Dr. Gabrielle Lyon 00:00

Part short.

Doug Lucas 00:00

Sure,

Dr. Gabrielle Lyon 00:02

I do want to highlight, though, that you are a Stanford surgeon, and I like that. And we’re ready. I am also really curious about the biomarkers, the bone markers, yeah, is alkaline phosphatidys really good. There’s another one that we were just going to start using, no, there’s one more

Doug Lucas 00:31

favorite. Okay, yeah, p1 and P and CTX, there’s so much literature using those. Okay, I think there, if you’re looking at bone turnover, that’s the

Dr. Gabrielle Lyon 00:39

but also is tummy over already, okay. we are ready. And if I pronounce anything wrong, stop me, Lucas. That’s correct. Dr. Doug Lucas, formerly a Stanford surgeon, you’re an orthopedic surgeon. You went to Stanford, and you gave that up.

Doug Lucas 01:06

I did

Dr. Gabrielle Lyon 01:07

unusual,

Doug Lucas 01:08

very..

Dr. Gabrielle Lyon 01:09

why I

Doug Lucas 01:11

saw the circle and the trap that I had put myself in, where I was doing great surgery. I love the operating room, but I felt like I was really cleaning up metabolic mess over and over and over again. Foot and ankle was my subspecialty. There’s probably not a subspecialty that is more perfect to see this issue than looking at the foot, because of the combination of all of the downside of diabetes, metabolic disease, and how that plays out.

Dr. Gabrielle Lyon 01:39

Was it different? Was it different than you thought as an orthopedic surgeon, and also you’re a very fit guy. If you guys are listening to this, you should watch him. I always have a ton of respect for physicians who practice what they preach. When you went into orthopedics, were you thinking it was going to be sports?

Doug Lucas 01:56

I knew I was going into foot and ankle, but it is very different once you’re in practice than it is when you’re in training. In training, you see new patients all the time. You only do the surgery, you have short follow-up. It’s very exciting, but in practice, you follow patients for a much longer time, and you see how the surgery that looks so good doesn’t end up having the effect that you hope it would over the long term. And it’s, it can be, you know, quite a letdown, both for you and the patient.

Dr. Gabrielle Lyon 02:22

Yeah, and to be fair, Stanford is one of the most competitive orthopedic surgical residencies. To even get there is a long and arduous and full of sacrifice road. To then get there, it’s very.. I would say very few times in our lives where we go, I have really worked so hard for this, and I’ve dedicated years, I mean, that’s over 10 years to say no thanks. Was there a moment?

Doug Lucas 02:58

There was a moment, and so just to be clear, I did a fellowship at Stanford,

Dr. Gabrielle Lyon 03:02

even better,

Doug Lucas 03:03

and so my residency was was at Ohio University in Columbus, but yeah, going from there into practice, and then starting to understand what was happening with my patients, the moment that the switch flipped for me was an emergency case, middle of the night, 3am diabetic patient, foot ulcer, gets infected. They call me in to do an amputation, and I remember very clearly skeleton crew, middle of the night scenario, nobody was prepared to do what we were doing. I remember the patient almost falling off the table, not enough people to keep him on the table. I was, you know, underneath his leg, this, you know, unfortunately very overweight individual trying to put on a tourniquet, so we could literally save his life. Time was of the essence, and I stopped right then, and I thought, what the hell am I doing? I could have saved this guy’s life, and I did, but I could have prevented what we were doing, and what I learned from that guy afterwards, because again, long-term follow-up in practice. What I learned from that gentleman is that he was young, he was listening to his doctors, he was following their advice, and their advice was killing him.

Dr. Gabrielle Lyon 04:10

It is, it’s a really, no pun intended, a hard pill to swallow as a provider actually being so invasive, surgery, surgery, no matter how it’s done, is an invasive procedure. I think it’s tremendous that you decided you weren’t gonna do that anymore.

Doug Lucas 04:29

It was a really hard decision.

Dr. Gabrielle Lyon 04:30

I can only imagine what I appreciate about many of the things that you say is you and I are really on the same – we’re two sides of the same coin. I am obsessed with muscle, and part of muscle, it’s called the skeletal muscle, or muscular system, is bone. Quite frankly, I’ve wanted to ignore bone forever, but in reality, I believe, and I’m curious as to your perspective. If we are going to see an epidemic of osteoporosis and sarcopenia that no one is prepared for,

Doug Lucas 05:09

absolutely,

Dr. Gabrielle Lyon 05:09

because of the use of GLP ones and their effectiveness.

Doug Lucas 05:12

Absolutely, I agree.

Dr. Gabrielle Lyon 05:14

In terms of longevity and these biomarkers of how we.. well, why don’t you just frame up bone for me before we go into these biomarkers that we were chatting about on this incoming epidemic. Just frame up bone, its importance, and how we need to be thinking about it. Ooh, thank you. No pressure.

Doug Lucas 05:32

So I love talking about bone, and as I got into the integrative space, I didn’t initially think like bone is going to be my thing, but I love talking about bone, because it is something that is so intrinsic to our success from a longevity perspective, health span perspective, but it is so much more than just the framework, literally, that our muscles are attached to. It is a dynamic organ system. It is talking to us every day. There are biomarkers that we’re going to talk about. There’s imaging that we can do, our bone is not something that we need to consider. We’re going to lose as we age, for the most part. Is that

Dr. Gabrielle Lyon 06:07

true? It is

Doug Lucas 06:08

true. I’ll give you evidence for that, but our bone is something that is going to help us to understand if something is wrong underneath the hood, and this is what I want everybody to understand. So, I talk about all day long with these biomarkers and imaging, is that in our community, in our clinical practice, what we see is that almost agnostic of age, we see people plateau their bone loss, and many of them are improving bone density, the quote unquote reversing osteoporosis, if you want to call it that, but ultimately they’re defying the average bone loss of point five to 1% per year, right. They’re almost all defying it. I don’t think we can avoid it forever, but I don’t think that we have to accept it as something that is inevitable throughout the majority of our health span. And what I’ve really come to identify bone loss as is a biomarker of health span, meaning if we’re losing bone, there’s probably something wrong, like something’s going on. We don’t know what it is yet, but we can use this as a red flag to say, hey, your body’s talking to you, something’s going on, we need to figure out what it

Dr. Gabrielle Lyon 07:12

Point five to 1% per year is bone loss, and when does that typically start? Is it around the same time that one would think about sarcopenia around 35 or 40 when someone’s done growing. Yeah,

Doug Lucas 07:25

I think it starts a little bit before, but they’re going to coincide. I think the the underlying mechanism is probably very similar. I think we just can measure it in bone faster.

Dr. Gabrielle Lyon 07:35

There seems to be a correlation, basically, is kind of what you’re saying. What would be a reason if someone is thinking about this, and personally, muscle, you feel you’re sore, you tore it, it grew, it didn’t, but bone, the way that bone has always been presented to me as a physician, and someone who trained a fellowship in geriatrics is a very static organ system until all of a sudden it’s not. How should we begin to think about our bone health? If, as someone is sitting here and they’re 35 and they are looking at their seven year old child, how do we think about

Doug Lucas 08:20

it? So, actually, the seven year old child is a great example of this. Our bones are a dynamic organ system. Imagine what happens in a seven year old’s body, right? How quickly are they growing, all of the open growth plates, all of that growth that doesn’t stop when you reach your peak height, or even your peak bone density in your late 20s, early 30s. That metabolism continues. On there’s this funny statistic, I actually don’t know where this comes from, but there’s this statistic floating around that says that we have enough bone metabolism to generate an entirely new skeleton every 10 years. I have no idea if that’s true, but I think something like that is probably plausible, and that’s how much bone metabolism is actually happening, there is that much breakdown and build up, and that’s why I really think that we need to reconsider accepting bone loss as a part of aging. We hear this all the time, age-related bone loss, quote unquote. Then I think that we need to reject that and say, hmm, no, if you’re losing bone, let’s look and see why. What’s happening? What’s imbalanced

Dr. Gabrielle Lyon 09:21

when I think about the way in which we were trained, the conventional playbook for osteoporosis, it’s here’s your dexa, it’s really actually two ways, it’s you are, have they changed the age of when you can, when insurance will cover the first dexa,

Doug Lucas 09:36

65

Dr. Gabrielle Lyon 09:38

I was hoping that that had changed,

Doug Lucas 09:40

it there’s there are a couple of different areas there, but yeah, right now the USPSTF still says 65

Dr. Gabrielle Lyon 09:45

and in our practice in strong medical, we reckon, I mean, we’ll get a baseline DEXA, yeah, there is no from my clinical assessment, there is no reason why you wouldn’t get it early, and the. Playbook has taught us 65 and up is when you’re even going to start screening with your first dexa, and then you will have the opportunity to have a prescription, and those prescriptions I would love for you to just kind of share, you know, I’ve got – we all remember bisphosphonate, I’m sure that there’s others, but that’s really the treatment, it’s resistance training, which people, the guidelines have just changed about that, and, and that’s that’s it. What’s wrong with that approach?

Doug Lucas 10:29

So it’s a very reactive approach, right? So let’s wait to screen until we’re likely to see the disease, which I understand the public health statistical analysis there, I get that, but the way I treat patients, the way you treat patients, is we want to prevent chronic disease, if at all possible. We want to catch it early, because it’s so much easier to turn that, turn that corner and resolve it early. If we wait until 65 it’s not too late, but boy, it gets so much harder the older we get. And so the conventional medical model is what it is, it has been for over 100 years, diagnose, treat with pharmaceuticals or surgery, that’s the system. If you want something different, we need to think about it differently, and that’s why you’re screening early, that’s why I’m screening early, because we want to prevent disease, and the conventional system is not set up for that, or at least not currently yet, it could be right, it could be. Let’s be hopeful, and the drugs are not ideal, and I’d love to get into all the different versions of it, but essentially the drugs have a short-term window for the most part, and if you are young, and by young I mean 50s, 40s, even 60s, honestly, if you are young, then you need to have a really comprehensive understanding of why you’re using these drugs. How long are you going to use these drugs? What’s the plan if you want to come off of these drugs?

Dr. Gabrielle Lyon 11:51

What are the drugs that people typically ask you about?

Doug Lucas 11:56

Yeah, there’s basically two classes, so there are the antiresorptive drugs, which is bisphosphonates, and a couple of others. I’ll get into it. Then there’s the anabolics, which are the ones that actually really help to build bone. Most doctors will start with an antiresorptive drug, that’s what the guidelines have kind of suggested and recommended. They’re easy, they’re cheap. Bisphosphonates are oral, right? So you know, and covered by insurance, and even if not, they’re generic and they’re inexpensive, so it kind of makes sense to do that, except that when we talk about bone metabolism, this breakdown and build up, and look at treatment with drugs through that lens, the antiresorptives are a bit limited because they essentially slow down bone metabolism, which is potentially beneficial. There’s a time and a place for these things, but if you slow down bone metabolism, slow down breakdown, you also slow down build up, there just isn’t a lot of bone turnover, and that’s okay. In the short term, it will, it will reduce fracture risk, it will increase on average bone mineral density, but what’s the long term plan here? The anabolics are an even shorter window, though, but they do build. What do you mean,

Dr. Gabrielle Lyon 13:03

shorter window?

Doug Lucas 13:04

So they are FDA approved to be used for up to two years, so shorter window, right? So, especially, I mean, if you’re, you know, whatever, 60s, 70s, 80s, two years is a really narrow window, narrow opportunity. And generally, these will be followed by an anti-resorptive drug. I like the anabolics. What are

Dr. Gabrielle Lyon 13:21

the names?

Doug Lucas 13:22

So, the anabolics in the US are going to be brand name Forteo, Terry Parrottide, Tim Loperatide. Those drugs work with all of our lifestyle things. This is why I like them. So, imagine if you’re doing the exercise, you’re eating the diet, you’re taking whatever supplement you think is good for you, you’re optimizing hormones, and you’re still not getting there, or you are at high, very high fracture risk. Taking an anabolic drug can help to just push everything forward. So, I really like that approach for those at very high fracture risk. But the question is, then what do you have to go on this antiresorptive approach, and again, that’s the bisphosphonates across the board, Prolia or Denosumab is another one, Avinidy Romosozimab is sort of like in between, it’s a little bit of both, but having a very good understanding of what the long-term plan is is critical, regardless of where you start.

Dr. Gabrielle Lyon 14:16

Would you equate it to a type two diabetic going on a insulin type medication, or a glucose, not glucose removal, but some kind of glucose disposal medication that when you come off of it one would anticipate those levels to just return to,

Doug Lucas 14:43

yeah, if you don’t fix the underlying issue, then the drug is simply suppressing or potentially improving, but for a short period of time, what was happening naturally. I talk a lot about this concept of quote unquote osteoporosis reversal, and many endocrinologists have given me some, we’ll call. Strong feedback to say that I shouldn’t say that, and the reason why I agree with them to some extent is that they equate it to diabetes, hypertension, where if you treat it with a drug, then you don’t fix the underlying issue, even if their biomarkers, their blood pressure, their A 1c their glucose, whatever is normalized, they still have the chronic condition, right, they still have diabetes and high blood pressure, osteoporosis is the same thing. If you go on, let’s call it Prolea, and your T score goes from negative three to negative two, you still have osteoporosis, even though you don’t meet the criteria for it anymore. But if you flip that script, and same thing with that diabetic, that person that has high blood pressure, you look for the underlying cause. It’s a different conversation. The

Dr. Gabrielle Lyon 15:40

idea that these medications, and I’ve heard you talk about this, that there’s a difference between quantity and quality of bone, which is the same for muscle. The studies have come out saying, well, that people that struggle with obesity also have a higher bone or a higher muscle mass, but the quality of that tissue, regardless if an individual is sedentary, regardless of the mass, is impaired. Right, there’s fat infiltration, the quality is not good. Talk to me a little bit about as we think about these medications, because that’s always the first step. Is here’s the problem. Here’s the medication, or we’re going to wait until you’re bad enough to treat quality versus quantity of muscle, or guys, you’re going to have to edit this. Let me say it again, because okay, highlighting the difference between bone quality and quantity.

Doug Lucas 16:38

Yeah, so ultimately the question is fracture risk, right? We use bone density to help to understand, or you could call that bone quantity, right? We use density, quantity, same thing, to help to predict fracture risk, but really the fracture risk equation is bone quantity plus bone quality equals fracture risk. Okay? Right. So it’s density, and density and quality or density and strength is another way to say, and this is why it gets confusing. There’s all these terms, but ultimately it’s more than just the quantity, it’s more than just the density, it is the quality. So then to get to your question with the drugs, yes, if you use an antiresorptive drug and you suppress bone building and bone breakdown, your bone will continue to calcify, it will continue to mineralize, so it will get more dense, and in the short term, that does decrease fracture risk, but the challenge is what happens in the long term, because if you can’t build bone, you inevitably end up with more dense, but potentially more fragile bone,

Dr. Gabrielle Lyon 17:35

and the outcome I like always highlighting what is the outcome that we’re looking for, and what I’m hearing you say is that the outcome that people are concerned about is actual fracture risk,

Doug Lucas 17:45

of course.

Dr. Gabrielle Lyon 17:46

Someone is there, anyone who should not take, say, that first line drug treatment.

Doug Lucas 17:52

So, there’s some research coming out now that I really like the angle of, which is looking at the order of these drugs. If you’re going to need a drug, look at the order of the drugs that makes the most sense. We know that if you start with an antiresorptive drug and you suppress bone metabolism, then follow it with the drug, the anabolic drug that can build bone. We know that that doesn’t work as well, because you’ve already suppressed the metabolism, and these drugs stay in the bone for a really long time. So, again, looking at this through bone metabolism, say, oh, well, let’s start with an anabolic drug. Let’s actually build up as much bone as possible, and then if you have to, then switch to something to maintain those gains. So that’s a different way of looking at it. And this is a totally new perspective that endocrinologists are really just now starting to get on board with.

Dr. Gabrielle Lyon 18:36

How sensitive are dexas for when. let me ask this a different way, what is the best test to identify bone quality?

Doug Lucas 18:48

There really isn’t a great one, so probably CT,

Dr. Gabrielle Lyon 18:51

that’s what for muscle it’s CT,

Doug Lucas 18:54

yeah, which is not a good screening tool, and that’s something we want to do over and over again, right? So yes, CT can look at strength, and that is good, except that I don’t want to expose myself to a CT every, you know, year or a couple of years. So, outside of CT, Dexa doesn’t look at quality at all by itself. There is an add-on called TBS, Trabecular Bone Score, and that is a software add-on, so same input, so questionable output, but it can help to stratify at least poor bone quality, better bone quality than average. And then there are other imaging modalities altogether. There’s an ultrasound device, which is kind of making waves in the wellness space, and it reports to, and is there’s a couple of studies supporting the idea of looking at quality with ultrasound, but it’s relatively new, and I think the data is, let’s just call it inconsistent.

Dr. Gabrielle Lyon 19:44

We definitely should pause on this part of what the mission of this podcast is, is to have really transparent conversations. What we are seeing with information, as it becomes more accessible, is that oftentimes things are. Heated without really being questioned, when I’m hearing you talk about Dexa, because Dexa doesn’t measure muscle mass directly, it extrapolates lean mass, and a percentage of that lean mass is muscle. Most people don’t consider that Dexa does not directly look at skeletal muscle mass, as you’re talking, I can’t help but think about bone through the lens of how I process muscle, and what I’m hearing you also say is that DEXA seems to look at the amount, but it’s not necessarily the total amount that matters, it’s the quality. Did I, did I get that right?

Doug Lucas 20:47

So it is both right, it is both, because we have these tools like Frax online risk fracture assessment tool that has tremendous data behind it, using just the density plus other risk factors to help to extrapolate fracture risk, so it is important, but it is missing a big piece of the puzzle, which is quality,

Dr. Gabrielle Lyon 21:09

that seems as if it’s kind of a big gaping hole.

Doug Lucas 21:14

It’s a huge hole. I’ll add one more layer to that, if you let me, which is that one of the challenges around DEXA is the the variability from scan to scan even using the same machine, the same operator on the machine? There is variability called LSC, or at least significant change from scan to scan. It’s essentially the margin of error, right? And so the LSC is well calculated on different machines, and it should be actually reported on the on the report, then it could be anywhere from, you know, a little under 2% all the way up to almost 6% So now we have this machine that isn’t telling us about quality at all and has an up to 6% variability measure from scan to scan, knowing that our bone density is really only changing for most people one, two, maybe 3% per year, so now we can’t even say that those gains or losses are real if it’s within that margin of error,

Dr. Gabrielle Lyon 22:07

and basic, you guys can take out basically this is important to understand, muscle is not very sensitive to change, right, the lean tissue when we look at a dexa, typically you think about an eight to 10% change over 10 years. It sounds as if they’re equivalent, but the data point to data point, the year to year change from a bone perspective doesn’t seem that it’s as sensitive as it should be, and I’m going somewhere with this. Is I think, okay, well, what is the practical information for people? Everyone over the age of 65 they’re getting a DEXA, but if we’re looking at our younger athletes and our 35 year old moms that potentially need to assess where their bone is at, and you have a list of bone turnover markers and things that I want to cover, that baseline score that someone is going to get at 35 Do we have a good algorithm, for example, their T score is that reflective? Do we have a volume or a population number that when that 35 year old goes in, is that 35 year old being compared to the same markers as a 65 year old, and how can we reconcile that?

Doug Lucas 23:24

Yeah, it’s a great question. And this is, there’s so much confusion around T score and Z score, because I get these questions all the time around Z score. People want to use the Z score. If you are over the age of 50, we’re going to talk T score, right, because you’re comparing with the T score actually to your younger, you know, gender and race related self, right? So, you’re, you know, you’re 20 something year old you when you are in your 30s and even 40s. We want to use z score because z score is comparing you to your age match population. So, what you want to know is where are you compared to others like you? And then you can say, well, I’m above average, I’m below average, knowing that average for that age group is quote unquote okay. It is still the general population, but at least you’re not, you know, in your 80s or 90s, where average is osteoporosis, and this is why we split and start using T score after the age of 50.

Dr. Gabrielle Lyon 24:18

Thank you for that clarification. I can’t also help but think that if it is, I’m guessing it’s based on population data, then that would mean it’s sedentary,

Doug Lucas 24:29

correct,

Dr. Gabrielle Lyon 24:30

a sedentary population.

Doug Lucas 24:32

So, I think there’s two ways that they do it. So, one is you can look at these massive cohort studies who have had dexas and we know t scores and z scores, and so you can get data that way, but also imagine these companies, like Whole Logic, these, you know, massive imaging companies that have DEXA scanners, they own all that data, right? So they have all of, they have their own internal database of all of these DEXA scans of different populations, because they have all the inputs that go into it too, right, but that is still the job. General population, so yes, sedentary poor nutrition, like all of the things that we would expect to see in the general population.

Dr. Gabrielle Lyon 25:08

Take it with a grain of salt, yes or no? The number,

Doug Lucas 25:12

I think it’s more than a grain of salt. I think it’s important to understand where you are compared to your population. One of the terms I used to use more than I use it now, but is this concept of aim for optimal, right? Like, we don’t want to be average, we want to aim for optimal, meaning it’s good to know where you are compared to the population at which you live, but where do you want to be in that? Do you want to be one standard deviation above, two standard deviations above? I would vote for probably more,

Dr. Gabrielle Lyon 25:36

at least. I want to, I realize that we didn’t close out the conversation of anabolics, the anabolic medications is that only directed towards bone.

Doug Lucas 25:51

Interesting question, bone specific.

Doug Lucas 25:53

So, what it is, the mechanism is parathyroid hormone, which is kind of intuitive, because a parathyroid tumor or elevated parathyroid hormone actually causes bone loss, but if you pulse it, it’s a very abnormal way of doing it, or non-physiologic way of doing it, but if you pulse it, daily injection of parathyroid hormone, or these analogs, then you see tremendous bone growth. So it is actually very specific to bone.

Dr. Gabrielle Lyon 26:17

Two more questions related to this, the are there off-label drugs that can be used for bone, you know, you’re talking about pulsatile release. I can’t help, I don’t prescribe growth hormone, but I can’t help but think about agents that are used in performance or optimization or quote wellness, however you want to frame that, things like growth hormone or other anabolic, and then okay, so it’s growth hormone, and then what about anabolic agents that affect muscle, and are these medications able to be used off label for bone?

Doug Lucas 26:52

Yeah, so growth hormone, I’ve not seen good data for. I would think it would be beneficial, but I just haven’t seen any data on it. As far as other anabolics, you and I have had conversations in the past about other potential tools, and there’s nothing that I would recommend right now, because I just don’t think the data is supported above what we are currently seeing, with the exception of the potential benefit of testosterone, but the research, especially in women, is still pretty limited. In men, it’s better, so definitely a tool worth considering, but clearly off label. The

Dr. Gabrielle Lyon 27:22

less than the next logical thought would be perimenopause, menopause decrease in estrogen. Where does that come in with the bone conversation?

Doug Lucas 27:35

It is just running parallel so strongly, and this is why I ended up in my career really talking a lot about hormones in both men and women, you know. Right now clinically I’m creating protocols for hormone optimization for both men and women, because bone is such an

Dr. Gabrielle Lyon 27:51

related to bone.

Doug Lucas 27:52

Yes, through the lens of bone. Now we do it. I mean, this is a we have a women’s health program that I’m leading, but it’s I love doing it through the lens of bone, because bone tells us what’s happening with hormones. It is one of the few organ systems that gives us great feedback on levels, dosing like we talk about symptoms of menopause, perimenopause related to hormones, but those symptoms are can be vague, can be related to other things, it can be challenging to dose just based off of symptoms, but our bones are telling us objectively what’s happening.

Dr. Gabrielle Lyon 28:24

Okay, talk to me about that. You’ve now piqued my curiosity. How would you dose hormone replacement therapy to direct it to be directed at bone?

Doug Lucas 28:33

Yeah, so first let’s talk about the bone turnover markers, because this is going to be really important. So, when we look at what’s happening in bone, we have an opportunity to use imaging, which we’ve talked about, has its weaknesses, and it doesn’t change very quickly, right. So, not a great tool from this perspective. The bone turnover markers I talk about often, which are blood markers you can measure as frequently as you want to get your blood drawn. They measure that bone metabolism, so the building of bone and the breakdown of bone. The building side, there’s a marker called p1 N P. It’s a long

Dr. Gabrielle Lyon 29:05

p1 N p1 N is

Doug Lucas 29:07

a Nancy P, long acronym, but it’s basically a type of collagen. And so, when your osteoblast, these cells that build bone are doing that, they release this end of the bloodstream, and you can measure it. Osteoclast, the cells that break down bone, release something called CTX or C telepeptide, that one’s easier to say, and CTX also released in the bloodstream. You can measure it, and you can objectify these things so quantifiably. You can determine, are you in more of a bone building dominant mode or more of a breakdown dominant mode. We see this in the phase three trials, for every bone drug that’s out there, they’re used, they’re used in research for nutrition interventions, supplement interventions. I mean, these things are used across the board, they’re awesome. And so now we have the opportunity to use them in conjunction with measuring serum or blood levels of hormones to understand what are the hormones doing. To your bone turnover, and this is beautiful, because again it’s the only organ system that really gives you this feedback. So, for our patients that have, you know, they have bone loss, osteoporosis, they’re worried about fractures, we’re talking about bone metabolism now. If they’re on hormones, we can say, okay, well, what is this form of estrogen, whatever, you know, transdermal gel cream, patch, whatever you’re using. What are those levels of estradiol? I also measure FSH, which we can talk about, which is kind of a feedback loop hormone. And then we also measure CTX and p1 and P, and we should see CTX drop by 40, 50% if it’s actually saturating the bone receptors for estrogen, and we could see p1 and P rise, or it’ll drop a little bit less than CTX again, changing that ratio, so that we’re favoring bone building.

Dr. Gabrielle Lyon 30:49

When we, when you are looking at a patient, do you say the target estradiol level is 40 or above? If you look at the literature, they give you a number between, and there’s a handful of different picograms per deciliter, but 40 to say 100 Do you look at that, and you say a woman’s estradiol number needs to be at least 40 for bone protection?

Doug Lucas 31:18

I used to, and so we had this, we used 60 as sort of our threshold cut off. There’s literature to support that, but what we realized is that I had women who were on very low doses of transdermal estradiol, where I would not expect to see much systemic exposure. You wouldn’t expect to see high levels, and we wouldn’t, but yet we would see FSH suppression, and I would see CTX come down, meaning that I can’t make an argument, actually, to increase her dose, if that’s what we’re aiming for. So, sometimes we see it be effective at less than that, but then the opposite is also true. I have women that hit 6080, 100 and their CTX is still 800 right? It just doesn’t seem to have had an effect on the bone yet. And so we will have women who will push that. It gets more challenging. We have to talk about how to protect organs, and you know, the uterus and breast tissue, et cetera, but women that have pushed that into the, you know, 100 to 200 range, and then you see the CTX drop. So I think there’s a receptor challenge that we can’t measure effectively. So I’ve stopped using estradiol alone as a goal.

Dr. Gabrielle Lyon 32:19

I absolutely agree with you. In a young woman who is 35 or 30, what would be a normal CTX number?

Doug Lucas 32:30

It’s going to depend on the phase of the cycle. So, this is one of the really cool things that I learned about starting to treat women in perimenopause, which is, if you understand what’s happening with the cycle, you can understand what’s happening with bone metabolism really well, right. So you know, if we look at the, you know, the estrogen levels throughout a woman’s monthly cycle, in the follicular phase, you see estrogen rise, right? It goes much higher than any other time, and then it drops, and then it kind of comes back up in the luteal phase, but the luteal phase is dominated by progesterone. You see very clearly the effect of estrogen, right? It slows down bone loss, and then, and so you’ll see CTX, you’ll see CTX rise during that time. I’m sorry, you’ll see CTX drop during that time, and then during the luteal phase, you’ll see it rise, and you see this natural push-pull of the estrogen and progesterone dominance, and so that is the natural cycle, this push-pull, this rhythm that’s occurred every month during the cycling years of a woman, that as you get into perimenopause, starts to get dysfunctional. These women, especially if they stop ovulating, then you kind of don’t have that progesterone rise, and this is where this dysfunction starts.

Dr. Gabrielle Lyon 33:35

You said, does progesterone. we talked about estradiol, estradiol’s effect on CTX is the same true for P I N P

Doug Lucas 33:47

p1 M P.

Dr. Gabrielle Lyon 33:48

Okay, well, you guys can edit that out. p1 M P, is it the same for p1 M P?

Doug Lucas 33:54

So it has an effect on both sides of the of the metabolic equation. So it has the most profound effect on C T X. It does have an impact on osteoblast. It’s just not as obvious, so we think that it supports osteoblasts, but really, progesterone is more supportive of osteoblast. We see that osteoblasts have progesterone receptors, that natural push-pull of the rhythm of the estrogen and progesterone flow that will encourage osteoblasts to either go away or to come back. Progesterone probably plays a bigger role than does estrogen, but it’s not as well studied.

Dr. Gabrielle Lyon 34:28

I also really appreciate what you said about the receptors. There is this idea of precision medicine, and it’s, it’s not going to be the right dose for everybody. It’s likely a receptor issue. It just makes me think about how we target testosterone. I don’t know if you’ve read much about CAG repeats. CAG repeats, it’s basically the androgen receptor. The higher the androgen receptor, then it would make sense that the less testosterone one would need.

Doug Lucas 35:00

Yeah, and does that play out?

Dr. Gabrielle Lyon 35:01

It does.

Doug Lucas 35:01

Amazing,

Dr. Gabrielle Lyon 35:02

it does. It’s called CAG repeats. They’re doing a lot of research at Baylor regarding CAG repeats. It’s not necessarily the dose of testosterone, it’s all about the density of the androgen receptors, which conversely, you have patients that they feel terrible on 300 milligrams of testosterone, which is you and I would never prescribe more than that. Sorry, guys, but, but there might be something to say for the fact that it really is the density of these receptors, and I’m, I’m curious, as it sounds as if it would be the same for bone, which makes testing blood markers really important to allow for precision, because what you’re saying is that it’s not just the symptomatic relief. How fast once you lower some of these blood markers, how fast do you anticipate seeing it in a scan or some kind of proof that it’s working?

Doug Lucas 35:56

Yeah, this is the frustrating part about bone health, is that it’s still a slow journey, Dexa is probably not going to change faster than every 12 months, and even then, when people don’t see if they’re on, if they’re doing all the things, and they don’t see Dexa improve like we would expect it to, I just tell them, look, it changes slowly, bonus, slow to mineralize, so even if all the good things are happening, you may just not see it yet. Now, the ultrasound device, in theory, is faster, but again, evidence is a little sparse.

Dr. Gabrielle Lyon 36:25

I’m sure you’ve watched closely the conversation around estrogen and bone loss. What does the evidence say in terms of prevention or even treatment?

Doug Lucas 36:34

Well, first off, let’s talk about when this actually happens, right? We think we, you know, we’ve talked a lot about this idea that in the five to seven years after the onset of menopause, you see up to 20% loss in bone density. Those are real numbers, and definitely worth pointing out. But what’s interesting is when you look at the graphs that show that it doesn’t start at 50, it starts at 45 So we talk about this, you know, quote unquote at the onset of menopause, but no, it’s actually during perimenopause, because that’s when the back and forth cycling starts to get dysfunctional, that’s when you start to lose progesterone, it’s when estrogen levels start to not actually reach the peak, so it starts much sooner than that. The opportunity for intervention is also not at 65 my goodness, at 50, sure, but I would argue actually before that, as well, like, let’s optimize hormones throughout the lifespan, especially midlife. For women,

Dr. Gabrielle Lyon 37:25

can you treat bone loss with estrogen?

Doug Lucas 37:29

So, estradiol specifically is actually FDA approved for the prevention of osteoporosis. So, I can even say prevention,

Dr. Gabrielle Lyon 37:36

yeah,

Doug Lucas 37:36

I can even say that out loud. It’s amazing. FTC is not going to come knocking on your door. What I would say about estrogen or estradiol specifically is that it is a very powerful lever. If a woman chooses to, is a candidate for using it both in prevention, but also when a woman has osteoporosis. I can’t say use it for osteoporosis, but when a woman has osteoporosis to improve bone metabolism, other symptoms of menopause, it will have a big impact on her bone density.

Dr. Gabrielle Lyon 38:06

I like the way that you said that, it was said very responsibly. Well done. Don’t know if you practice it, but you did a great job. It’s, it’s tricky in medicine, because even with, say, Alzheimer’s and estrogen, we can’t say, well, the, that there’s any treatment with Alzheimer’s memory with the use of estrogen, but you can say we have a good understanding of what happens when estrogen is low or removed or suppression therapy, it’s, it’s, it’s tricky,

Doug Lucas 38:40

so I look at this one in two very clear ways, and I’ve had some fun interviews lately that have really driven this home for me, but I think of if you look at women who have their ovaries and uterus removed, they have a hysterectomy in their young, right, so 30s or 40s, the guidelines clearly state use hormones and optimize levels, not just for symptom prevention, but higher levels of hormones to stave off early what Alzheimer’s, dementia, heart disease, and osteoporosis. So that physiology doesn’t change as we get older, the risks might change. I had two interviews lately with Dr. Perlmutter. Do you know David Perlmutter? He’s awesome. I really enjoy talking to him, and he says very clearly and openly, yes, the literature is not clear. We cannot say that we’re using hormone replacement to treat, prevent anything Alzheimer’s related, but what we can see clinically is the profound impact that optimized hormones have on cognitive function. I see it

Dr. Gabrielle Lyon 39:38

same,

Doug Lucas 39:39

I’m sure you see it same, right? It is clear as day, but we have to be careful what we promise.

Dr. Gabrielle Lyon 39:45

You also talk about finding the root cause. You have a.. I really like frameworks, and you have a 4r method. First one is, recognize why are people having bone loss and. Um, I’m going to just leave it at that. And then, selfishly, I want to hear about the nutritional aspects.

Doug Lucas 40:05

Yes, of course. So, again, I don’t believe that we should accept bone loss as a normal part of aging. It’s going to happen at some point, but how long can we stave it off? So, again, if you’re losing bones, something’s wrong, let’s figure out what it is. And this is why we created the four framework, because most people, especially with a diagnosis, are told this is age-related, you know, it’s due to hormone. They actually say, like, it’s due to a hormone decline, and there’s nothing you can do about it, which is a clear contradiction in terms. But even more so than that, I feel like there are so many different levers. When you start looking under the hood, there’s so many things that you could potentially address when it comes to bone loss, nutrition certainly being one of them. So we created this framework to help people to understand this concept of root cause medicine, that’s what we’re talking about. So the four framework is recognize why you’re losing bone, right? And then shit, what’s the second recognize?

Dr. Gabrielle Lyon 41:00

I have it here. Yeah,

Doug Lucas 41:01

what

Dr. Gabrielle Lyon 41:02

is it? Recognize, hold on, hold on.

Doug Lucas 41:07

I love that. That’s funny.

Dr. Gabrielle Lyon 41:09

I don’t know, Matt. Will you look it up? The four hours, just Google his

Doug Lucas 41:14

recognize.

Dr. Gabrielle Lyon 41:15

It’s probably, oh, reverse

Doug Lucas 41:17

those causes. Well, okay,

Dr. Gabrielle Lyon 41:18

wait. But what are the other two? So, recognize,

Doug Lucas 41:20

reverse, retest, and revive,

Dr. Gabrielle Lyon 41:22

and revive. Okay? Do you want to talk about this? I do like the idea that there’s a framework.

Doug Lucas 41:26

Yeah, no, it’s good. I think just to understand that there’s an underlying cause. Okay? Yeah, yeah, we’re

Dr. Gabrielle Lyon 41:32

gonna go really fast, because I want to. I really want to talk about nutrition. I want to talk about some of the things that, that we would normally, yeah, say I’ll just hit from the

Doug Lucas 41:42

second R, yeah, okay, which then leads to the second R, which is reverse those causes of bone loss. So again, identify why you’re likely losing bone. Let’s pick a couple of levers, and then let’s do something about

Dr. Gabrielle Lyon 41:54

Talk to me about why. Why are we losing bone? And specifically, selfishly, I want to know how much this system has been. Very controversial, calcium.

Doug Lucas 42:04

Oh my gosh,

Dr. Gabrielle Lyon 42:05

yeah, I want to hear about calcium.

Doug Lucas 42:08

Yeah, so I think no surprise to you that most cases of osteoporosis are not a calcium deficiency issue, right? If you look across the board, most Americans are eating 700 to 800 milligrams of calcium a day from all sources, that is probably enough to support bone metabolism. The recommendations for over the age of 50 are up to 1200 milligrams of calcium, but that I feel is a little bit of a surplus to help to build bone. If you think that it helps to build bone, but we don’t really live in a calcium deficient society.

Dr. Gabrielle Lyon 42:37

We do not, and I haven’t been able to reconcile the fact that we have some of the highest rates of osteoporosis, but we have and are eating a ton of dairy. Talk to me about the role of calcium. Is it is that something that people should take from a supplement standpoint? Is it calcium? Is it vitamin D? Where, where are, is it? Are we supposed to be eating leafy greens? I mean, when I was in fellowship, there was an osteoporosis screening from a nutritional standpoint. It was dark leafy greens. How much caffeine? How much alcohol are you drinking? Do you smoke?

Doug Lucas 43:14

It’s this is really tough when you start talking about nutrition and bone health, because we get into the bias of the last, you know, 40 years, right? So, if you were to paint a bone health picture through nutrition and do it from, you know, the time of Ansel Keys on, you have this really conflicted, like, you know, don’t eat too much protein because it’s bad for you, watch out for dietary fats, you know, certainly don’t consume dairy because it has saturated fat and it’s inflammatory, and then get your calcium through leafy greens, and you’re kind of like, whoa, whoa, whoa, whoa, like that doesn’t actually make a lot of sense. And so I was just reading a book, prepping for an interview, and I’m not going to say what it is, but that was the nutrition advice, and it literally said red meat is inflammatory and Americans eat too much protein. I was like, ah, like my population, because I have them all track what they eat. They do not eat too much protein. They under eat protein significantly, and most of them are actually getting adequate calcium. So, what we’ve been told over the last several decades just doesn’t jive with where people with osteoporosis and bone loss are now.

Dr. Gabrielle Lyon 44:15

Is calcium something that is important? Do you recommend supplementing with calcium,

Doug Lucas 44:21

I recommend everybody track what they eat for at least a short period of time. I know it’s a pain, but track what you eat and be honest about it, so you can understand how much calcium you’re getting through diet. If you’re under 800 in theory, I should say 1000 but if you’re under 800 to 1000 then yeah, you should probably add some, but don’t add too much, because it’s not a calcium only problem, it is a mineral problem, right? But that means you need all of the minerals, not just calcium.

Dr. Gabrielle Lyon 44:46

What else is another big, or what are other minerals or vitamins and minerals that are really important for bone?

Doug Lucas 44:53

Yeah, I mean, the supplement stack is can be really long, but let’s just start with the basics, right? So, yes, potato. To the calcium, but you also need magnesium, you also need phosphorus, you also need potassium, and that’s why the products that we talk about generally are going to have at least trace minerals or other minerals that go along with it. From a vitamin perspective, vitamin D is critical. If you’re going to consume calcium and minerals, you need vitamin D. Should also be measuring that one. Know what your levels are. Vitamin K in various forms have different reasons to use one or another, but vitamin K is also really important, and I think vitamin E is coming out as a bigger player. Vitamin E, you know, in again different forms than what’s traditionally been available, also becoming a bigger player in the bone health space. So, minerals, vitamins, and then you start getting into like all the other things that could potentially impact bone metabolism. We don’t

Dr. Gabrielle Lyon 45:43

want potential, we want what do we know? Is there one superfood for, I mean, because for muscle, I think lean red meat.

Doug Lucas 45:54

Yeah,

Dr. Gabrielle Lyon 45:54

for me, if I had to pick one food, it would be lean red meat. When I think about muscle health,

Doug Lucas 46:01

I think, for bone health it’s the same, so you and I are on the same page. Lean red meat, or if you can tolerate the saturated fat, you know, fattier red meat. I will say there is a standout, though, for bone when it comes to small fix.

Dr. Gabrielle Lyon 46:13

Please don’t say sardines, you’re gonna say sardines, I

Doug Lucas 46:15

know, but so powerful, right? Protein, omega threes, calcium and minerals. It’s, it is just a super

Dr. Gabrielle Lyon 46:25

food. I, I agree with you, and makes you very unpopular when you’re on the plane.

Speaker 1 46:32

True, the

Dr. Gabrielle Lyon 46:33

sardines for a super food, you eat the little bones. Do you think that there’s any utility in eating? I mean, I don’t even know how else to say it. Eating bone, having when you’re stewing broth, are you extracting some of those nutrients? Because, and this might be outside your scope, I know it’s kind of outside my scope, I’m not stewing bones, but I can’t help but think, man, the nutrients, when you open that, is probably nutrients that are viable and important, and in the West, we typically just eat muscle meat, or not eating a ton of organs, or or bones. Do you think that that would be something that you add in once a week? Have you thought about it?

Doug Lucas 47:13

It totally makes sense. Again, there’s no good data. Yeah, but yes, it makes sense.

Dr. Gabrielle Lyon 47:19

Are there conversely things that would affect negatively affect bone loss, diet soda, sparkling water. I love bubble drinks. Talk to me, talk to me, Goose. What are we doing?

Doug Lucas 47:32

I looked up this one because I love sparkling water. I stopped drinking alcohol about six years ago, so now, like, my go-to happy hour drink is sparkling water. So I needed to look this up, and I’m happy to say there’s zero evidence to suggest that sparkling water is bad. Now, if you talk about colas, like sodas, like if you have a phosphate-rich soda, then that actually could be an issue.

Dr. Gabrielle Lyon 47:53

When you say phosphate-rich, what would I – again, I’m not a soda expert – there’s added phosphate in

Doug Lucas 48:00

phosphoric acid, right? So, generally, your dark-colored sodas,

Dr. Gabrielle Lyon 48:04

that means energy drinks too.

Doug Lucas 48:06

I don’t know that that’s true.

Dr. Gabrielle Lyon 48:08

Okay, we’re gonna look it up, because I’m asking for a friend, mostly me. Sparkling water, you’re okay with the effervescence. What else is an absolute if you want to destroy bone? Here’s your playbook.

Doug Lucas 48:21

Yeah, if you want to destroy bone, undereat protein, right? Eat an inflammatory diet, high ultra-processed foods, high quantities, get poor sleep, live in chronic stress.

Dr. Gabrielle Lyon 48:32

Okay. Well, the sleep part bothers me. But do you think that, you know, when we were in training, there was talking about the brittle bones, diabetic brittle bone,

Doug Lucas 48:44

metabolic health is big.

Dr. Gabrielle Lyon 48:46

How does metabolic health and bone go hand in hand?

Doug Lucas 48:50

Yeah, it’s chronic inflammatory state. I mean, it’s a simple way to say it.

Dr. Gabrielle Lyon 48:56

All right, well, friends, you, you heard it here. Is there anything that people can do to improve their nutrient absorbent? Is there anything that people can do specifically to improve nutrient absorption with bone being the endpoint with anti fracture diet?

Doug Lucas 49:19

Yeah, so from a dietary perspective, we need to make sure that the gut works right, so you can eat the best diet in the world, and you can have $1,000 a month supplement stack, but if your gut doesn’t work and it’s not absorbing it, that’s a problem. So we do a lot of, you know, in the functional testing space, dual studies looking at function and then creating a plan around treating that. It’s a challenging space to live in, but at least improving gut function or understanding if you need hydrochloric acid or enzymes or whatever to help with absorption, so definitely worth testing, and then from there eating a protein-forward diet that is micronutrient dense and not too calorically dense.

Dr. Gabrielle Lyon 49:54

The one of the biggest misconceptions that we have heard over the years is that protein is bad for. Bone, and when I was in fellowship, geriatric fellowship, those individuals that had the lowest protein diet had the greatest risk for fracture. It is not, it’s a complete myth, it should die and be dead and be buried. Protein bone is made from protein. When you think about people or populations that are at risk, are those individuals with celiac with gluten intolerance. Who do you go? Okay, here are the three people again, preexisting or comorbid conditions. Yeah,

Doug Lucas 50:33

so celiac is a super common one, right? And we actually diagnose a lot of celiac because they come in with osteoporosis, and that’s one of the things we check. They just didn’t know, and so, yeah, if you can, if your gut doesn’t work, you can’t absorb, and

Dr. Gabrielle Lyon 50:46

celiac is is an autoimmune response to gluten or glide in.

Doug Lucas 50:52

Yeah, so then the question is, you mentioned, you know, non-celiac gluten intolerance, so then how likely are they to have bone loss and osteoporosis? And the answer is, we don’t really know, because it’s a spectrum, right? But you know, I, I don’t need a lot of grains. I discourage the use of consumption of a lot of gluten, or any gluten, across the board, almost, because I just see it so commonly. So, I think it probably is having an impact. Does it actually cause osteoporosis? I don’t know. I wonder if you’d give me two minutes on the pH thing. Oh my gosh, so I talk about this every time I get an opportunity, because it is one of these things, and you mentioned these dogmas earlier. It’s one of these things that gets repeated over and over again, that you want to alkalize your body for your bones. You learned it, I learned

Dr. Gabrielle Lyon 51:37

it, I heard it. I would say I never learned it

Doug Lucas 51:39

right, because it didn’t make sense,

Dr. Gabrielle Lyon 51:40

no,

Doug Lucas 51:41

yeah, and so I had to look into this because it just doesn’t intuitively make sense to me, and yet even in authors that I really respect, doctors, when it comes to talking about bone, they just, it just comes out of their mouth, like, but you need to make sure you alkalize your diet for your bones, like, what if it doesn’t make any sense, because if you do that, then, like, you just said, protein is quote unquote acidifying. It’s the opposite of what this principle would suggest, but yet protein is the most important component from a nutritional perspective for bone health. So, it just doesn’t make sense. The literature actually are many studies looking at an alkaline approach, some kind of intervention, and it always fails, except one study where they control for protein. First,

Dr. Gabrielle Lyon 52:25

you guys heard it here first. If someone is trying to sell you or talk to you about a pH diet, next, what is it? Swipe right or swipe left? Swipe in one of those directions. Talk to me about medications that we don’t think about, medications are pervasive. Are there a handful of medications that people take routinely that affect bone?

Doug Lucas 52:52

I mean, the first one, hopefully, is not routine, but if you are using systemic, either oral or any other form of steroid,

Dr. Gabrielle Lyon 52:59

meaning it’s like a metal dose pack,

Doug Lucas 53:01

yes,

Dr. Gabrielle Lyon 53:02

for asthma or something like that,

Doug Lucas 53:04

including inhaled ones. If you’re using them frequently and consistently, definitely check and see what’s happening with your bone. That is a public service announcement. Outside of that, because everyone’s usually pretty well known. Outside of that, the ones that I would say that surprise people would be like your PPI drugs, right, the drugs that you’re used, the Nexium, I always forget the brand names, but like Nexium, things that are now over the counter, trilo

Dr. Gabrielle Lyon 53:28

sac,

Doug Lucas 53:28

yeah, that suppress stomach acid in an attempt to reduce symptoms of acid reflux, those drugs are associated with increased fracture risk, ironically not with decreased bone density, though, which I can kind of explain, but ultimately, if you’re having to take these things for a long period of time, try to understand why there is a time and a place for that, but should not be for chronic acid reflux without a reason. And then another really common group that’s concerning are the SSRIs, so SSRIs, antidepressants, anxiety drugs, these are also associated with osteoporosis. I don’t actually understand the mechanism there,

Dr. Gabrielle Lyon 54:06

associated but not causative, with no underlying mechanism. I

Doug Lucas 54:09

don’t know the mechanism correct, but we do see the association, and it’s pretty strong.

Dr. Gabrielle Lyon 54:13

Okay, the PPIs, I think, surprise a lot of people. Probably 15 years ago, there was a maybe mid 50 year old woman that she had fractured something, it was weird, she was super fit, and I remember talking to her physical, I will never forget this, talking to her physical therapist, and I told this patient that she had to come off these PPIs, that I believed at the time that it was affecting her vitamin mineral absorption, that physical, that physical therapist called me, screaming at me. How dare I tell this patient that the reason that they may, or something that contributed to this fracture, was the use of these PPIs?

Doug Lucas 54:58

It’s odd coming from physical therapy.

Dr. Gabrielle Lyon 54:59

I understand. On, but there’s yes, it was odd, and now I think, fast forward, that one of the things interesting in medicine is that we see things in patterns over time that we might not be able to exactly explain the mechanism, or it takes time for the mechanism to come out. What about the use of Advil, or things that affect potentially gut integrity or birth control. I understand they’re two separate, but do those either of those play a role?

Doug Lucas 55:28

So, gut integrity does play a role, for sure, because it relates to the inflammatory component, the immune system. Absolutely, the effect of NSAIDs like ibuprofen and naproxen, I’ve not seen a direct causative or correlation, there it makes sense to me again, and I discourage the use unless somebody really needs it. Birth control is an interesting topic, because my gut told me that birth control is bad for bones, but when I looked into this to try to create this, like again public service announcement, what I found is that because the progestins, the synthetic progesterones in birth control tend to be anabolic, there’s a couple of exceptions there, but they tend to be anabolic and actually push on androgen receptors, be likely because of that they do not seem to be associated with bone loss. There are some that are, though, and actually don’t remember the names off the top of my head, so I’m not going to say any out loud, but definitely for a woman who is suppressing her cycle using birth control, understand what’s happening with your bone

Dr. Gabrielle Lyon 56:30

and test early,

Doug Lucas 56:31

test early

Dr. Gabrielle Lyon 56:32

exercise. I want to, I have a patient that she is, she was an ultra runner, she’s 60. This woman puts me to shame. She out trains me. She is three times stronger than I am, and she’s been a lifelong athlete. When she came to see us, she was osteoporotic, crazy. Higher protein diet makes sense. She’s running ultras, like that’s kind of crazy. We changed her training to now she’s pulled back on the ultra, and she’s lifting, she’s osteopenic, which I was surprised, I mean, yes, we’ve obviously we’re improving her bone density, but still osteopenic, and as I was thinking about, okay, what is our net, her hormones are optimized, we have not done CTX. I am going to get that, and a handful of other lab values. It just makes me think, and I had this aha moment, which you can tell me this is totally wrong. Is that we have her on a resistance training protocol, she is doing her cardiovascular activity, she has a higher protein diet, she’s on hormone replacement, she’s doing no high impact jumping, plyometric broad jump, any of those activities, and so I’m gonna, I’m gonna stop there.

Doug Lucas 57:52

Yeah, so the first thing I would say is, how long has it been? How long have you been working with her to see that? Two years,

Doug Lucas 57:59

yeah. So two years still relatively short, right? You are seeing improvement in two years, which is great. So the first thing I would say is let’s be patient, because it’s probably all working anyway. But if you wanted to optimize exercise, yes, resistance is great, and we should continue to do resistance, but the bones really do respond to impact, and the challenge then is, how do you do impact in a way that doesn’t hurt the body. I love the concept of plyometrics and jumping, but it’s really hard to recreate in studies like how I jump and how you jump and how you land is going to look very different. So, how do we recreate that intervention? There are some studies on some very simple things, like heel drops, not sexy.

Dr. Gabrielle Lyon 58:36

I hate those. I know

Doug Lucas 58:38

they’re not sexy, and they actually don’t feel very good, but that’s kind of the point, is that you can generate over four multiples of body weight just by doing a simple heel drop.

Dr. Gabrielle Lyon 58:46

Basically, standing on a bench, you.. I’ll do a video on this. JJ Thomas, my physical therapist, has had me do heel drops because we’re on a return to run program, for whatever reason she has me doing it. I stand on a bench, I put my.. how should we describe it’s my one foot, as if you’re stepping off of a stair, and

Doug Lucas 59:06

so maybe we’re thinking about different things. Okay, so when I think of a heel drop, at least the study I’m referring is essentially standing on flat ground, and the advanced version is barefoot on concrete. Don’t start there, but barefoot on concrete, if you want to get the maximum effect, rise up onto the balls of your foot, and then just let your body weight fall with your knees essentially locked out. Now, everybody listening, please don’t go do this right. Well,

Dr. Gabrielle Lyon 59:31

we’ll do a video of it, but yeah, we’re talking about two separate things. That seems as if that’s almost no impact,

Doug Lucas 59:38

so we’re gonna try it, and you’d be shocked at how much impact it is.

Dr. Gabrielle Lyon 59:44

Heel drop, what else do you, as when you see patients, do you say you do need is it jump rope, or how do we begin to challenge one of the other things? I’m sure that you’ve heard is that people are afraid to fracture their bone,

Doug Lucas 59:57

of course.

Dr. Gabrielle Lyon 59:58

How do they do activity? T that is meaningful to bone that’s already compromised.

Doug Lucas 1:00:03

It’s a very difficult position to be in, and this is why early intervention is so important. Because when I do get those questions from women in their 60s and 70s with a T score of negative three and negative four, inevitably they’re asking, well, will this cause a fracture? And the answer is, I have no idea. I can’t tell you if it will or if it won’t, but what I can tell you is that if you do nothing, I know what that trajectory looks like, right? It will get worse. So we have to pick a starting point that you’re comfortable with, and I would say start low, go slow.

Dr. Gabrielle Lyon 1:00:31

But basically, there’s no data to say this is the amount. No,

Doug Lucas 1:00:34

there’s no way to know

Dr. Gabrielle Lyon 1:00:37

vibration plate

Doug Lucas 1:00:38

fun,

Dr. Gabrielle Lyon 1:00:40

and

Doug Lucas 1:00:41

I like them, it’s an oddly controversial space, so there’s essentially three different types of vibration plates, one of them is good for bone, both in the hip and the spine, but of the three versions, that’s not the most common out there, so I’ll just run through them real quick, if you go on Amazon, you type in whole body vibration, you’ll get all these different things usually they are 102 $100 that kind of go side to side, right. That’s not a device that I would recommend for your bones. And then there are a couple of devices on the market, I’m not going to name any names, that have what’s called ultra low displacement or micro displacement, meaning that they don’t move up and down very much, and they market, not making direct claims for bone, but they kind of mark it in the bone space, and the literature does not support that these devices will increase bone density at the hip and the spine. And then there’s the devices that I do personally use or recommend, which have a displacement of between two and four millimeters, meaning they go up and down two and four millimeters, they’re vertical, so they’re not going side to side, they’re just moving up and down between 30 and 40 hertz, that’s the frequency, so that’s how many times per second. Those devices actually have a ton of data supporting that they can either slow down or increase bone density.

Dr. Gabrielle Lyon 1:01:54

And are the where do you get those devices? Are those medical, are those medical devices?

Doug Lucas 1:01:58

So, direct to consumer, the company that we use is Power Plate, and so they’re their home devices, yeah, the personal and the move have the exactly the requirements that I look for from the research.

Dr. Gabrielle Lyon 1:02:10

How often, because I mean, there’s no reason why, I mean, I’ll check to see if it’s cost prohibitive, but there’s no reason why we shouldn’t be doing that,

Doug Lucas 1:02:21

they’re pretty expensive, so the Power Plate Moo, which is the version I have, I think is close to $3,000 so yeah, it can be a cost issue. Their personal is a little bit less, but it’s still probably around $2,000 so yeah, it’s expensive, but it is a passive tool, not everybody can use it, there’s a few contraindications, especially like eye ear things, but most people can use it. It’s passive, literally stand on it, and that’s all you need to do for 10 minutes a day, five days a week.

Dr. Gabrielle Lyon 1:02:50

10 minutes a day, five days a week. And gyms have it, right? It’s something that,

Doug Lucas 1:02:54

yes, I’ll say a caveat about the professional versions, because they have commercial for gyms, they also have healthcare versions, the those versions go up higher than the thresholds that I just mentioned, so they do move up and down, potentially more, and potentially faster, so more is not better, right? If you go more, then you could potentially get to a point where you don’t want to stand on it, it’s too much, and faster actually decreases the benefit, so stick with those thresholds,

Dr. Gabrielle Lyon 1:03:21

what else are we missing in that story? Anything else

Doug Lucas 1:03:26

from an impact perspective? So, there’s there are devices that are very popular, or kind of popular, that use this concept of osteogenic loading. Are you familiar?

Dr. Gabrielle Lyon 1:03:36

I believe so, but I’d like to hear.

Doug Lucas 1:03:41

So, the franchise name out there is Osteo Strong. It was another company, but I was thinking Biodensity. Yeah, so these are really interesting devices. The initial research, I think, again was interesting. It was not well done, no big studies, but the principle is there, and the whole concept here is that can we create at a certain range of motion, which is nearly, you know, nearly straight with your legs and with your arms, because you can generate so much more force there. Can you generate that over four multiples of body weight, which is potentially the trigger for bone growth, just by pushing on an immovable object? So the early research was promising. The franchise took off, so Osteo Strong available around the globe. Biodensity kind of a different business model, but also available very similar devices. But the research that’s come out over the last 18 months has not been convincing. There was a long period of time where these companies grew without any good randomized control trials. They started to ask almost the right question. Now we have some randomized control trials. The four that have come out over the last 18 months, none of them showed any benefit of using these devices. Now that doesn’t mean it’s only four

Dr. Gabrielle Lyon 1:04:52

months.

Doug Lucas 1:04:53

Well, so only four months of what?

Dr. Gabrielle Lyon 1:04:56

Randomized control trials. If a randomized control trial is

Doug Lucas 1:04:59

so.

Dr. Gabrielle Lyon 1:05:00

Formal trial.

Doug Lucas 1:05:00

No, there’s four randomized control trials.

Dr. Gabrielle Lyon 1:05:02

Oh, and how long was each trial?

Doug Lucas 1:05:04

There were different lengths, but usually 10 months to 12 months, I think. If I remember off the top of my head, but the challenge is, is that these trials were not asking the right questions. They, I said, close to the right question. They did not ask the right question. So, the question that we need to answer with these devices is, Who is the right population right? Is this women who are perimenopausal in their 40s? Is this women who are, you know, frail in their 80s? Which group? They’re very different, HRT plus minus. If you’re on bone drugs, plus minus. So we’ve started to ask close to the right questions. The data don’t support using them, according to these studies, but again, these were not good studies. They were poorly controlled, in my opinion, poorly done. I have a video on each one in our YouTube channel, and basically, we’ll link it. We’ll link it. Yeah, I just rip apart the methodology because I’m so frustrated, because I have so many people who have a lot of hope with these machines, and I think it does make sense, but I can’t say for whom it is the right person to do this with

Dr. Gabrielle Lyon 1:06:01

what is the minimum effective dose that we know of and the the load necessary to impact bone density and I know it’s a really hard question but what I liked about those machines is it it basically it used AI and it worked off of your resistance, the amount of force that you were applying.

Doug Lucas 1:06:23

Yeah, I love the concept. Right, so the machine doesn’t push on you, you push on it. So, as a result, like this feels like it’s relatively safe, and you can generate a tremendous amount of force. That

Dr. Gabrielle Lyon 1:06:35

doesn’t mean it affects bone.

Doug Lucas 1:06:38

Yes,

Dr. Gabrielle Lyon 1:06:38

and I want to know, what is the minimum effective dose, if you were to say, here are the exercises that, again, people should do for, because the areas of concern for you are the spine and the hip. Are there other areas that you are concerned about?

Doug Lucas 1:06:52

I’m concerned about the whole body, right, but the hip fracture, in particular, is the one that you want to avoid at all cost. Those are, I don’t know, how many hundreds or even 1000s, potentially, of these things I have operated on, and quote unquote fixed, and the outcomes, even if the surgery is perfect, the outcomes are abysmal.

Dr. Gabrielle Lyon 1:07:07

Talk to me about again, what we’re really, we are talking about the activity to impact bone and hip fractures. You don’t really hear a lot about back fractures, do you?

Doug Lucas 1:07:21

I mean, they are problematic, or they cause a significant amount of pain. They can cause deformity. I mean, they can be a very big deal, but no, they’re not. They’re just not sexy to talk about, because the statistics aren’t as

Dr. Gabrielle Lyon 1:07:32

robust as a hip. And also, we see when someone falls, and is it that they fall and break a hip, or just the hip fracture, and then they fall?

Doug Lucas 1:07:40

It can be both. Yeah, I surprisingly hear more of the latter. The other one I want to point out that isn’t talked about often is the top of the arm, right around the shoulder. If you break the top of your humerus bone, the top of the shoulder itself, you will likely lose a significant amount of range of motion that has tremendous impact on your life. So, especially for women, imagine men, maybe they care too, but for me, I don’t care if I can brush the back of my head, but I have so many patients who can’t get their hair brushed to the back of their head, and it really bothers them, they can’t reach up and grab something off the top shelf because they have a restricted range of motion of their shoulder after these things heal, in surgery doesn’t necessarily make that better, so again, these are just fractures we want to avoid,

Dr. Gabrielle Lyon 1:08:22

we did. We really did frame this conversation around women. From my perspective, we have – it’s very rare to see, at least in our practice, to see osteopenia, osteoporosis. The time that we have seen it is when we’ve gotten patients that have been on long-term anastrozole, long-term estrogen blockers are men and women. Do they have the same risk factor?

Doug Lucas 1:08:46

Well, estrogen is the primary sex hormone driver for bone in both men and women. And I actually was thinking about this today because I just had a patient who went and got a consult from some longevity doc in Miami, and he said, ‘Hey, you should go on testosterone and anastrozole in AI, and I said, for bone that doesn’t make any sense at all. You need the estrogen level, right? You want your estradiol to be, you know, upper end of normal. And so, yeah, I think it’s a big concern, especially for men who are in that zone of treatment, right? That’s really common to use anastrozole. I’m concerned about all of the men that have been doing that at high doses for years, because I bet that we’re going to see again this landslide of osteoporosis as a result.

Dr. Gabrielle Lyon 1:09:31

Do you, is osteopenia osteoporosis as common in men in general?

Doug Lucas 1:09:38

Certainly not.

Dr. Gabrielle Lyon 1:09:38

It’s not,

Doug Lucas 1:09:39

not because they don’t lose bone, they do, but if you think about what happens with sex hormones, right, testosterone levels decline more gradually. There is no, like, andropause is not as sudden as menopause, it’s not

Dr. Gabrielle Lyon 1:09:50

even a thing, right? You could potentially

Doug Lucas 1:09:53

not have men, potentially might not even ever get a decrease in testosterone, which is really fascinating. Yeah, I mean, in your world, I see it all the time. Yes, right, you have optimized patients, so I am worried, though, about low testosterone levels out of the gate for men. I am worried if they’re on AI’s, I’m worried if they’re doing other things that are bad for their bone that they don’t know, but they have a higher starting point, and this is the difference. If you look at the graph, you know, women hit a certain threshold, on average, men are another standard or deviation or two above that. They just have more room to fall before they hit it.

Dr. Gabrielle Lyon 1:10:27

And when he says AI, he’s talking about aromatase inhibitors. I have a question, and this is not a – this is kind of a scientific question, but this is really a personal opinion question, as you’re talking, I’m thinking, okay, men have higher levels of muscle mass and testosterone, people will be like, oh, well, it’s relative, all this other stuff, but I am curious, we do, you think again, I don’t really know how to frame this, but do you think that there’s an inherent, inherent sex difference, or is that we’re not having women out there pounding weight in the same way? I mean, just think about it, women are not, they’re just not out there pounding weights in the same way, and they’re just not, you know, I look at my son Leonidas, who, you know, it’s five, he’s out there, he’s mom, where’s the keto bell? Mom, where’s the ghetto? And my daughter’s over there dancing, she’s like, mom, did you see zombies, right? And she’s put on this song, and I realized that over time that just their physical nature is different. What do you think

Doug Lucas 1:11:40

I mean? So, similarly, I have two boys, and I have a seven year old girl, and yes, they are doing wildly different activities, just naturally. Yeah, now I do think it’s interesting. My daughter is into gymnastics, which actually is a profound bone building exercise, but yeah, I mean, in general, my boys are, they’re just, they’re wrestling, they’re falling off stuff, like they’re impacting their bones, you know. My oldest is already into lifting weights, and so, like, I do think there is going to be a natural split there, but there’s also, you know, genetic changes. Testosterone levels rise faster, I think, in young boys. There’s hormone, other hormone changes, there’s dietary changes, right? So, like, boys just eat constantly, just machines, whereas my daughter is like a pretty picky eater, and like really struggling to get adequate protein in there for her, so it’s a combination of all of it.

Dr. Gabrielle Lyon 1:12:32

Yeah, I, it reminds me of the athletes’ triad for the girls, they lose their period, they’re under eating, and you know, I, I don’t see those same behaviors. I think, in the end, the guys doesn’t mean that they don’t exist. But I also wondered, is that, is that setting us up for a milieu of bone mistakes? Well, I think

Doug Lucas 1:12:57

what’s happening in young men, especially, is I do see some of the same risk factors, right? Like, we don’t have a cycle to go off of for men, and so, like, I see some of these same risk factors: sedentary lifestyle, video games, poor nutrition, ultra-processed food. Like, I watch it, and in my boys’ classmates early on, they get away with it, right? They eat this garbage diet, they’re playing Fortnite all the time, and yet they’re still like pretty active, healthy-looking kids. That’s going to change, right? As they start to go through adolescence and early adulthood, that’s going to change, and it’s going to look more like what women, on average, are doing. Of course, there are exceptions on both ends of that.

Dr. Gabrielle Lyon 1:13:36

That’s a really good point. I recognize that I didn’t get your answer on guys, you have to edit this back in the minimum effective dose for what you would like to see, and the amount of weight. For example, women will go to a class and lift lighter weights, more repetition. Do we know if there’s a particular stimulus required for bone?

Doug Lucas 1:14:00

So we don’t really know a clear answer to that, and I think it vary from person to person, so I have, I’ve had some women, especially like my older patients, 70s, even 80s,

Dr. Gabrielle Lyon 1:14:11

what the fuck is that? Okay, go ahead, you weren’t,

Doug Lucas 1:14:16

yeah,

Speaker 2 1:14:16

ask that question, yeah,

Dr. Gabrielle Lyon 1:14:19

minimum effective dose for the input, the stimulus required for bone health.

Doug Lucas 1:14:26

I think it’s going to vary from person to person. There are studies looking at a certain amount of exercise, right? Is it two days a week of resistance, is it three days a week of resistance, one day a week of impact? Like those studies exist, but exercise is kind of hard to study. Populations are different, hormone levels are different, like all this stuff. So I have had patients in their 70s and 80s who can do no more than like two days of resistance training at pretty light weights and still see improvement

Dr. Gabrielle Lyon 1:14:54

in bone,

Doug Lucas 1:14:55

in bone. Wow, but they’re not pulling that lever very hard, right? They’re pulling other levers. Covers harder for my women and men who are more active, more capable, like harder, better, right? You can certainly overtrain, but generally we’re coming from a sedentary background, so harder, better. But I don’t go more than, you know, three, maybe four days of resistance training. They have to be able to recover, and then if you’re doing that much resistance, it’s going to pull back on like whatever else you think you might be important for you, like, is it high intensity interval training or cardio respiratory work, or whatever. So, just finding that balance based off of your goals. It is

Dr. Gabrielle Lyon 1:15:31

complicated to study, and I think again, what is probably good for muscle is good for bone, if you’re building. Is it fair to say that if you’re building and maintaining muscle, you are impacting bone?

Doug Lucas 1:15:48

I think if you’re spending enough time in an anabolic mode where you can actually put on muscle, my guess is you’re probably putting on bone.

Dr. Gabrielle Lyon 1:15:56

Dr. Doug Lucas, when does your book come out?

Doug Lucas 1:16:00

I don’t have any book.

Dr. Gabrielle Lyon 1:16:01

Well, you should. I know I wanted to just put that right in there. I think a book on this would be amazing, and in fact, I’m going to introduce you to someone who I think is going to be extraordinary. Joy, my book agent, you should definitely – you should have a book on this. It

Doug Lucas 1:16:18

is, it is, it is past time. I’m ready to do it. Okay, I just need to do it.

Dr. Gabrielle Lyon 1:16:22

Okay. Well, I’m gonna make that intro. Any last words?

Doug Lucas 1:16:26

The biggest thing for me is know your starting point. We all have risk factors for bone loss, so please get a DEXA if you want to get a REMS. Get a REMS, but get a DEXA. Know what your starting T score is and Z score, depending on your age, so that you know what that trajectory looks like, and if you’re losing bone, figure out what it is.

Dr. Gabrielle Lyon 1:16:44

All right. Well, great to have you on.

Doug Lucas 1:16:47

Happy to be here. Thank you. A

Dr. Gabrielle Lyon 1:16:48

couple questions. I’m gonna make an intro to a book agent. You should definitely have a book. Let’s do our strong.

Doug Lucas 1:16:54

Thank you. It’s time.

Dr. Gabrielle Lyon 1:16:57

What’s

1:16:57

your.