The Dr. Hyman Show - How Inflammation Drives Osteoporosis

Episode Date: July 29, 2022

This episode is brought to you by Rupa Health and Athletic Greens.   Osteoporosis is very common, especially as we age, but it doesn’t have to be the life-threatening risk that currently it is. We���ve been led to believe that getting enough calcium is the key to healthy bones. In truth, your bone health is determined by your diet, gut health and nutrient absorption, physical activity levels, muscle mass, and more.   I talk with Dr. Todd LePine, Dr. David Ludwig, and Dhru Purohit about the myths surrounding bone health and why it’s important to take steps to strengthen your bones at every age.   Dr. Todd LePine graduated from Dartmouth Medical School and is board certified in Internal Medicine, specializing in Integrative Functional Medicine. He is an Institute for Functional Medicine certified practitioner. Prior to joining The UltraWellness Center, he worked as a physician at Canyon Ranch in Lenox, MA, for 10 years. Dr. LePine’s focus at The UltraWellness Center is to help his patients achieve optimal health and vitality by restoring the natural balance to both the mind and the body. His areas of interest include optimal aging, bio-detoxification, functional gastrointestinal health, systemic inflammation, autoimmune disorders, and the neurobiology of mood and cognitive disorders.    David S. Ludwig, MD, PhD, is an endocrinologist and researcher at Boston Children’s Hospital. He holds the rank of Professor of Pediatrics at Harvard Medical School and Professor of Nutrition at Harvard School of Public Health. Dr. Ludwig is codirector of the New Balance Foundation Obesity Prevention Center and founder of the Optimal Weight for Life program, one of the country’s oldest and largest clinics for the care of overweight children. For more than 25 years, Dr. Ludwig has studied the effects of dietary composition on metabolism, body weight, and risk for chronic disease. Described as an “obesity warrior” by Time Magazine, Dr. Ludwig has fought for fundamental policy changes to improve the food environment.   Dhru Purohit is a podcast host, serial entrepreneur, and investor in the health and wellness industry. His podcast, The Dhru Purohit Podcast, is a top 50 global health podcast with over 30 million unique downloads. His interviews focus on the inner workings of the brain and the body and feature the brightest minds in wellness, medicine, and mindset.   This episode is brought to you by Rupa Health and Athletic Greens.   Rupa Health is a place where Functional Medicine practitioners can access more than 2,000 specialty lab tests from over 20 labs like DUTCH, Vibrant America, Genova, and Great Plains. You can check out a free, live demo with a Q&A or create an account at RupaHealth.com.   Right now when you purchase AG1 from Athletic Greens, you will receive 10 FREE travel packs with your first purchase by visiting athleticgreens.com/hyman.   Full-length episodes of these interviews can be found here: Dr. Todd LePine Dr. David Ludwig Dhru Purohit

Coming up on this episode of The Doctor's Pharmacy. So if you have chronic gut, low-grade gut inflammation, that's gonna potentially increase your risk for osteoporosis. Hey everyone, it's Dr. Mark. Like many of you, I'm terrifically busy throughout the week. I'm a doctor, a podcast host, a writer, a speaker, a father. And on top of all those commitments,

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All you have to do is visit athleticgreens.com forward slash hymen. Again, that's athleticgreens.com forward slash hymen. And now, let's get back to this week's episode of The Doctor's Pharmacy. Hi, this is Lauren Feehan, one of the producers of the Doctors Pharmacy podcast. Osteoporosis is a common and life-threatening condition that affects the strength of bones. It is typically caused by inflammation, poor diet, and a sedentary lifestyle. As with other widespread health conditions, there are many things we can do to increase bone density and reduce our risk of brittle bones. In today's episode, we feature three conversations

from the doctor's pharmacy about the root cause of osteoporosis and why just taking a calcium supplement is not the answer. Dr. Hyman speaks with Dr. Todd Lapine on the drivers of brittle bones, with Dr. David Ludwig on why dairy is not the best prescription to strengthen our bones, and with Drew Prowitt on why your net amount of calcium is so important. Let's dive in. Osteoporosis is a condition that you don't want to have. You want to preempt it. You want to get the horse out of the barn.

By the time you have osteoporosis- Well, that's the thing. I mean, it's really the thing that often is killing people because if you're old and frail, you fall, you break your hip, and you end up with a blood clot, and you get pneumonia, and it's really a killer. And life expectancy a year after a hip fracture is dismal. It's like worse than cancer. It's like 50% life expectancy.

So it's no joke. And there's about 10 million Americans, older Americans that have osteoporosis, and about 43 that have osteopenia or low bone mass. That's like 53 million Americans who are headed for disaster. And it's one of those things that most doctors don't check. They don't really think about until the horse is out of the barn and you've already broken a hip or you've already got osteopenia or osteoporosis. And I don't know if it can start early. So why are we seeing this incredible rate of osteoporosis? Because we as a society drink so much milk and have so much calcium and we're told to take calcium.

But what is going on? Why are we seeing these incredible rates of osteoporosis? Well, you bring up a really good point, which is that most patients and most doctors think, oh, I just need more calcium for osteoporosis. Yeah, well, you bring up a really good point, which is that most patients and most doctors think, oh, I just need more calcium for osteoporosis. I need to drink more milk for my osteoporosis. And I'll never forget it. When I was in my primary care practice, I had a patient who was an older woman

who had severe kyphosis. So she had the hunchback. Yeah. And guess what she did for a living? She was a farmer and her family had a dairy farm. And guess what? She drank milk every day of her life. And she had the most severe case of osteoporosis I've ever seen.

That didn't work out so good for her. Exactly. Right. And I think, as I mentioned earlier as we were talking, is that for every 200 grams of milk that you drink, you have a 9% increased risk for osteoporosis. Okay. So every glass of milk that you have, you increase your risk of osteoporosis by 9%? Yeah. Of a fracture or osteoporosis?

Osteoporosis. A fracture though. Yeah. I mean, this is incredible. I encourage people to check out this brilliant article in the New England Journal of Medicine. You can just go online and Google, it's called Milk and Health by Dr. David Ludwig and Walter Willett. And it really is one of the most well-researched, profound analyses of all the data on milk and whether or not there's any data to support its health benefits. And I do believe it's nature's perfect food,

but only if you're a calf. Because for humans and adults, it seems to cause a lot of issues, including osteoporosis, so it doesn't decrease fractures. So, but that's not the cause of osteoporosis. What are the real causes in our society of osteoporosis? Why are we seeing these high rates? Because it seems like a design flaw.

Why are we seeing such high rates of osteoporosis in this population? Well, I mean, there's the risk factors for osteoporosis. Obviously, as you get older, you will lose some bone mass. I mean, that's part of the aging process. And I always want to look at the risk factors. So women are more prone towards that. Is it aging or is it what we do while we're aging? Inflamaging.

Inflamaging. Is it what we do while we're aging that makes us age faster? Yeah. Actually, it's inflammation. Chronic inflammation is one of the big things that's tied in with osteoporosis. And there's a term called inflamaging. So as you age, your body can develop more inflammation. So chronic low-grade inflammation, patients who have colitis,

patients who have rheumatoid arthritis are at higher risk for osteoporosis. Patients who have heart disease. That's right at higher risk for osteoporosis. Patients who have heart disease. Yeah, absolutely. Absolutely. So there's this phenomena where we're seeing high rates of osteoporosis. And as I dug into it, and one of the things we had to do at Canyon Ranch is we had to give lectures three or four times a week. And one of the lectures I gave was on osteoporosis. I got really smart about it. And we also, at Kenya Ranch, it's a lot of preventive screening. And we used to do a lot of DEXA scans. Now, a DEXA scan is a special machine that is a low-dose x-ray.

It's like flying across from New York to LA, that amount of radiation you'd get when you fly in a plane, very low dose. And it looks at the bone density. So you can see on this very low-dose x-ray whether or not you have thin bones or strong bones and where they're weak or where they're thin. And so we treat a lot of patients. But I gave these lectures. I started looking, why are we seeing such high rates in this society?

And we came up with so many different factors. Our diet. We know that sugar, alcohol, caffeine, salt, and even what is consumed in massive quantities, about 10% of our calories, soda, phosphoric acid in sodas and the colas is incredibly dissolving of your bones. Stress makes your bones soft. And of course, lack of activity.

We're all sedentary. We don't use our bodies. And you mentioned aging, but if you keep up your muscle mass and if you keep up your activity level, you can maintain your bone mass. We often talk of osteopenia or osteoporosis, but we don't talk of sarcopenia, which is the loss of muscle, and that's what goes along with bone loss.

So you have all these factors, and we're literally peeing out calcium. Yeah, exactly. In our urine because, you know, in some countries like in Africa, they have like intakes of calcium of two, 300 milligrams a day, but they don't really have osteoporosis. Here we have intakes of a thousand or 1500 milligrams a day and we see high rates of osteoporosis. What's the difference? It's not the total calcium.

It's the calcium balance. It's what you're peeing out compared to what you're taking in. So in Africa, they're not doing all these bad things and they're not losing their bones and their urine. And we actually have tests where we can measure if you're peeing out your bones. When you do that at the Ultrabundas Center here,

we measure markers of increased bone turnover because there's this constant dance, right, between bone buildup and bone breakdown, right? Exactly. And so we've got to kind of make sure we're constantly pushing the bone buildup and not so much the bone breakdown. Exactly. Yeah, the osteoclast, the analogy of it is like somebody building a wall. And osteoclast, which are the cells that break down bone, and then there's the osteoblasts, which the cells that build up bone. And normally our bodies are constantly doing it in a balanced way. So there's just as much bone breakdown, turnover, and then you rebuild the bone. When you have too much osteoclastic activity, which happens in chronic inflammatory conditions,

then what you're doing is you're breaking down more bone than you're building up. And the other important thing, which is also, it's not actually determined by DEXA scanning is the quality of the bones. Yeah. So tell us about the quality of the bone, because you can look at a scan and see it's good or not good, but what if it's more fragile or brittle? Exactly. So you want flexible bones. You want bones that bend. You want bones that are a little more rubbery, if you will. And I remember this very well because when I was in my training, one of the things that they used to give for patients with osteoporosis was fluoride. Do you remember using fluoride? And what they found is that, guess what? You did get denser bones with taking fluoride, but guess what? The bones were more

brittle. So they broke. So you want actually healthy quality bones, not just the density, but it's the quality of the bones. And what determines the quality? The connective tissue that's in the center of the bones. It's not just the calcium, it's the connective cartilage tissue that's in the center of the bones that makes it healthy. And that's also, this is a very simple thing to remember is one of the big things that increases a person's risk for osteoporosis is smoking. And I always tell my patients, you know, you ever see somebody who's a chronic smoker? What do they have? Wrinkles. Okay. They have more wrinkles. Right. Smoking upregulates matrix metalloprotease enzymes, which are breakdown collagen. And that's why

patients who are smokers have higher risk for cardiovascular disease, higher risk for osteoporosis because they're actually breaking down their connective tissue. Wow. Yeah. That's another reason to stop smoking. Exactly. Right. Well, actually, it's funny because if you have a woman who's a smoker, oftentimes, one of the things I'll tell them is, well, you don't want to have wrinkles and they'll stop smoking.

Because, you know, the vanity, that name is woman. That's right, that's right. Well, you know, you mentioned something I want to come back to, which is this whole idea of inflammation. And we've talked about all kinds of conditions on this podcast and the house call. And the truth is most chronic illnesses

are related to inflammation. Heart disease, cancer, diabetes, dementia, depression, autoimmune disease, obviously. But osteoporosis just seems a little bizarre to be related to inflammation. How does that work and how do we identify what the factors are that are causing the inflammation that leads to osteoporosis?

Well, yeah, there are measures that you can do to check for sort of low-grade inflammation, things like HS or high sensitivity C-reactive protein, glyc-A, looking at their diet. So an anti-inflammatory diet helps to decrease inflammation. Looking at essential fatty acids are also important. Looking at whether or not there's any silent gut inflammation. When you do stool analysis, you can check for markers, which I call my CRPs of the gut, which is calprotectin. So if you have chronic gut, low-grade gut inflammation, that's going to potentially

increase your risk for osteoporosis. If you have sort of low-grade osteoarthritis, rheumatoid arthritis, which is more severe than osteoarthritis, it's more of a significant joint destructive inflammatory arthritis. Those are things which break down bone very, very slowly. It's like a slow leak. And our American diet, our standard American diet, is a very inflammatory diet of processed foods, sugars, refined oils, and lack of protective anti-inflammatory foods, which are the phytonutrients and plant foods. And so we get this incredibly upregulated immune system, which is why we're all suffering from COVID in America.

We've had over 11 million cases, over a quarter million deaths to date as this recording. And I think we're uniquely susceptible because we're so inflamed. And osteoporosis is one of the victims of inflammation. Our bones are one of the victims. And it's from leaky gut, it's from our processed diet, it's from a lack of protective foods. So we really have an opportunity to really change that dynamic and shift the balance from bone breakdown to bone buildup, right? Exactly. Healthy bones. Yeah. And how do we normally treat this with traditional

medicine? What is the general approach in terms of diagnosis and treatment? Well, diagnosis, as we mentioned, is really with DEXA scan. And I always like to emphasize, especially as women tend to have osteoporosis more than men, but men can get osteoporosis, you know, and there are certain medications that can do that. But I actually think that one of the ideal things to do is to actually get your bone density checked when you have no symptoms whatsoever. When you're at peak bone mass, which is around 30 to 35 years of age, you want to know what your bones are then. What your baseline is.

Right, exactly. Because I can't tell you the number of times that I've seen a patient, and they're a woman, especially a woman, they're entering into the menopause. And I ask them, have you had your bone density test checked? No. Well, I said, well, you need to actually have that checked. And if you have one when you're at peak bone mass, is around maybe 20 25 to 30 years old and then you get one as you're entering menopause of the perimenopausal area then you can see okay where are your bones going where are they going you have two

points one data point doesn't show you much two data points show you a trend of it is going up going down staying the same very very important information so make sure you get your bone density early and at intervals that are depending on what your bone density shows if you're great at 30 you can probably wait till you're 50 yeah but if you're menopause you want to check more and men men men get osteoporosis too absolutely men get osteoporosis it's not exactly anybody can get it and you know again you know high levels of alcohol high levels of caffeine the ppis which uh acid are acid blockers, big ones. Okay. That's the third leading most prescribed drug in the world. And it's an acid blocker.

And if you take this like for heartburn or reflux, you're going to get osteoporosis because you're inhibiting mineral absorption, right? That's like Protonix, Prilosec, Asifex, Nexium, all those drugs. Yeah. Chronic steroid use is a big risk factor for osteoporosis, a huge one. And then, as I mentioned earlier, smoking. And then just sedentary lifestyle. If you're not stretching your bones, you're not putting stress on your bones. I remember when I was in my training. Use it or lose it, basically.

Use it or lose it. And there's actually an interesting thing. It's called Wolf's Law, which is that bone responds to stress. And I remember reading this article, looked at astronauts. They were in their young, 30 years old, and they went up into outer space. And guess what? In outer space, you float around. There's no stress on your bones.

And when they came down on planet Earth, they actually lost a significant amount of their bone mass because they were not having the body. And it says, oh, you know, we don't need our bones. We're just going to jettison. It's like a balloon where you jettison the balus and you get rid of the bones that you don't need. So our bodies naturally will make stronger, better bones when we respond and use stress, weight resistance exercise, bands, you know, resistance machines, et cetera, is very, very important for maintaining good bone mass. And let's get back to the diagnosis part.

Because, you know, you do a DEXA scan. Let's say you have low bone density. What do you look for next? Because there's a lot of things that doctors don't often check that we look at here. What do you think about? What are the most common things that maybe a traditional doctor might look at? And what are the tests that we might do that are quite different?

Oh yeah, so some of the tests that we'll do is the, as I mentioned, the DEXA scan. We will then do urinary bone resorption. So we can actually measure the collagen breakdown products like NTL-O peptides in the urine. Basically, you're peeing out your bones. We can check that. Exactly. When you lose your bones, you pee them out.

That's exactly right. You can do that. Measuring the vitamin D level is very, very important. That's another. Yes. Vitamin D helps to regulate calcium and calcium metabolism. Far more important than calcium. Yeah, way more important than calcium.

And then the other thing that's also important is to realize is that you do not wanna take too much calcium. And I actually tell my patients, I don't want you actually taking a calcium supplement most of the time. I want you getting it through your diet. Yes, exactly. And if you do take it in a supplement form, you probably don't need, uh, and you don't want to go over probably about 600, 500 to 600 milligrams. And there's studies showing that women who are taking higher doses over a thousand, like 1200, 1500 milligrams, they actually get more calcification

in their arteries too. Yeah, well that's, the calcium is nature's band aid. So wherever there's inflammation, calcium goes. And so when you talk about hardening of the arteries, it's so many calcium buildup in the arteries and plaque. So that's not good. So we look at vitamin D, we look at the bone density, we look at the bone resorption, we look at-

Vitamin K. Vitamin K. Vitamin K is a big one. Which is a vitamin made in your gut. And if you don't have a good microbiome, that can be a problem. Exactly. Yeah. So there's actually two forms of vitamin K.

There's the vitamin K that you find in plants and the vitamin K that you make from gut bacteria. And vitamin K is traditionally thought of as a vitamin which helps with clotting. But vitamin K actually has an effect on bone density. And it's very, very important to get adequate amounts of vitamin K. So you can actually take low levels of vitamin K and that can help with clotting issues. But you need much higher levels of vitamin K to have a bone effect. And we do the test here, which is a mouthful, but it's called under carboxylated osteocalcin. And it is a biomarker for a functional vitamin K deficiency. And this is a test I love to do in patients.

Yeah. People don't know about it. Doctors don't usually take it. It's, yeah. Yeah. There's, right now there's only one lab that actually does it. But measuring that can tell you whether or not you have a functional vitamin K deficiency. And I oftentimes, and most of the time, if I'm giving vitamin D, I will give vitamin K at the same time. Otherwise, you'll start getting calcium deposition in tissues that you don't want to. That's right. And then there are other conventional things that often get looked at, like parathyroid hormone. If you have a tumor on your parathyroid gland, it causes more bone turnover. If you have certain cancers like, you know, blood cancers,

but you can look at protein levels in the blood that look like protein can be affecting bone health. And also, you know, people can get weird things like Cushing's or adrenal tumors or brain tumors that cause high steroid levels in the body. So there's a lot of things that we look at. Most of those don't turn out to be, it's mostly the age-related, just general sedentary life, bad lifestyle habit, osteoporosis.

But we also look here at the Altra Juana Center at a lot of other things that give us clues about why you might have a problem. For example, we look at the gut. Because if you have leaky gut, you could drive inflammation that causes problems. If you have digestive issues and not absorbing minerals, if you're taking an acid blocker, we care about that. And also gluten is a huge cause of osteoporosis. People don't realize that if you have celiac for sure, but even if you have low grade non-celiac gluten sensitivity, definitely it causes leaky gut, impairs absorption. So there's a lot of things we look at that may be different than what you see at a normal practice.

Yeah. It's interesting you mentioned that because one of the biggest risk factors is having celiac disease because gluten issues can affect mineralization. And one of my take-home things when I do with patients is I often ask them, because I have a family of dentists, is I often ask how many fillings do you have, do you have any cavities, do you have weak teeth? It's a very common thing. People say, well my dentist said I have weak enamel. Well, why do you have weak enamel?

Well, guess what? Celiac disease is associated with enamel defects. So not only do you have weak enamel, you've got weak bones. Yeah. Yeah. So we do this workup and someone has osteoporosis. On a traditional doctor, what do they give them?

Usually the bisphosphonates. Those are the things like- Like Fosamax, Actenel. Fosamax, Boniva, Actenel, those kinds of things. And the interesting thing about them is they have a not so good risk benefit ratio. You can get significant side effects. You can get osteonecrosis of the jaw.

They're not to be used. They're not risk-free. They're not risk-free. And they're not cheap. And there's injectable drugs. They do them injectable now. And also there's Forteo, which is like a parathyroid hormone-like drug.

And sometimes doctors even use drugs like Avista, which blocks estrogen receptors. They're selective estrogen blockers. And of course, doctors use hormones like estrogen therapy, although that comes with certain risks. And even in men, testosterone therapy. So these are all therapeutic options out there, but we take a different approach in functional medicine. So what would be an approach that we would focus on with osteoporosis that's different? Where do you start with patients and how do you build up the treatment model for them? Well, the first thing I get people to do is to start using their bones, start using their muscles. So getting people to

the gym, you know, doing some resistance exercise at least three days a week where you're really stressing the bones is going to be the biggest thing. Optimizing their vitality. Strength training, weightlifting, bands, body weight exercise. You just really need to push your bones. And at the same time, you're building the muscles. And then you're also helping with balance. So it's not so much that when you fall, because everybody falls, okay? But you want to have the muscles and the reflex time to be able to catch yourself so that you don't necessarily break something. That's right. So really important to have the muscle mass and the reflex time to be able to catch yourself so that you don't necessarily break something. That's right. So really important to have the muscle mass and the-

It's true. Yeah. Core strengthening exercises are so important. People have just so low stability as they get older and they lose their balance. And that's an important point. And then also optimizing vitamin D levels. And we actually will do some genetics related to that.

And interestingly, there are some gene variations related to the vitamin D receptors. So people who have genetic variations of the vitamin D receptors need higher levels than quote unquote normal. So if you look at the range of normal vitamin D, the standard laboratory is about 30 to 100. And if you're at 32, your doctor will say, oh, you're fine. You have enough vitamin D. Well, guess what? If you have a problem with the polymorphisms related to the vitamin D receptor, you need to have that be on the higher end. You may need to be up to about 80 to 100 in order to have the beneficial effect. That's right.

So we really focus on exercise and strength training, focus on vitamin D levels. We also do a lot with diet, right? Because you want to eliminate the bone dissolving things in your life and your lifestyle and your diet, and you want to add the bone building things. So what are the bone dissolving things we want to help people get rid of? And you talked about it a little bit, but Yeah, well, oh, excess amounts of protein. And also if you have, um, uh, acidic urine, you're,

you can actually be more susceptible to more or less peeing out your bones. So, um, uh, decreasing, uh, those things, actually be more susceptible to more or less peeing out your bones so um uh decreasing uh those things which is our processed diet will cause you to be more acidic exactly and then the green leafy vegetables uh are very good uh and then you know things like sardines which are great because they're they have natural uh sardines are one of my favorite foods because guess what they got great protein they have great omega-3s and they have great calcium and it's highly absorbable calcium. So if you want to actually help your bones,

eat sardines. Yeah, herring, sardines, mackerel. That's what I remember for lunch. Mavin, canned mackerel. They get ones with the bones in them, it's even better. Exactly. That's how a lot of the populations

who lived on islands would get their calcium. They'd eat the fish bones. Yeah. Yeah. So getting rid of things like alcohol, caffeine, excess salt, excess protein, too much sugar, obviously all the sodas, the junk food, the food additives, that's so important. And then adding in all the foods that are going to build your bone, like the sardines or herring

or mackerel, but also the greens. I mean, where, where do cows get their calcium from? Grass, right? So you can actually get more calcium, more absorbable calcium from things like tahini, which is sesame seeds. Sesame seeds is probably the highest source. Chia seeds have more calcium per serving than milk. And it's better absorbed. Plus omega-3s and fiber.

All the dark green leafy vegetables that you mentioned. The vitamin K is also in these green leafy vegetables. So your omega-3s and fiber. All the dark green leafy vegetables that you mentioned. The vitamin K is also in these green leafy vegetables. So your omega-3 fats are really important, which you can get those from the sardines and the fatty fish. So a lot of foods that are bone building foods. So we do need calcium. There's no question. Your bones are made primarily of calcium and phosphate.

But how much calcium. And the minimum requirement to have perfectly healthy bones are probably at most a half of what has been traditionally viewed as necessary in the United States. In the UK, their minimum calcium requirements are about a half of what they are here. And in some populations, like in South America, the adults do perfectly well getting even a third or a quarter of the amount of calcium, like 300 milligrams a day. So that level of calcium can be obtained from – so if you're going to get a gram or more a day of calcium, milk is sort of the obvious source. But if you accept that we don't need that much,

500, 600 milligrams a day are probably more than sufficient, well, that's easily obtained from just a basic diet. A serving of kale is going to get you a third to a halfway there. A serving of sardines, nuts, seeds. Chia seeds, tahini, those are my favorite. I mean, one of the things you said that I just want to come back to, which is really important, is this whole idea of calcium balance. And when you look at countries like Sweden that you wrote about in your paper,

they have the highest intakes of calcium and the highest risk of fractures. And countries like Indonesia and China have the lowest intakes of calcium and the lowest risk of fractures. And countries like Indonesia and China have the lowest intakes of calcium and the lowest risk of fractures. So one of the things I remember when I was a medical director at Canyon Ranch, I often talked about was osteoporosis. And it was really clear that there are a lot of things in our culture that drove calcium loss. So it's not just about how much you take in, it's how much you pee out, right? So caffeine, alcohol, sugar, phosphoric acid from sodas, too much meat, perhaps. I don't know if that's true, but that's what it seemed to be, the high protein acid load. All these things, stress, all these things cause bone loss. And if you mitigate those, in other words, you cut those out of your diet or you reduce them,

and you deal with stress and you deal with the fact of how you're losing calcium, that your net-net may be better than if you're taking super high levels of calcium. And the other thing that's interesting to note is that, you know, cows get their calcium and have great bones. Where do they get it from? Grass, right? They're drinking milk. They're drinking three servings a day. For a little bit and then they don't, and they're getting it from grass. So why not? Why get secondhand calcium? Green leafy vegetables are actually a very good source of calcium. You know, kale, a serving of kale has almost as much calcium as a serving of milk, and you get many fewer total calories that way. But let's go back to these ecological

comparisons. Those are the comparisons where you look at different countries and see different risks. It's important to understand that there are limitations to those kinds of analyses. What they do convincingly tell us is that it's possible to be a human being, consume no milk, relatively low levels of calcium, and have low fracture risk. The problem with these studies is that they're very confounded. So when you look, compare the Swede to the Filipino, there's a big difference in height, and height is a major risk factor for boning fracture. So ironically, it may be that milk consumption in adolescence, in childhood and adolescence, actually increases risk for fracture in adulthood. So how could that be?

We've talked about that you don't really put away a calcium bank in childhood. You don't get that benefit. But the one thing that is pretty clear that milk does in childhood is accelerate growth. It's not hugely, it's not gonna turn a, you know, a horse racing jockey into a baseball player, but you get about an extra centimeter for every additional serving glass of milk a day. So maybe, and this is a population average, but so maybe for comparing low and high consumers, you grow an extra inch. But on a

population basis, that increased height is one of the major risk factors of having a fracture. You know, simply put, the bigger they come, the harder they fall. Sam's kind of screwed. I'm like six foot three. I would just advise you don't fall. Well, I'm working on my core strength and muscle mass, and that also helps mitigate it. But this is one of the first myths to go. The drinking a lot of milk as a kid is going to reduce your risk

of getting a fracture in his adulthood. And if anything, it's the opposite. So this is the basis for our recommendations, which is you need calcium-preventing osteoporosis, and that's why our guidelines tell us to have three glasses of milk a day. Yeah, well, you do need calcium. You just don't need that much. And the amount that you need can be obtained from other sources. And so what about the idea of weight?

Which, again, is not to say that milk is inherently bad or toxic. I mean, you know, we talked about one situation where it could be helpful. People with borderline nutritional status, when they drink milk, they're drinking, you know, you're drinking like a glass of milk, and maybe you just have two cookies after school as a kid, instead of having the whole package without milk, or with fat-free milk, which doesn't taste very good, and isn't very satiating. Yeah, I want to get into the fat-free thing in a minute, because I know that's your favorite topic, but I just want to sort of summarize here about the calcium story, because what you're saying essentially is that all the data, and there were over 100 papers you reviewed, all the data really didn't point to

a benefit of increased calcium intake through supplements or through dairy, and that there was potential risks as well. And then it wasn't just a benign intervention, that there may be increased risks with increased calcium intake in different situations, whether it's cancer or whether it's from perhaps the high levels of calcium causing greater growth and fracture risk. We don't know, but it's not a slam dunk. So you think based on the current data that you reviewed in the New England Journal of Medicine study, you think that the government should change its dietary guidelines? Well, let me just say, so, you know, we talked about the trade-offs and milk.

So one downside of extra growth we talked about was fracture risk. But another downside of being tall is cancer risk. Being the taller you are, the higher your risk of cancer. Partly it's more cell. You're okay. You're taking good care of yourself. But first of all, you've got a bigger body. But the other thing about milk is to consider how milk has evolved.

I mean, the purpose of milk is to help grazing animals on the plains of Africa, you know, the infants that are at high risk of being eaten by the local carnivores, grow rapidly so they can be strong enough and fast enough to be free of predation. So that's a very strong selective fitness factor, this evolutionary drive to get these baby ruminants, the gazelles and the other grazing animals, to grow very quickly. So that's a good thing, except if you're consuming these foods that stimulate growth in children,

but in adults, these growth factors that may be stimulating biological systems that relate to cancer. And while the data are definitely not clear yet, there seems to be evidence of cancer, of high levels of dairy consumption causing prostate cancer in men, especially aggressive forms of prostate cancer and endometrial cancer. Although, interestingly, milk intake may protect against colorectal cancer, and that may be an effect of the calcium. You know, the issue around growth is very interesting because there are 60 different naturally occurring hormones in milk, not including the ones that they pump into the cows or that they milk them all pregnant or that they give them for growth factors. So these are just naturally occurring. And the purpose of

these is to grow a little baby calf into a big cow very rapidly, like you said. So I think, you know, that might be good for infants, but it's probably not good for long-term, long-term health. And it's worse now because of modern industrial farming, because in the, you know, a hundred years ago, you'd, you know, send the cows out, they'd get pregnant, and you wouldn't be breast, you wouldn't be milking them during pregnancy. The baby cow would be born, would feed a little bit, and then you'd milk for a while until the next cycle. But now in hyper-efficient industrial agriculture, cows are being milked throughout their pregnancy. And so those hormones that would be normally present in pregnancy, estrogens and progesterones and other hormones, get dumped into milk.

So the milk supply is, even though milk normally has many growth-promoting factors, it has even more so today. So that's something to bear in mind. And even if you're having organic milk, it could still be the case where you're milking pregnant. Organic milk, unless you're getting it from a local farm that's using more traditional, low-intensity agricultural practices, organic milk's not going to be any different in that regard. So, David, in terms of the recommendations, I want to sort of pressure a little bit on that, because I think we have a government that's telling us we should be having three glasses of milk a day and we can't have school lunches without milk. Do you think that's the right policy? Do you think it needs to be modified? What should we do? It's wrong. We came forth in our paper,

at least in our opinion, quite clearly that there is no evidence basis for all adults eating three servings of dairy a day, milk or milk equivalents. And we recommend zero to two, which takes into account that milk and dairy products have been traditionally part of many cultures. They can be delicious, cheese, yogurt, and fermented dairy products actually look very good. They tend to be in the best epidemiologic studies consistently popping up as among the most protective foods we eat.

Now, that might not have to do with the inherent dairy per se, but the fact that yogurt is one of the few naturally fermented foods that remain in our diet. A hundred years ago, most cultures, Germany or France, where a lot of what we would have eaten would have been fermented at least through the winter. But now very, even the foods that people think are like pickles aren't naturally fermented. They might be chemically treated to pickle them. Whereas yogurt, especially if it's not sugar sweetened, is one of those traditional fermented products that may be beneficial to the gut microbiome and have other, you know, health Yeah, I mean, that's important we just said, the sweetened ones.

I mean, there's more sugar per ounce in sugar-sweetened yogurt, like fruit-sweetened yogurt, than per ounce of soda. So it's definitely not a health food when you add the sugar in. And I think that the question then comes to – So we're not arguing to get rid of dairy products, but we just don't think that this super intense consumption, I mean, three servings a day, which would make dairy products among the most dominant source of calories for any single food in many people's diets.

We think there's no evidence basis for that. And for people who, we don't think that there's going to be much harm from consuming one or two servings a day, but for people who are not consuming any dairy products and eating a high quality diet, they shouldn't feel badly about that choice. There's no reason to suddenly dump in a lot of dairy. The osteoporosis is really a common problem. And as we chatted about earlier, one of the challenges is if your bones get thin and weak and you fall and break a bone, particularly a hip as you get older, it's like getting a terminal cancer diagnosis in terms of your risk of death.

So it's really quite shocking. I think 50% of people who get a hip fracture die within a year. So that's not great. So you really don't want to get osteoporosis. And historically, you know, we really didn't have a lot of it because most of us were out there working hard, using our bodies and eating a very nutrient-dense diet. And unfortunately, the dogma has been that if you want to prevent osteoporosis, you have to drink a lot of milk and take a lot of calcium. Unfortunately, that's not true. And the got milk ads were taken off the air and out of magazines because the FCC, the Federal

Trade Commission, which regulates truth in advertising said, there's no data, you have to stop advertising. And by the way, these ads were part of a campaign that's a government-sponsored program called the Checkoff Program, which partners with industry to help, quote, do research on various nutritional and agricultural products. But unfortunately, it's used to actually promote products. It was a kind of a government-sponsored program with the Dairy Council that put these ads out without a lot of data. Now, you don't take my word for it. You simply need to Google milk and health. And Walter Willett and David Ludwig are the authors, Harvard researchers, who reviewed all the science and published it in the New England Journal of Medicine, again, the top medical journal in the

world, showing that not only was milk not good world, showing that not only was milk not good for your health, not only was milk not good for fractures, but your risk of fracture went up by 9% for every glass of milk you had. So it's actually the opposite. Also, calcium supplements, not so great either. And it's not about the calcium you're eating, it's the calcium you're losing. So if you look at what really makes the most difference for bones, it's the calcium you're losing. So if you look at what really makes the most difference for bones, it's vitamin D. And if there's one thing I would say to you is make sure your vitamin D levels are 50 to 75. That is so important. And I say what your vitamin D levels are, not what vitamin D amount you should take, because it's different for everybody. Some people

might get there with a thousand units of vitamin D. Some people might get there with 5,000 or maybe 10,000 based on their genetics or their absorption or various issues. So don't think that milk is going to help you, number one. Take vitamin D, number two. And number three, understand that you need to have not only the right nutrients in your diet, but you need to exercise. And before I get into the exercise piece, I just kind of want to come back to this calcium issue. If you look at calcium intakes, for example, in Africa, I mean, they might have three, 400 milligrams of net calcium intake a day, but they actually have very, very strong bones. Now, if you look at American intake, they're saying take 1,500

milligrams of calcium a day. Well, it doesn't matter how much you're taking in. It matters how much you're losing. And we have a calcium losing environment. What do I mean by that? Well, if you have sugar, if you have caffeine, if you have alcohol, if you have soda, it's the worst, like the colas particularly have phosphoric acid in them. That causes you to lose a tremendous amount of calcium. If we eat an acidic diet, which is processed food and sugar and so forth, that acidity causes you to lose calcium. So you're basically peeing out your bones, literally peeing out your bones in your urine. And we actually can do a test to measure this.

I do this with women who come to see me with osteoporosis. I measure their urine levels of certain markers that tell me that their bones are dissolving and are coming out in their urine. So it's really, really important to not look at the total calcium intake, but the net calcium retention. So you could be, for example, taking in 300 milligrams of calcium and losing 200. That means you're up 100. If you're taking in 1500 and you're losing 1700, you're down 200. So it really matters what your net calcium absorption versus your net calcium losses. And that, and then all those things I mentioned are the things that cause calcium loss. And there's, there's lots more. So really important to look at, at your diet as a key factor and making sure

you're eating a nutrient dense diet, making sure you're not doing the things that cause you to lose calcium and make sure you're taking adequate vitamin D. Now, you say, well, why do I need vitamin D? Because, you know, hunter-gatherers never had vitamin D, and they didn't have bad bones, and why do I take vitamin D? Well, sure, if you want to go around in a loincloth naked, outdoors most of the time, you know, hunting and gathering and getting sun exposure on your whole body, go ahead.

Or if you're going to be living in a coastal area, if you're eating only wild, wild fatty fish all the time with lots of vitamin D, okay. If you're hunting and gathering and eating like tons of wild mushrooms, you're probably okay. But most of us don't do that. So most of us live and work inside and we need plenty of vitamin D and we can get it through vitamin D supplements. Unfortunately, I think we have to take them. It's one of the most important things we need to do. It also helps so many other things like immune function and COVID prevention and many other things. In fact, one study I think was from Israel, they found out their vitamin D levels were over 50, there was zero death from COVID. So

it's a really critically important nutrient. So you kind of have to make sure you're not actually losing calcium, that you're actually getting vitamin D, and that you're then exercising. So you can do all the right things, but if you actually are not exercising, it's like putting all the ingredients for soup in a pot on the stove, but not turning on the heat, right? You're not going to make soup. It's just going to bunch of ingredients in the pot with no soup. So you have to turn on the heat, and that's exercise. And I've seen women, even at 70 years old, take seriously exercise.

One of them started like a vinyasa yoga practice, like a power yoga practice. She increased her bone density by 10%, which is more than any of the drugs you'll see. Now, you mentioned you don't want to be on hormones. It's too late for the hormones. Well, that's not true. You can sometimes use hormone therapy like estrogen, progesterone, testosterone. And by the way, testosterone is a great bone builder. And a lot of women have low testosterone and women can actually take testosterone. Women have testosterone, men have estrogen. It's not like it's sort of a binary thing. It's just that women tend to have more estrogen, obviously, and men have more testosterone. But you have to have the right balance for your sex.

So you can, through a number of lifestyle factors, really, really improve your bone density at any age. There are certain things that really tend to cause osteoporosis that are concerning that may be not thought of. Like, for example, leaky gut and gluten. Gluten is a huge factor because it causes all kinds of problems in the gut, absorption, and a lot of osteoporosis risk comes from gluten issues, which, by the way, may affect up to 20% of the population in some level of gluten sensitivity, or we call it non-celiac gluten sensitivity. Like 1% has true celiac and that they're really at risk, but even the non-celiac gluten

sensitivity people have an issue. So, you know, you want to make sure you're really taking your bone health seriously. And that's why, you know, I've really doubled down on my exercise and strength training, and I really focused on it. And I really, I made sure that I really take adequate vitamin D and exercise and my bone density, it keeps increasing, which is amazing. So even as I get older, I get better. I hope you enjoyed today's episode. One of the best ways you can support this podcast is by leaving us a rating and review below.

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