Welcome everyone to another edition of the Doctor’s Note where we talk about what’s on our minds when it comes to your health.
This past week I invited Dr. Doug Lucas to join me on the Common Sense MD podcast to talk about bone health and his approach to identifying, preventing and reversing osteoporosis. I’ve never heard anyone talk about bone health the way he did. I connected with his passion for prevention, his courage to blaze new trails, and his insight for the future of medicine.
In this Note, I will introduce Dr. Lucas and give a brief outline of our conversation. Hopefully, it will encourage you to check out his website and listen to his podcasts. There is hope for optimal bone health!
Let’s get started.
Intro to Dr. Doug Lucas
Douglas Lucas, DO is a retired orthopedic surgeon who transitioned into functional medicine. He is currently the CEO and Founder of two sister companies: Optimal Human Health and Optimal Bone Health. His story is similar to mine.
Dr. Lucas was trained in the traditional medical model for orthopedic surgery, doing his residency at Ohio University and finishing with a fellowship in foot and ankle surgery at Stanford University. Like me, he got frustrated practicing traditional medicine, and even though he was doing a lot of good (i.e. surgery, fixing fractures, etc) he could have a greater impact by addressing the root cause.
Note: Osteoporosis is one of those diseases (like diabetes, dementia, cancer, and cardiovascular disease) where our traditional medical system fails to prevent these things from happening. We’re good at treating, but not preventing!
Dr. Lucas went on to pursue two more fellowships, one in epigenetics from The Academy of Preventive and Innovative Medicine and Wild Health, and the other in anti-aging and metabolic/functional medicine from The American Academy of Anti-Aging (A4M). The rest of his story, as Dr. Attia would say, is Medicine 3.0.
Preventing Bone Disease and Osteoporosis
With patients who want to improve their bone health, we usually find out that (a) they have a fear of drugs, (b) they have side effects from the drugs, or (c) they just don’t like the traditional approach and want to do something more natural. For example, “My doctor said I have osteoporosis and they have put me on Fosamax. Is there a more natural way to do it?”
I get this all the time. My first response is always EXERCISE and MAINTAIN NORMAL WEIGHT. Then I suggest VITAMIN D with K (in the form of MK7) and looking at hormones.
Dr. Lucas developed an amazing framework for Osteoporosis. As he said in our conversation, people often come in with the same history. Typically, it’s a perimenopausal or early postmenopausal, 50-55 year old woman who gets screened and has a surprise diagnosis. They go to her primary care, internal medicine, rheumatologist or endocrinologist who typically recommends a bisphosphonate right out of the gate. Note: There is an 80% failure rate of those drugs because people don’t want to take them and they end up doing nothing, which is not serving them either.
Dr. Lucas said that this is where the traditional medical model fails osteoporosis patients. With the DEXA scan you’re looking at one thing, mineral density. It doesn’t look at bone strength. What usually comes with the DEXA scan is a diagnosis and a drug recommendation. Is there a better solution? Yes. Ask questions.
Dr. Lucas begins his approach with: Why are you losing bone in the first place? Is it only because you lost estrogen, or did you not have good peak bone mass to begin with? Do you have gut dysfunction? Are you not eating well? Are you not absorbing well? Are you getting adequate protein? What kind of diet are you following? What supplements are you taking?
To that end, Dr. Lucas developed the 4R Method.
- Recognize why you’re losing bone.
- Reverse those causes of bone loss.
- Retest to make sure you’re headed in the right direction.
- Revive your life and live without fear of fracture.
Note: Part of this is a discussion of hormones, because most of these women are premenopausal, perimenopausal, or postmenopausal. They are going to predictably lose estrogen, progesterone, and testosterone. It’s important to know that you’re much more likely to die of a fractured hip than breast cancer. Either way, bioidentical estrogen replacement DOES NOT cause breast cancer.
Bisphosphonates and DEXA Scans
I loved the way Dr. Lucas talked about Bisphosphaontes and DEXA scans. I wanted to get some guidelines from him about when you should get tested with a density test, and which one you should get. When is the right time to know your bone mineral density? His answers are below.
Enter Dr. Lucas:
Bisphosphonates are popular because they have a profound impact on bone mineral density. But is it building the right kind of bone?
- We know people stay on bisphosphonates for longer than the recommended time, which is either three years, five years, or seven years (depending on the drug).
- We know that their bone mineral density will continue to go up, but the benefit of “the risk of fracture” starts to go down. That’s because you are creating dense, BUT fragile bones. They are more like chalk. More like concrete without rebar. This is because you are essentially stopping the bone metabolism balance.
- You’re poisoning the cells that break down bone, the osteoclasts. When you poison the osteoclasts, the osteoblasts (the buildup cells) stop too. So, essentially you are halting bone metabolism.
- Your bone mineral density goes up because your osteoclasts aren’t doing anything. Eventually you’ll be subject to atypical fractures, other fractures that you wouldn’t normally get. The scary one for me is the osteonecrosis of the jaw. It’s a rare side effect of the bisphosphonates, but it is devastating.
When is the right time to know your bone mineral density? Really it’s in your mid twenties. Peak bone mineral density occurs early in adulthood. It would be helpful to know if you had osteopenia at 22, so you can be more aggressive. You would know that restrictive diets are probably not a good idea. You would know to watch your hormones very carefully. Oral birth control would be terrible for you, so you wouldn’t do that. If you had an early diagnosis, you could change your lifestyle to help prevent those things from impacting your bones over time.
Realistically, getting every 25 year old a DEXA scan, from a public health perspective, is impossible. Know if you’re at risk and know what those risk factors are, then get a DEXA if you need to. The reason why I keep saying DEXA is because DEXA is universally available. Is it the best test out there? Probably not, but it is the only test that most people have access to. It’s relatively inexpensive and the radiation dose is extremely low. It will give you some good information.
For those that want to do this on their own, just knowing your T-score is a good starting point.
Diagnosis for osteoporosis is a T-score of negative 2.5 or lower (meaning more negative) and osteopenia (which isn’t actually a diagnosis) between negative one and negative 2.5. Understanding that just because you have Osteoporosis or severe osteopenia doesn’t mean that you’re necessarily at as high risk of fracture as your score might indicate (because it doesn’t tell us about strength).
Medications For Osteoporosis
I asked Dr. Lucas if he had to use medication for Osteoporosis, which one would he choose. His answer really impressed me.
Enter Dr. Lucas:
There are three categories of medications that I look at: the antiresorptives (all bisphosphonates), Prolia (Denosumab), and a newer drug called EVENITY.
All of the antiresorptives will stop osteoclast function almost completely. They will have an impact on osteoblast function as well. So when to use these drugs? I would say if you are in a bone loss free fall, and you can’t stop it. Those are going to be people that have breast cancer, are being treated with anti-estrogen therapies, and we can’t use estrogen. With people that have other reasons for rapid bone loss (i.e., chronic steroid use, or iatrogenic issues), I think there’s a reason to stop osteoclast function. I don’t necessarily like the IV versions, because the half-life is so long. That drug is going to be in there for a really long time.
Then, I look at the anabolic drugs. Drugs like Forteo and TYMLOS. These are parathyroid hormone analogs that are pulsed daily. When you do that, you are not messing with osteoclasts at all. You’re pushing the osteoblast function UP. These drugs are for people that I think have a very high risk of fracture, that can’t wait to see how a more natural approach is going to pan out. I have a few patients that are on these drugs, so I do prescribe them, just rarely. These are patients that have very low T-score (negative 4 and beyond) and are the primary caregiver for the family. For these patients, we say let’s use the cool medicine that we have, and let’s bump this thing up. We’ll do all the other stuff too, but we’re going to do this because it’s not impeding the metabolic function of the bone.
Then, there’s the third class, which is kind of the newer space. EVENITY is the new drug on the market. It is utilizing the technology of antibodies, so it is actually going after sclerostin (a protein in the bone metabolism pathway, actually in Osteocytes. It will impact both sides. It will slow down osteoclast function, and it will increase osteoblast function. The only downside is that it’s relatively new. We don’t know what the long term impact is, but for somebody who is suffering continuous fractures, EVENITY will stop it cold. In that case, the risk is outweighed by the benefit.
When I asked him if men should get tested for bone density, his answer was an emphatic yes. Anyone with Low T and Low Estrogen should get tested for bone density.
Closing Thoughts
If you read this Note all the way to the end, I’m impressed! There was a lot to cover, so much that you will have to check out the podcast/video on YouTube to get the full/unedited version. It’s 36 minutes of functional medicine gold!
Dr. Lucas is not only a smart physician and impressive speaker, but more importantly a caring person who likes to partner with his patients to achieve their health dreams. Be sure to check out his website and podcasts. Start thinking about your bones now! Don’t wait until you get a diagnosis. If you have osteoporosis, talk to somebody who knows about the natural approaches, as well as the medications.
Stay educated. Stay healthy.