story. There's epidemiological support. In the Framingham osteoporosis study, higher intakes of lycopene, the red pigment in tomatoes, were associated with protection against bone loss in older men and women over a period of four years, as well as protection against hip fractures over 17 years. Perhaps this helps explain why studies show that an increased adherence to a more Mediterranean style diet is associated with about 20% fewer hip fractures. Then there's laboratory evidence. Lycopene inhibits bone loss in a pediatrician, preserves bone mass in rats. However, so does green tomato extract, which is richer in compounds such as tomatine, rather than lycopene, so maybe there are multiple protective factors in tomatoes. Anyway, let's feed people some tomato products and see what happens. Postman apostle women randomized the lycopene in the form of a cup and a third of regular tomato juice a day, experienced a significant reduction in a marker of bone loss by month 2, and the opposite was found after just a month of restricting lycopene consumption, so no tomatoes, watermelon, or other red fruits like pink grapefruit. This suggests that just regular dietary intakes are protective, but does this translate into retaining significantly more bone over time? Postman apostle women, given about two-thirds of a cup of tomato sauce a day for three months, suffered significantly less bone loss than those in an age-mashed group who didn't, though it does not appear that the study subjects were assigned randomly which could bias the results. So, should we go out of our way to include these specific fruits and vegetables in our diet? Normally we're just left with a can't hurt shrug, but a group of New Zealand researchers put together a randomized controlled trial to find out. They developed the Scarborough Fair Diet, named for the presence of presumptive bone-protecting herbs, parsley, sage, rosemary, and thyme from the song popularized by Simon and Garfunkel. The diet included prunes, onions, and tomatoes. They compared that to a diet similarly packed with nine or more servings of fruits and vegetables, but ones that were not suspected as having particularly skeleton-saving properties. Markers of bone turnover were measured after three months, and the specially concocted diet of bone-preserving produce did no significantly better than the diet packed with non-bone-preserving produce, or a diet with just six servings of fruits and veggies a day, suggesting that the focus should just be on stuffing your face with fruits and vegetables of any stripe. Okay, so, rather than picking or choosing specific bone-boosting produce at the bottom line, based predominantly on that acid-base study, is to just probably eat more fruits and vegetables in general. Next, we will turn to exercise. What's the best type and frequency of physical activity for bone health? But we're right about at the hour, so why don't we take a five-minute break, and then we'll come back, and we will talk about physical activity to protect our skeleton. Okay, what is the best type and frequency of physical activity for bone health? Let's find out right now. When it comes to bone health, it's use it or lose it. Physical activity is considered a widely accessible low-cost and highly modifiable contributor to bone health. Exercise transmits forces through the scales and generating signals that are detected by our bone-building cells. This is why the National Osteoporosis Foundation, International Osteoporosis Foundation, and other agencies recommend weight-bearing exercise for the prevention of osteoporosis. These include high-impact exercise, such as jumping, aerobics, and running, as well as lower-impact exercises, like walking and weight training, to create those mechanical signals that spark bone growth. But sufficient intensity and frequency are critical. The large variation in bone benefit across different studies, from negligible changes to substantial improvements in bone marrow density, have been attributed to the adequacy of the exercise regime. To improve measures of bone strength at the spine and hip, the most effective exercise training protocol appears to be a combination of progressive resistance and impact training at moderate to high intensity. Low intensity exercise does not appear to be sufficient. For example, while regular walking is often prescribed to prevent osteoporosis, it appears to offer limited benefit for bone loss prevention. On its own, walking has no significant effect on bone marrow density of the spine, wrist, or overall skeleton, but it has been shown to significantly improve hip bone density in studies that have lasted more than six months. More effective would be brisk walking, walking with a weighted vest, or combining walking with more vigorous exercises such as jogging, stepping, or stair climbing. Non-impact activities such as cycling or swimming have been shown to have little or no effect. An elegant study to determine the optimum frequency of high-impact exercises for bone health involved hopping on one randomly chosen foot with a person's other leg acting as the control. Women were randomized to hop 50 times on that one same leg, either seven days a week, four days a week, two days a week, or not at all for six months. And the brief daily hopping increased hip bone density but less frequent hopping was not effective. The only group that built significantly more bone in their hip on the jumping versus non-jumping side within those six months was the seven-day-a-week group. If you jump 50 times with about a 10-pound weighted vest on, however, you may be able to preserve your hip bone density with just three sessions a week instead of every day. Note weight-bearing impact exercises may be contraindicated, meaning not advisable, in those with severe osteoporosis or recent history of fracture. So make sure you check with your medical professional before you get going. I love that hopping study so much. Brilliant, brilliant. All right, the greatest benefit of exercise, this is interesting, this was new for me, and this is what really I center my chapter on protecting your skeleton in my How Not to Age book, which will be out in December. I'll proceed as I receive, go to charity. It was the fact that I'm always thinking of exercise as increasing bone mineral density. That's how we're going to prevent fractures. But the greatest benefit of exercise may have nothing to do with bone mineral density. As I explained in the video, I will close out with, before we start taking questions. And the video is entitled the single most important thing to do to prevent osteoporosis bone fractures. Are you ready? Let's do it. Bone mineral density screening may be a billion-dollar industry, but only 15% of low trauma fractures are due to osteoporosis in older women, meaning from a fall no more than from standing height. Only 15% of fractures are due to having low bone density. Between the ages of 1680, hip fracture risk increases 13-fold in men and women, whereas the age-related decline in bone mineral density accounted for only a two-fold increased risk. So the contribution of declining bone density to the exponential increase in hip fracture risk with age is relatively small. The vast majority of our age-related rise in hip fracture risk appears to have nothing to do with the measured density of our bones. So what's the main contributor? Fall risk. Without a fall, even fragile hips don't fracture. Falls are the primary cause of fractures, including vertebral fractures. The disparity between men and women in hip fracture risk is primarily not because men have stronger bones, but because women fall more often. Doctors just asking the simple question, do you have impaired balance? Can predict about 40% of all hip fractures, more than a bone scan diagnosis of osteoporosis. Even a weak osteoporotic bone is strong enough to survive normal life activities without the excessive loading that comes from a fall impact or, in the case of the spine, bending with your back to lift something rather than your knees. The primacy of falls in fracture risk explains a number of apparent osteoporosis paradoxes. For example, despite the fact that about 75% of your bone mass may be determined by your genes, the heritability of bone fractures appears negligible at older ages, because the propensity to fall is much less inherited. It also explains the poor predictive value of bone density screening for fractures. Adding bone mineral density measures to a hip fracture risk score based just on age, sex, height, weight, the use of a walking aid and cigarette smoking did little to improve its predictive power. A provocative editorial published in the Journal of Internal Medicine entitled Osteoporosis The Emperor Has No Clothes suggested that it would be safer and more effective to focus on fall prevention rather than pharmaceutical intervention. Even though only about 5% of falls result in a fracture, falls are very common among the aged, due in part to age-related muscle weakness and loss of balance, more than a third of those aged 65 and older fall each year. And after a hip fracture, fewer than 50% regain their prefracture function in terms of walking ability and independence. What can we do to prevent injurious falls? Based on dozens of randomized controlled trials, the single intervention most strongly associated with a reduction in fall rates, exercise. So exercise doesn't just boost bone density. More importantly, it also reduces the number of falls over time by 23% and the number of fallers by 15%. So if you followed 1,000 people around age 75 for a year and 480 fell a total of 850 times without exercise, adding exercise would be expected to result in 72 fewer fallers and 195 fewer falls. Tai Chi appears to reduce falls by 19%. Balance and functional exercises like sit-to-stand may reduce falls by 24% and multiple exercises, typically balance and functional exercise plus strength training may reduce falls by 34%. The reduced falls rate then translates into fewer fractures. A recent meta-analysis found the exercise interventions, mostly using a combination of resistance exercise to improve lower limb muscle strength and balance training, cut fracture rates nearly in half. One year-long trial that combined strength training with step-and-jumping aerobics and focused on balance and agility resulted in 74% fewer fractures over the five-year period after the study ended. Furthermore, more than 70% of the women in the Combo Exercise Group went those five years without a single injurious fall compared to less than half of those in the control group. Trials on hip protectors, which cushionous sideways fall on the hip with plastic shields or foam pads sewn into special underwear, are often plagued with poor compliance. Studies have not found them to be useful for reducing hip fracture rates among those living at home, but trials in nursing homes or residential care facilities do show a small reduction in risk, translating into about 11 fewer people out of 1,000 suffering hip fractures due to wearing hip protection. There are also common sense measures one can employ. Quality improvement trials involving interventions like patient education have shown a 10% reduction in fall rates. For example, keep things within reach so you don't need to use step stools. Use non-slip mats in the bathroom shower. Add grab bars in the bathroom. Keep floors clutter-free. Remove small throw rugs or use double-sided tape to keep them from slipping and make sure all staircases have handrails and adequate lighting. You could also avoid taking walks during inclement weather, and for those who walk leashed dogs, consider choosing smaller breeds or ensuring proper training to prevent them from lunging. Otherwise, the main ways to prevent fractures may not have changed much over the decades, since the classic paper entitled Strategies for Prevention of Osser Process and Hip Fracture. The main ways to prevent these fractures are to stop smoking, be active, and eat well. Okay, so we have a bone mineral density-focused mindset in medicine for osteoporosis because there are billions of dollars invested in scanning and drugging people to track and improve their bone density, but only a small percentage of hip fracture risk has anything to do with bone mineral density. Peer is the best estimate, 15%, right? So it's just like most of the risks for lifestyle diseases like atherosclerotic heart disease or high blood pressure has to do with diet and lifestyle. The money is in the drugs and procedures, right? So that's where our focus has been. Heart disease is all about putting people on statins and stents, right? But if we think of a wait a second, what about treating the cause, right? And so if we really just cared about people not breaking bones, we would be focusing on falls. And we have this miracle intervention called exercise. Resistance exercise to improve lower limb muscle strength training combined with balance training, cutting fracture risk in a half, beating out drugs. So it's not just, you know, it's safer and cheaper, but works better and of course only has positive side effects. So I like ending on that happy note. Of course we're not ending, we're just getting started for the Q&A. So what we're going to do, we're going to give nutritionfacts.org staff five minutes to compile some of the most commonly asked questions. And then I'll be right back to attempt to answer those questions. I know there was a huge amount of information thrown at you. Tons of videos that whizzed by. And so I don't want you to think, oh, wait a second, maybe you addressed that. He kind of addressed that. Maybe I shouldn't ask a question. No, ask the question. That's exactly the kind of question I want because I want to clarify stuff, emphasize stuff. So don't be afraid that did he answer that already? Maybe he came in halfway through whatever. Just ask your question. We'll compile those questions. We are going to have lots of time for questions. We set it up that way. And so hopefully I'll be able to help out with them. All right, five minutes and I will be back. All right. All right, we are back. Okay, close down that. Let me pull up my list of questions here. Okay, feel free to continue to churn through. We have lots of time for questions. So if you have questions and questions about answers to my questions, continue to add them and we'll continue to update this document. Okay, where'd they go? Okay, hold on. Okay, here we go. Nice long list here. Okay. I've been told that calcium and plant milks sold in stores is the same as that found in Toms. Is that true? Should we be avoiding plant-based milks? What about calcium? It's banana to food. Like calcium fortified orange juice. Does that raise heart attack risk? If you remember back from the calcium video, the reason that supplement calcium seems to increase cardiovascular disease risk, but food level calcium does not, is because of that exaggerated spike, right? When you take 1,000 milligrams of, you know, you get this huge spike in calcium in your blood and that makes your blood more clotty. Whereas foods have a little bit of calcium kind of throughout the day. And so you don't get that big, you don't get all your calcium all at once. And so that would be the same with, you know, adding some, I forget what the number of milligrams but in like a cup of soy milk or something. But it's way below what you would get in a supplement. And so same thing with calcium fortified orange juice. These are typically in kind of milk, you know, standardized kind of milk doses. And so you would potentially get the benefits of the calcium without the downsides of the milk sugar, lactose or whatever it is in milk that seems to be increasing fracture risk. Now, is that my preferred source? No. What's preferred source? Dark green leafy vegetables. Low oxalate green leafy vegetables, which means all greens with the exception of beet greens, swiss chard and spinach, which are fantastic greens, but it just stings you with their calcium. So, but all other greens like kale and collards, bok choy, et cetera, that's the best way. Why? Because it's the most nutrient-done food on the planet. And so for all sorts of reasons, vegetable nitrates and all sorts of wonderful things you want for other parts of your health, but specifically for bone, if you remember that acid-base graph, the single most alkaline producing food is the vegetables, those dark green leafy vegetables. And so even greens, you would get that benefit more than kind of, you know, fortified food supplement. So one of the reasons why dark green leafy vegetables is one of my, on my list of my daily dozen checklist of the healthiest of healthy foods I encourage people to eat every day. And it's available on a free app, iPhone, Android called Dr. Gregor's Daily Dozen, and you can just kind of track your progress, et cetera. Okay, next question is about algecal, which is a type of calcium supplement from an algae. What about that versus some mineral-based supplements? Calcium is calcium, it's an element, but we would not expect any difference at the same dose of the source of that calcium. So it's not whether it's, you know, calcium carbonate or one of these other kinds of calcins or the source of the calcium. It's the fact that you get so much calcium in your blood so quickly. And so I would encourage people to stay away from calcium supplements of all stripes, regardless of what their marketing promotional materials may tell you. Next question, how important is adequate hydration and sleep for osteoblasts or bone building cells? You know, I did not run across anything about hydration or sleep with bone marrow density or fracture risk. I would assume, I mean, so remember, since most of fracture risk has to do with falls, right, even a fragile bone doesn't break unless you traumatize it. I, you know, I assume if you're sleep deprived, I mean, really, you'd be more wobbly on your feet and that could increase falls risk, but I don't know if it's ever been studied. So it's not something to run across. Okay, so that doesn't mean that there aren't important relationships, but not important enough to pop up in my searches of lifestyle interventions for improving bone health. Can I speak to the efficacy of full body vibration therapy for bone health? Ah, that's funny. Yeah, there's those funny, you know, things that you stand on vibrate. Let us, I'm gonna do a quick, let us do a, I'm gonna do a quick PubMed search is National Library of Medicine, largest medical database in the world, looking for vibration in the title and fractures and a meta analysis and boom, there it is. Systematic review and meta analysis. Let's see what it says, at least in the abstract. Whole body vibration, ah, interesting. Okay, so it has no effect on bone mineral density or micro architecture, meaning the architecture of your bones, but it does appear to reduce falls risk. And of course, that is an important part. So you could imagine actually reducing fracture risk, if indeed it's true that reduced falls rate. That's really exciting. But there's only one study that actually looked at hard fracture endpoints and did not find a significant, the reduction in, the reduction in fracture risk did not reach statistical significance. And so we cannot tell for sure. If it's used so many things it reduces falls, presumably it will be helpful. Our next question, do you think working out on a rebounder does any good for bones? I'm assuming, I'm assuming a rebounder is like one of those little mini trampoline thingies. All right, let's look it up. Okay, trampoline. Oh, that's funny. What comes up, of course, when you type in trampoline and fractures, is all the horrible kids breaking their bones, jumping on trampolines. Okay, that's not what we want. Let's look at bone mineral density. Okay, there we go. Affectiveness of mini trampoline training on balance and mobility, gauge strength, the bone mineral density, et cetera, older women osteopenia, pelvic intervention. Oh, interesting. Okay, oh, same thing. No effect on bone mineral density. So I guess jumping on a trampoline doesn't have the same impact. You would get like jogging or vigorously walking, but improved balance. That would make sense, right? Improved balance and functional mobility. Okay, so, hey, again, anything improving balance would be expected to reduce fracture risk even if we don't have that endpoint data. And that's exciting. All right, see, I'm learning stuff just along with you. Okay, I've made a decision not to take drugs for osteoporosis. Should I bother with continued dexa scans over two years? Are they inaccurate for small bone thinned women? How accurate are dexa scans? Well, they're accurate for what they're testing for, which is bone mineral density, but they're not accurate. I mean, but in terms of their in terms of their predictive power, their very small predictive power, as I talked about in that last video, in terms of what we really care about, which is whether your bones are going to fracture or not. So, but I mean, they should be just as accurate for, I mean, small bone thinned women tend to have worse bone mineral density just because they don't have the weight-bearing exercise of carrying around lots of fat, right? I mean, you imagine someone who's obese, they can have strong bones because they have like a 100-pound backpack all over the place. It's actually a front pack, but just walking across the room is some exercise. Whereas your thinned, like women, they may be at higher risk just because they're not putting in much weight on their bones. So it's even more important for them to do weight-bearing exercise. Again, that's for the small amount of fracture risk. That's for bone mineral density. The most important thing about exercise is lower limb training, balanced training to prevent falls. In terms of whether you should continue to get monitored, the use of diagnostic testing for lifestyle diseases really comes down to motivation. So it's like the recommendation from the USPSDF is to not get calcium heart scans because you're exposed to radiation. So they basically come out. We're not sure the pros are where the cons. But if getting a calcium scan, if you're the kind of personality where you are not going to eat healthy, but if I gave you a heart scan showing you had all this calcified plaque in your arteries and that would actually change your life and you'd actually start eating healthier, clean out your cupboards, well, then that test could very well save your life. But if you're the kind of personality who's like, I don't care if the test is bad or good, I'm going to keep eating my crappy diet, well, then why are you getting the test? We only get tests as physicians in general. If we think it's actually going to affect our management, it's actually going to affect anything. And so if you have been lounging on the couch and you know, you should exercise, but you're like, whatever, there's a great new show on Netflix, but you got a dex scan showing that compared to two years ago, you're bones are even worse now. Even farther off the bell curve, if that would motivate you to be like, okay, that's it. I'm going to get into a habit every single day. Remember that hopping study? It was really that constant, like seven days a week, or maybe only three days if they did with a weight of vest, but it's like, you know, lots of high frequency exercise. If that's going to motivate you, then yes, I would say get that scan. But if it didn't motivate you in the past and you think it's not going to motivate you in the future, if it's not actually going to affect anything, then you know, you can ask yourself why you're getting it. Again, something to talk to your doctor about, but that's kind of how I go into it. Okay, what's the best test measure if you're actively using bone? Is there any type of bone density screen that doesn't subject the person to radiation? Yes, so there's an ultrasound, but it has not been... Let me see what the USPSTF has to say about... Hold on. Let me see what they say. Okay, here we go. QUS, use ultrasound to evaluate peripheral bone sites. The advantage, no exposure to radiation, we knew that. Oh, and it may increase access because it's like a portable device, and so maybe we'd be able to get out there more often. But oh, cannot be routinely used to initiate treatment without DEXA just because the treatment studies... We don't have treatment studies that have actually followed the ultrasound, probably because we have a big industry that invested in the DEXA scanning and studies about DEXA scanning. And so, okay, all right. So, but yeah, most treatment guidelines recommend using the DEXA scanning. Okay, is what about hormone replacement therapy or menopausal hormone therapy for improving bone density? Well, you can imagine, am I preserving your hormone chapter in how not to age? I talk a lot about the pros and cons of hormone therapy for menopause. And that's one of two things that estrogen, systemic estrogen is effective at. So, number one, reducing hot flash frequency and severity by about 80% compared to placebo. And so that's a consideration. If you have intolerable so-called vasomotor symptoms like hot flashes that cannot be managed through other means, and I have lots of videos and also some natural means to do it, then that's... At one point, one might consider systemic estrogen use. And hormone therapy can also reduce the risk of osteoporotic fracture. So for women with an intact uterus, this is how the numbers play out. I just actually pulled up some reading, basically reading from the chapter in the new book. So here's a little sneak peek of how not to age. So, if women with an intact uterus, if 200 women took hormones for 10 years, 200 women 10 years, we would expect nine fewer fractures. 200 women for 10 years, nine fewer fractures, then they would have if they weren't on the hormones. Okay, that's the upside. Symptom release like the hot flashes and fewer fractures. In that same scenario, let's weigh those benefits. Those benefits would have to be weighed against this best out of best available evidence. Four additional heart attacks, fatal or not. Two extra strokes. Four more cases of dementia. Two more cases of breast cancer. One more case of fatal lung cancer. Four extra cases of gallbladder disease and 10 extra blood clots. Though not a single partridge or pear tree. That's actually written down there. All right, there's a lot of bad humor in the book, just because I try to keep things light because it's a heavy topic. Okay, and so basically, I talk about how unless the mental possible symptoms are absolutely debilitating and nothing else helps, it's hard to imagine anyone accepting that kind of risk benefit balance based on those facts. So nine fewer fractures, but four heart attacks, two strokes, four dementia, two more breast cancer, fatal lung cancer, gallbladder disease, extra blood clots. Okay, now the safety profile is better for women who lack a uterus. Why? Because then we can use estrogen only preparations. The reason that we have to take pregesterone along the estrogen is to protect against endometrial cancer, uterine cancer, which is caused by kind of unopposed estrogen. Ah, but what if you are quote unquote lucky enough to have a hysterectomy? Okay, so what if you have no uterus? Then you can get away, you can only use estrogen, estrogen only preparations. Okay, and so then if you just give estrogen, you get the same symptomatic relief in terms of the hot flashes. So it wasn't really a pregesterone. It was the estrogen that was helping get 11 fewer fractures. So a few more fractures prevented in 200 women over a decade and no extra heart attacks or dementia and two fewer cases of breast cancer. That's exciting against six extra cases of gallbladder disease, only one extra blood clot and so same two extra strokes. All right, in either case, the U.S. Finderger's administration recommends estrogen only prescribed lowest dose, shortest duration. It's actually not clear that lower doses are actually safer or not. Okay, so that's the bottom line on that. You can run those numbers for yourself and make up your own mind because that's what it's all about. Okay, what do I think of the Combs study, COMB study, which is evidently D3K2 strontium magnesium DHA and calcium. If this works, does that alter my view of taking vitamin K, strontium-valuable supplement for osteoporosis. Combs study, never heard of the Combs study. Let's find out what the Combs study is. Combs study, oh, standing for a combination of micronutrients for bone. Combs study, interesting, published in some Environmental Public Health Journal a dozen years ago. I've never heard of it. Okay, 12 months consecutive supplementation. Oh, come on. Oh, so this is not a controlled study. Ah, okay, so there was no control in the study. So this is just kind of before and after. And they say it improved bone marrow density, but that doesn't mean that it had anything to do with micronutrient regimen because there was no control to show, I mean, maybe everyone's bone marrow density got better. So what I would do is actually do a kind of web of science search to see how many studies have cited this study. So maybe there's an update, maybe this inspire. I mean, not saying, I mean, there's a value to this kind of study, not in actually telling you what to do, but in spurring research that could actually tell you what to do. Actually spurring research that could prove cause and effect. And so maybe this study actually made, maybe they actually did a double under civil controlled study. I am skeptical because I presume I would have run across it, but so you can do a Google Scholar search. You go to Google Scholar, it's free. You type in that study and you see all the studies that cited and run through there to see if there's an update. If there was, I'd be happy to do a video about it. I'm either way. In terms of Scrantium, I'm just pulling up a Cochrane review, which is kind of like, or at least used to be kind of a gold standard for evidence-based medicine. What about taking Scrantium? Oh, it looks like I have, it's been updated. It looks like the last one was in, oh, here we go. 2006, let's see what we got. Four trials, increase in diarrhea, okay. But it does say there was an increase in bone mineral density with Scrantium, sublimitation. That's interesting. Okay, so of course what we want to know is the important thing is does this actually reduce fracture risk? For that, it does not look like it's said here, but again, this is 2006. And I'm surprised if that's the latest Cochrane review. Presumably nothing much has happened since then, but again, it's something that I could certainly look into. Next time I update my osteoporosis video, so thank you so much for that question. Okay, next question. I do Tai Chi, yoga, play pickleball, pickleball. I always wanted to try pickleball. One of these days I'll speak somewhere with a pickleball court and get to play pickleball. I go to the gym, I'll go to the gym twice a week. Great, have osteoporosis. What else can I do? Oh, so they want to start reclass infusion. Is there a better approach? Okay, well hopefully you saw kind of the pros and cons of that class of drugs and then you can make up your own mind. And so anything else you can do? So I think the Tai Chi. So remember that last study where talked about the significant reduction in fractures and those randomized to the kind of lower limb impact actually pull up that study. But actually talked about Tai Chi. I think Tai Chi had 30% lower fractures and then the lower limb strength training combined with balance had 50%. So that was the best, but I think Tai Chi was like 30% reduced. So that's fantastic. But I would move to, I don't know what's involved with playing pickleball, but I would move to that resistance training plus balance seems to be the best combination. So I would incorporate that. Maybe you can do that in kind of the gym twice a week thing or even more often. Okay, what do I think of terosa? I don't know if that's a drug or a supplement. I've never heard of it. I am sorry. What factors contribute to, oh, young men getting this disease. And she would be screening more young men interestingly. The USPSCF, which is again is kind of this authoritative body on preventive medicine, which is independent, actually independent from the government, independent from everybody, but very well respected, very resistant to kind of political maneuverings or relatively resistant to political maneuverings. And so that's where people go to. And they've actually concluded there's not enough evidence to support even bone scanning for older men. So they recommend women at age 65 get bone scanned for osteoporosis, but there's no recommendation for men on to do the same because we just don't have the data isn't in. So not even young men. They don't even think older men. But of course that may change, but as of now, there's no recommendation for screening men period from the USPSCF. Okay, any research on osteostrong, anytime there's a capital letter, you know, I'm thinking it's some branded thing I've never heard about, but it goes on to explain. Osteostrong is the type of bone strength training program that uses low impact, high intensity exercise to increase bone density and reduce risk of fractures. Okay, well, if it's low impact, then it's probably not going to help your bone strength. The whole point is your bone has this easy electric quality, which is amazing because it creates electrical signals when the bone is compressed. You can actually do this on cadaver bones. You squeeze the bone and attach electrodes, you actually get an electric charge coming out. I mean, that's actually the bone remodeling signal. Actually use electricity, isn't that wild? So every time when we jogging or anything, every time we impact that foot, we get this jolt of the little electrical signals telling our bones, oh my God, this person's off the couch quick. We need a stronger skeleton. Again, that's only 15% of hip fracture risk is the density of your bones, the strength of your bones. Most of it is whether you're following or not. So of course, that's the important thing. And whether or not osteostrong helps reduce falls, that would be my key question for them. That's what we want to know. Because that's the predominant use of exercise to protect our bones. What does research say about sauna use for bones? Sauna use? All right, let's look it up. Didn't run across it, but that doesn't mean, that doesn't mean because I certainly wasn't looking specifically for it. Okay, we have, there's only one study published that in the medical literature, as far as I can find in history, that looked at bone mineral density and sauna. This was a sauna bath. This was young, healthy men. And they found out that bone mineral density increased. Wait a second, of the left leg? Increase the left leg. Okay, oh, okay. I see right leg and left leg. Yeah, okay. So there was an increase in, is there a control group? Yeah, control group, sauna group. And, ah, okay. Wow, I would not have thought of that. But there's actually, so the one study, the best available balance of evidence, there's one study of 23 people, healthy young men, actually found an increase in bone mineral density after just, after how many, how long did I say? It says 12 sessions. It says 12 sessions of sauna bath at high temperatures, 100 degrees C. Woo, okay. Wait a second, 100 degrees C. Is that boiling? That's quite a sauna bath. Anyway, okay. I don't know if I would, I would do saunas just for that. But if you enjoy saunas, maybe it helps, maybe it helps your bones. That's interesting. I would not have thought that. Okay. Oh, the same questionnaire said on a related question, what about post-electromagnetic field therapy? I'll do that. Let's see. Post-electromagnetic field. Okay, let's see if there's a meta-analysis. Oh, let's do it. There's a 2022 meta-analysis of randomized controlled trials. And they've found, Oh, okay. So no benefit for bone marrow density of the spine. But may increase the bone marrow density of the femur. Huh, that's interesting. I can't tell just from the, just from the abstract, funded the study or how many studies there were. But that's something, something to look into. That's interesting. All right. Any advice for breast cancer survivor who must take an aromatase inhibitor to prevent recurrence? Which may affect bone density? Well, anytime you do anything that put your bones at risk, the way of your smoker or something, obviously the best thing to do is stop smoking. But if there's anything that puts you at higher risk, that's not reason to just kind of throw your hands up in the air. Oh, well, no, it's time to double down. It's like if you have a high family history of a lifestyle disease, a lot of heart disease in the family, a lot of breast cancer. Oh my God, well, then you, it's not time to give up. It's like you got to, you, some people can get away with eating some crap, but you really got to eat healthy. Right? You really got to exercise. You really got to not smoke because you have this genetic risk. Or in this case, some pharmacological risk. And so it's like people who take, there's these anti-psychotics increase that make people obese. Oh my God, well, they really got to watch their diet. You know, it's no excuse. They just have to work even harder than everybody else around them. And so that's what I recommend for you. I'm using some of the advice that I talked about here in this webinar. Okay. Oh, is there a relationship among poor, finger and toenail health thinning hair and osteoporosis? By thinning hair and cracking nails, are they concerned about osteoporosis? No, completely different thing. Actually, hair and nails may be similar in terms of they're made of kind of a similar material. This kind of correctness material. But bones are made of something else. You call them with this, in this mineral matrix, completely different. But I do have entire chapters. You will not be surprised. I'm taking on what you can do about fingernail health, toenail health, talking about toe fungus, talking about brittle nails, and a whole hair loss chapter, of course. And so I talk about, you know, the failure of biotin supplements for hair loss, utter failure, and can actually be bad because you muck up your laboratory tests, including life-threatening laboratory tests. But the evidence is more nuanced with biotin for nail health. And I talk about, you know, what the available data is, and if you want to try it, what kind of dose would be safe. But yeah, that one would not expect that to have anything to do with bone health. Okay, can you reverse osteopenia? Yes. So osteopenia is kind of on the spectrum towards more severe forms of osteoporosis. And so can we basically, can we improve the density, the strength, the micro-architecture of your bones? Absolutely. How are we going to do that? We're going to do that with healthy diet and lifestyle, particularly. So, you know, the type and frequency of exercise I talked about, there was obviously lots of videos on osteoporosis. I have dozens. I was only able to show a few of them, but you can go. So I have, there's a video talking about people randomized in post-mortemopausal women to soy milk or regular milk. And so in the regular milk group, there had a worsening of their bone, mental density over time. But in the soy milk group, we think because of the phytoestrogens in soy, they actually built more bone over time. You know, you think as you get older, you lose bone, but actually was able to reverse the bone loss and was significantly different than the milk group. So, and soy foods are great for, really should be the first line of therapy, and it's recommended as such for handling these vasomotor symptoms of menopause, you know, the hot flashes, night sweats, etc. So lots of other, soygoodnutritionfacts.org type in osteoporosis, lots of other videos. And so lots of other like specific foods and things like, I'm going to mention the prune thing really quick. I got lots of, I think I got like three videos on prunes and bones. All right. How do I speak slash reason with my doctors who push oral calcium supplements? How do I speak slash reason with my doctors who push medical treatments for osteoporosis without talking about the negative sides of it? Well, I mean, if you feel that you are being kind of, that you are not being fully informed, if you, I mean, the role of the doctor is to, in that video talking about, you got to scare your patients into graphic descriptions of, right? No, that's not the role in my opinion. That's not the role of medicine. The role of doctors is to give you the numbers. If you take the drugs, this is the benefits. This is the risks. And guess what? It's your body, your choice. And the doctor's salary should not depend on whether or not they've prescribed it or not, right? That's one of the downsides of these kind of kickback culture that has historically been, where you get some fancy new drug and every prescription you write, you get like a, you know, a trip to some fancy island if you write enough or miss is ridiculous. So, but right. I mean, the doctor should just be about informing you based on their knowledge and experience. And so if you feel that you are being kind of pushed in one direction and not giving both sides, then maybe an in new doctor who will take that kind of shared decision-making approach with you. And just because the doctor themselves, particularly believes that this is the right course for you, doesn't necessarily mean it is the right course for you, but they should describe why they think it is and kind of make that convincing argument or not. And it's very possible that, look, the doctor's just ignorant. I mean, do they just not know about all this? The calcium risk data that's relatively new. Certainly wasn't around when I went to medical school. So maybe just haven't heard of it. Look, I have the luxury of just combing through thousands of articles all day long, every day for years on end. I don't have a clinical practice anymore. So, you know, they're busy. They're in the clinic. They don't have time to do this. So I read those studies that you don't have to. And so, you know, they may not be familiar, like in that study that looked at resident physicians. They just weren't aware of the atypical femur fractures, the austenarocrosis and the jaw. I mean, they were just... So if you're not aware of that and you just get drug industry propaganda, put all your drugs, put all your patients on these drugs to save their bones, well, then you can see how you pass them along to your patients and so you can educate them, you share with them information, which may be helpful for their other patients. Or if you don't want to make that your job, you can find a doctor that treats you and your autonomy with more respects. Okay, please address the effect of carbonated beverages and sodas on bone health. Oh, you know, that was a... I wonder if I still have that somewhere. I was debating whether or not to add that video. So it's like, I could have added 10 more videos, but I would have less Q&A time. It was hard to kind of make that decision, but I have a whole video on beverages, kind of besides milk. I covered the milk thing. And so soda is associated with... in observational studies with higher fracture risk and green tea consumption associated with significant and lower. I think there's actually interventional trials with green tea as well. So green tea good and soda bad. Okay. Oh, that's the next question. Is green tea recommended for bone building? Oh, I would love to... Let me see, let me pull that up really quick just because... All right, let me... So that would be in my Preserver Your Bones. I'm trying to think of the keyword to... Here we go. Should be right after the milk thing, because then I'm like, what about other beverages? There it is. Dun-dun-dun. Okay. What about other beverages? Literally, that's the sentence. Okay. I'm going to read you from how not to age. Amen analysis and effects of alcohol in osteoporosis found that compared to abstainers, people who sipped one or two glasses, one or two drinks a day had 34% increased risk of developing osteoporosis. Having more than two a day, two drinks bumped that elevated risk to 63%, which appears to translate into increased hip fracture risk. This may be partially from alcohol's negative effect on bone health and also from all risk due to impaired coordination. That makes total sense. Okay. Ah, this section is called T and T totaling. Ha-ha. Now I know why. Okay. Okay. One of the ways sugary soda appears to cause negative effects on bone is the same... Oh, is the same way sodium does. Oh, I didn't even talk about sodium reduction. That's important. By increasing calcium loss through urine, actually does not appear to be the caffeine in soda, since although drinking three or more cups of coffee a day is associated with doubling hip fracture risk, habitual T consumption is associated with significantly lower risk. So, coffee bath for the bone, soda bath for the bones, T good for the bones, at least in these observational studies. Hope was raised that the T-link was causing an effect when the randomized trial found improvement of bone turnover markers in women and actually higher bone mass. Oh, and T fed rats. Well, okay. But in the Minnesota green T trial, which is the largest and longest clinical trial on the effects of green T extracts on post-menopausal women, no significant benefit on bone mental density was found. Ah, bummer. Okay. So, we do not have a cause and effect evidence that T is good for the bones, just the fact that T drinkers tend to have fewer fractures. Oh, that's a bummer. Okay. All right. Well, you heard it there first. You think I would know this because I wrote that, but it's a long book. That's why I have to go to it. Okay. Oh my God. Okay. Let's, I think we have to wrap up. Thanks so much everyone for joining me. Stay safe. Be kind. Eat your vegetables and protect those bones.