The Truth About Osteoporosis How To Prevent And Reverse It With Lisa Tamati

Lisa: Well, hey everyone, Lisa Tamati here at Pushing the Limits podcast, and also my YouTube channel, and welcome in. Today I'm going to be doing a deep dive into osteoporosis and all the implications, the drugs, the medications that can cause osteoporosis, and we're going to be looking at what nutritional things you can do and what you need to know, basically, about osteoporosis.

Lisa: Now, this one is close to my heart. My mum recently broke her hip because of osteoporosis, and so it's become a bit of a passion of mine to share some good insights and information about osteoporosis and what you can do to prevent it, because the implications of things like hip fractures in the elderly can be absolutely deadly. Dealing with that myself right now, trying to rehabilitate, has been a mission. In fact, many people who are elderly and have hip breaks don't survive the year. So it's a major thing for us to be thinking about, osteoporosis.

Lisa: So what is osteoporosis? It's basically a skeletal condition characterised by a decrease in density, in the mass and the volume of normally mineralised bone, and this reduced bone density leads to decreased mechanical strength, thus making the skeleton more likely to fracture. Now, postmenopausal osteoporosis, or type one, and age-related osteoporosis, type two, are the most common primary forms of bone loss seen in clinical practice. Secondary causes of osteoporosis can include things like hypercortisolism — it's a mouthful to say — hyperthyroidism, hyperparathyroidism, alcohol abuse and immobilisation, when you're unable to move. And in the development of osteoporosis there's often a long latent period before the actual appearance of the main clinical manifestations and pathologic actual fractures. And that's the good news, because that means we've got time to do things about it if we know that we're at risk for it, and we can counteract it.

Lisa: So I'll tell you a little bit of a story with Mum. She's actually got a very, very complicated background with aneurysms, strokes, concussions, brain cancer, CNS lymphoma, many falls and a lot of medications over many, many years. We've done absolutely miracles to keep her going and she's still enjoying life. But recently she got up out of bed and fell over and broke her hip, and this was a neck of femur break. The implications for that are huge. She's 82. The risk of things like pneumonia and clots and never being able to walk again and losing muscle mass and losing more bone density because you're not moving — all of these things add up to being one problem after the other. And of course operations, activation of the immune system, you're more likely to get infections. Some of the drugs that they use can have lots of downsides, which we're going to get into today as well. And unfortunately we experienced some downsides with some of the bone density drugs, and I'm not a big fan of those. I'll just sort of preface it, saying from the get-go, she had a seizure after having one of the bone density drugs, and so I've done a deep dive into this to see what's the real ins and outs of this and what you need to be thinking about if you're recommended those.

Lisa: And so we're in the middle of a rehab journey with her, and so if I can prevent other people going through this, if I can just provide you with some information, some resources to go and check out some research — I'll be linking to all the research papers that I'm talking about in this video down below, so make sure you check out the show notes.

Lisa: So who is at risk? Well, ageing is commonly cited as a risk factor for osteoporosis, but other factors include a lack of physical activity. So for those people who don't want to exercise or can't exercise, that is a major problem. Then there is the other side of the coin, and probably I fall into this one: excessive exercise. That can also lead to bone density problems. I know that I've experienced things like tooth loss after doing extreme ultramarathons, experienced that type of thing, so probably I'd be a candidate to be on the lookout for this.

Lisa: So excessive exercise. Being a woman is a risk factor in general, and being a postmenopausal woman even more so. Smoking is another risk factor. Alcohol use is very definitely a risk factor. A history of bone fractures that aren't caused by trauma — like if you've had a major trauma and you broke a leg, okay, but if you've had a fracture that really wasn't explained, then maybe you're more at risk. A family history puts you at more risk. Frequent pregnancies can put you at more risk, and nutrient deficiencies can put you at a higher risk too.

Lisa: And so osteoporosis can be caused by other abnormalities and diseases as well. For example, conditions that limit your mobility, as we said — exercise is really important — lead to osteoporosis. And other associated conditions: things like chronic kidney disease, hyperthyroidism or overactive thyroid, or Cushing's disease, where you've got pituitary tumours at play. Anorexia is another risk factor. Malabsorption, if you've got problems with your gut and you're not absorbing your nutrients well. Amenorrhoea is another risk factor. Early menopause is a risk factor, and hypogonadism, testosterone deficiency in men. And one of the ones that surprised me, because we have a family history of it, is coeliac disease. A lot of coeliac patients end up with osteoporosis before their time.

Lisa: So how is osteoporosis or osteopenia diagnosed? Well, typically it's done with something called a DEXA scan, which is a fancy machine that will measure bone density, and they will give you a T-score. And if you have a T-score between minus one and minus 2.5, it's considered osteopenia, or the beginning stages of bone loss. And if it's a T-score less than minus 2.5, it's considered to be osteoporosis. Now, the DEXA scan only shows you the density of the bone. It doesn't tell you much about the quality of the bone, so that's one of the issues that you also need to consider.

Lisa: Now, the bone is a living organism and it has a turnover approximately every 90 days, and you need cells that produce bone and then break down bone. Called osteoblasts, they build the bone, and then osteoclasts, they break down the bone. So this has to work in some sort of a synchrony, because if one works too fast, then you're going to have either too much deposition of bone or a lack of deposition of bone. So you need to have this work in synchrony, okay. And this is a good point for later on when we talk about bisphosphonates, which are one of the classes of drugs that they use to do bone density. They're basically just putting more inorganic calcium into the bones and stacking it and making it more dense, but making it more brittle and making it less elastic, and so that leads to problems. But we'll get into that a little bit later.

Lisa: Now, bone is made up of 40 to 50% inorganic material, and 35% organic material. It's basically made up of minerals and hydroxyapatite. About 10% could be made up as water, and about 35% is organic material. Now, I didn't explain that very well, but you get the picture: some is inorganic, some is organic. Now, about 90% of that organic material, the part that's organic, is made up of collagen type one, and oftentimes in the treatment and management of osteoporosis they neglect the collagen aspect of bone. So that's 90% of the organic material is collagen type one.

Lisa: So in the healthcare industry, in medicine, they're always like, have your calcium, have your calcium. But it's more than that. The bones are not just calcium, they're a whole matrix of minerals and collagen, and it's the collagen that creates the elasticity, the flexibility of the bone, and this is just as important as the density of the bone. So collagen is a really important thing to consider.

Lisa: Now, your bone is an organ that produces blood cells — red blood cells, white blood cells, platelets — and it's very important for oxygenation as well as your immune system. It also stores your minerals and your fat, so it helps you when you have a depletion of minerals in your blood. It can be utilised as a reservoir, or it can store it for future use. So it's very important in terms of function. It's not just a hard thing that sits there holding your skeleton up. It's actually a living thing that is changing and producing things.

Lisa: Now, calcium phosphate is the other component, and that's the mineral complex that attaches to the framework and gives it the rigidity of the bone. So that's where the calcium comes in, but also other things. So osteoblasts, the things that produce bone, give off something called alkaline phosphatase, which attaches to the collagen framework, and these calcium molecules give it that strength, okay, that flexibility.

Lisa: So collagen is really necessary and it's really neglected. It's what absorbs the impact. If you get tackled in a rugby game — say you're a rugby player and your ribs get tackled — if they bend, you'll be able to withstand that impact, perhaps, to a certain degree, obviously. But if it's rigid, then it's more likely to snap. Like steel is more likely to snap than something that's more flexible. So even when you think of skyscrapers, they're made nowadays to actually have a bit of movement in them so that they're not just rigid and snap.

Lisa: Now I'm going to talk to you about something called Wolff's Law. Bones are not inert structures, and within the human body they continue to change over the course of our lifespan, and this process of skeletal change is known as bone remodelling, which both protects the structural integrity of the skeletal system and metabolically contributes to the body's balance of calcium and phosphorus. Now, remodelling entails the resorption of old or damaged bone, followed by the deposition of the new bone material.

Lisa: Now, there was a German anatomist, a surgeon, by the name of Julius Wolff, who developed a law that describes the nature of bone remodelling regarding stressors. So Wolff's Law states that bones will adapt to the degree of mechanical loading, such that an increase in load will cause the architecture of the internal spongy bone to strengthen, followed by the strengthening of the cortical layer. Furthermore, a decrease in stress on the bone will cause these bone layers to weaken.

Lisa: Now, the duration, magnitude and rate of forces applied to the bone — in other words, the tendons pulling on their attachments — dictate how the integrity of the bone is altered. And there are two primary cells responsible for both the resorption and deposition phases of bone remodelling. They are the osteoclasts, as we said, and the osteoblasts. However, osteocytes also have a role in this process. Now, the activity of these cells, particularly the osteoclasts, is influenced directly and indirectly by hormonal signals. I'll repeat that: the osteoclast is influenced directly and indirectly by hormonal signals. This interaction between both bone remodelling cells and hormones creates the opportunity for a multitude of pathophysiological consequences.

Lisa: Now, the cells of bone remodelling, the major players. The bone remodelling cycle begins in early fetal life and depends on the interaction between two cell lineages. The osteoblast cells contribute to bone growth and are derived from the mesenchymal origin, and mesenchymal cells are stem cells that can differentiate into various cell types such as osteoblasts, chondrocytes, myocytes and adipocytes. Now, osteoclast cells cause bone resorption and originate from the haematopoietic lineage, which includes multiple blood cell types from within the bone marrow.

Lisa: Now, the cellular process of remodelling begins with osteoblast and osteoclast precursor cells, and they fuse to form a multinucleated osteoclastic cell. So, osteoclast. Once the fusion of the osteoblast and the osteoclastic precursors has occurred, the resulting multinucleated osteoclast attaches to the bone surface and commences resorption, and these cells use a combination of lysosomal enzymes and

Lisa: Hydrogen ions to break down the bone matrix. Now, this bone matrix has an inorganic portion of calcium phosphate crystals, or hydroxyapatite, and an organic portion comprised of collagen, proteoglycans and glycoproteins. Now, the resorption process leaves scooped out regions of the bone matrix. Scooped out. It is believed that mononuclear macrophage lineage cells then conduct a reversal phase, which continues to degrade and then deposit organic material while releasing growth factors to initiate the bone deposition phase. All really complicated, right? But there's this beautiful dance between osteoblast and osteoclast.

Lisa: So now let's go to the osteoblast. The differentiated mesenchymal precursors fill that hollowed out area by depositing new collagen and minerals. And once the osteoblast has completed the task, it will encounter three fates: it will either flatten and become a cell to line the bone surface, become an osteocyte, or undergo cell death or apoptosis.

Lisa: Then there are the osteocytes. Bear with me, okay? I know this is a bit deep, but it's really good if we can understand the basics of this at least. Osteocytes are the most abundant cell type in the mature bone, and these cells are situated within the bone matrix and occupy microscopic spaces called lacunae. They play a role in bone remodelling by transmitting signals to nearby osteocytes regarding bone stress, so tendons pulling on the bones. And osteocytes also regulate fluid flow within the bone, and these cellular signals may be due to changes in fluid flow in response to mechanical stresses on the bone.

Lisa: Now, these cells are involved in mechanotransduction, where the mechanical forces are converted to biochemical signals, and osteoclasts act as conductors for the signal or lack thereof, and instruct surrounding cells on compensating for and adapting to mechanical stresses.

Lisa: So the function of bone modelling is to adjust the architecture to meet the changing needs of the body. So in other words, if you were doing a lot of weight training and you're lifting a lot of heavy stuff, the body's going, "Oh, we're having pressure put on our bones, we're going to have to respond by laying down more bone." And this is why resistance work and weight training is super, super important as we get older, because it creates that environment for that bone remodelling to take place and for your bones to actually get stronger.

Lisa: Bone remodelling also helps to repair micro damage in the bone matrix, which prevents the accumulation of old bone. So this is the other piece. When you do the bisphosphonate class of drugs, it can stop the reabsorption of the old bone, and so you've got more density, but it's not good bone, it's old bone, and it needs to be gotten rid of. So additionally, bone remodelling aids in maintaining plasma calcium homeostasis as well.

Lisa: So the DEXA scan: what they tell us and what they don't, and what their limitations are. So it tells us the density, but it doesn't tell us the strength and the quality of that bone. So one of the doctors that I listened to on a lecture, he was talking about it's like putting a bunch of bricks into an organic structure, like putting a bunch of bricks in your lounge and going, "Look, we've got bricks in our lounge, stronger." The room is not stronger unless those bricks have been built in, for a start. Just sitting in the lounge without having been built into a wall, they're not stronger, they're just there taking up more density, they're more dense. So there's a little bit more to that story.

Lisa: And then there is hormones, and hormones have a major role to play in the story. So hormone impact. There's parathyroid hormone, or PTH. It is a polypeptide hormone secreted by the chief cells of the parathyroid glands, which act to raise calcium levels in the bloodstream. And parathyroid directly acts on bone and the kidney, and indirectly acts on the intestines via the influence of vitamin D.

Lisa: Now, the parathyroid hormone has a physiological negative feedback loop influenced by the amount of calcium that's in the blood. Now, when there is a decrease in plasma calcium concentration, there is less binding to calcium sensing receptors on the parathyroid gland. This will lead to an increased release of PTH to raise calcium levels. And PTH has an indirect action on the osteoclast by increasing the receptor activator of nuclear factor kappa-B ligand, or RANKL for short, which regulates the osteoclastic activity of bone resorption and leads to more calcium released into the plasma.

Lisa: Now, in contrast, high levels of plasma calcium bind to the CaSR, or the calcium sensing receptors, on the parathyroid gland and inhibit the parathyroid release. So stimulating these causes a conformational change of the receptor and stimulates the phospholipase C pathway. This ultimately leads to higher intracellular calcium, thereby inhibiting exocytosis of parathyroid from the chief cells of the parathyroid gland. And this details only one piece of the calcium homeostasis puzzle, because parathyroid also acts at the kidneys and the intestines to regulate calcium and phosphate levels.

Lisa: Then there is oestrogen. We are using oestrogen with Mum. We put her on an oestrogen patch even though she's in her 80s and 30-something years out from menopause. Oestrogen is really, really important to stop bone loss, basically. So oestrogen deficiency can lead to increased bone remodelling where bone resorption outpaces bone formation and decreases bone mass. So I'm personally on oestrogen, as a menopausal woman going through menopause. I'm on oestrogen to make sure that I maintain — one of the things oestrogen does, it does a lot of things — to maintain my bone mass.

Lisa: And based on animal studies, it's believed that oestrogen may influence local factors that regulate the precursors of osteoblasts and osteoclasts, and oestrogen may block the production and action of interleukin-6, hindering bone resorption. Also, it's believed that osteoclast survival thrives in the deficiency of oestrogen, where the degree of bone turnover would be more significant. So you're going to have more breakdown of bone if you've got low oestrogen levels. We won't go into that, because I could talk about hormone replacement therapy till the cows come home, and why oestrogen, under the guidance of a medical professional, could be something that you want to look at, for the ladies out there especially.

Lisa: So, calcitonin. Calcitonin is a polypeptide hormone and it's released from the thyroid C cells in response to elevated calcium levels, and calcitonin binds to calcitonin receptors on osteoclasts to inhibit bone resorption. And calcitonin is believed to not play a prominent role in calcium homeostasis in adults, but it may be more critical in skeletal development throughout childhood. And calcitonin may be used clinically as a treatment option to treat osteoporosis.

Lisa: And then there's growth hormone, a peptide hormone secreted by the pituitary gland that acts through insulin-like growth factors, IGF, to stimulate bone formation and resorption. So growth hormone acts directly and indirectly via IGF to stimulate osteoblast proliferation and activity. It also stimulates osteoclastic bone resorption activity. The cumulative net effect of this dual activity favours bone formation.

Lisa: Then there are the glucocorticoids, and glucocorticoids decrease bone formation by favouring osteoclast survival and causing osteoblast cell death. There is an increase in the RANKL — that's what we talked about before — action, and a decrease in osteoprotegerin, OPG. OPG is a cytokine receptor, a member of the tumour necrosis factor superfamily, that acts as a decoy receptor for RANKL. It also typically hinders the RANKL-RANK interaction and activity.

Lisa: Then there's thyroid hormone: thyroid stimulating hormone, or TSH, thyroxine T4, and T3 stimulate osteoblastic activity and cause bone elongation at the epiphyseal plate — I can't say that one — of long bones through chondrocyte proliferation. Now, in states of hypothyroidism — and how many people are dealing with that — or hyperthyroidism, the degree of bone turnover is either low or high respectively. So the rate of bone turnover is due to the effect of T3 and T4 on the number and activity level of osteoblasts and osteoclasts. For example, the increased metabolic state of thyrotoxicosis causes increased osteoblast function and increased osteoclastic number and activity, leading to a higher bone turnover.

Lisa: Right, so that was what hormones do. So hormones are something that you really need to be thinking about in relation to your bone health, and working with a doctor, a medical professional, who can help you use the right things to optimise your bone health.

Lisa: Okay, now let's look at medications that can be detrimental to bone health. So some medications can weaken your bones, which leads them to breaking more easily, and this includes some of the very common medications. And you need to know these ones, because if you're on them, you need to know that you have this risk. The corticosteroids, one of those family; the selective serotonin reuptake inhibitors, or SSRIs; and then proton pump inhibitors, or PPIs — those are the things that stop the stomach acids. So your antidepressants, all of that, your steroid drugs.

Lisa: Now, other causes of bone loss can include certain diabetes medications, loop diuretics, and some seizure medications as well. And your risk depends on a number of factors, including the medication, the dose, and how long you've been taking it for.

Lisa: The steroids are prescribed for multiple conditions, including asthma. And as an asthmatic who spent my entire childhood taking steroids to manage that, I'm mortified now at what that must have done to my bone density, and I need to be really aware of that now. Luckily I don't have asthma anymore and I'm not on any of those medications. But if you are on those, you need to know that these will impact your bone. Also things like prednisone, methylprednisolone and Flovent. Now, bone loss is a well-known side effect of those, and that's because these medications decrease bone formation. Without new bone cells to keep them strong, your bones weaken and become more likely to break.

Lisa: Now, bone loss is more likely with high doses of oral steroids, and it's also more likely if you take them for a long period of time or if you're over 65 years of age. And so to avoid the side effect, you should talk to your healthcare provider, who may have you take these medications for the shortest amount of time possible and do other things with you. So if you're doing it for a long time, make sure that they are all over that and thinking about that.

Lisa: SSRIs, like Prozac and co., they are also a major problem, and often people are on these for years. Once again, I was on those in my past, and nobody told me any of this. That's why you need to know about it.

Lisa: Proton pump inhibitors — the amount of clients that I have walking in through the doors who have just been on proton pump inhibitors for years is horrific. And there are so many downsides to proton pump inhibitors, not just bone density, but bone density as well. So make sure that you're only on those for short periods of time. And researchers suspect that PPIs may stop your body from absorbing calcium, and so instead your body takes calcium from your bones and it weakens them. And the FDA requires prescription PPIs to include a warning about the risk of bone loss. But have you been told? Probably not. And you probably didn't read the small print.

Lisa: And unlike other medications, this risk is linked to both short-term, less than a year, and long-term use. However, the warning doesn't apply to over-the-counter PPIs. That's because you shouldn't take those for more than two weeks, but a lot of people do.

Lisa: Certain diabetes medications can also — so make sure you check if you're on any diabetes medications — they have been known to lower bone mass and cause fractures. There's different ones that are involved in that.

Lisa: Then, anti-androgen medications, things that are taken, for example, to treat prostate cancer or breast cancers as well. These medications, the prostate cancer ones, lower male hormone levels and help prevent prostate cancer from returning. However, they can result in bone loss and osteoporosis, and this is because hormones like testosterone play a large role in bone health. One of the other things that one of my doctors is trying to get my mum on...

Lisa: ...is testosterone cream. We're not able to at the moment, but because it's anabolic as well, it would be very, very powerful for her if we could get that in, and it plays a big role in bone health — the testosterone cream in her case, for a woman, at a low dose. There are lots of good things to say about testosterone for women as well, which would be a podcast for another day on hormone replacement. Getting off track again. But if you're on anti-androgen medication, your healthcare provider has to monitor that.

Lisa: The next one is seizure medications. Some of the seizure medications — check with your provider if they also deplete your bone mineral density. Vitamin D is a nutrient that we need to keep our bones strong, but it's not active in our body as vitamin D. It's converted to 25-hydroxy vitamin D and then to calcitriol, and that's the active form. There are certain drugs that can intervene with this process and turn on a liver enzyme that breaks down the 25-hydroxy vitamin D before it can be activated, leading to weaker bones. Another one is things like phenobarbital and other seizure medications.

Lisa: Then there are things like loop diuretics, for getting rid of water in the body. Some of those can also lead to a risk of fractures and osteoporosis. So if you're on a water pill of any type, talk to your medical provider about that risk.

Lisa: And then anti-oestrogen medications — therapies to treat certain types of breast cancer that block oestrogen, like tamoxifen and Arimidex and co. These medications can also be super detrimental to bone health, and this is because oestrogen plays an important part in preventing bone loss, and blocking oestrogen can cause your body to break down more bone than it should.

Lisa: Then common painkillers like Tramadol, which is an opioid pain medication, has many risks, and bone fractures are one of them. You might want to make sure that you're not taking those. And then there are certain transplant medications such as cyclosporine, so if you're on those, you just need to have those conversations with the healthcare provider so that they're monitoring you as well.

Lisa: Also pain medications that cause deficiencies in vitamin C and the B vitamins and iron — these deficiencies cause pain. So when you have a deficiency in vitamin C, you're going to have more pain, and so this leads to a bit of a vicious cycle of more pain, less movement, less exercise. So just make sure that you are covering your bases with your supplements if you're on any of these medications that can deplete any of those basic nutrients.

Lisa: There are tables online that you can find that show all the nutrient depletions of common medications, and I would encourage you, if you're on some medications, to go and look those up and to find out what are the common deficiencies with certain medications. You'd be surprised. And then cover those bases if you're on those, and if you have to be on those. So nutritional deficiencies themselves can lead to bone loss, which leads to more medications, which can cause more nutritional deficiencies, and so on. It becomes this horrible vicious cycle.

Lisa: So currently it's estimated there's about 200 million people suffering from osteoporosis, and according to the recent statistics from the International Osteoporosis Foundation, worldwide one in three women over the age of 50 and one in five men will experience osteoporotic fractures in their lifetime. It's a pretty horrific scenario and it's not a nice thing to experience.

Lisa: Now, is bone loss a calcium deficiency then, like so many believe, and we just need to take more calcium and have your dairy and your milk? It's not like that at all. It's a lot more complicated than that.

Lisa: So how in fact does nutrition and a lack of physical activity affect osteoporosis? High-carb processed foods, gluten-rich foods, a sedentary lifestyle. Going back to Wolff's Law, sitting all day puts no pressure on your joints, and this causes the body to put energy elsewhere and not into building bones. People would always say, "Oh, you exercise too much," and yeah, I probably did exercise too much, but probably better than not exercising at all.

Lisa: So avoid high-carb foods, avoid processed foods, anything that's going to cause nutrient depletion, and gluten, especially if you are gluten sensitive, which is a lot of people. You don't have to be coeliac, but even just gluten sensitive, this can lead to a lot of stomach problems, a lot of nutritional deficiencies, which can have a flow-on effect then to things like osteoporosis and many other things.

Lisa: So eating wrong for who you are. If you're an athlete, you may need more protein and more things than you think you do, so more minerals. Make sure that you're taking that into account. Postmenopausal women, or those who have a gluten sensitivity, people on vegan diets and low-protein diets, they need to be more aware of what they're doing.

Lisa: Alcohol can cause nutritional deficiency, zinc and vitamin D deficiency, and alcohol is a poison of sorts. I know we all love our glass of wine or a glass of beer, but really think about it twice before you have that regularly, because it is going to, over the years, lead to many, many problems, not just osteoporosis.

Lisa: So gluten — just going back to gluten — there's a study that shows osteoporosis can be the sole symptom of those who are coeliac. So many people with coeliac disease have a reduced bone mineral density when they're first diagnosed, and some will go on to develop osteoporosis, and both men and women are at risk. So if you have coeliac disease, you'll also have an increased risk for developing osteoporosis at a younger age.

Lisa: I mean, if we all lived into our hundreds, we'd all get osteoporosis, so it's something that's going to happen. It's just a matter of when, and preventing it for as long as you possibly can — that's the thing that we want to do.

Lisa: So going back to the coeliac: according to pooled results of several studies, about 14% of men and premenopausal women with coeliac disease have osteoporosis — that's premenopause — and then nearly 40% have low bone density, also known as osteopenia, which typically precedes osteoporosis.

Lisa: So a gluten-free diet has been shown to significantly increase bone mass density in those with both coeliac disease and with bone loss. In the study, recently diagnosed coeliac patients with reduced bone mineral density were put on a calcium-rich gluten-free diet for a year, and after treatment the researchers found that bone mineral density increased throughout the body, including the spine, neck and hips, in most patients. And they also reported that increases were most significant among women and younger patients.

Lisa: Another study reported similar results, although gender and age didn't come into play. However, what's interesting about the study is that although 50% of patients experienced improvements in the lining of their gut on the gluten-free diet after one year, those with low bone mineral density still experienced a significant increase in bone mineral density, which provides more evidence that the effects of gluten go well beyond just your gut.

Lisa: Now, stress is another issue. Yeah, who's not dealing with stress nowadays? But stress is an issue that can lead to osteoporosis. So chronic stress activates the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system — that's your fight or flight. When you're in a state like this, which I know I am a lot of the time, it suppresses the secretion of gonadotropin hormone and growth hormone and increases inflammatory cytokines, eventually leading to bone loss by inhibiting bone formation and stimulating bone resorption.

Lisa: So what nutrients are important to take? Getting into the crux of this video, really: what can you take from a nutrient perspective to prevent and reverse osteoporosis? It's not an exhaustive list, the one I'm going to give you, but it's some common things that you should be monitoring and making sure that you're getting enough of.

Lisa: So magnesium is super critical. Magnesium does over, I think it's 300 things in the body, so it's not just for osteoporosis, but magnesium is a part of that matrix, and you want to make sure that you're having it as well as your calcium. But it's not just taking tons of calcium, and taking calcium without things like vitamin D3 with K2 and MK4 and so on can actually be detrimental. So you want to have these things in balance.

Lisa: Vitamin D3 with K2. I always take iron, zinc, B9 or folate, B12. B9 and folate are part of that methylation process; they do a lot of other things as well. One of the markers that you can have a look at is your homocysteine levels, if your doctor will check that, and if that's raised, that's an increased risk for cardiovascular disease, but also it impacts the osteoporosis story. So making sure that you've got adequate levels of folate and B12.

Lisa: Vitamin K2, both the MK4 and the MK7 — so typically we hear about the MK7, but actually MK4 I'm going to get to in a little bit and talk about a doctor's work that I really find interesting. Then selenium is another important thing, and strontium is not talked about very much either, and you can get that as a supplement as well. And then collagen, type 1 especially, and also type 3.

Lisa: And there's one that I wanted to particularly highlight known as tocotrienol, which is a form of vitamin E — the Delta is the most important one — and another one called geranylgeraniol, or GG. For a deep dive into this, I highly recommend the work of Dr Barrie Tan — that's Barrie, B-A-R-R-I-E — Dr Barrie Tan, who I will be interviewing soon on my channel. Dr Barrie is the world's foremost thought leader and researcher on vitamin E, on the tocotrienols. There are tocopherols and there are tocotrienols, and the tocopherols are nowhere near as powerful as the tocotrienols, and in fact the tocopherols can interfere with the function of the tocotrienols. I won't go into that, because it's another whole thing, but it's really, really fascinating. A lot of the research around vitamin E not being very good, it's because of the tocopherol story, not the tocotrienol. Tocotrienols are amazing, powerful, and you want to do your research on tocotrienols, especially the ones that come from something called the annatto plant.

Lisa: So again, go and see Dr Barrie Tan and look his work up, or wait for my interview with him. He discovered a plant that is solely tocotrienol without the tocopherols in it, which can inhibit the effectiveness of those tocotrienols, and this same plant is called the annatto plant. It also contains a second incredible bioactive called geranylgeraniol, GG for short, and this ingredient extracted from that plant has been shown to benefit bone and muscle health, and it's crucial in the biosynthesis of menaquinone-4, that's MK4, as well. It's also beneficial in the production of coenzyme Q10 and has pain and inflammation reduction activities.

Lisa: Now, MK4 is crucial for bone health, and it also helps take calcium out of the arteries. So for a deep dive into these two wonderful supplements that I definitely have my mum on, and myself — I have the Delta Gold tocotrienols and the annatto GG. I'm going to be having those in my shop, so if you're looking for those, head down below to the show notes to my shop. These are really, really powerful.

Lisa: So suffice to say, MK4 has been used in Japan even as a drug to prevent osteoporosis, at 45 milligrams of MK4. So that's actually used as a drug only in Japan, but they seem to know a thing or two, and it's not used anywhere else for that, unfortunately. But you can get it through this annatto plant. So reach out to me, or leave a comment if you want to know...

Lisa: ...more about this, and I might be able to help you. It is a clinician-only supplement in New Zealand, so I'm not going to actually have it freely available in the shop, but if you want it, I can help you organise to get it after a consult with me.

Lisa: Now, another specific supplement with clinical research to back it up is something called KoAct, and I'll put the link below to this one. It's a combination of calcium and collagen, and it's a chelate. There was a study done with 39 postmenopausal women — there was a three-month one, but also a 12-month one — and it was checking bone markers in the blood. Basically it was 5 grams of this KoAct, which is the calcium plus the collagen complex, and also vitamin D in it.

Lisa: It showed that the loss of whole body bone mineral density in women taking this was substantially lower than that of the control at 12 months. KoAct improved bone synthesis and reduced bone loss. KoAct counteracts the natural processes of bone loss in postmenopausal women. It improves bone mineral density. It improves bone mineral density better than calcium in postmenopausal women. It improves total body bone mineral density significantly better than calcium in three months. The biomarkers for bone formation were increased significantly with KoAct, and KoAct improves biomarkers for bone formation better than calcium. KoAct also improves bone strength significantly better than calcium in the animal studies, and we'll link to that in the show notes.

Lisa: The next thing I want to put on your radar is protein, protein, protein. Most of us are not getting enough protein. You need about 1.2 grams to 1.5 grams per kilo of body weight, and if you're a postmenopausal woman, go for that upper end. So for someone like me, around 56, 57 kilos, that's in the magnitude — I can't do my maths, but it's about 85 grams a day. That's quite a lot for me and I have to struggle to get that in, but eating that much per day would be really, really good. So good quality protein — most of us are getting nowhere near that much, and so that's really important.

Lisa: So the last thing I want to talk about is an osteoimmunology field. This is a new area of science that has found a link between chronic inflammation and bone health. So inflammatory compounds, i.e. cytokines, have been shown to influence the function of both osteoclasts, used for bone resorption, and osteoblasts, used for bone formation. Plus, chronic inflammation and poor bone metabolism accelerate the ageing process. Okay? Chronic inflammation and poor bone metabolism accelerate the ageing process, which is a risk factor for osteoporosis.

Lisa: Different epidemiologic studies report an increase in the risk of developing osteoporosis in various inflammatory conditions. So immunological dysfunctions, autoimmune and chronic inflammatory diseases — things like HIV, hyper IgE syndrome, rheumatoid arthritis, haematological diseases, in particular myeloma, and inflammatory bowel diseases — are associated with osteoporosis. Erosions seen in conditions such as gout, osteomyelitis, rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis are typically associated with inflammation in the joints and pro-osteoclastic cytokines, the ones that break the bone down, such as tumour necrosis factor alpha, or TNF alpha, and interleukins, which we mentioned earlier. Those are two that usually go up with age as well, just generally, and are elevated in these conditions. And the local cytokine profile is consistent with the cytokines that modulate bone resorption.

Lisa: C-reactive protein — now this is a marker that you can look at. The production of it in the liver is upregulated by IL-1 and IL-6, interleukin 1 and interleukin 6, and tumour necrosis factor alpha, and it is regarded as a sensitive marker of systemic inflammation. So keeping an eye on your C-reactive protein — sometimes it's called hs-CRP — and this is an easy one to get your doctor to do, usually. It's a generalised inflammatory marker. It doesn't tell us where the inflammation is coming from, but it tells us there's something going on and you need to have a look at it.

Lisa: An association between circulating high-sensitivity CRP level and bone mineral density has been observed in several immune and inflammatory diseases as well as in healthy individuals, suggesting a relationship between subclinical systemic inflammation and osteoporosis. So we want to keep all our inflammatory markers and our cytokines under control, not have an overactive, overstimulated immune system that's running amok. We want to make sure that we're taking things that lower inflammation — so some of the good things like fish oils and curcumins and some of the polyphenols, etc., which is again a podcast for another day, on all the anti-inflammatory things that you can do.

Lisa: One of my favourites at the moment is immune defence proline-rich polypeptides, which we're using in one of our formulations for our company, Aeon Labs. And there are many others: colostrum, lactoferrin — all these things that help lower the inflammatory response in the body, because it's low-grade inflammation that leads to ageing, that leads to osteoporosis as well.

Lisa: So let's just talk about bisphosphonates. Let me preface this by saying I'm personally not a fan of this class of drugs, because my own mother had a severe adverse reaction and nearly died after an infusion of Aclasta. She had a hypocalcaemic seizure, which is low calcium, and further complications. And it stays in the body for a couple of years, up to 24 months, so we'll be dealing with this for a long, long time. And I know personally of other cases of friends who have lost, and even lost loved ones, because of this drug. So I'm slightly biased, so do your own research on this one. They do have a place, but you want to know the ins and outs. You need to look at your particular case. Don't let yourself be bullied into taking them like I was, and I wish I hadn't now, with my mum, especially with her complicated history.

Lisa: So yeah, just be aware that there is downside. So what do they do, what are their side effects, when might they be useful, and what questions should you ask before taking these bisphosphonates? So bisphosphonates like Aclasta, Fosamax, Actonel, Bonviva, Didronel and others reduce the function of the osteoclasts, the ones that break down the bone, which sounds great, right? But there is a catch — but more about that in a minute.

Lisa: So some side effects: stomach irritation, oesophageal erosion, which can lead to not being able to eat well and more nutrient deficiencies; bone, joint and muscle pain, which leads to you not wanting to move, which is also bad; osteonecrosis of the jaw is a rare but terrible thing that can happen, so the death of the jaw bone — dentists usually pick this up in people who have been on it for longer periods of time; atrial fibrillation in the heart with long-term use; and then atypical fractures of the femur. The very thing you're trying to prevent is what this drug can cause if you're on it for the long term, and so they typically do, after three years, a drug holiday, they call it. But I don't know. So you have an increased risk also, long term, of oesophageal cancer, and an increase in bone brittleness — so that's that bricks in the house but not built in, just stuffing calcium into the bones, making them stiffer and more brittle than they need to be.

Lisa: Then there are things like biologics, like teriparatide, Forteo, and these utilise a segment of human parathyroid hormone to mobilise osteoblast activity and inhibit maturation of osteoclasts. Its side effects include nausea, constipation, low energy, muscle weakness, joint aches, leg cramps and more.

Lisa: So that was just a very brief overview on some of the standard drugs. All I can say is, it's not "definitely do" or "definitely don't", it's a nuanced conversation. If you are younger when you get diagnosed with osteoporosis and you have a long life ahead of you, then you really want to think twice about these interventions. If you're at massively high risk and you're fracturing just when you sneeze and blow your nose, then you're probably going to have to. But in between those, you need to do your research, get second opinions, look around and find good people to learn from before you get pushed into anything. In the meantime, do all the nutrients, do all the vitamins, the things that are low risk, do the exercise.

Lisa: So the last thing we didn't cover was resistance exercise. Cardiovascular is also good, but not too long — like I did, no ultramarathons, probably not great. Resistance work, weight training, putting your bones under load. In fact, I did a podcast with Osteostrong, one of the owners of an Osteostrong gym, and this is a gym that is specifically made to make strong bones, and they have a specific way of doing it with these amazing machines. Most of us are not going to have access to Osteostrong, which would be fabulous, but you can do a lot of good by going to your local gym and lifting heavy stuff under the guidance of a good trainer, obviously. If you're new to this, don't go and lift super heavy, you have to build into it. But even a little bit of resistance work — our bodies are a use it or lose it thing. You have to use your body in as many ways as you possibly can to prevent the breakdown.

Lisa: And that's something I truly believe as we get older. I don't just run, I don't just do weight training, I don't just do yoga or Pilates — I do them all. And I do balance, and I do stuff to calm my nervous system down. We need this whole sort of approach, not just a one-sided approach. And I know I have a lot of runners who listen to this channel. Running is very one-sided. Make sure you are building muscle. Build muscle — after the age of 40 you're losing muscle, and that's part of that anabolic versus catabolic. You want to be anabolic in the fact that you want to be building muscle, building bone, at least some parts of the year. And if you're smashing the crap out of yourself doing long, long distance stuff, that can be detrimental. And of course, sitting on the couch is definitely detrimental.

Lisa: If you're unable to exercise — like my mum is obviously limited in her capacity to exercise with her disabilities — I do things like red light therapy. It's an exercise mimetic. It's not going to replace it, but it can help, right? And you've got to do what you can do. I also do vibration plates. You've got to be careful they don't weaken your bones — if you've got really, really weak bones, just take that with the guidance of a medical professional before you start jumping into vibration training. But it can be really beneficial to strengthen bones, because again, it's putting load through without you having to actually do too much. So if you're immobilised in some way — I do get Mum on a vibration plate at a low level and try and support her bone density that way, as well as doing all of the supplements.

Lisa: There is a whole range of peptides as well, but I won't go into those today, that can be used for bone health. If you want to know about that, please leave a comment below and maybe I can do a podcast on that.

Lisa: And yeah, that's it for today. Thank you so much for listening, for getting to the end. I know a lot of that's very technical and very scientific, so well done if you got to the end. I hope you got a lot of value out of this. If you can, please, please share and like and follow this channel and subscribe on YouTube, and give us a rating and review if you're listening on the podcast. That would be really, really appreciated. And let me know where you're coming from, let me know your stories in the comments on YouTube. And yeah, thanks for being here. Really appreciate you.