Fracture Proof Transcript

Re-release of interview with Fracture Proof Your Bones author Dr. John Nuestadt

I am re-releasing this episode in transcript format of a podcast interview that I did with Dr. John Neustadt, a naturopathic doctor and expert in bone health. He is the author of Fracture Proof Your Bones, A comprehensive guide to Osteoporosis.

The discussion revolves around osteoporosis, its prevention, and treatment. Dr. Neustadt shares insights from his extensive research and his new book, emphasizing the importance of preventing fractures and falls rather than just focusing on bone density. He highlights the role of medications, diet, and exercise in maintaining bone health. Dr. Neustadt also discusses the significance of vitamin K2, particularly the MK-4 subtype, in bone health and its potential immunological benefits. The conversation touches on the broader implications of bone health, including its role in the endocrine system and overall metabolic health. Dr. Neustadt encourages a holistic approach to bone health, emphasizing the importance of early intervention and proactive measures. scroll down for the interactive transcript that will take you to the video playback.

Adam Rinde, ND (00:00):

John, welcome back to the One Thing podcast. I'm here with Dr. John New welcome, and thank you for joining us once again.

John Neustadt, ND (00:09):

Thank you for having me. It's great to be back and share what I've learned since the last episode. And I do want to make sure that your audience knows that you and I go back over 20 years now. I mean, we went to medical school together and since 2000, when did we start one? 2001. It's been a long time.

Adam Rinde, ND (00:29):

Yes. Yep. I still think about the days of physiology class when you were getting to the finish line with the concepts way before all of us, and we would consult with you in the cafeteria about what did the professor just say? And you always have a really good way of simplifying it.

John Neustadt, ND (00:53):

Oh, that's nice of you to say. I always felt like I was just drinking from a fire hose and trying to keep up as best I could. I think we were all in the same boat.

Adam Rinde, ND (01:03):

Well, you played that off because it sure didn't seem that way. It seemed like you were really getting the concepts, and I know it's just been great to see your career continue to grow and it's, I'm, I'm proud of the work you do and the way you do it. So thank you for all your hard work and I'm sure that it's been quite a journey for you.

John Neustadt, ND (01:28):

One of the things that I love is

Adam Rinde, ND (01:31):

Educating

John Neustadt, ND (01:31):

People how they can take care of themselves and part of that journey. And as naturopathic doctors, were one of the philosophical underpinnings of our profession as doctor, as teacher. And part of the exercise for me with writing and writing the book and the other publications that I've done is for me, if I can explain the research which can get complicated simply so that anyone can understand it, then I know I finally understand it. So it's been a journey of discovery for me as well, of going through the research and making sure I really can communicate it effectively to people.

Adam Rinde, ND (02:13):

And one of the takeaways from the last time we spoke was sort of your prioritization of what are we really going for? What are the outcomes we're really looking for with bone health and what really matters when it comes down to it? And your emphasis on preventing fractures and preventing falls and those types of, I guess, benchmarks or outcome goals. And I'm curious with your research for your new book, did you have any moments where you just have, this is something new and exciting and that really brought together concepts that you had previously thought about but became more solid with?

John Neustadt, ND (03:11):

I think it solidified a lot of the, what I'd already learned in terms of, let's not get distracted by the noise. Let's not get distracted by what in medicine we call surrogate markers. A surrogate marker is a number on a test and I want to keep the patient the person at the center of the entire conversation. And for me, as you mentioned with fractures, that's the most, not just for me in the research and with this condition, that is the most dangerous thing with osteoporosis, it's breaking a bone. So it really solidified that as I was going through the research and when I originally wrote my first professional articles on this, I think it was 2008, maybe 2009, that fundamental concept has not changed. There's nothing in the research since then that refutes that or changes that. What I did learn that was absolutely shocking to me is that every three seconds, someone with osteoporosis in the US breaks a bone and a woman is more likely to get an osteoporosis fracture than she's to get breast, uterine and ovarian cancer. And not only that, osteoporosis causes more days spent in a hospital than diabetes, heart attacks and breast

Adam Rinde, ND (04:36):

Cancer.

John Neustadt, ND (04:37):

And that really drove it home. What a tragic epidemic we have and how the conventional approach, the narrow-minded approach of just focusing on improving bone density is doing a huge disservice to everyone and has failed people with osteoporosis because a bone density test is not the most predictive, is not the most sensitive at predicting

Adam Rinde, ND (05:04):

Fractures. Yeah, yeah. One of the practice changing takeaways for me was how important it is to prevent falls. I mean, at the end of the day, the fracture happens after a fall and you really honed in that concept and that importance in our last discussion. And patients feel very confident with that advice. And also it's very empowering to know that there's some proactive measures you can take to prevent fracture. And you point those out in your new book, many of the different strength training modalities and also just the importance of muscle health. Can you talk a little bit about that?

John Neustadt, ND (05:59):

Absolutely. So you hit the nail on the head, 95% of fractures occur because somebody falls. So anything we can do to prevent somebody from falling by improving balance and strength, we are going to prevent falls and fall related injuries. And there are a couple of things. There are three categories that I think of when I consider somebody's risk for falling. The first, and I always like to go through this with people, is what medications are they taking? There are medications that increase the risk for falling. There are also medications that strip bone of calcium or damage bone in other ways and cause osteoporosis and increase the risk for fractures. And there's some medications that do both of those. So reviewing a patient's medications is really important. There's a whole chapter in my book, which is right here, by the way, very proud of that cover. I love, I think the cover came out beautifully that the,

Adam Rinde, ND (07:01):

Oh yeah, it's very nice.

John Neustadt, ND (07:04):

A chapter, a whole chapter called Medication Induced Osteoporosis. And over 90% of the elderly that's 65 years and older are actually on medications that increase their risk for falling. And not only that, a study looked at for the several months before a patient broke a bone, what medications were they on? And they identified which medications caused falls and osteoporosis and fractures. And they looked at after they were in the hospital for the fracture and they have osteoporosis, but they looked after they were discharged where they were taken off of those medications. And the research showed that actually there was no change, no overall change if they were taken off of a medication that was known to cause osteoporosis and fractures, many of them were put on a different medication that did the same thing and the doctor was not aware of it. And so really looking at medications is a big piece, but removing things that can be causing the problem is one.

(08:15)
Then the other big category is what can we do then to help the body function better? What has been shown to increase muscle mass? What has been shown to increase balance? And within that, you mentioned exercise and it's important with osteoporosis that people be careful with exercise because if you have osteoporosis and you don't exercise correctly, it can actually increase your risk for fractures. And so in the exercise chapter, I address that in detail, but also diet crucially important. Even with the keto and high diet craze, what I found is that most people aren't actually eating enough protein when I have them tell me do a diet recall and we calculate how many grams of protein, they're not getting enough. And even the US RDA for protein recommended daily, recommended daily allowance for protein in adults is insufficient to prevent muscle wasting and muscle loss.

(09:21)
And so there are recommendations, look exactly what does the research show, how many grams of protein does somebody need based on their body weight per day to maintain and actually increase your muscle strength and your muscle size? And then some dietary supplements as well, like vitamin D for example, making sure vitamin D is sufficient. The research has shown that your vitamin D level between 30 and 44 is what's optimal for reducing is associated with reduced risks of falls and fractures. And so I go through in different chapters in these discrete areas that people can evaluate and I help them create their holistic plan and also gather questions together, important questions for them to ask their doctor to make sure they're getting the best recommendation. They can make the best decisions for

Adam Rinde, ND (10:16):

Themselves. Yeah. I want to come back to diet, but I want to circle back to something you pointed out about medications. And I think there's been a lot of news about certain medications in their association with bone density issues such as proton pump inhibitors. You go much deeper in the book into other categories of medications that some people might not even think of. What were some of the more common other commonly used medications that the research points out strong associated risk of bone density issues.

John Neustadt, ND (10:54):

So the biggest shocker for me is when I discovered the antidepressants, and they're so common, especially the categories, the selective serotonin, re-uptake inhibitors and the serotonin and norepinephrine reup intake inhibitors. So the SSRI and the SNRI categories, medications like fluoxetine, Zoloft, those medications really harm bone and they create osteoporosis and fractures. And not only that, research has shown that what we can expect now is that for every 42 women who are taking an SSRI, that one of them is going to break a bone doctors, doctors don't know about this

Adam Rinde, ND (11:47):

To do with. Yeah. And does that have to do with how long you use or is it just sort of any duration length?

John Neustadt, ND (11:56):

So there's actually an increase after the first year, but like all medications, the higher the dose and the longer you take them, the greater the risk. With proton pump inhibitors, for example, there's risk after the first year, but after four years, there's risk increases of a 60% increase in hip fracture risk in one study. So duration and dose are very important, but even after the first year, the risk is there with those antidepressant medications.

Adam Rinde, ND (12:35):

And I think at least with proton pump inhibitors, a lot of people aren't given any endpoint on when to stop taking them. It's just sort of just take this. If it helps your reflux or helps your gastritis, you can just keep taking it, not giving any of this data. So I think it's really great that you point that out. And especially with SSRIs, I think most people are on these SSRIs on average for a minimum of six months and many people much longer. So thank you for bringing that to light. I don't think I have ever heard that until I read your book. So any other categories that we should just have our eye on?

John Neustadt, ND (13:25):

Well, there are ones that are commonly known, but even when I talk to patients, it's unfortunately they haven't been told by their doctor, even though doctors do know about these or they're not being treated appropriately to protect their bones. So the glucocorticoids like prednisone, dexamethasone, we've known for a long time that long-term use of those destroys bone. But what a lot of doctors don't know and what patients don't know are two things. One, that the damage to bone and muscles, it also damages muscle as well occurs. And the risk for osteoporosis increases before changes can be detected on a bone density test.

(14:13)
And the second thing is it used to be commonly believed that the short term, the dose packs we call them of glucocorticoids. So maybe on a seven day or 14 day dose pack where we're tapering them for shorter term use of the medication that is now also associated with increased osteoporosis and fracture risk. And it's been very well established that that as well creates risks. So one of the challenges is that there is a lack of sometimes recommendations or research showing if somebody is at risk because of a medication, are there other medications? Are there FDA approved medications that have been studied in these cases to prevent osteoporosis induced by another medication or prevent fractures? And so I go through that in the book because it's really important for people to understand that their cases, and I've seen them, I've had them, I've consulted with people on them where they're on a medication and they were on a medication that damaged their bone and caused their osteoporosis and their doctor prescribed a bisphosphonate, an oral bisphosphonate like Fosamax to help with the bones. And now we know based on the researchers actually that was never studied before, that it just became standard practice without any clinical trials and combining those medications. And actually in the clinical trial that came out recently, those people who were on the medication and then were also given the Fosamax, the bisphosphonate medication, their fracture risk went up, it was even higher. And that's because the mechanism of action

(16:09)
By which those bisphosphonate medications work on the bone is not to help the bone, is not necessarily the same as the ways in which the bone is being damaged by the other drugs.

Adam Rinde, ND (16:26):

Interesting. Yeah. Even being given out now for osteopenia, like early stage bone density issues. So going, going back to what you were mentioning about diet, I think that in my pioneer, at least my learning and vitamin K2, especially the MK-4 subtype of vitamin K2, I had love to just hear, I've always wondered where you first landed on learning about the differences between MK-4 and MK-7 and just sort of what your current thoughts are on the matter of how vitamin K two plays a role in bone density and the different subtypes.

John Neustadt, ND (17:21):

So I first learned about MK-4 from an oncology lecture at school at Bastyr in our oncology classes. There's research on MK-4 up to what I discovered after that is up to phase two clinical trials that have come out of Japan looking at people with acute myeloid leukemia, myelodysplastic syndrome, hepatocellular carcinoma, and one case study pro myelocytic leukemia and giving them MK-4 45 milligrams per day or higher. These are in the clinical trials over in Japan and it's not approved as a medication in Japan for that. And it's not approved by the US FDA to diagnose, treat or prevent any disease. So I want to be clear about that. But I first learned about that because in those patients and in those clinical trials, it promoted healthy blood production, it supported healthy platelets and it was shown to support healthy red blood cell and white blood cell production and to actually reduce the number of blast cells that are there when somebody has myelodysplastic syndrome or acute myeloid leukemia.

(18:40)
And it also promoted liver health in people with cirrhosis of the liver from hepatitis C, which is a risk factor for getting liver cancer. And it helped maintain and support that liver health so that those patients did not, in the clinical trial, did not go on to have liver cancer in a significant number of those. So that's where I first learned of it. And then because of that research, because of the cases I was having with osteoporosis, I ran across it just in looking and doing some research. And because I was already a little bit familiar with that nutrient, I think it caught my attention. So MK-4 is a type of vitamin K two, it's natural. There are different types of vitamin K2, it's a category. The most common that people hear about are MK-4 and MK-7 because those are what are dietary supplements.

(19:36)
But over 90% of what the body accumulates is the MK-4 form of vitamin K2, and it accumulates in different tissues in the body, in the brain, in the breasts, in the pancreas, in the colon and the testes. The list just goes on, on and on. And our body actually has the enzyme, the machinery to convert dietary vitamin K1 into MK-4. And so that suggests that MK four is the predominantly physiological active form of vitamin K two in the body and may have many health benefits beyond just what I already talked about and beyond bone health. Now it's been shown in clinical trials that both MK-4 and MK-7 can promote healthy bone density. But as I already mentioned, bone density is really not the most important thing. That's not the most important indicator of bone strength and our goal is to keep bones strong.

(20:40)
MK-4 is the only form of vitamin K too be shown in clinical trials to maintain bones as indicated by reduced fractures over 70% in clinical trial volunteers. MK-7, there are no clinical trials showing fractures or that looked at fractures as the primary endpoint of the studies. In contrast, MK-4 there are over 28 human clinical trials, five of them specifically looked at fractures as the endpoint. There have been two meta-analyses done on MK-4 and different types of vitamin K1 since 2006. And looking at all the clinical trials, the researchers concluded that only the MK-4 form and in the amount of 45 milligrams per day is the only form shown to maintain strong bones in the dose of 45. As I mentioned, 45 milligrams per day as indicated by reducing fractures in those clinical trial volunteers. And so that's why when I was trying to help my patients when I was starting my dietary supplement company, I looked for that nutrient in the dose combined with calcium and vitamin D. It didn't exist. So I created my company, I created the products to help my patients and sort of just kept going with the research. And as things grew, and here I'm 20 years later with articles and book and multiple books and

(22:18)
A company that's helping people all over the world.

Adam Rinde, ND (22:24):

That makes sense. Yeah. Well, is there a role for MK-7 in our patient population?

John Neustadt, ND (22:32):

So I think that still early in terms of the cardiovascular benefits of MK-7 or MK-4, when people ask me should I take MK-7 , I ask, is it because are you looking for bone? Are you looking for cardiovascular? If it's a targeted cardiovascular approach, the research is stronger supporting MK-7 So I do recommend at this point that that's what people use for bone though to get those results in the clinical trials, the MK-7 simply was not used and it doesn't have the research supporting outcomes and those benefits.

Adam Rinde, ND (23:16):

That makes sense. And as far as pivoting from the MK-4 discussion since it seems to have some immunologic properties, can we talk a little bit about the framework of thinking of osteoporosis as a immunologic disorder? I know a number of medications are at least developed to target cytokines that are involved with bone metabolism. Can we think of it as that now instead of just sort of a degenerative disorder?

John Neustadt, ND (23:53):

So I think that it's a complex situation, right? It's a chronic diseases and all chronic diseases that I know of at least our complicated, and I hesitate to say it really just boils down to immune system activation, although that's important. And the research has shown that chronic inflammation damages bone, and that's one of the mechanisms by which autoimmune diseases cause osteoporosis and fractures, denosumab or Prolia, those monoclonal antibody type drugs that are in Exgeva, that target the immune system have been shown to reduce fractures. And so there are reasons to use those. But in my book, in the chapter on osteoporosis medications, it's important to understand whether or not a specific medication is appropriate for a person's diagnosis and medical history. What I mean by that is if they have the most common type of osteoporosis is postmenopausal osteoporosis and all the FDA approved medications are approved for that.

(25:11)
But the question is have they had a previous fracture and denosumab and the other medications have not actually been shown to prevent a first fracture? They're good at preventing second or third future fractures if you've already had one. Why this is important and gets back to the immunological question is that if it were just purely an immune activation situation and they were targeting the immune proteins involved with those medications, it would also I assume prevent a primary fracture as well. And it's not doing that. It really does for much higher risk with other things may be going on physiologically also. But chronic inflammation and activation of the immune system with inflammatory cytokines IL-1, IL-6, TNF-alpha, NF-kappa-beta, the list goes on and on, has been shown to damage bone and change the physiology of bone to make it more brittle and less healthy.

(26:19)
There are things though that I think of in terms of immune system activation that are also does impact the immune system, but I say really at a secondary level. And what I mean by that is deficiencies in micronutrients like zinc, selenium, copper, which are not as uncommon as a lot of people think many of the processed foods are just stripped of those nutrients actually creates DNA strand breakage, reduces our ability of our antioxidant system in our body to function and stop the inflammation from occurring. I talk about Inflammaging, the concept of inflammation in the body and that chronic immune

Adam Rinde, ND (27:13):

Activation

John Neustadt, ND (27:14):

With the inflammation, how deadly that is. So I think you're right, inflammation is a huge part of it and I think that targeting that with a holistic approach can really go a long way to helping prevent fractures and protect bones.

Adam Rinde, ND (27:34):

Yeah, and I think this really shines light on the timing of thinking about your bones. Like the earlier you start thinking about prevention of osteoporosis or if you've received your first hint that you might be having some starting signs of bone density, this is really where your work shines. And as far as getting ahead of things before they become really progressed,

John Neustadt, ND (28:09):

I think that it's important.

Adam Rinde, ND (28:11):

Just so I think that it'd be interesting to hear you comment on that.

John Neustadt, ND (28:15):

I think you're right. The earlier people can be interested and understand the importance of their bones, the better because bones really are not just things that are inside of our body that allow us to walk around and hug our loved ones and garden and run and do all the activities that we love. But there's a chapter in the book called Miraculous Bones. And in that chapter I talk about a lot of things the bones do for us that people aren't even perhaps aware of, including they are our productive, they produce our white blood cells for our immune system, they produce our red blood cells and our platelets for healthy blood and blood clotting. And research now is actually shown and uncovered that it's part of our endocrine system as well. The health of the bones and proteins that the bones produce are intimately associated with blood sugar and insulin regulation. So when you're looking and focusing at this organ that's throughout your body, everywhere in your body and working in ways to keep it healthy or improve the health of your bones in a holistic way, then you are going to be by default also improving health in other areas of your life as well.

Adam Rinde, ND (29:47):

Yeah, I love it. I love the thinking about the bones is part of, it's a metabolic organ. It's not just this kind of inert substance that we hang our tendons and muscles off of. It's actually alive and rich with blood supply and it produces all kinds of signals and it's a living organ. And I think when you go back to anatomy class and think of the bones, the first thing you think of is the skeleton that's immediate. It doesn't give you a clear sense of how alive this organ system is. So thanks for pointing that out.

John Neustadt, ND (30:30):

And in fact, every 10 years our bone is totally new. So there are two primary cells in bone. The osteoblasts and the osteoclast and the osteoblasts are always creating new bone and the osteoclasts are breaking apart old bone, old worn out bone, and yet it's being replaced by osteoblasts. And so that bone remodeling, that healthy balance that is there is important. And when we give our body and our bones what it needs, they do better. It used to be thought that once you started losing bone mass and it's basically a one-way street of decline and decay, and now we know that that old model of bones is just a static column of chalk essentially is not accurate. There are over 250 different proteins in bone. And so it's not just about the minerals in bone, it's about the micro in environment in bone, it's about the proteins in bone. It's about giving your body the environment and the raw materials that it needs to thrive and do as best it can. And we know that now people actually can grow new bone, they can increase their bone density and reduce their fracture risk.

Adam Rinde, ND (31:54):

It's very exciting. And my hope is that instead of people turning to Dr. Google, when they get their first DEXA scan, they turn to Dr. Neustadt. So they can go on your website, they can order your book and have really a guide because you don't have, but the first thing your doctor says for bone issues, you have time. This is not an acute diagnosis. It's something that you can develop a roadmap and take your time to craft out what are the implications of your decisions. And that's the beauty of the foundational approach is that you can really set up a roadmap and then you can measure it over time to see if it's succeeding or not.

John Neustadt, ND (32:44):

That's correct. Absolutely. And I talk about that in the book that this is not an emergency. It's scary, absolutely. But it's important to take your time, gather your questions, and create a plan for yourself that is measurable, that you can track, that you can feel good about. That's not just looking at bone density because fracture risk depends, as I mentioned, largely on factors other than bone density. In fact, a bone density test only predicts 44% of women and only 21% of men who will actually break a bone.

Adam Rinde, ND (33:23):

Alright, well, this has been very enlightening and I would say that there's going to be more and more questions that come up from people who listen to this podcast and hopefully they'll turn to your book for a deeper dive into the topic. Is there any parting words that you can give us? And then also I'd love for you to just tell us about all that you're involved with and your website and those types of things.

John Neustadt, ND (33:48):

Oh, thank you. So I think for me, the parting word is the only way that somebody can lose is if they give up. There are so many ways to improve your health where we can really meet patients and where they're at. It's not that you have to do everything at once, that can be overwhelming, but if you just pick one or two or three things and start working on those, the research is clear. Whether it's starting to improve your diet or starting to get better sleep because poor sleep has been associated with osteoporosis and stripping the bone of minerals, whatever it is, what the research shows is as people start to do one thing proactively and have a little bit of success, they're more likely to build on that. And I talk in the book and walking through helping people create their action plans. It's about going from success to success.

(34:43)
So people can not only feel that they're on the right path, but they can know that they're on the right path. And also lots of questions that they can ask doctors as well to make sure they're getting the right information and making the right decisions. So I wrote the book because I've worked with thousands and thousands of patients over the years on this issue. And a lot of the issues, the topics, the questions that I get asked a lot, they're all in the book. I'm involved in other things as well. I'm on the corporate advisory round table for the Bone Health and Osteoporosis Foundation. I'm currently the vice president of our state Naturopathic Medical Association, the California Naturopathic Doctors Association, and I'm the chair of the membership committee. As I mentioned before. I own a dietary supplement company that a lot of doctors practitioners are using to help their patients and general public also coming to and finding the company as well.

(35:46)
And I've got about a dozen orphan drug designations from the US FDA I talked about the research before in MK-4 in these different indications, and that's some of the orphan drug designations I have from the US FDA. They looked at the data and the research and said, yes, this has the potential to help in these cases. And so they granted this special designation to me in one of my companies for MK-4. But to be clear, and I just want to make sure I say it again, MK -4 is not a medication. It's not been approved by the FDA to diagnose, treat, or prevent other diseases. It is a nutrient that promotes and supports powerfully promotes and supports the body's health. And people can find me@nbihealth.com.

Adam Rinde, ND (36:34):

Excellent. Yeah, great website. And you have a really nice newsletter and they like how you communicate. You're even on TikTok. I see it there.

John Neustadt, ND (36:45):

I've been encouraged by my team to get on TikTok. I'm told I had to do it. I'm having a hard time being consistent with it though. But yeah, we have the newsletter people can sign up for. I have my own podcast, the Delivering Health podcast, lots of great blogs and information@nbihealth.com.

Adam Rinde, ND (37:06):

Excellent. Well, it's good catching up with you. I can't wait to have another chat with you down the road sometime. And thanks for all your contributions to not only our profession, but just the thousands and thousands and people that you've helped. So thank you.

John Neustadt, ND (37:22):

Thank you. Thank you for saying that. It was a pleasure. Thank you for giving me the opportunity to share what I've learned.

Adam Rinde, ND (37:29):

You are welcome. All right. Nice work.

John Neustadt, ND (37:37):

Thank you. That was so.

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