548: Fracture-Free for Life: The Truth About Bone Health Scans and Medications

In this eye-opening episode of the Learn True Health Podcast, Ashley James sits down with Dr. John Neustadt to unravel the surprising truths about bone health that most people—and even many doctors—overlook. Together, they explore the dangers of common osteoporosis medications, the life-changing role of hormones, and the essential lifestyle habits that can truly rebuild strong, healthy bones. Whether you're navigating your own bone health journey or supporting someone you love, this empowering conversation offers the clarity, science, and hope you need to take control and thrive.

Highlights:

• Certain osteoporosis medications may increase the risk of atypical femoral fractures. These fractures can occur spontaneously with minor movement and take longer to heal.
• Bisphosphonates impair the natural bone remodeling process by disabling osteoclasts. This results in unhealthy bone layering, leading to brittle bones over time.
• Many patients are not given true informed consent about osteoporosis medications. Risks like osteonecrosis of the jaw are rarely discussed in brief doctor visits.
• People living a healthy lifestyle can still develop bone issues. Factors like nutrient-depleted soil and chronic inflammation complicate prevention efforts.
• Bone density tests become less predictive of fracture risk in people with low fall risk. For women, predictive value can drop to as low as 4.3%.
• Sex hormones are essential to bone strength for both men and women. Estrogen and testosterone replacement therapies can help, especially when monitored safely.
• Osteopenia can carry a higher fracture risk than osteoporosis in some studies. This may be due to a lack of caution or proactive care in those with milder diagnoses.
• The majority of people at risk are not being screened for bone loss. Around 95% of eligible Medicare patients don’t get bone density tests.
• Balance training, like standing on one leg while brushing teeth, supports longevity. Simple habits can significantly improve fall prevention and bone health.
• Slow, controlled resistance training is key to safer, more effective bone building. Time under tension increases muscle strength and connective tissue resilience.

Intro:

Hello True Health Seeker and welcome to another exciting episode of the Learn True Health podcast. Really quick message you need to know about before you jump into today's episode.

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Thank you so much for being a listener. Thank you so much for sharing my podcast with those you care about. My mission is to transform your life and the lives of those you care about so that we can be symptom-free, so that we can be so healthy we get off of meds, so that we can recover really fast when we get hit by a cold or flu, so that we can live high-quality and vibrant lives—emotionally, mentally, spiritually, physically, and energetically—well into our 80s and 90s.

Health isn't that you won't get sick. Health is how fast you recover and how strong you feel later in life. It is now, in your 30s and 40s and 50s, that you're building your health. Even in your 60s, you're building your health for your 70s. I'm in my 40s; I'm building my health for the rest of my life. Honestly, we don't really get that in our 20s. If there's a 20-year-old listening, you are doing such a service to yourself now. I think we would all want to go back to our 20-year-old selves and give some health advice to them, because we feel it. Ten years later, 30 years later, you feel the impact of your choices just like you will feel the impact of the shifts you are making by listening to this podcast and implementing the health changes.

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Enjoy today's interview. Welcome to the Learn True Health podcast. I'm your host, Ashley James. This is episode 548.

Ashley James (0:06:37.604)

I am so excited for today's guest. You naturopathic physicians are my favorite guests, right along with all the other wonderful holistic and functional experts that we have on the show. Today we have an amazing guest, Dr. John Neustadt, who specializes in helping people not only to prevent osteoporosis and osteopenia and reduce fracture risk, but actually reverse those illnesses—reverse those issues.

I hate to use the word disease because disease is this man-made construct that makes people think, “I'm going to get it because my grandma had it,” or, “I have it, so therefore I'm going to always have it.” Really, healing does begin with our mindset—the belief that our body can heal itself. It will heal itself all the way up until the day you die. You have a chance to heal. You have a chance to reverse issues, especially because the body constantly is wanting to make healthy bones. The body wants to do it. We just have to know what to do, know what to stop doing to help the body have wonderfully strong, healthy bones and joints.

We can even reverse osteoarthritis. This is a thing that MDs hate, hate, hate. I don't know why, but they are adamant that you can't reverse arthritis. It's really weird. Maybe because it takes so much money away from mainstream medicine, but we can reverse osteoarthritis as well.

So Dr. John, I'm so excited to have you here today and talk about how we can support the body's God-given ability—to reverse illnesses, to rebuild itself, to even reverse cellular age, to reverse the age of your bones and your joints, and to become the healthiest version of yourself.

Welcome to the show.

Dr. John Neustadt (0:08:32.016)

Thank you.

Ashley James (0:08:33.952)

Absolutely. So your website is nbihealth.com and of course all the links to what Dr. John does are going to be in the show notes with today's podcast at LearnTrueHealth.com.

Now, you went to Bastyr University, which is close to where I live, and you have an amazing track record of helping people gain health back. But what I want to know is what happened in your life that you went, “I've got to help people reverse and prevent osteoporosis.” What happened that light bulb went off for you?

Dr. John Neustadt (0:09:10.650)

My mother-in-law happened, and I was in clinical practice a little over 20 years ago now. I can't believe it's been that long. My goodness. I was working with patients. I was a baby doc, kind of fresh out of school and in my own private practice. I had some patients coming in with osteoporosis, and I was helping them with lifestyle changes, nutritional medicine, dietary supplements, and their bone density was going up. So I was happy.

My mother-in-law—her physician gave her Fosamax, and I was giving her some recommendations for similar approaches, integrative approaches, and her bone density was going up. So I was happy. It's what I was taught to evaluate. I think what most clinicians are taught to look at and track. Her physician, her medical doctor who prescribed Fosamax to her, was happy, and she was happy.

We all thought that she was protected. Then she tripped on a throw rug in her house, and she fractured her hip. I thought to myself, something's wrong with this picture because by that objective measure, she should have been okay. I started digging into the research, and I was absolutely shocked by what I found. That almost myopic approach of only looking at that test result misses the forest for the trees—misses the most important things about this condition—and that is fractures.

If somebody breaks a bone with osteoporosis, there's up to a 36% chance that they're going to be dead within a year. About half of people who end up surviving that never regain their full pre-fracture level of mobility and pain-free life that they had before. In fact, if you're a woman with breast cancer and you end up in a hospital with a fracture from osteoporosis, there's an 83% increased likelihood that you're going to die compared to a woman with breast cancer who doesn't fracture.

Globally, osteoporosis is the second biggest health concern after cardiovascular disease. Every 30 seconds, somewhere, someone in the world is breaking a bone because of osteoporosis. Yet we've known in the research since the 1990s that a bone density test predicts less than half of patients with osteoporosis who will break a bone.

In 2008, in the Annals of Internal Medicine, there was an article that was published that quantified that even more. It showed that for women with osteoporosis, a bone density test only predicts 44% of them who will fracture. For a man, it's even worse. It only predicts 21%.

So I started looking at really trying to understand what is it about bone density that is not giving an accurate understanding about bone strength? What can we do to maintain strong bones and reduce people's fracture risk? Every conversation in a clinician's office, when you're talking about osteoporosis, in my opinion, should be focused solely on that question: What can we do to reduce your fractures?

The medications—the track record of medications for fracture prevention in osteoporosis—is quite poor. There are some benefits to them, and I'm happy to go into that research and the details of the medication. But there are other things that have been shown to be crucial, if not more important than a medication, and more helpful than a medication.

In fact, if you look at the osteoporosis medications, the change in bone density that the osteoporosis medication causes is not even an indicator that fracture risk is being reduced. That's not just my opinion—the American Academy of Clinical Endocrinology—that's their position as well: that a bone density test predicts less than 20% of the ability of an osteoporosis medication to reduce fractures.

So there's lots of other things going on that people have control over, by and large, which is amazing. It really comes down to empowering people and helping them understand what they can do to reduce their fracture risk, improve their bone health, improve their bone density, and maintain strong bones.

Ashley James (0:13:36.522)

Is there a test that determines fracture risk?

Dr. John Neustadt (0:13:41.625)

There's not a great one. There are quite a few tests out there that claim to do that, and they all have quite severe limitations. So a bone density test, a DEXA test, dual X-ray absorptiometry test, it's an X-ray, gives a diagnosis of osteoporosis. It's used to track osteoporosis. The results of that test are used then to predict fracture risk.

But as I said, that's not very accurate in terms of prediction. There is a free online tool, a tool called FRAX, which is a Fracture Risk Assessment Tool that people can put in the country. They have to go to the country of origin. So you go to the website. If you just Google FRAX, you'll find it. The data is based on the country you're in. So you choose your country.

Then you can enter the data such as your age, your bone density if you have it, certain medications. It's very limited the types of medications you can put in and a few other details and can give you a probability of a fracture in the future. But even that is quite poor because for many of the medications that cause fractures and osteoporosis, it doesn't ask about antidepressants, anything that artificially increases serotonin.

SSRIs, category of medications, Prozac, for example—for every 19 women taking them now, we expect one to break a bone if they're taking them for more than a year. Fracture risk even begins to increase earlier than a year. It doesn't ask about proton pump inhibitors. Those medications increase hip fracture risk and overall fracture risk as well, taking them long-term. So there are many risk factors that doesn't taken into account. It also doesn't take into account your cancer history or if you are on an aromatase inhibitor for cancer. So that even is quite limited.

95% of fractures occur because somebody falls. So one of the most predictive variables in terms of somebody's future fracture risk is their gait and their mobility. It's not really a test from a machine.

But you can test yourself in terms of your own physical strength. There are validated tests out there that clinicians can do in an office. But there are tests that have just been developed, simple things—can you walk about a little more than half a mile, six-tenths of a mile? That's a recent study that was published. With ease, with some difficulty, not at all—the more difficulty you have, the greater the risk for falls and fractures.

One of the biggest predictors is if you've had a previous fracture with osteoporosis. So people who have fractured with osteoporosis—about 30% of them will fracture again in the next five years.

Can you get up from a seated position unassisted? What is your grip strength? One of the things that we see is that with people as they get older, when they lose muscle mass and strength and balance, that's when it becomes really dangerous with osteoporosis.

Ashley James (0:17:07.513)

How do we prevent muscle loss? So I've been seeing people talk about, you really need to start in your 40s building more muscle, being intentional with lifting, and lifting heavy objects often. You don't have to necessarily go to the gym. You can get yourself a kettlebell, but lift heavy objects often and protect your muscles in your 40s and your 50s.

It's going to affect you in your 70s and 80s. We are living longer and longer, to some degree, and that directly affects the quality of your life. So, you said, can you get up unassisted? Do you have grip strength? Can you walk a half a mile or a mile? Sure, no problem when you're in your 40s.

If you're sedentary and you don't double down on protecting and building your balance and your strength, then the quality of your life is going to go down significantly in your 60s and 70s. I just watch people lose so much of their muscle mass.

Is it called syncope? What's the word? Sarcopenia. That's it. I was close. Why do we lose muscle mass? Is it because our digestion stops working as well? What are the nutrient deficiencies? What's going on? Not from an allopathic standpoint, but from that standpoint of—if we don't get enough nutrition, the body starts to break down. Where does it all begin?

Dr. John Neustadt (0:18:45.189)

Well, I love what you said at the beginning. It really all begins in somebody's mindset. That mindset is: I can improve my health at any age and at any stage. In fact, research has shown that. Even in the clinical trial that was published, that was last year or the year before, the oldest people in the clinical trial were in their 80s. I think 85 was the oldest. Even them, they were able to build muscle mass with resistance exercise. So at any age, you can improve your health.

I think that your question deserves a bit of a nuanced answer because there are two major sort of categories of how I think about this. There's exercise and movement—obviously quite important—resistance exercise, lifting your body weight, lifting heavier weights, stressing your muscles a little bit because that's how they grow.

But then there's another issue and another challenge, and that is getting adequate nutrition. Micronutrients are very important. Eating that Mediterranean plant-forward whole foods diet is really, really important for bone health and overall health. It's associated with a 20% reduction in osteoporosis risk and a 21% lower risk of hip fractures, as well as lower cardiovascular disease risk, obesity risk, cancer, death from cancer, and all-cause mortality.

That dietary pattern—I’ve never seen one negative study about it—and it’s the way that I eat. But what is missing oftentimes in the conversation about diet is protein. As people get older, the US RDA for protein is insufficient to maintain healthy muscle and bone. In fact, as people get older, they are not eating enough protein to begin with. They're getting less than the US RDA, but they even need more than that to build and maintain bone and muscle.

There’s a study that came out in Europe a few years ago. It's actually a position paper by several different organizations on osteoporosis, bone, and joint disease. Their position was that the amount of protein somebody consumes in their diet alone can account for 2 to 4% of bone mineral density.

When it comes to muscle mass and sarcopenia, what happens is you get a phenomenon as people get older called anabolic resistance, meaning your muscles just are having a little bit tougher time making and building new muscle. So you've got to create the environment to give even more protein for them to be able to use that to grow more muscle.

The research is quite clear that at a minimum—the US RDA for protein is 0.8 grams per kilogram body weight per day—I’ll translate my recommendation in a moment into pounds, grams per pound, because that’s what we use in the US, but the research uses kilograms. The research on how much protein somebody should eat, minimum, comes out to about 1.3 grams per kilogram body weight per day.

So take your weight in pounds and multiply it by 0.6. That’s the minimum number of grams of protein people should be eating every day. For me, for example, I’m 95 grams of protein, approximately. That can be challenging to get. That’s where dietary supplements come in to bridge that gap. Ideally, it’s coming from diet first, and then supplements just to give that—as the FDA intended supplements to be used for—to supplement what hopefully is already a healthy diet.

Then the timing of the protein consumption becomes important. So two things: one, that’s the minimum amount of protein that I recommend people consume. Another study looked at the maximum amount of protein that you can consume and your muscles can use at any one time.

A lot of people out there in the internet world are recommending two grams of protein per pound of body weight per day, or just your body weight per that number of grams of protein. That’s a tremendous amount. What the research shows is that your body can only use a maximum in this clinical trial, if you take your body weight and multiply it by 0.73 grams—you divide that up into about four equal servings during the day. That’s about the maximum number of proteins you should eat at a time. So not overeating protein and not under-eating protein.

To make it as simple as possible for people, I say: look, just eat about 20 grams of protein at every meal. Eat 20 grams of protein within two hours of waking up, within about an hour of exercise, and make sure you’re doing that at least four times a day, depending on your protein requirement. That’ll get you probably into that range. Then you can supplement a little bit more if you need to.

That’s really important because bones also, in terms of their protein requirements—there are 180 to 200 different proteins in bone. It is highly protein-dependent, in addition to collagen, which is the main structural protein in bone.

For the dietary component, that’s what I see is missing most often from the discussion of diet. Then from the exercise component, you’ve got to get out there and move your body. You’ve got to increase your mobility, stability, and strength. There are tons of options to do that. You don’t have to go to a gym and lift weights. It’s one option.

But there are exercise classes. There are things you can do at home just to implement some exercise in your daily routine at home. Even just walking—research has shown that walking 7,000 to 7,500 steps a day is associated with a 50 to 70% reduction in all-cause mortality, which is death from any cause, including osteoporosis.

So, tons of options out there. I discuss these in my book Fracture-Proof Your Bones just to give people opportunities to create customized approaches that work for their interests, the time they have available to them, and their financial resources.

Ashley James (0:25:35.024)

You had touched on something that I definitely wanted to talk about, which is the collagen and the protein that's in bones, because as the DEXA scans show, more dense bones doesn't mean less brittle. In fact, in some cases, it can mean more brittle, especially with Boniva and Fozimax. You can just build up a bone bank, a mineral bank in your bones, you can build up a lot of mineral storage in your bones, but they can be incredibly brittle.

In Asian countries, they have incredibly flexible bones and some of the lowest fracture rates in seniors. Of course, they're more mobile, they're definitely more active. We look at, for example, in Japan, how their femur is incredibly flexible. It doesn't snap from a fall from a few feet.

This idea that, yes, minerals are incredibly important. They make up the majority of our micronutrients. We definitely are not getting enough of our trace minerals. However, minerals are not the only thing bones are made of. In fact, to protect them from fracture, what we really want are flexible bones. So increasing that collagen, that protein, and everything that makes up that matrix inside them.

I definitely want to get into that. But before, I just want to touch on this protein thing. The quality of where your protein comes from is incredibly important because someone could say, “I'm going to open a can of Spam. Look, there's 20 grams per however many servings,” and they're going to be doing themselves an injustice.

Whereas they could, for example, definitely get a cup of lentils or legumes in their diet. They can get some nuts and seeds, leafy greens, and potatoes, and all that adds up to protein. If they want to consume animal products, doing so in a way that makes sure it's the healthiest for them.

For example, are you going to eat a can of Spam or are you going to go for that grass-fed, organic, free-range whatever, or that wild-caught versus farm-raised fish, for example?

So the quality really matters, but I want you to share your thoughts on where to get your protein from. Get that four servings of about 20 grams of protein. Where do you see it being the most valuable to get it from? Are there any particular foods that are sort of your favorites?

Dr. John Neustadt (0:28:16.630)

I can only talk about what the research shows in terms of what it is that I recommend people consider. I obviously have my own dietary pattern that works for me, works for my lifestyle and my taste, but that may not be good for somebody else.

What the research shows in terms of dietary patterns—emphasizing lean proteins, fish, chicken, legumes, those sorts of things—are associated with those reductions in all-cause mortality and linked to reduction in osteoporosis and hip fractures and cancer and diabetes, all those things that I mentioned before that are part of the benefits of the Mediterranean dietary pattern. It's essentially the opposite of the standard American diet, which is really high in processed foods and red meat.

I'm glad we're talking about diet more and I'm really glad you brought this up because we start to get to the edge of what science has really evaluated and the different variables that it's considered. One of the things that's emerged in the research that is an absolute killer of health are ultra-processed foods. They are linked to all of those conditions that the Mediterranean dietary pattern is associated with improving. Ultra-processed foods are linked to causing all of those problems.

In the US diet, about 60%—to be very specific, 57%—of the calories of American diet, now is made up of ultra-processed foods. So I'm not so sure if it's necessarily which protein that somebody is consuming that is the bigger problem or whether it's that they're consuming also too many ultra-processed foods. There's a dose-response relationship with ultra-processed foods.

A lot of the studies will show if more than 10% of your calories are from ultra-processed foods—remember, 57% of Americans' calories are from ultra-processed foods—then you're really messing with your body's biochemistry and creating health problems.

In fact, the first clinical trial—was done in 2019 where they fed controlled diets. It was at the NIH and they housed people for weeks and they had chefs prepare diets, bought food at local supermarkets, and they either had a whole food diet, whole food snacks, or ultra-processed diet, ultra-processed snacks.

What they found in that, in just those few weeks when the clinical trial was happening, not only did the people eating ultra-processed foods gain more weight, they ate more calories because they ate faster. Ultra-processed foods tend to be lower in fiber, so people take a shorter amount of time to chew and swallow. So they're consuming a higher volume of food before those satiety signals—those biochemical signals to tell your brain that you're full—are able to kick in.

But then also, what's happening with the ultra-processed foods is they're changing your biochemistry. So people listening to this are probably very familiar with GLP-1s. It's a very popular category of medications now for weight loss. They found out in this clinical trial by taking blood tests of the people taking the ultra-processed foods and the people eating a whole food diet— that the people eating the ultra-processed foods, their GLP-1 decreased, which contributed even more to them eating more and not feeling hunger and the obesity and the weight gain that they were getting.

The other problems is that thyroid function started to decrease. The thyroid test, it was moving in the wrong direction, in an unhealthy direction as well. That's just a couple of examples.

So I'm not so convinced that it's necessarily the quality of the protein and focusing on just one individual component of the diet as the overall dietary pattern. I believe it's really important to take this into consideration.

Ashley James (0:32:36.912)

So the 0.6 grams per pound being the minimum, is that overall body weight or is that lean body mass?

Dr. John Neustadt (0:32:49.414)

Just body weight, standing on a scale and then the maximum would be  0.73.

Ashley James (0:32:55.690)

Got it. It's good to do about 20 grams per meal, do four meals or three meals and a snack.

Do you have emphasis on how many grams of fiber from whole foods people should be aiming for, or how many cups of vegetables, or how many servings of fruit?

Do you have any other things that you want to incorporate with protein that you find is very important?

Dr. John Neustadt (0:33:22.696)

That is a great question. Absolutely. The Mediterranean diet—what I've done is I took the data from that dietary pattern. I created a system called Three Steps to Eating Healthy for Life. It walks people through quantifying exactly what you and I are talking about now, so they can start to get a sense of the dietary—how they begin to eat. Most people aren't eating this way, and how they can transition into eating this way.

So with fiber, dietary fiber, I recommend a minimum of 30 grams of total dietary fiber per day. I’d recommend people don’t make any changes to their diet for a couple of days. If they’re looking to transition into eating healthier, I want them to write down what they’re eating each day for two days and then calculate the number of grams of total fiber, approximately, and the number of total grams of protein they’re getting in a day. Then they can compare how they’re eating to what their goals are, how they should be eating, and then begin to transition to that over time, over a time period that’s comfortable for them.

Most people aren’t eating this way. Major changes done overnight or too quickly tend not to be sustainable. So whether it’s over four weeks, six weeks, eight weeks—whatever it is—the goal is to transition into eating this way to the point where it becomes a new habit. You don’t have to worry about quantifying things. It just becomes part of your lifestyle.

What happens during that process is people find that they’re needing to maybe shop differently, find different snacks, cook differently, maybe with different spices. If there is a family involved, involving the family in that as well is important. There are also these social environments in which people are living that need to be navigated. I think those also need to be part of that dietary discussion because there’s no part of our health that exists in isolation, including the way we eat.

Research has shown that the dietary pattern and how we eat is highly influenced by the people around us. They can be viruses or bacteria, conceptually speaking, in that they can spread. They spread from person to person—those behavioral patterns.

You mentioned at the beginning how family influences your health, and genetics is really not the main driver. You’re absolutely right. As we get older, it’s diet and lifestyle that are the major drivers of long-term health. The research has shown, when it comes to osteoporosis, that we’re more likely to have a problem not with our genetics, but because we’ve adopted and inherited the diet and lifestyle patterns of our parents and our family of origin.

So breaking those patterns and doing it in a way that allows you to develop new habits, and having that mindset and having the knowledge and creating the systems to do that, are important for reaching people’s long-term goals.

Ashley James (0:36:39.232)

We talked a little bit about this idea of the bones. Well, you've written the book Fracture Proof Your Bones, this idea that we need to make sure we're supporting the collagen production and all that wonderful elastic matrix that protects them from being brittle.

In your research and in your clinical experience, what are the steps that we absolutely need to do to make sure we protect that?

But what are also the things that we should stop doing?

Is there anything we're doing that's robbing our bones of their wonderful flexibility?

Dr. John Neustadt (0:37:14.374)

Collagen, strand for strand, is stronger than steel and it's flexible. It is what gives bone its ultimate strength, its ability to withstand a fall. Let's say you fall and have that force be dispersed over a larger volume of bone, and that bone can bend a little bit and absorb that force without breaking. The bone mineral density gives the quantity of bone—but it's that collagen and those other proteins, that extracellular matrix, that gives bone its ultimate quality and strength.

So there are two ways to think about then: how to protect bone collagen and bone strength, and how to promote more of it, and how to improve it. So on the one side is avoiding things that damage collagen, avoiding things that strip bone and destroy bone strength.

One of the biggest offenders of that, I've already alluded to it a little bit, are medications. The most common medications that people are on—the doctors have no idea that it's destroying bone. So people really should take their medications, if they're on any medications, and do a Google search or even better yet, talk to their pharmacist, talk to their doctor, get a medication review. But don't only talk to your doctor—talk to your pharmacist, because they have access to quick databases. They are the experts when it comes to medications. Try and understand: is the medication you're taking increasing your fracture risk and making your bones more fragile?

Prednisone or glucocorticoids is a common offender of that. 1 to 2% of the general population is on long-term glucocorticoids, and it destroys collagen. So it reduces your ability to produce collagen, and it makes the collagen that is there more brittle. Even before an increase in fracture risk would appear on a bone density test, if somebody's taking prednisone or one of the glucocorticoids, their risk for fractures is already increasing before it shows up on a bone density test.

In fact, it doesn't just cause problems with bone collagen, but it also causes problems with muscle microfibrils and helps to destroy those and reduce the health of your muscle so that people's balance also decreases, which increases their risk for fall. So a medication review, I think, is really important.

Reducing the dose—whatever the condition is—you may be considering a holistic or naturopathic or functional medicine approaches so that perhaps you can not need that medication or at least reduce the dose, or perhaps switch to a safer medication. I've only mentioned a few—the glucocorticoids, SSRIs, the proton pump inhibitors—but there is a long list of additional medications: anti-seizure medications, even the anti-hypertensive medications.

While they don't destroy bone collagen, they increase the risk of people for falls. In fact, 95% of the elderly are on a medication that increases their risk for falls. Not just not having the right dose of your blood pressure medication, which means your blood pressure can drop too low—that causes imbalance and increases your risk for falls—but sedative medications, medications for anxiety—the benzodiazepines, Balsambra, Lunesta—those medications also increase the risk for falls.

Now, I've gotten sidetracked a little bit because that's not directly related to collagen.

Ashley James (0:41:14.268)

No, this is great. I think people really need to understand that medications are incredibly dangerous and that they affect many systems of the body. In fact, I was just looking this up today because I have someone who has a parathyroid issue, but they never always had it and they developed it suddenly. I have a sneaking suspicion it's due to one of the medications they're on.

So, for example, lithium, diuretics, and then you said—the heart medications, the anti-convulsants, there's a whole list. Corticosteroids. There's a whole list of medications that directly impact the parathyroid, which the parathyroid—maybe you could explain what the parathyroid is and why that's important to protect it and not negatively impact it when it comes to our bone health.

But this is it—medications don't just work, for example, if you're taking a blood pressure med, you're like, well, it's only affecting my blood pressure. No, it's affecting your bones and your kidneys, affecting everything. It's weird, this concept that this little tiny pill, smaller than a pea, could have such a profoundly negative impact. They soften it. They soften the blow by saying “side effects.” Side effects are not everyone experiences them. Some people may experience some of these side effects.

They're not side effects. They're consequences. They're robbing the body of nutrients because the body has to metabolize them. This is my large frustration—as I'm sure it is yours and many naturopaths and holistic practitioners—because the philosophy that many people have been indoctrinated into is this idea that we wait to get sick, then go to the doctor and get put on a medication. That’s it. That’s life. That’s health. That’s healthcare.

But really it is this juggernaut of a system that has fooled all of us. We believe we need this system to survive when, in fact, if we take our health into our own hands—which is why learning from you is so important, listening to this podcast and other health podcasts and learning how to advocate for ourselves, learning how to nourish our body so our body is so healthy it stays healthy—we never get on meds.

You want to prevent at all costs to have to get on a medication. Now, if you need one to save your life immediately, thank God it's available. But 99% of medications out there are doing more harm than good. We're also losing accountability by waiting to get sick and then getting put on a med instead of doing everything we can to prevent and support our body's ability to stay as healthy as possible.

That spills over into mental health and emotional health and spiritual health, because physical health affects all of that, and your interpersonal relationships and your career and everything is impacted. So we have to be very protective. Everything you put in your mouth, every single meal, is you protecting your health.

If you're going out and eating highly processed crap because it tastes good, then it's like you're going out and doing heroin because that's fun. It's fun. Food can be fun and taste good. So can alcohol and street drugs. But you're not going to give that to a 10-year-old. You shouldn't give it to yourself. Every meal—you can design it to protect yourself so that you have the highest quality of life.

This is why it's so important to understand that medications have a negative impact that spills over into so many systems of our body that we're not even aware of. How many people are taking depression meds that don't realize they're actually causing themselves to have the last 30 years of their life to have osteopenia and osteoporosis? How many people are on digestive medications?

For—you said—the proton pump inhibitors, which are just nasty drugs, because now it's depleting the body further from being able to digest and absorb nutrients. The body's going to break down further. How many people are on these medications because they temporarily relieve the symptoms? Thank you, doctor. I feel so much better now that I don't have this heartburn, or now I'm a little bit happier now that I'm on this medication.

But look at the negative impact. The years, decades of your life, are being stripped away. So this is my passion—to wake people up and bring them people like you so they can finally figure out what they can do to not have to get on those meds in the future. If they are on those meds, how to get so healthy they get off of them and prevent, or reverse any of the impact.

So thank you for kind of exposing this. Who knew that all these medications made it so your body couldn't produce collagen? Collagen. I mean, if you're just even vain—as women, collagen makes us look good. You look at the skin on your arm. Is it hanging? Is it kind of looking weird? You got skin hanging on your face? That's collagen.

So we don’t want to do anything to stop having wonderful collagen production so our skin stays firm as long as possible. But if you look good on the outside, you're healthier on the inside. So let's protect the collagen so we can protect our bones, man. That's amazing.

Dr. John Neustadt (0:46:47.204)

I love so much of what you said. I say often in my medical talks and in talking with people on podcasts, interviews that with every bite of food, you're either feeding the disease or improving your health. So you've got to make a choice.

I think with the medications, if I can build on that topic for just a moment, it's important to understand the collagen is really a crucial component of this, but not all the medications are working off of that mechanism. That's where it becomes really challenging from a conventional medical perspective. They don't really understand how to deal with these things. I'll give you a couple of examples. You mentioned the proton pump inhibitors.

Those are not directly causing damage to collagen, but what they're doing is they're causing nutritional deficiencies and dysbiosis, which then have this downstream cascading effect that affect bone health and create more brittle, fragile bones. 

The challenge is, when you look at the osteoporosis medications, which are the mainstay of conventional medical approach, they're prescribing bisphosphonates, oral bisphosphonates—Fosamax. Well, the majority of the research on any of the medications for bone health are on postmenopausal women with osteoporosis. So you've got all these patients that are showing up with osteoporosis caused by different things, different underlying issues going on.

They're saying, well, if the bisphosphonate works for postmenopausal osteoporosis—which I can get into whether or not it works, it's questionable in many cases, the benefits—but since we use it for one type of osteoporosis, we're just going to use it for all types. Somebody decided to finally do that, to research that, because they were using that approach for proton pump–induced osteoporosis.

What they found out is that when patients took a proton pump inhibitor—that category of acid-blocking medications—plus a bisphosphonate—Fosamax—their risk of fractures was 52% higher than people who were just taking the bisphosphonate alone. So the combination was actually increasing their fracture risk.

When it comes to the antidepressants that increase serotonin, the SSRI, SNRI categories of medications, they work differently. They work because there are serotonin receptors in bone. The serotonin receptors, when you get an abnormally high amount of serotonin, they activate osteoclasts. So they create more osteoclasts and they allow osteoclasts to live longer, and osteoclasts are the cells that break down old, worn-out bone.

The osteoblasts build up, create new healthy bone, and you need that recycling—it's called bone remodeling—going on for healthy bone. In fact, about every 10 years in a healthy bone, you've got all new bone. It's completely recycled, remodeled—all new bone—about every 10 years.

So these drugs interrupt that delicate balance. Essentially, osteoporosis fundamentally is a condition of imbalance where the destructive forces are winning. Our job is to identify what those destructive forces are.

See if we can get rid of them and correct that balance and stack the deck in people's favor so we're getting more osteoblast activity, more collagen production, more bone mineral deposition, healthier bones, stronger bones, so people can live longer, more vibrant lives instead of getting into their old age. Too many people are in pain and discomfort or living the last end of their years bedridden, not even able to dress themselves or go to the bathroom alone because they've fractured with osteoporosis.

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Ashley James (0:52:16.759)

You had mentioned things to avoid dizziness. Certain medications can cause dizziness, which then of course leads to falls, and falls lead to fractures if their bones are not super strong.

Dehydration is another one that's really important, especially if you're dealing with a senior. I don't know what it is about seniors—but please, could you just drink more water? I don't know. Why are you guys being so stubborn?

I work with some seniors and it's so hard to get them to drink more than 40 ounces of water. I'm like, you're killing me. Just, just please drink more water.

When there's a heat wave and the seniors I work with, they all remember when they were 20. They're like, I grew up in Texas or I grew up in California—and 95 is not really warm. So they don't turn the fans on or open their windows or turn the AC on or anything.

Then they're sweating and then they further get dehydrated and then they get dizzy and fall and get a fracture. That's the biggest thing we could do to help our parents and our grandparents—make sure that they are staying hydrated, that they don't get overheated.

Even if they say, I'm fine, I'm fine. I'm not really hot. They're not getting enough water. Maybe you can talk about this, but when we get older, we're losing that muscle mass, we actually lose the amount of water we retain.

How they say that we're 70% water, but it's really—seniors are more like 60% water. Babies are 80% water. We just seem to lose it as we get older. Not everyone, but it's a big thing to make sure that we stay hydrated for many reasons, many health reasons. But if we can prevent that dizziness, we could prevent the falling—hopefully.

Dr. John Neustadt (0:54:12.107)

It's interesting because water and staying hydrated is obviously important for our cellular environment and for our biochemistry to function appropriately, for kidney health, for so many things in our body. The connective tissue in our body will attract water and hold on to water. So I think it goes kind of hand in hand as connective tissue is decreasing throughout the body, and there's collagen all over the body.

Not just in bones, as you mentioned, skin, but also around and inside all of our tissues. So the ability to stay hydrated starts to decrease. You see that in skin. I mean, that tends to be a very telling and obviously outward sign of things going on inside the body as well. In fact, there's a study years ago that linked, as people's skin becomes thinner and more fragile, it's actually an indicator that they can be losing bone density as well. Their bone mineral density is decreasing.

What we see with collagen, hydrolyzed collagen dietary supplement clinical trials, repeatedly in the research is that taking 10 grams of a hydrolyzed collagen dietary supplement that's types one and three collagen has been shown to improve skin hydration and skin elasticity and reduce the visible signs of wrinkles, meaning skin is more plump, it's more hydrated, those wrinkles then are less visible. So that's, I think, a very easy way for people to understand some of these effects between the status of their connective tissue, the status of their underlying health, and this question of hydration.

Are they even able to retain enough water, or an optimal amount of liquid that they're consuming? Then if they're on a diuretic, a medication that increases urine output because they have high blood pressure, then you've got another challenge, because they're actually increasing the amount of urine they're producing, they're flushing through that even faster.

One of the problems with the medications for high blood pressure, in all medications really, is that as people get older, their ability to break down the medication in their liver—typically it's the liver—decreases. So what was a healthy dose giving them a healthy blood pressure at a younger age becomes too high of a dose as they get older.

Doctors unfortunately are not doing medication reviews often enough and adjusting the doses. So people, when they're maybe in their 50s and they're on a blood pressure medication, it's great. But then they don't go back to a doctor for a long time, they're on the same dose, they hit 60, 65, 70, and suddenly that medication is too high. So they become more dehydrated, they become dizzier, their blood pressure drops too low, and it becomes a very dangerous situation.

Ashley James (0:57:24.183)

What's the elephant hiding in the room is what imbalance has been happening in their body for 30 years that they need to be put on a medication for. We don't just have high blood pressure. High blood pressure is a result of an imbalance.

So what's going on? Is it a chronic nutrient deficiency? Is it chronic unresolved stress, which wears down the body?

They looked at the impact of stress. There was this massive study and they found that the number one cause of all premature death was stress.

It was the most important thing, and we really don't take it seriously. We put it in this category of, that's just weak people. That's just emotions and weak people feel that. But stress isn't an emotion.

I've had clients tell me—because I give them some exercises for reducing stress—and they're like, “Well, I didn't feel stressed, so I didn't do the exercises.” I've known people to literally faint.

They're super strong people, but they were so stressed out, their body just shut down. Their body said, “I'm done.” We don't feel it. We don't feel stress. We've got emotional stress, mental stress. We've got physical stress. We have environmental stress. Not sleeping well is stress. Bills piling up is stress. But stress causes the body to break down and not heal because we're in that fight or flight mode, not in the heal and repair mode.

That can be the cause of blood pressure issues. And the body’s constantly breaking down more than it's building up—and it's a ticking time bomb.

Dr. John Neustadt (0:59:07.893)

I think a lot of people don't know how stressed they are because they've adapted and they think it's normal. There's a research study years ago that looked at “healthy adults” and they tested their cortisol—the stress hormone cortisol in these healthy adults.

What they found is that even adults that were in the normal range of blood or serum cortisol, not abnormally high, just towards the high end of normal, that they were breaking down bone faster.

What research since then has shown is that just because cortisol is like prednisone, it's a glucocorticoid. So cortisol will make, and that stress hormone can make the body reduce the production of collagen, make collagen more brittle. But get this: research has shown it actually shrinks the size of your brain. Chronic cortisol elevation.

So it is just a killer. I think you are so right on the mark in making that a focus with people and helping them understand that they may not be aware of it. But I don't know one person who's not under too much stress in our modern-day society.

Ashley James (1:00:22.581)

The fact that it's shrinking your brain, it's robbing your bones, it's just really whittling away your life. 

Dr. John Neustadt (1:00:32.387)

Yes, here's another study that shocked me. When the stress hormones kick in—epinephrine, norepinephrine, cortisol. Epinephrine and those are fight-or-flight hormones. Epinephrine, they're quick-acting. Then cortisol is longer acting. It actually causes different genes to turn on and turn off those stress genes.

When your fight-or-flight is kicked in, that sympathetic part of the nervous system, that stress-anxiety part of the nervous system, it changes the blood flow in your brain. It moves it away from the prefrontal cortex. It shuts down those blood vessels. That is the area of your brain that is responsible for reasoning and logic and understanding the consequences of your decisions and making decisions.

It puts it more into the limbic system part of the brain, that emotional component of the brain, because you just want to flee. You're either going to fight and run, or you're going to fight, or you're going to run. So it's more of an escape mechanism.

What they've shown in studies is that people who are in that fight-or-flight response, they make worse decisions. They're more likely to make decisions for themselves to get them out of the immediate situation but are going to be harmful. They're actually more harmful to them.

That's what I think a lot of people are dealing with. It is not a good situation. Breaking that cycle, learning strategies and ways to do that. Even people waking up in the middle of the night, not being able to sleep, having it affect their sleep. I hear that all the time.

I teach people a simple breathing exercise. It's taught to our Special Forces and Navy SEALs and other Special Forces. They're in the most incredibly stressful situation—at least that I've ever experienced in my life. They're taught a breathing exercise where you just breathe. You breathe in to the count of three, you hold it to the count of three, and you breathe out to the count of three. You just repeat that.

Every time I do that, within a few rounds of that, I don't even realize I've fallen asleep, and I wake up hours later or the next morning. It's just a great way to regulate your nervous system. You can do it any time. It doesn't have to just be in bed.

Ashley James (1:03:05.793)

I love that you said to regulate your nervous system when it comes to breathing. Isn't that neat? Breathing is such a cool thing if you study it. That's what part of the autonomic nervous system can we can take over. You can't take over beating your heart, but you can take over breathing. Then when you forget to take it, your unconscious takes it over. It's really neat. By you taking over and controlling it, you're programming your body. You're telling your body, for example, we're safe.

How would you breathe if you were safe? How would you breathe if everything was okay? Well, I could take a three-second breath in and hold it, and a three-second breath out. But if you were being chased by a bear, you wouldn't breathe that way. So it's a direct door into the unconscious mind, into that autonomic nervous system, in order to regulate the nervous system. It's so neat.

There's one thing I would add to your box breathing. They found that if you make your out-breath longer than your in-breath—you could add one second, for example, to the out-breath or three seconds or whatever—just make the out-breath longer, that it directly affects the heart rate variability.

They can monitor heart rate variability. For those that don't know, it is a really cool way to observe your stress levels. Life insurance companies are considering using heart rate variability as one of the monitors to determine whether they want to insure people because poor heart rate variability is a direct indication that you are going to die sooner than later because of stress.

So everyone should definitely do some breathing every day. Carve some time out, even if you're just at stoplights. They're, what, a minute to 30 seconds to 90 seconds long, just depending on the stoplight. You could just be doing some deep breathing. It's not about falling asleep or going into meditation. Your eyes are open, you're still alert, but you're regulating your nervous system.

As a parent, sorry.

Dr. John Neustadt (1:05:24.768)

Great suggestions. I love it.

Ashley James (1:05:26.374)

As a parent, we figure out how to help our child regulate their nervous system. It's such a reflection upon us. Wow, I'm not good at this. I didn't know I wasn't good at regulating my nervous system until I had to deal with a child. Then they're getting intense and then I'm getting intense and I'm like, well, if I'm getting intense, we're just mirror matching each other.

If I'm getting intense and getting stressed out, that's not going to calm them down nor teach them how to regulate their nervous system. So then I need to have more emotional quotient. I need to grab myself and get out of that reptilian brain and get back into the prefrontal cortex and go, okay, I'm taking some breaths and you're going to take some breaths with me and we're going to regulate our nervous system.

But if you're an aunt or an uncle or parents or grandparents, you just have some access to children when they get in an emotionally dysregulated state, work with them to help them regulate their nervous system and it'll teach you how to regulate your nervous system.

This all pertains to bone health, believe it or not. It does.

Dr. John Neustadt (1:06:39.050)

Absolutely. Absolutely. Well, it also pertains to how we are going to walk through this world. What are we projecting in terms of who we are? Anyone with children can understand that they are going to learn from us more by what we do than what we say.

I think it's any area of our lives as well. We can only take people as far as we've gone ourselves. If I'm going to see a doctor and they look overweight and unhealthy, they're not going to engender the greatest confidence for me. But if I see a doctor who is fit, who's walking the walk, not just talking the talk, but their actions are matching their words.

It's the same in any organizational environment, whether it's business or family. That's why I believe that I think people make a mistake when they're so focused on fixing other people and not fixing themselves. We all have work to do. When we focus on our own personal development, that doesn't mean ignoring everybody in your life.

But really focusing and understanding that we don't see the world as it is. We see the world as we perceive it, as we think it is. When you begin to shift your mental model, you begin to do your own self-work, whether it's physical, with nutrition and exercise, things we've been talking about, whether it's emotional with the breathing or other developmental work or psychological with counseling or other emotional sorts of work that people can do as people move through that journey.

That's all part of a health journey. Just saying it's the physical body that's affected is not accurate. We are an integrated whole of body, spirit, mind, emotions— all of it interacts. So when you work on all of those components, and people are surprised when they open my book, there's a whole chapter in there just on connection, connecting with other people. I've never seen it talked about in any other bone health or osteoporosis book, but even that's been shown to reduce all-cause mortality. Being connected to the community is part of a holistic approach.

So I'm a big fan of people doing the work. What's the saying? Don't throw stones if you live in glass houses. Well, we all live in glass houses.

So it's important to have empathy and compassion for other people and what they're going through, but also understand that we can only control ourselves and what we do. But in doing that, we're setting the examples for people around us because as I mentioned before, behaviors are contagious. So if you're doing that, then the people around you are going to become more interested in doing that as they see you grow and you become healthier and stronger and more vibrant. They're going to want to be a part of that.

Ashley James (1:09:53.786)

I love it. In researching for your book, Fracture Proof Your Bones, what are some of the most exciting or mind-blowing things that you discovered? I know there's going to be a bunch of stuff you already knew. As you're going through the research, it was just validating what you knew. But was there anything that you were like, my gosh, I didn't know this?

Dr. John Neustadt (1:10:16.922)

I think the long list of medications that destroy bone was shocking to me. I never realized how big it was. It was never discussed in medical school. You never see it anywhere. So there are common drugs that are known, but there are many drugs that are commonly prescribed that are not on doctors' radars, and it's causing people osteoporosis.

Many of these drugs are prescribed to people at the highest risk for osteoporosis: people with autoimmune diseases, people with irritable bowel disease, the elderly. So it's just really a hot-button issue for me to get across.

The other thing I would be that I was shocked about is the misuse of research when it comes to dietary supplements out there and marketing dietary supplements, and how people are just having the wool pulled over their eyes by a lot of these marketing claims that are out there by companies that really don't have any, or from my point of view, the highest level of data supporting their research and their products.

What I mean by that is, and full disclosure, I own a dietary supplement company. MBI is a dietary supplement company, mbihealth.com. I created it though, because this again goes back 20 years, when I could not find the doses of nutrients shown in clinical trials to work that I needed for my patients.

So many of these companies out there are using, they're citing research in clinical trials on a nutrient, but then they put less of the nutrient shown in the clinical trial to actually work, or they use an entirely different nutrient but are citing the studies.

I'll give you some examples when it comes to bone health, because that was the impetus for me, or one of them, for me creating the company—because I needed a solution for my mother-in-law and I needed a solution for my patients.

When it comes to bone health dietary supplements, the way that I look at the research—and this is how I've settled on evaluating things—since the most dangerous thing about this condition is whether or not somebody has strong bones, the most important question I ask is: whatever it is, whether it's a nutrient or a medication, has it been shown to maintain strong bones as indicated by fewer fractures in clinical trials?

So many companies out there are putting out marketing information, and they're putting out their products, and they're formulating their products saying the nutrients or our product has been shown to improve bone density. Well, as I've already told you and shared with you in terms of the research, that's just a number on a test. It predicts only 44% of women with osteoporosis who will fracture, only 21% of men.

The absolute bottom line is: do you break a bone?

So when you look at clinical trials, when I look at clinical trials, I want to see that fractures were the endpoint in the clinical trial that they evaluated, not just a number on a test.

When it comes to bone health, there are only four nutrients that have been shown to reduce fractures in clinical trials: calcium and vitamin D, about 18 to 23%, and then a specific form of vitamin K2 called MK4.

MK7 is a very popular form of vitamin K2. Vitamin K2 is a category of nutrients. MK4 and MK7 are two of the types of vitamin K2 that are commercially available.

You have these people marketing MK7 and saying it has a longer half-life so it's better. It has better bioavailability, meaning it's more absorbable than MK4, so it's better. It changes a blood marker, so it's better.

But none of those are the outcomes that are most concerning to people. None of those are direct indicators of bone strength. In fact, just because something maybe has a longer half-life—meaning it stays in the body longer before your body eliminates it—is not an indicator at all that it's effective.

So when you look at the clinical trials on MK7, just for bone density—so let's look at bone density—what they don't say in their marketing is that MK7 has been shown to improve bone density, because in fact it hasn't even been shown to do that.

There have been, in the National Library of Medicine's PubMed databases—the sort of the warehouse for over, I think, 40 million peer-reviewed articles, medical articles, and scientific articles—when you do a search on the PubMed database for MK7 or one of its synonyms that it's known by and the clinical trials on it, there are only, and I just did this the other day because I'm working on the second edition of my book now, so I'm just making sure, reviewing the research again—five clinical trials on MK7 that looked at bone density.

None of the clinical trials showed that it stopped the loss of bone density or improved bone density. It only slows down how fast somebody loses bone minerals.

In fact, in one clinical trial—and this is at all doses, at any dose—in one clinical trial, the women taking the MK7 lost bone density at their hip faster than the placebo group.

There are no clinical trials, none, on MK7 that looked at fractures. None. So it has not been shown to maintain strong bones.

When it comes to MK4—now, they're both types of vitamin K2, but they're different molecules—as we know in biochemistry, if you change just one atom in a molecule, one carbon atom for example, you can get overlapping activities, but you also get very different activities and very different results.

So MK4 has been the subject of over 40, I think 45 clinical trials. I think 24 of them, 25 of them have looked at people specifically for bone health.

What it's repeatedly been shown to do is not only stop the decrease in bone density but improve and promote healthy bone density in women with postmenopausal osteoporosis, but also stop the loss of bone density when it comes to medications like prednisone or androgen deprivation therapy that's used for prostate cancer and some other conditions, in other types of bone loss conditions—people on hemodialysis for kidney disease, people who are immobile from a stroke, girls with anorexia nervosa that increases bone loss.

In all of those populations, this has been studied for bone mineral density. But again, that's not the most important thing. It hasn't been shown to maintain strong bones.

What we have though, in the published peer-reviewed medical journals, are multiple studies looking at fractures as the endpoint in volunteers in randomized clinical trials using 45 milligrams per day of MK4.

Repeatedly it shows in those volunteers that fractures are reduced. In some cases, over 76% reduction in fractures in postmenopausal women with osteoporosis taking MK4 45 milligrams per day compared to those not taking it.

There have been three meta-analyses. All have concluded very similar results: that MK4 not only can improve bone density and maintain and improve bone density, but maintain strong bones as indicated by fewer fractures in clinical trials.

It's been so well studied that it's been approved by the Ministry of Health in Japan for bone health since 1995.

It didn't exist in that clinical trial dose 20 years ago in this country. So I was the first one to bring it in. I've now created three different versions of the formula, all with the same amount of MK4 per day, 2,000 units of vitamin D3 because there's synergy between the two—when MK4 was combined with vitamin D3, bone density improved greater than just with the MK4 alone. So I'm so passionate about this that any chance I get to share this, I'm excited to talk about it so that people can understand how they can read marketing materials better, to make better decisions for themselves and evaluate the research and ask better questions.

Ashley James (1:19:15.414)

You had mentioned that these increased bone density. We talked about how bone density isn't necessarily an indicator of fracture-proofing bones because we want to make sure that our bones are flexible and that in some cases, just higher bone density can actually mean fragility.

Increasing calcium, vitamin D, vitamin K—that's the good, absorbable, usable form. 

Dr. John Neustadt (1:19:52.620)

So if I could correct you just for a second, because it's not just vitamin K. Because vitamin K1 has never been shown to improve bone density or reduce fractures. It's not just absorbability, because MK7, which has been shown to be bioavailable, as well as MK4 is also bioavailable. They're both absorbed. Also has not been shown to reduce fractures. It's specifically the form of vitamin K and the dose that's important. They're not just, the MK4 is not just improving bone density in these clinical trials.

Studies show, because it's a nutrient, so all nutrients have many positive actions in the body. So MK4 has also been shown to activate genes that promote collagen production. It's been shown to help with healthy inflammatory balance. MK4 is produced in our own bodies. The MK7 is not. Vitamin K1 is not.

We convert vitamin K1 and MK7 in our bodies into MK4. It is the primary form of vitamin K that accumulates in all tissues in our body, except for the liver, which vitamin K1 is the primary form of vitamin K in the liver. But it points to the wide-ranging other potential health benefits that MK4 has.

In fact, there are up to phase two clinical trials in the research of MK4—45 milligrams all the way up to 135 milligrams per day in people with acute myeloid leukemia, myeloid dysplastic syndrome, liver cancer, and hepatitis C who are at risk of progressing to liver cancer, and a case report of acute promyelocytic leukemia.

So it does many other things, and it does have the outcomes in terms of the studies showing that bone strength is maintained, that it does promote strong bones. It promotes collagen production. It promotes and supports bone mineral density because it's the collagen that the bone minerals bind to. So they need that scaffolding for those minerals to hang on—like ornaments on a Christmas tree.

Ashley James (1:22:09.956)

I love it. Thank you for clarifying that because just saying this supplement increases bone density, well, certain medications claim that they increase bone density, but that doesn't mean it's going to help prevent fractures.

Dr. John Neustadt (1:22:09.956)

You're absolutely right, which is why I was very careful to make sure that I also discussed the clinical trials with MK4 showing that it maintains strong bones as indicated by fewer fractures, up to, in one meta-analysis, 76% reduction in fractures relative compared to people not taking the 45 milligrams of MK4.

Ashley James (1:22:48.098)

Now, a healthy person with a healthy gut microbiome makes their own vitamin K.

Dr. John Neustadt (1:22:55.634)

MK7, only MK7. The bacteria make MK7, that's what's made in our gut. It may have some benefits locally in the gut and it may have some other benefits in the body. But what we do know and what studies have shown is that the MK7, when it enters the body, same with vitamin K1, is converted into MK4 by an enzyme called UBAD1.

It is the similar pathway that is used to produce coenzyme Q10 in our bodies. There's a branch point where it creates menaquinone four or MK4. Those other forms, the MK7 is not produced in our body. It's only produced by bacteria. Then when it enters the body, our body converts it into MK4, but you cannot get enough MK4 from that source or from diet. Because mammals like us—manufacture MK4, so it's also in dairy products and in meat.

But you can't get enough that has been shown to be the dosages in clinical trials shown to work. Need that 40, you're getting maybe micrograms per day by those other sources, but the clinical trials use milligrams. One milligram is equal to 1000 micrograms. So 45 milligrams per day is the clinical trial dose. That equals 45,000 micrograms.

Ashley James (1:24:20.558)

Do cholesterol meds negatively impact our ability to convert the vitamin K in the body because it impacts CoQ10 production? Does it also impact vitamin K?

Dr. John Neustadt (1:24:40.234)

You are so astute. I love that you asked that. Yes, not just the statin medications—Lipitor, atorvastatin—but the nitrogen-containing bisphosphonates—Fosamax, alendronate—those also block the production of MK4.

So, it's crazy because MK4 has so many great bone-building and health benefits, yet these nitrogen-containing bisphosphonate medications for bone health are actually blocking our own production of it.

Ashley James (1:25:15.312)

Yes, so you mean the medication they give you to help your bones is actually stopping your body from helping your bones? 

Dr. John Neustadt (1:25:21.992)

In some ways, yes, absolutely. In fact, it's been shown to reduce collagen production as well. Now we know from research that for every 100 fractures that are prevented, it may be creating one what's called an atypical femoral fracture. These are 100 hip fractures that are prevented and the atypical femoral fracture.

Typically, when you break your femur, your leg bone, with osteoporosis, it's high up. It's what's called the femoral neck, up towards the hip. In these atypical femoral fractures that are caused by not just the bisphosphonates but Prolia, Xgeva—those medications—Denosumab is the generic, those also can cause atypical femoral fractures. They're mid-shaft fractures. They're lower down in the femur, in the leg bone.

They tend to be breaks that can happen without you even needing to sustain a major fall. There are lots of case reports in the literature of people just stepping wrong. There's one woman who was watering her plants and stepped down off the step stool. Didn't fall, didn't trip, didn't lose her balance, and just stepped down and went to turn. As she torqued a little bit, just turning her body, her leg fractured.

What happens when you get an atypical femoral fracture and you're on one of these medications, it actually takes longer to heal. So these medications—the bisphosphonates, not the denosumab, but bisphosphonates—work by poisoning the osteoclasts. So they stop the activity of the osteoclast. That old worn-out bone that needs to be recycled is not getting broken down and recycled. All you get is new bone being produced and layered on top of old weak bone.

So it gets this really unhealthy and unnatural bone pattern deposition, I should say. This unnatural and unhealthy pattern of bone deposition that is actually weaker. That's why people say, that's why the guidelines now say, you don't take it for more than three years because the risk goes up. You're also at risk, by the way, of osteonecrosis of the jaw.

So that if you go in and get a tooth pulled, even something as simple as that, while you're on a bisphosphonate or Prolia or Xgeva, there's a risk that your jawbone can just literally start to disintegrate.

Ashley James (1:27:58.204)

I seriously hope no one listening is on these medications, and if they are, or if they have a loved one that is, that they will share this episode with those they care about because people really need to know. Unfortunately, we're not given true informed consent when we go to a medical doctor and they put us on a drug. They barely see us for 15 minutes. The nurse sees us longer than the doctor does, and they're just very happy to prescribe all kinds of medication like it's candy.

They don't sit down and give you true informed consent, which is telling you all the benefits, all of the effects and side effects, and telling you about the alternatives. They don't sit down and educate you, because if you knew that your jaw could die, you wouldn't take this.

Dr. John Neustadt (1:28:55.346)

Well, there are studies that have looked at this, and there's a whole section in my new book. The second edition of the book that's coming out, I expand the whole concept of informed consent so people can understand what questions to ask their doctor.

Studies have looked at this, and part of the challenge is the doctors don't know the information, first of all. Second of all, they're in a financial business model that doesn't give them enough time to have these conversations specifically around alternatives. They're more nuanced. They're not educated, especially when it comes to bone health. They're confused about the medications, they're confused about the test results, or they don't have the training in these integrative approaches. So they're just not equipped to have these conversations, and the medical system in which they're working, the financial reimbursement model, also does not allow for that.

But I do want to just correct something. I have to disagree with something you said. I do believe that there are reasons to take the medications. There are cases where I think it is important to strongly consider taking a medication, an osteoporosis medication, and that goes for, I think, many other medications as well.

Specifically for the osteoporosis medications, let me be very clear. They have been shown to reduce fractures in clinical trials. Now, the nuances are important though when people are making a decision. When somebody has a new diagnosis of osteoporosis, and they've never broken a bone, what we're trying to prevent is getting the first fracture, what's called primary fracture prevention.

So what does the research show with the medications and their ability to reduce the risk of a first fracture? Well, they don't do a very good job. Studies have shown that the bisphosphonates, for example, don't prevent both vertebral and hip primary fractures. Most of the studies will say just for T-bone fracture, they'll only report vertebral fractures because they don't even report hip fractures.

But the research shows that for primary hip fracture prevention, they're just not efficient or not effective. Meta-analyses have been done more recently that have looked in real world situations, not clinical trials, and have concluded that the bisphosphonates don't prevent fractures at all. So maybe they're going to prevent a vertebral fracture for primary prevention, not a hip fracture. Maybe they'll prevent, or maybe they won't prevent a fracture. So that's where the clinical trials are with those.

Now for secondary fracture prevention, that means you've already had a fracture with osteoporosis. We're trying to prevent you from getting another one. The medications are much more effective. There are more options. The vast majority of the published clinical trials on these medications are secondary prevention studies. They're in high-risk populations, primarily postmenopausal women with osteoporosis who have already had a fracture or are extremely high risk for fracture. They're mostly secondary fracture prevention studies.

They do prevent both vertebral and hip fractures in those situations. So if somebody's already had a fracture with osteoporosis, I think it is important to look at the medications as a potential option. But it's important also to understand the potential benefits and the potential risk and what else you can do.

So I think that having those, again, those more nuanced conversations are really important because in order to get the benefits of the osteoporosis medication, somebody has to take it 70 to 80% of the time. So you have to be consistent, and you have to be willing to do it for years.

So for the bisphosphonates, the oral bisphosphonates, that means on an empty stomach, 30 minutes before eating, standing up, not laying down, because if you lay down, it can go back up into your throat and cause esophageal erosions. About 60% of those patients who start an oral bisphosphonate, because of the side effects, discontinue it within the first year. So again, you've got to be able to commit.

Then once you go through that three to five years on the bisphosphonates, which is usually the first-line therapy, they're going to typically want to switch you to a different medication called sequential therapy. So then it'd probably be Prolia or one of the other medications. So you just have to be willing that, okay, this is going to be then probably what you're doing, or you can decide to stop at any time.

I do want to correct one thing I said. I was talking before in terms of primary fracture prevention with osteoporosis, the oral bisphosphonates. Now there's only one medication that has been shown to prevent primary vertebral fractures and primary hip fractures, and that's intravenous Zometa or zoledronic acid, zolendronate. That's the only one.

So if anybody wants to consider for primary fracture prevention of vertebral and hip fractures, any of the medications, the best data is going to be on Zometa, that type of medication, the IV zoledronic acid or zolendronate.

So again, there are, I believe, cases to be made for when the drug should be considered more strongly than other times. There are some benefits in the studies to the medications. There are also risks, but this is again where the details matter.

Is it being prescribed? Is it appropriate for your diagnosis? For example, if you have proton pump-induced osteoporosis and somebody prescribes Fosamax to you, they're increasing your fracture risk. That's not ambiguous.

There are also studies if you have breast cancer and bone loss. There are studies using some of those medications that have looked at metastases or the first skeletal events and preventing those. So there are all these nuances that are important.

So a medication needs to be appropriately prescribed based on the clinical trials for your diagnosis and with your medical history. Those are the types of conversations that I really try and educate people in my books about. In my book Fracture Proof Your Bones, the questions they need to ask their doctors to make sure they're getting the best possible information so they can make the best possible decision for their health.

Ashley James (1:35:36.714)

People who eat a whole foods diet, minimally processed diet, get plenty of plants, so they're getting hopefully minerals, although that's debatable because of farming practices, and walk often, lift heavy things often. What percentage of people who do all that still have bone problems?

Dr. John Neustadt (1:36:10.792)

I don't know. There's no way to answer that. There are too many variables. No studies looked at all of those variables that I've ever found. But what we do know is that if somebody's fall risk is reduced, meaning they're at the lowest risk for fall. Again, there are tests that are done that measure gait, that measure mobility and strength.

If people score low or well, I should say, on those tests, what we do know is the ability of the bone density test to predict fractures goes down. As I said before, if you're just looking at the bone mineral density test for its ability to predict fractures in women with osteoporosis, it predicts 44% of women who will fracture and 21% of men. Now, if their fall risk is low, that predictive value of the bone mineral density test goes down to about 4.3% in women and I think a little over 5% in men. So basically 5%. Huge.

Ashley James (1:37:08.516)

It’s huge. So really the reins are in our hands, the control, the steering wheel’s in our hands. So much that we can do before we ever got to that point where we needed to have a talk with our doctor about medication.

The important thing is to get out and do it every day. I was shocked that the hormone cortisol played such an important role in bone health or in negatively impacted bone health.

What about for men and women? What about estrogen, progesterone, testosterone? What about the sex hormones? We talked about steroid hormones. What about sex hormones? How big a deal is it in terms of the longevity of our bone health?

Dr. John Neustadt (1:37:58.392)

It's pivotal. Both of those hormones are key. I've seen so many men who have come to me with a diagnosis of osteoporosis and have not had their testosterone tested. Even if they have had their testosterone tested, they haven't had their estradiol tested along with it. Estrogen in men, just like in women, is crucial for improving bone health and maintaining bone health and maintaining bone strength.

So for women who enter menopause or are in perimenopause, starting hormone replacement therapy has been associated with a 28%, I believe it is, reduction in fracture risk. Now that's when they started around perimenopause, and it's FDA-approved estrogen therapy for the prevention of osteoporosis. A lot of doctors, including myself, advocate for using bioidentical hormone replacement therapy for helping people reverse osteoporosis as well, when it's safe to do. There are some cases where it's not safe.

That is the research though—it tops out at about 60 years old. We don't have any data if somebody starts it after 60. Similar to other things, if you stop it, your kind of bone density starts to go down again, your bone quality begins to decrease again. But it's shown to be very safe, not just for bone health—also for cardiovascular health and protecting brain health and those sorts of things.

For men, again, looking at testosterone replacement therapy is really important. Men's testosterone starts to go down around 40 years old, and for a lot of men it starts to decline. So I'm actually a big believer that men should be tested for testosterone routinely around 45 or 50, and then you begin to track it and see if it's going down.

Then testosterone replacement therapy, just like with estradiol or estrogen, is used just to get it back into that normal, healthy range—not with testosterone, we're not talking super physiological, not competitive bodybuilding type stuff that people see. No, it's just to restore it back into the normal, healthy, optimal range.

Now we don't have fracture outcomes data on men with testosterone therapy. Again, most of the clinical trials—the vast majority—are done on postmenopausal women with osteoporosis for all things having to do with this condition. That's because 80% of osteoporosis is in women and only 20% in men.

So we do have extrapolated data from the research on postmenopausal osteoporosis and it's applied to other conditions. For men, what we do see is that bone density does go up. I think it is logical, and it makes sense though, that it would be reducing fractures in men as well, because it's promoting that overall bone health. Unlike a medication that's taking over the body's biochemistry, it's just working with the body's own natural biochemistry to help it produce healthier, strong bones.

Now, I do want to mention though, because this is a huge blind spot for the general public and clinicians, just because a woman comes into your office—or just because you're a woman, maybe—and your estrogen is low, a lot of times the doctor is going to say, their evaluation just stops there: “You have low estrogen, you're perimenopausal, that's all we need to deal with.” Same with men: “Oh, you're low in testosterone, so let's just do testosterone replacement, that's all we need to look at.”

But in postmenopausal women with osteoporosis, up to 30% of those cases have to do with something other—or in addition to—the drop in estrogen that comes with menopause. So there's something else going on, a secondary cause also happening that then is often missed in the evaluation. It could be a medication, it could be another disease, it could be sedentary lifestyle contributing. I mean, there are lots of different things—chronic inflammation.

For men, up to 50% of male osteoporosis is caused by things other than or in addition to the drop in testosterone.

Ashley James (01:35:15.512)

So potentially men are impacted even more from lifestyle and diet.

Dr. John Neustadt (1:42:32.494)

Well, it's interesting. So men, the mortality risk in men—the risk of death in men with osteoporosis—is even greater than it is with women. So men with osteosarcopenia, if they were to fracture, are at a much higher risk of dying than women with osteosarcopenia. Men with osteoporosis who fracture are at a higher risk of dying than women. That's hip fractures I'm talking about.

It's believed that the reason is because men, as we get older, the other diseases that we have tend to be more severe than in women. Just like with COVID, if people had other comorbidities and other diseases and they're more severe, they had a higher risk of dying if they got COVID. Well, it's the same with breaking a hip with osteoporosis.

Ashley James (1:43:22.230)

Interesting. I'm sure you mentioned it, but what is the percentage of men that have osteoporosis versus women? In my mind, it's so much less.

Dr. John Neustadt (1:43:35.636)

20% of cases are in men, 80 % in women.

Ashley James (1:43:40.312)

That is higher than I thought it would be. Out of the population, what percentage of people experience osteoporosis in their lifetime?

Dr. John Neustadt (1:43:52.788)

Oh, that's a great question. I knew I saw that data at one point. Right now I believe it is, well, about 40%, 45% of women will break a bone with osteoporosis at some point in their life. I forget off the top of my head. I could pull up the data, but a lot of people obviously have bone loss. But I also think the numbers for osteoporosis and bone loss are misrepresenting the actual number of people that are struggling with this. 

Then a lot more people have it than the data show because look at the highest risk population—people 65 and older. As we get older, that's the Medicare-age population. Ninety-five percent of Medicare patients who should get screened with a bone density test are not.

Then you've got all these other people, so we don't know if they have it or not. Oftentimes it's a silent disease with no symptoms. Oftentimes the first symptom is somebody breaks a bone. In fact, the Bone Health and Osteoporosis Foundation—I'm on the corporate advisory round table for that association—the recommendation is that at age 50 for men and women, if you break a bone at age 50, you should get a bone density test.

But the U.S. Services, the Preventative Services Task Force, and the official U.S. government and guidelines from many medical organizations are: you don't start screening for osteoporosis unless it's a post-menopausal woman or somebody with some other risk factors or a few other things, but definitely not somebody who just happens to come in at 50 and break a bone.

There are many cases and studies out there looking at people who are taking medications or have diseases—irritable bowel disease—that destroy bone or medications that destroy bone and cause osteoporosis. Even when official guidelines are recommending that they get screened for osteoporosis with bone density tests, the vast majority of those patients are not getting tested, are not getting screened.

So I think there's a whole lot of people walking around who have lost bone and are at an elevated risk just by the fact of fracture, just by the fact that they don't know. So they're not being proactive because they're not getting screened.

I think whatever numbers that I would cite in terms of how many people are affected by this is a gross underestimate.

Ashley James (1:46:23.394)

That makes sense. We don't know for sure. I just Googled it and it says 12 and a half percent of people over the age of 50. But, like you said, so few people are being screened appropriately. 

Dr. John Neustadt (1:46:38.090)

But that's just osteoporosis and there's osteopenia. We're talking over probably over 50 % of people.

Ashley James (1:46:40.826)

That's just osteoporosis. That's not osteopenia, that's not bone loss.

There are many things leading to osteoporosis. Maybe you could differentiate what is osteopenia versus osteoporosis versus just bone loss on the way to like at what point are we at risk of fractures?

Dr. John Neustadt (1:47:03.958)

So osteoporosis and osteopenia are defined by the results of a bone mineral density test. Or if another type of machine is used, they can translate that, do some calculations, and create an equivalent score. But the official diagnosis and definition was created in 1995 or 1994 by the World Health Organization.

It's defined by a T score. A T score measures somebody's bone density compared to the bone density of somebody of the same gender in their twenties and of the same race. So if I am a Caucasian woman, 67 years old, my T score is going to compare my bone density to a Caucasian woman 20 to 29 years old.

A T score is reported as a negative number because you're losing bone. So a T score of minus one to minus 2.5 is considered osteopenia or pre-osteoporosis. A T score of minus 2.5 or lower—minus 2.7, minus 3—is osteoporosis. They're only validated measures as low as 50 years old.

Less than 50 years old, you have to use another score that's reported on the test called a Z score. I mean, we could probably spend another 20 minutes just talking about the test and how to interpret it and apply it and all of that. But the basic definition of osteoporosis is just as I described it—based on that T score—and research has shown that the lower your T score, it is linked and associated with higher risk of fractures.

But here's the kicker. In clinical trials, people's risk for fractures was higher if they had osteopenia than if they had osteoporosis. Now it's confusing as to why that's been shown to be the case. Some people are saying we need to change the cutoff values for how we define osteoporosis. So it's really just a definition.

I think it might be because if somebody just has osteopenia, maybe they're not being as proactive as somebody with osteoporosis. But I don't really have any data to support that. But basically it shows as your T score goes down, even with osteopenia, you're already at risk for increased fracture risk.

Ashley James (1:49:51.846)

That was my first thought with osteopenia having more fractures, is that maybe they're not protecting themselves. When someone knows they have osteoporosis, they generally are going to pamper or baby themselves a bit more. They're more concerned about a bone fracture.

Some of the osteopenia might be going out there and be more physical and then potentially injuring themselves.

Dr. John Neustadt (1:50:15.518)

Yes, you remind me of something that I think is really important to mention about men with osteoporosis, especially if anybody listening to this is a man with osteoporosis who starts testosterone replacement therapy or a woman who has a man in their life who they care about who's starting testosterone replacement therapy with osteoporosis.

The research shows that in the first year after starting testosterone in men with osteoporosis, their fracture risk actually went up. They broke more bones. Now, why is that?

Well, the reason is because these men—it's not because of the bone health—it's because us men are a little bit stupid sometimes. As soon as we start feeling better—and I'm on testosterone, I've been taking it for years, I had low testosterone—so I went through this as well. I didn't break a bone, but I went through feeling horrible. Then suddenly I felt so much better and had more energy.

I started wanting to do all these activities I used to do when I was 20. So what they found in these men—when they feel better, they start doing these activities that they used to do younger—and they're more at risk, they become, taking more risks and doing more dangerous things.

So that's why their fractures went up—because of the activities they started doing in the first year after starting testosterone, not because of the testosterone. Basically, because we're idiots.

Ashley James (1:51:33.054)

No, it's so funny. That’s happened so many times with my clients. I have to warn them. When you start to feel better, you're going to push yourself and then you're going to come back to me and tell me you feel worse and you're in more pain. But then I'm going to ask you, what did you do this week?

You're going to tell me, “I just went on a five-mile hike,” and I'm like, “Well, what did you do before you talked to me?” I'm like, “Well, I was just a couch potato.” I'm like, “Okay, well, you started feeling so good, then you push yourself and then you feel bad because you pushed yourself too much. You just went too hard, too fast.”

 I can imagine for a man getting on testosterone, all of a sudden they feel amazing and they're going to push themselves and they have to be careful. We need to just pamper ourselves a bit more as we're building back our body.

One of my naturopaths actually told me about how he used to work in a gym and he said he would see new members in the first six months, most of them would experience some kind of injury because they pushed themselves too far.

What people don't realize when you go to a gym, your first six months—your connective tissue. So think about your ligaments and your tendons. Your tendons attach from your muscle to the bone. The ligaments are keeping your joints together. But this connective tissue hasn't been trained to lift tens of pounds or hundreds of pounds.

We always think we're strengthening our muscles when we're lifting heavy weights, but we don't think that we're actually also strengthening our connective tissue. So the most important thing to do in your first six months of implementing a regular exercise routine is to not push yourself too hard because the more stress you're putting on your body, you're stimulating your body to increase—and hopefully healthfully increase—that connective tissue, which we talked about: things you can do and not do to support your collagen production.

Which is one of our connective tissues made up of collagen. Lift your heavy weights. Know that you're also stimulating healthier tendons, healthier ligaments along the way.

Nourish your body with really good food. You said, supplement to fill in those nutrient gaps so the body can rebuild itself. I love that you talked about how important hormones are because we don't need to be our grandparents and feel really crappy after 50. We don't.

But we also need to be very careful and definitely seek out a well-experienced doctor that specializes in hormone—natural or bioidentical hormone replacement therapy—because just so many people out there do it wrong and overdo it and that can also lead to not feeling great and negative effects.

So we just have to do everything in balance, and less is more in a lot of cases.

Dr. John Neustadt (1:54:40.526)

Yes, absolutely. I'm glad you mentioned the exercise because the overall concept in this for me with bone health and osteoporosis and really any chronic issue is slow and steady wins the race, being measured in your approach, taking consistent action, day after day, just moving in the right direction. It's taken probably decades for you to get in this situation. So it's not going to turn around immediately and it takes time and consistent effort.

When it comes to exercise in particular, there's a concept called time under tension. So a lot of people want to go, I see them in the gym lifting weights or even in exercise classes and they're just, they're moving as quickly as they can. They're snapping the weight up, they're finishing the rep quickly. But really in terms of building muscle, slower is better.

So the longer that you can have your muscle be contracted, and it's not just on, let's say you're doing a bicep curl, curling up, but it's even when you lengthen your muscle and allow your arm to kind of go back down and uncurl, moving slowly and not letting gravity take over has a couple of benefits. One, it improves how fast or how well your body's going to respond and you're going to build muscle, but it's also safer.

So moving slower when it comes to exercise and learning the proper technique is so important for not only long-term safety, but long-term results.

Ashley James (1:56:20.932)

I got to share with you my favorite exercise at the gym for balance because we talked about how important balance is. You get a BOSU ball. For those who don't know this, it's a half a ball. It's got a flat part that's hard, then it has a ball underneath it, a half a ball. I stand on the BOSU ball, standing on the flat part, then I'll grab either weights in both hands or I'll grab a medicine ball or a kettlebell, whichever one I kind of feel like.

I'll do a squat, proper squat. You want to get something to teach you how to do a proper squat or make sure you're looking in the mirror. I do a squat and then I lift that weight and slowly lift it all the way above my head. Then I go back down to doing a squat and then I lift it, and my legs are wobbling back and forth because I'm trying to maintain balance. I also am squeezing my core, doing a kegel. So I'm getting my core in, I'm getting my leg balance, all those wonderful little muscles in your lower leg.

That helps your foot stabilize, all those foot muscles, everything that's helping you stabilize. Then you're getting your arms and you're getting a good stretch as you go up and come back down. That's my favorite exercise, probably because it takes so much of my attention. It's not boring, but it's using your entire body. It's really fun. I love kind of looking around, seeing all the people stare at me like, what is she doing? It's fun. 

You don't have to start with weights. You could just do a squat, and I also do it. It's funny. I'm not necessarily an advanced person, but I play around, and I do it over by something you can grab onto. So if you feel you're going to lose your balance, you grab onto something.

But yes, squat, and then you could start with just regular squats. I love that idea of anything I can do to challenge my balanced muscles. So I love BOSU balls for that purpose.

Dr. John Neustadt (1:58:14.354)

Balance is so important. The research shows too that being able to balance on one leg for 10 seconds is a predictor of longevity. Even just building balance exercises into your daily life can be helpful.

I love the stork exercise while brushing your teeth. You're going to brush your teeth twice a day. As you're brushing your teeth, you stand on one leg for your bottom teeth—that'll be a minute. Switch legs for your top teeth.

Do that twice a day. You're working a little bit of your core muscles, your abdominal muscles, your legs, balance, strength. Then when it gets really easy, switch to your non-dominant hand and try it that way.

There are different ways you can, as well as going to the gym and doing other things, things that you can work into your life. I love that you said that it's fun for you, that you can find things that are fun. If people can find things that they enjoy doing and that are fun to do, they're more likely to succeed and excel at them. If people get bored, because it can get boring doing the same exercise or doing the same routine over and over, switch, try something new, switch it up.

Ashley James (1:59:21.636)

I love it. Thank you so much for coming on the show, Dr. John Neustadt. This has been amazing.

Of course, the links to everything that Dr. John does will be in the show. So today's podcast—LearnTrueHealth.com, NBIHealth.com is your website, and you have all your socials. You're on Facebook and everywhere. We'll make sure we follow you.

Give us a piece of homework that we will do today and for the rest of the week. Give us some homework to improve our overall health, our bone health. I know you've already given us so many points, but is there anything you would want 100% of the population to do?

Dr. John Neustadt (2:00:01.324)

Yes. It's not directly related to bone health. I want people to take some time to sit with themselves without any distractions, without phones, without kids, without interruptions. I want you to imagine your life in five years. I want you to imagine if you didn't change anything in your life, what are you going to feel like in one year? What are you going to feel in three years and five years? How are you going to think about yourself? You look in the mirror. How is that going to feel? What example are you setting if you have kids or loved ones? If you don't change things in your life that you know are not where you want them to be.

Then I want you to actually write that down, how that felt. I want you to take a deep breath, and I want you to do it again. I want you to imagine that in a year, you've taken whatever that is, whatever that issue is, and you've changed it. How are you going to feel in a year if you've made progress to making this change, to reaching that new goal? How are you going to feel in three years? Visualize it. What's it going to feel like when you look at yourself in the mirror, when you look at your kids or your partner? How you walk, your energy, your mood—how are you going to feel in five years if you've made those changes?

Then I want you to write that down as well. That's your North Star. That's your goal. That's what you should be working to achieve every day.

Ashley James (2:01:31.730)

I love it. Thank you so much, John. I'd love to have you back on the show when you have more to share. You've been a wonderful guest, and it was great learning from you. Thank you.

Dr. John Neustadt (2:01:42.866)

Thank you. It was fun. I enjoyed it.

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