Ep. 519 We’re Failing Women’s Bones – The Shocking Truth About Early Bone Loss with Dr. Doug Lucas

Today, I’m thrilled to welcome Dr. Doug Lucas for the first episode of a two-part masterclass on bone health. Dr. Lucas is double board-certified as both an orthopedic surgeon and an osteoporosis specialist. He is on a mission to show the world that osteoporosis is both preventable and reversible.  

In our discussion today, we take a deep dive into existing guidelines and their limitations and examine how Depo-Provera and oral contraceptives affect women’s bone physiology, particularly in younger women. We clarify why no ovulation means no bone balance, how breastfeeding affects bone health, and the importance of peak bone density. We explore the importance of early interventions and screenings, risk factors for poor bone health, the concept of relative energy deficiency, and the limitations of DEXA scans compared to REMS technology. Dr. Lucas also discusses bone health markers and the effects of frailty, falls, and sarcopenia, and shares the foundational pillars of health and longevity.

Stay tuned for part two of our masterclass on bone health.

IN THIS EPISODE, YOU WILL LEARN:

• How existing osteoporosis guidelines tend to overlook the key nuances of prevention and care

• The importance of early bone-health screening 

• How Depo-Provera and the contraceptive pill disrupt bone physiology in younger women

• How bone balance becomes disrupted with suppressed ovulation 

• Why peak bone density is a critical target in early adulthood

• How breastfeeding affects bone density 

• Where DEXA scans fall short and how REMS technology offers a clearer picture of bone health

• How relative energy deficiency impacts bone health in active women

• Why muscle mass is essential for protecting bone health and preventing frailty 

• The lifestyle pillars for long-term bone health and longevity

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“If you have a uterus, you need progesterone with estrogen.”

– Cynthia Thurlow

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Transcript:

Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.

[00:00:29] Today, I had the honor of connecting with Dr. Doug Lucas in person. This is the first of a two-part conversation about bone health masterclass. He's a double board-certified orthopedic surgeon turned osteoporosis specialist on a mission to show the world that osteoporosis is preventable and reversible.

[00:00:48] Today, we spoke about existing guidelines and limitations, the net impact on bone health of Depo-Provera and oral contraceptives, especially for bone physiology in younger women, how no ovulation equates to no bone balance, the impact of breastfeeding on bone health and the importance of peak bone density, why early intervention and screenings are important for bone health, risk factors for poor bone health, what relative energy deficiency is particularly in women, limitation to DEXA screenings and why REMS is so beneficial, bone health markers, the impact of frailty, falls and sarcopenia as well as key pillars of health and longevity.

[00:01:35] Again, this is the first of a two-part conversation with Dr. Doug Lucas. Stay tuned for the second conversation.

[00:01:44] Dr. Doug Lucas, welcome to the podcast. I've been looking forward for this conversation.

Dr. Doug Lucas: [00:01:48] Oh thank you. So happy to be here.

Cynthia Thurlow: [00:01:49] As a, in your past life, former orthopedic surgeon, now turned functional integrative medicine practitioner, what is one thing that you think women in perimenopause and menopause need to understand about their bone physiology way before they get to middle age?

Dr. Doug Lucas: [00:02:08] Can I get more than one thing?

Cynthia Thurlow: [00:02:10] Absolutely.

Dr. Doug Lucas: [00:02:10] I'll start with one thing. I think the biggest thing to get across to any woman who is going through midlife, regardless of health status, regardless of what's going on with hormones, is that we need to understand what's happening with our bones much earlier than we do. Because once you get screened, if you follow the guidelines at 65, I'm not going to say it's too late, but it's so much easier to protect your bone when you have it than when you don't. So, we need to be educating women and men, but really women that we need to screen early. We need to know what risk factors are. We need to follow bone over time just like we follow every other biomarker of importance.

Cynthia Thurlow: [00:02:47] I couldn't agree with you more and the thing that I find really interesting is-- so, my new book will be out in 2026. There's a whole chapter dedicated to the gut-bone axis. And when I was knee-deep in the research, the things I was shocked by as someone from a generation that was put on oral contraceptives early to fix irregular cycles, the net impact of young women being placed on not just oral contraceptives, but things like Depo-Provera that has a black box warning. The net impact of augmenting bone physiology and bone-- laying down healthy bone at a young age, I thought was really astounding because I think not a lot of people are perhaps having those conversations with their patients. I know that Depo-Provera is reversible. You know, with two years of use, it is reversible.

Dr. Doug Lucas: [00:03:39] Sure. Yes.

Cynthia Thurlow: [00:03:40] But how many women from my generation were told they were osteopenic not because they have an eating disorder, not because they were smoking, but because they never had the ability to lay down healthy bone in their teens and early 20s?

Dr. Doug Lucas: [00:03:53] No, it's really common. I think going back to the screening point, we don't screen young adults, so we don't know. We say there's 200 million people in the world with osteoporosis. We have no idea how many people have osteoporosis, especially women, for a lot of reasons. You just mentioned some really big ones. But the birth control topic is really interesting because I looked at this in depth. If you look at women who are cycling-- so, premenopausal women who are cycling hopefully regularly, if they become irregular and they lose at least half of their cycles, if they're not ovulating at least half of the year, then they're losing bone. That natural push-pull is so important.

[00:04:31] And then when you obliterate it with oral birth control or oral hormonal contraceptives, you are going to have an impact on your bone. Now, I will say I was surprised in the research to see that because some of the progestins are androgenic, meaning they're going to support bone building in some way, although not naturally, the impact was not as bad as I thought it would be, but it's still not natural and I think it is still having a negative impact on a much broader scale.

Cynthia Thurlow: [00:04:55] Yeah and even like when I interviewed Dr. Vonda Wright earlier this year, we were talking about the impact of breastfeeding. So, again, you're still talking about young women. So, they might have gone two years out of a menstrual cycle because they were pregnant, then breastfeeding and the net impact of bone loss and upregulation during those periods of breastfeeding. There are certainly a lot of women that breastfeed beyond like the six to 12-month mark. They're women that are doing it for years.

Dr. Doug Lucas: [00:05:21] Yeah. And I think there's so much value in that. I never want to discourage women from breastfeeding if they're interested in doing that. It is so good for the baby. But we know that women are going to lose bone during that time while they're pregnant, while they're breastfeeding. It's just natural. It's part of what happens with the body. This is why it's so important to have good peak bone density, hopefully before you get pregnant.

[00:05:42] We reach peak bone density in our 20s. Right? Of course you could get pregnant before that. But ideally you have a really great starting point and then these fluctuations don't matter as much because it's going to happen. You can't do impact exercise and heavy resistance training and eat a ton of protein and optimize hormones while you're pregnant.

Cynthia Thurlow: [00:05:59] Certainly, I think the message that we want is just to bring greater awareness because I think for many women it's not until they get that first DEXA screening at 65, which to me is way too late. I was fortunate that I had a GYN who was testing my-- I did DEXAs in my 30s, 40s, and my 50s. I think for many individuals that are hearing this podcast, it's with the realization of saying okay I need to be looking at this much earlier.

[00:06:27] DEXA screenings are pretty inexpensive, although I know from doing my research to prep for this podcast, a lot of the interpretation can be highly dependent on the machine, the physician that is reading the information. Maybe it's not a terrible time to kind of talk around the subject. I know we'll get around-- we'll dive more into the testing piece further into the conversation.

[00:06:53] But if you were speaking to a 25 or 30-year-old woman right now, what would you be suggesting in terms of a baseline screen to get a sense of where they are? If they weren't a gymnast or they weren't someone that was doing a large amount of strength training or maybe they're someone that-- certainly my generation was told "thin is in." Younger generations are being a whole lot smarter about their approach to physical fitness and body composition.

Dr. Doug Lucas: [00:07:21] Yeah, well, you hit on a couple of really good points there. What's really interesting is if you look at the USPSTF, United States Preventive Services Task Force, these are the guidelines-- the screening guidelines that physicians pay attention to. It is exactly what it says, 65 years old for women, 70 years old for men, if they have risk factors. And I try not to be a conspiracy theorist. I do my best to try to stay level-headed.

[00:07:43] But when you think about the fact that women go through menopause on average at 50 or 51, we know that estrogen loss is one of the biggest risk factors for developing osteoporosis. We don't screen before menopause, so we have no idea what their starting point is. Then we wait 15 years and then we screen. And then we tell them that it's too late to start HRT, which is another conversation. But that's the general language, right?

[00:08:05] Again, I try not to start a conspiracy here. But how does that make sense clinically? And I understand from a public health perspective, you want to screen for something when you're more likely to see it. Okay, that makes sense statistically. But what about the patients? We want to prevent bone loss. We want to prevent osteoporosis. And, from a hormone perspective, every woman that is considering HRT, which should be all women, at least having the conversation about risk-benefit, if you're having that conversation without knowing what your bone density is and what your bone quality is, you're missing a really, really big factor in that equation.

[00:08:39] I understand why they do it. At the same time, we should be listening to more like ACOG or like the Menopause Society, which says “Hey, let's consider screening if you have risk factors around menopause, if you have hormone fluctuations in perimenopause, which is extremely common.” Right? And if you look at the risk factors, basically every woman has a risk factor for bone loss. So, then why don't we just change the guidelines to say, “Hey, let's screen all women at 50 or 45? Or hey, what about 30? Why not?”

[00:09:08] To get to your next point, for women in their 20s and 30s and you mentioned some groups of women that should have good bone density, women who've been doing heavy resistance training, women who are gymnasts in general, have the most dense bones of any athlete on the planet. However, it is also common to have eating disorders, to have other things that are going on and likely to be on birth control like we talked about, likely to have hormonal disruption. So, honestly, I think that we would be doing a disservice if we excluded those groups of athletes. I think we need to be screening all women in their 20s and 30s because every one of them has a risk factor.

Cynthia Thurlow: [00:09:42] Yeah, and I couldn't agree with you more. I think that we need to start these conversations way earlier. We need to have the conversations that even include if we suppress your normal physiologic sex hormones for contraception as one example. I'm very pro-women having the opportunity to determine when they choose to become parents or not.

Dr. Doug Lucas: [00:10:01] Sure.

Cynthia Thurlow: [00:10:02] I think that that has to be part of that informed consent. I don't know how many providers are actually saying, "Hey, by the way, you're 16 years old, you're 17 years old, you're 20 years old. Your body has not yet hit its peak threshold for building bone. So, let's be cognizant of the fact that we may want to be even more conscientious about bone health." And I say this as someone who saw her Gyn this morning for her yearly exam, and we talked about this.

[00:10:30] She's young. She's in her 30s. I asked her, I said, "How frequently do you screen your patients for DEXA or looking for bone health?" She's like, "I usually have to see pathologic fractures or something that is, you know they're smokers, they're big drinkers if they even admit to it." But she's like, "I generally am thinking about that when I see my frail or older patients." And so, I asked her, just out of curiosity, “What is your screening metric?” and she trained at arguably one of the best medical institutions in the country. She said “Screening younger women was never part of the conversation.”

Dr. Doug Lucas: [00:11:04] It's not on the radar.

Cynthia Thurlow: [00:11:05] No, not at all. Like so many other things. Right? Let's talk a little bit about bone as a living tissue. I think many people think about bone from the perspective of, "Oh, bone is bone. It's just there to hang my body on. It's like a coat hanger." Let's talk a little bit about bone physiology, just basics, so that people understand there's a constant balance of bone breakdown and bone building that culminates until we go into this menopausal transition, where we have an acceleration of bone breakdown, which is what contributes to why many women are at risk for developing osteopenia and osteoporosis.

Dr. Doug Lucas: [00:11:43] You said it nicely. People think of the bone as the skeleton. It is. Right? And we think of the skeleton as something that you can hang your clothes on and you can take out and you can set on your door during Halloween, which is coming up. Like the skeleton is just a static thing, but bone is so much more than that. Bone is a very dynamic organ. Like you said, it's always turning over. It actually does all kinds of things. It makes red blood cells, it makes stem cells, like all this really, really cool stuff.

[00:12:09] But from a bone health perspective, it's always turning over. It is always breaking down. It's always building up. About every decade you have an entirely new skeleton from your skull to your fingertips, which is remarkable, right? How does that happen? But it's always breaking down, always building up.

[00:12:26] When we talk about the drugs, you can then see like, "Ooh, this is potentially a problem because we're shutting down bone metabolism." When I look at osteoporosis, I really think that we need to get away from, not eliminate, but get away from this T-score DEXA picture of a pathologic, geriatric disease model to really thinking what's happening with the bone, what's happening with the bone metabolism, which we can measure in blood, by the way.

[00:12:50] So, what's happening with bone metabolism? And if you are breaking down more than you're building up for enough period of time, you will develop osteoporosis. It's just a statistical equation and it's just a matter of time. So, the nice thing about that perspective though is that then if you want to improve your bone density, if you want to stop your bone loss, actually reverse your osteoporosis, looking at it through that model, all we have to do is then figure out what are the tools to change that equation from breaking down more than building up to building up more than we're breaking down.

Cynthia Thurlow: [00:13:20] And so, from your perspective, when you're working with patients, what are some of the red flags for you? Like people that you're genuinely more concerned about in terms of having poor bone health, even if they're not. I think we all understand like the stereotypical patients that we're like, "Okay, that's someone who's probably going to have some bone health issues." But what are clear-cut red flags for you as a clinician?

Dr. Doug Lucas: [00:13:45] Yeah. I mean there's the obvious ones, right? So, like you see the 80-year-old woman that has the dowager's hump and maybe she's smoking a cigarette and drinking a martini. You're like, [Cynthia giggles] "Oh my gosh, that's a hip fracture waiting to happen if you haven't had one already.” But if we get away from that, and again, we need to think of this as a young person discussion, not even a problem, hopefully. But who are the people at risk? And it is both women and men, but for women in particular, because women have a lower starting point on average than do men, if they are not maintaining their bone, they will run into trouble faster. So, this becomes more urgent to talk about.

[00:14:20] And if I go through my framework in my head of what we do to improve bone density, you can go backwards through that to figure out the things that are going to put you at risk for bone loss. So, if I start at the bottom, nutrition. I know you talk a lot about nutrition from what I've listened to and read, you talk about, we're totally on the same page here. We need to be eating a protein-forward, whole-foods diet. It's just that simple. Right?

[00:14:41] You can have whatever beliefs and etiology you want, but we need to be getting adequate nutrients and especially in the generation that you're in and the one above you and below you, women have been told for too long that "skinny is in." When "skinny is in" and you're chronically dieting, you're underfed. You are. So, we see that universally in our patients.

[00:15:00] And then the exercise piece. Are you sedentary? Are you a chronic endurance athlete? Are you fueling yourself appropriately? Are you a swimmer and not in a gravity state? All of these things put women at risk. I have a ton of young patients who are long-distance runners, long-distance female runners that have-- I've had women who've never had a cycle, never menstruated in their life, and also never been evaluated for it, which blows my mind.

[00:15:25] We actually had a patient. I won't tell her because people would know who she is, but relatively well-known and people don't know this about her. She was a runner. She's relatively well-known professional now, and never had a cycle and when she went through our clinical program, we talked about food and nutrition and we talked about all the things. And she actually had her first cycle as a patient and she was in her late 30s at that point.

Cynthia Thurlow: [00:15:46] I think the ramifications of not having a cycle for all of those years is quite significant. Like I will generally say to patients, “Your menstrual cycle is another vital sign.”

Dr. Doug Lucas: [00:16:00] Absolutely.

Cynthia Thurlow: [00:16:00] And I think that we have to go into those conversations irrespective of what area of medicine we work in, because it's missed opportunities. To your point, no one had ever talked to this patient about this being an issue.

Dr. Doug Lucas: [00:16:12] Right. Well, she was healthy, she was active, she was motivated, she was super successful. It just never came up.

Cynthia Thurlow: [00:16:18] Wow.

Dr. Doug Lucas: [00:16:19] So, then keep going. So, then what is someone's mindset? Are they a stress ball or do they live in fear? Are they worried about every single thing that's going to happen to them and that could lead to bone loss. Do they live in an inflamed state? [giggles] I just pulled down walls in my house, and we have mold that we need to take care of. So, if my voice is a little bit deeper than it usually is, it's because I was breathing mold and drywall dust yesterday.

[00:16:42] But, we are living in an inflamed state in our house because of this exposure and many people don't know that.

[00:16:49] Keep going. What's the other one? Sleep. Poor sleep. Right? How many women are not getting adequate sleep, especially as they start to go through midlife? All of a sudden that sleep is lighter. Everything wakes you up. You're getting up for your kids. You're getting called by your parents late at night because they don't sleep any-- This gets harder and harder as we go through midlife, especially for women.

[00:17:08] And then hormones. Right? “Do you have hormone dysfunction?” We've already talked about that quite a bit. But for women who go through menopause and decide not to go on HRT, which is totally their choice, that's the natural way to age. I'm not telling anybody not to do that, but there are ramifications to that, right? There are consequences to being estrogen deficient. You will likely see bone loss. Not necessarily if you do all the things, you can really fight against it, but it's a powerful thing to fight against. So, I'll stop there. There's more. I could keep going.

Cynthia Thurlow: [00:17:37] Yeah, no. I think you bring up so many good points and I want to zero in on one thing that you focused on, Relative energy deficiency, so it's called RED. Dr. Stacy Sims talks about this a lot. We talked about it on the podcast. I think especially now that intermittent fasting and time-restricted feeding have become quite popular. I think for a lot of people they enter into the discussion about eating less often, and it's for a lot of benefits, even if it's 12 hours of digestive rest, which I think everyone can do.

[00:18:09] But I think we have a special subset of that, where these are individuals that probably for many, many years were calorically restricted. The concept of "thin is in" was certainly, growing up in the 80s and 90s, that was a huge focus of everything, all the messaging that I certainly received and that's back when people read magazines and watched TV. You know it was a different time. But I think for a lot of people, they have been chronically nutrient-depleted for 10, 15, 20+ years and understanding that it isn't just, "Oh, I'm thin," or "My body composition isn't ideal," maybe I'm skinny fat or I don't have adequate muscle composition. But then it's also the piece of you're also impacting the quality of your bones.

[00:18:53] When you're working directly with patients or your team, because I know you have an extensive team, what are some of the things that you're helping women understand in terms of it isn't about calories, but it's like, “Are you eating enough macronutrients? Are you eating enough high-quality sources of food so that you're actually fueling your bodies?” Because I think unfortunately the messaging has been so scattered for so many years that a lot of people just don't eat enough. Like they don't understand that eating enough can also make them weight loss resistant, which is sometimes a source of endless frustration for middle-aged women.

Dr. Doug Lucas: [00:19:27] Absolutely. Well, especially as women get into middle age, it just gets harder to follow that same recipe. Right? Like what worked for them for decades now isn't working and I hear it's very frustrating. I see it. You brought up RED-S, Relative Energy Deficiency. My wife, who you know, Dr. Ashley Lucas, her PhD thesis was on the female athlete triad, the earlier version of it. So, I was actually in her work and that's when I got my first DEXA and found that I had low bone density, a 20-something-year-old male, not because I had RED-S but because I lived a very low-fat lifestyle. My parents were very, “healthy” and so I was essentially eating almost a carbohydrate diet, almost no protein. I grew up that way.

[00:20:08] As a result, low peak bone density. So, now we see women who are going through this and they hit midlife and they want to maintain their body composition, which I also get. There's nothing wrong with aesthetics and worrying about aesthetics. It's totally okay. But if you continue to eat less and less, you will lose muscle and you will lose bone. Then you have to decide what's more important. But the good news is that there is a way out of that. You just have to work with somebody who can help you to understand what are the foods that you can eat. We maybe need to change our macros. Maybe there is a component of fasting in this or time-restricted feeding in this, but we have to be able to get adequate protein primarily and then I do like to count calories. I'm a little old school. It's not all about calories.

Cynthia Thurlow: [00:20:49] Which is okay, I just wanted to put that out there.

Dr. Doug Lucas: [00:20:52] My wife doesn't like to count calories. I get it because it's not all about calories. I don't think it's just a simple equation, but I think numbers do help because when we have people track their food and they're eating 800 calories a day, I'm like, “There's no way you're going to build muscle and bone on 800 calories a day.” And so, then we start bumping up and they're like, "I haven't eaten this much food since I was a teenager." I'm like, "Right, yes, exactly." So, we need to go back to where you were and then what's amazing is that yes, they will gain weight, but if they're doing resistance training, if they're getting all the sleep and they're doing it at the right time, they gain muscle mass.

[00:21:23] And in our community, as you mentioned, we have women and men in their 40s, 50s, 60s, 70s, and 80s that are gaining muscle mass and improving bone density. So, with the right recipe, it is possible to do that, but recognizing that it's a problem is so critical.

Cynthia Thurlow: [00:21:40] Well, and I think for a lot of people, it's having to reframe the way that they look at food, their relationship around meal timing, meal frequency. To your point about tracking, I do think tracking macros and calories can be very insightful for some people. I'm like, “This is not forever, but we have to get a baseline.” To your point, a lot of women in our programs are eating 600, 700, 800, 900 calories a day and they're telling me they're just doing OMAD, one meal a day. I'm like, “This is exactly why your metabolism is negatively impacted, because your metabolism and your body thinks you are starving. It's going to hold on to everything you're consuming.”

[00:22:21] So, whether it's reverse dieting, which I hate that terminology, but sometimes it's helping people understand you may have to have an additional 100 calories of protein a day for a period of time and then monitoring body composition. I think in many ways, again, also that toxic diet culture where people have been indoctrinated into the number on the scale is what you live or die towards. I think for a lot of individuals, helping them understand, like that's just one metric. It's far more important to have body composition bioimpedance ratings where you can really get a sense of where’s your fat-free mass, where is your muscle mass, where we ideally want to be. Like working towards that metric as opposed to just a solitary number.

Dr. Doug Lucas: [00:23:05] Absolutely. I love the idea of measuring body composition. So, I'm trialing a band-scale combo device right now and it's actually been helpful for me. I tend to be on the other side. I have really strong obesity genes. Everybody in my family-- everybody has been over 300 pounds except for me. I've been pretty heavy, but not that heavy. So, I'm always fighting to stay lean. Ironically, I actually kind of live in that chronic diet phase as well.

[00:23:28] So, when I talk to trainers about my own path, they're like, "Doug, you need to eat more." For me, they're like, "1,600, 1,800 calories. Not enough for you." Which is true. I'm six feet tall, I'm 195 pounds, I have a lot of lean mass. It's not enough calories. I can really appreciate it. But what helps me on my journey is to understand that my weight fluctuates up and down by around 10 pounds. I mean it's a significant swing, but my body composition is what matters.

[00:23:52] So, when I look at my body fat percentage, even though bioelectric impedance is not probably that accurate, but it's precise. It'll keep measuring it over time and you can track it. So, I'll have my patients in our community we'll talk about, "Hey, you should make sure that you're monitoring your muscle mass. What they say about bone, “Don't read into that, it's not accurate." But follow your muscle mass more than anything and if you're gaining a couple of pounds, but you gained most of it through muscle, that is something to celebrate.

Cynthia Thurlow: [00:24:18] Absolutely.

Dr. Doug Lucas: [00:24:18] Because not only are you going to be healthier just across the board, but you're actually going to look better in your clothes too. I forget who it was, but somebody I heard recently say that muscle is Spanx on the inside. Right? Like it makes everything look better.

Cynthia Thurlow: [00:24:32] Yeah, absolutely, and it's interesting, I've been very transparent with my community that-- I lost my dad in 2024. One of the things that contributed to his death was frailty and he had a series of falls, and it made such an indelible impression on me, having to make all the medical decisions at the end of his life. One of the things I promised myself and my kids and my husband was I need to be more conscientious about building muscle. I put on five pounds of muscle in the past year. It takes longer. It's greater effort at this stage of life, but it is certainly possible.

[00:25:05] I think for a lot of people, I always look at Train With Joan. I don't know if you've seen Train With Joan. She's, like, in her 70s, she went from being obese and overweight and very unhealthy to suddenly weight training. She's this incredible role model for women. I'm like, “This is clearly a very menopausal woman who has been able to shift body composition, is incredibly strong, and looks very healthy.” So, the message needs to always be that there's always room for improvement for all of us and I think it's not just because you messed up for a couple years or something happened in your personal life. We can always get ourselves back on track which I think is really important.

[00:25:40] Now when we're looking at the evaluation of bone health, you mentioned DEXA may not be the best option for individuals and certainly screening is important. Screening earlier, being more conscientious, having these conversations earlier. In your clinical practice. What else are you looking at in terms of metrics for bone health? Because I think for a lot of individuals, it's having these conversations earlier and then being very proactive about asking for bone evaluation, bone physiology-- someone online had said, "Oh, are the orthopedic surgeons handling this or the endocrinologists? Who's championing bone?" I said, "That is so highly dependent on the individual."

Dr. Doug Lucas: [00:26:22] Yeah, and the answer is no one. No physicians really want it. There are people out there that love it and that's great, but they're rare. It's because to be a true bone health champion, you need to be an expert in the things that we've been talking about. Food, exercise, mindset, sleep, supplements, hormones. And who is that doctor? There isn't one. Right? They also don't have time to do it in their clinical practice in the conventional model. They have surgery and they have drugs, and that's it.

[00:26:51] And I'm not faulting any doctor for that. That is the system that I was trained in. It's the system you were trained in, right? People ask me all the time, they say, "Why did my doctor prescribe me a drug when this seems like a lifestyle problem?" I'm like, "Hey, you nailed it. It is a lifestyle problem." But that's all they have. They want to prevent fracture. It's the only tool that they have.

[00:27:04] So, then when it comes to imaging, we are stuck with DEXA for now and for the foreseeable future. It is an imperfect test. It's old technology, but it is universally available across the globe and insurance covers it. Medicare, Medicaid, third-party payers, every system across the-- across the globe. So, when people ask me what is the "best test," different answer. But what test should I start with? Get a DEXA. Because you'll be able to get continuous DEXAs throughout your life. DEXA, as you mentioned, is not perfect. It has quite a bit of variance from scan to scan.

[00:27:44] We use the term LSC, least significant change. And LSC is sort of like the margin of error and this is something that should actually be on your report. The machine should actually-- or the software should give you the LSC and what the LSC means is if you are within the range of the LSC, let's say it's 3%, plus or minus 3%, right? If you are within plus or minus 3%, we cannot say that change is actually real. If you're plus 2%, you're like “Woohoo.” You're like, "Oh, the LSC is 3%, I don't know if that's real or not." You have to continue to see improvement over time. This is a big problem with DEXA because most people are going to see if they can slow down bone loss rate. They can grow bone. 1, 2%, or 3% would be amazing. But it's all within the LSC, so we need a better tool.

[00:28:30] Also, I just want to let people know, DEXA-- if you have rotation of the spine, like scoliosis, if you have arthritis of the spine, if you're going to different centers, different machines, different software, right? Different operators, which you have no control over. All of these things make a difference in DEXA. There's some studies that would say that LSC is actually more like 6%. I've seen numbers like 10%, right? When it's that big, you just don't know, which is really frustrating.

[00:28:55] So, there are other ways, though. There are other imaging modalities that we could consider. One would be this test called REMS, and it's by the company Echolight. Echolight's an Italian company, and they brought this thing to market, which is an ultrasound device, just like you would see at your Ob-Gyn's office and you can view bone with an ultrasound device with the right algorithm behind it. That's what this company has done.

[00:29:17] I like REMS because it tells us not only density, like DEXA, but also quality. We know that bone quality is probably about half of the equation around fracture risk. So, while we can infer quality with some calculations and things like FRAX online and that kind of stuff from DEXA, if we could actually directly measure it, that's better.

[00:29:37] But the problem with REMS is it's not perfect either. It probably is more accurate. It has a statistical LSC which is much smaller, less than 1%, probably changes faster. But we don't have enough data sets. Like, I wish Echolight would be more open about the research they're doing. We don't have enough data sets to confidently say, especially at the edges of some of these areas, like particularly older, younger adults. What does this information really mean?

[00:30:02] We probably don't have enough data to know that the fragility scores are extremely beneficial for all populations. When we see subtle changes up or down, what does that mean? We don't know. There are still some unknowns. I generally will tell people to get both, which then is more expensive. REMS isn't covered by insurance. You're doing both. It's inconvenient and I get it, but we just don't have a perfect test.

[00:30:23] The best test is actually CT, but CT comes with a lot of radiation, so you're not going to do that over and over again. We really only see CT in research studies, which is fine, but again it's a lot of radiation, so we can't rely on that either. So, in between the modalities, we've started using bone turnover markers. I love the bone turnover markers because they are a way to understand bone metabolism. So, go back to what we were talking about in the first place. What's happening with breakdown? What's happening with buildup? You can get these in blood. The breakdown one is called CTX. The buildup one is called P1NP. I want to do this. It's hard to do through talk and maybe, I don’t know we can like draw it out.

Cynthia Thurlow: [00:31:01] We will put the resources. I've got all my notes, so I'll make sure this is available.

Dr. Doug Lucas: [00:31:04] Because it's the ratio that's important between the two. Because if you measure them independently, but they move in different directions, or they move together, but they're-- like, what does it mean? The ratio is what matters. I can say it, but it helps to see it. So, P1NP over CTX adjusted for units, which is really hard to understand, but basically it's a two-digit number divided by a three-digit number and you move the decimal point over three positions. That can give you a number usually between 150 and 300, and higher is better. So, this is cool.

[00:31:33] Now we can measure in between our imaging studies. But the challenge is these things change on a daily basis. Then, there's more variables, right? We have to make sure we're hitting all the same variables. For women who are still cycling, we make sure you're doing it on the same day of your menstrual cycle. We need to do it fasted in the morning. If you had a big dinner the night before the last time you had it tested, you want to do that again, right? You want to control as many variables as possible. We've been using this now for several years in our clinic, but also in our community where we have thousands of people who have been doing these tests and it is really helpful because when things start to fall off, you can tell early, right? You put an intervention in place and it doesn't seem to make a difference. You can tell early.

[00:32:13] Having to wait a year or two years to see if the thing that you're deciding to do for your bones is working is way too long. So, while none of these things are perfect, if you do all of them, if you can, except for CT, but if you do all of them, then you are getting more data, you can have a clearer picture and it can help you to define your path.

Cynthia Thurlow: [00:32:30] Well, I think this is important because there are many listeners who like to go above and beyond. They're like, "I don't want to be average. I want to be-- you know, for me, I want to be optimal." Are there a lot of REMS modality centers throughout the United States or is it still so kind of new that it is just localized to certain parts of the country?

Dr. Doug Lucas: [00:32:52] It's still localized, is the short answer. There are over 80 machines, but the United States is a big country. What we've done in our community is to establish basically a sheet of providers that we know. Because unfortunately, one of the things that Echolight is doing that I don't like is that they will sell it to anybody. So, this is not a medical device, although it is cleared as a medical device. It is not a medical device they will sell it to anyone that has a business model to support it. So, while they do have training on how to screen, I think that training needs to be updated. They're working on this, I get it. But there are people out there screening who don't know what they're doing.

[00:33:25] The idea is that the computer algorithm is so good that it doesn't matter, but that can't be true because we do see people that get REMS in locations that we don't know about and they show us the report and the report doesn't look right. Like you can see, as an orthopedic surgeon, I know the anatomy and when you see what they were scanning because it gives you an image, it's not right. Like this wasn't the femoral neck. So, again, we have a list of vetted people and we also have a list of questions in our community. Like if you're going to get a REMS, ask them these questions and if they can't answer them, then don't get it there. Again, it's not perfect, but it is additional data if you have access to it.

Cynthia Thurlow: [00:34:00] I think it's reassuring to know that as an orthopedic surgeon you have a very unique lens of which you can view this information and knowing that you have vetted professionals that you've worked with that you can refer to, I think is also very helpful. There were two other bone turnover tests that came up in my research. One was the N-telopeptide and then the bone-specific alk phos. Do you use either of those? Are they helpful?

Dr. Doug Lucas: [00:34:26] So, they are actually-- If you look at-- I've looked at all these research studies on bone turnover markers because I want to pick the best ones and not do all of them because it gets really expensive really fast. NTx is the urine version of CTx. So, this is the-- if you want to test your urine and do a 24-hour urine collection, go for it. Then you can test NTx.

Cynthia Thurlow: [00:34:44] Carry your jug around your house sometimes. [giggles]

Dr. Doug Lucas: [00:34:47] You might be doing that anyway for a 24-hour calcium. More data is usually better, not always, and then the bone-specific alk phos is a test that looks at bone building. In theory, you could do the same thing with NTx and bone-specific alk phos, but I've not seen any studies look at them together in a way that I could come up with any meaningful path forward. The great thing about P1 and CTx is they have become the most commonly used. There's enough data out there where you can say look at the trend, how they're going together. Look at studies where an intervention didn't have the outcome they thought it would, and then they did the bone turnover markers too.

[00:35:22] I've looked at this in enough studies where I can say “Yeah, it looks like if this is happening with these bone turnover markers, the outcome can be anticipated.” It's not perfect. I'd love to see better research, but there's enough on those two that's what we're leaning on.

Cynthia Thurlow: [00:35:35] It's interesting. My DEXA, pretty consistently over the last 10 years, I've been osteopenic, but it's stable. But my functional medicine doc actually did the P1NP and the CTx and he said “Okay, everything's stable. So, we're just going to continue with building muscle strength training. Your diet's dialed in.” But I think for listeners, understand that there are other things we can look at that can be helpful. Are there other types of labs? Because certainly I'm thinking from the perspective of people who are at greater risk because they have nutrient depletion, they have poor absorption of nutrients. Like, I'm thinking about the celiacs, many of whom don't get diagnosed till they're in middle age

Dr. Doug Lucas: [00:36:16] With osteoporosis.

Cynthia Thurlow: [00:36:16] Correct. It's like, “Hello.” From your perspective, are there other types of labs that you like to use to screen for people that are at greater risk?

Dr. Doug Lucas: [00:36:25] Yeah, So, I get in trouble with labs because I love data. [Cynthia giggles] When we built out our lab panel, our LabCorp rep called us and they were like, "You can't add any more labs. We're going to-- like, all your patients are going to pass out." I love data. The answer is yes, there's all kinds of labs. Which ones are really important? Out of the gate, you want to make sure that you don't have a true case of secondary osteoporosis, which we don't even need to define because I think they're all actually secondary. They're all from something, which is what it means. But something like a parathyroid tumor. You want to make sure that you don't have hyperparathyroidism. You want to see what's happening with your thyroid and make sure you don't have hyperthyroidism, which is leading to bone loss.

Dr. Doug Lucas: [00:37:03] You want to rule out some of these things. But really, when I talk about optimization, it's similar to how you talk about it. Like we're using the same terminology, which is, if you look at nutrients, like, is your red blood cell magnesium where it needs to be or are you deficient?

Cynthia Thurlow: [00:37:17] That's music to my ears as a cardiology person, I'm like, yes.

Dr. Doug Lucas: [00:37:20] Yes, if you've never measured it, you're probably deficient. Unless you're consuming enough oral magnesium, where you actually have figured out what your oral tolerance is, you're probably deficient. You can look at things like B12 and folate. Like, you can look at RBC zinc, and there's a lot of stuff you can look at to see if you're deficient. Sometimes functional testing is really helpful here too. But I look at this from a comprehensive perspective. I also want to look at cardiovascular risk markers. I want to look at inflammatory markers. Right. I want to look at definitely sex hormones. I want to look at all of these things, and it becomes a really really long list.

Dr. Doug Lucas: [00:37:53] Most people are going to have a hard time getting these labs from their provider, even if they have a functional provider, because they don't know what to do with them. As physicians, as you know, we run into problems if we don't know what to do with the results that we're getting. Generally, we're afraid to order it because what if we're liable for what it says? If we don't know what it means, I'm not going to order it.

This is why we've started. I love the direct-to-consumer lab options that are out there. Like, we do it through our community, the OsteoCollective. LabCorp is becoming more direct-to-consumer. So is Quest or all these other companies that are offering these panels, which I love because we need to be empowering people to get the information and then directing them on how to interpret it.

Cynthia Thurlow: [00:38:35] Well and I think for a lot of individuals, they get frustrated because maybe their provider will order a third or a quarter of what they want. And o your point, I think for a lot of listeners, sometimes they don't know, it's not that your provider doesn't want to order it. To your point about you're then responsible. It's like a hot potato. You order the test, you are responsible for the results. If you don't know what to do with the results, that then becomes one extra thing that's on your to-do list that you have to do before you go home from work that day.

Dr. Doug Lucas: [00:39:04] That and another piece about labs too that a lot of people don't know is that most people will say, "I'm going to take your lab panel to my doctor and have them order it so insurance will cover it." You're welcome to try. But here's what happens and this is why I went to an all-cash model for this. Because insurance might cover some of it, but what they don't cover, then you're stuck paying the insurance rates. The insurance rates for labs can be 10x, 20x what a cash rate would be.

[00:39:29] Our entire panel costs around $600, which is a lot of money, I get it. But some of these labs, the insurance rates are going to be over a $1000. You ordered-- you just ordered 80 of them, right? You could get hit with this massive bill from LabCorp that you definitely don't want just because you wanted your insurance to cover the CBC and the CMP, right? which are $5 anyway. It can-- it's really hard. I understand we want to use insurance and I get that. I'm helping the new company I'm working for, LifeMD, to build insurance models because I want to get this in front of everybody. But we have to understand what it is and how to use it, when to use it and not get stuck with these massive bills.

Cynthia Thurlow: [00:40:08] Yeah, and I think being judicious is really what you're speaking to and I think that unfortunately-- and I say this lovingly, I think that certainly my generation, certainly my parents' generation grew up with like insurance covers everything. My mom and my stepfather are retired. They don't pay a dollar for prescription medications. They don't have any copays. They have great insurance. But more often than not, that's not the case. People have a little less flexibility. So, I'm always incredibly sensitive when we're ordering testing, recommending testing and staying very upfront. There are limitations to this insurance model and if we want to do some of these additional tests, it's either out-of-pocket, you're using flex spending, maybe you set aside.

[00:40:52] A lot of people go out to dinner multiple times a week. I'm like, maybe this month you don't go out to dinner three times a week. Maybe you go out once the entire month and put that money towards this testing, which in many instances is going to be really invaluable for getting you towards that optimal range. Not just average. We don't ever want to be average. We really do want to be optimal. That sometimes means we need a little bit more information to help fine-tune what we're looking at.

[00:41:16] Now, when you were working in traditional orthopedics medicine, you probably had a lot of patients who dealt with frailty. Frailty, we know, leads to falls. Sarcopenic obesity is a real issue. From your perspective-- let's look at it from an allopathic lens, and let's look at it from a more integrative lens, frailty is something that I fear, which is why I jokingly say to my husband, “This is why we do strength training. This is why we do solid core”, which he hates, but it's really good for him. I'm like, “The things you hate to do are things you need to do more of.” From a traditional allopathic lens versus a more integrative lens, talk us through what your thought process is when patients express concerns about wanting to avoid frailty.

Dr. Doug Lucas: [00:42:06] This is great because I see it all the time, but our conventional system is so reactive, right? We don't have these conversations. Nobody made an appointment with me to say, "How do I avoid frailty.” Right? "How do I avoid you fixing my hip?" I never had that conversation. Not once. The conversation is always usually in the emergency room in the middle of the night while you're on morphine and Valium because your muscles are spasming around your femur fracture. Right? It is not a good time to have that conversation.

[00:42:34] But yet when you look at the statistics, you realize, “Okay, what are the things that are likely to kill us?” Like, even if you're a longevity person, right? You're like, "I'm going to be, the health span, the best health span. I'm going to live to 180 with Dave Asprey” [Cynthia laughs] If you're going to do that, you have to understand the things that could kill you are heart disease, cancer, and frailty, and yet we don't talk about frailty. Over the age of 65, fragility, fractures, and falls, it's number three. We talk about all these-- I'm not saying we shouldn't talk about dementia. I'm not saying we shouldn't talk about these other things. But man, frailty has to be up there. We don't have this conversation and I think part of it is because doctors are not equipped with the tools to solve it. Also true for cancer and heart disease, arguably, right? But we at least have-- we have drugs for that, right? Like I have a statin for cholesterol if you want to use it. But I don't have anything for frailty and falls because it's all lifestyle, right?

[00:43:26] It is how you eat. It is how you live. I don't have time as a doctor, even if I'm trained in it, to talk to you about it. I don't have a drug to give you. I don't have a surgery to offer you. So, the conventional system is just not built for that.

[00:43:39] Then you get into the functional system and we all have different ways to talk about it. I talk about my pillars of health and every time I'm on a podcast, somebody tells me theirs. They're all the same, right? We all understand that this is a lifestyle-first problem and then you have to work your way up from there. How do we deliver that? How do we help people to make these lifestyle choices? This becomes the conversation.

[00:43:59] That's why my practice went from essentially these super long consults where I thought people wanted like three hours of my time. Like, this is going to be the answer. It didn't help anyone. It educated a lot of people maybe. It didn't actually help anybody move the needle because it isn't a physician-led thing. It is a dietitian. We have functional dietitians. It is a health coach, one-on-one or group. Like, it's a community. It's accountability. It's the people that you are surrounding yourself with, not necessarily your provider. I'm just the person, somewhere in a corner being able to write scripts if you need it, helping to do the research, to figure out what's the next thing that I can offer somebody, what supplements actually make sense, how do I optimize hormones, how do I help you avoid risk of other things? Like, that's my job.

[00:44:42] And I've started seeing less and less patients because of that. Now I see maybe see a patient this week because I'm spending more of my time building programs, educating the people that can help you to do the things and then actually creating content so we can do stuff like this, so we can educate the masses. Because ultimately, we need to educate people to get empowered about their health, to save money for the testing that their insurance model won't cover. We need to encourage people to look at things like bone health and all of these things that are part of what is going to help drive our health span, how long we're going to live better.

Cynthia Thurlow: [00:45:14] I think you bring up so many good points, and it certainly typifies that traditional allopathic model. I was an ER nurse in my past life. We saw a lot of orthopedic surgeons in the middle of the night because grandma fell out of bed, broke her hip or broke her femur or any number of catastrophic injuries that can happen. I think for a lot of people that are listening, they're probably like, "Okay, I'm processing. We definitely want to be thinking differently if we're trying to avoid frailty." The thing that I found really interesting when I was preparing for our conversation was helping my community better understand the things that contribute to avoiding frailty. Because I think many people probably don't think about it until they have a family member that falls. Like, I have a loved one who fell last year. She had fractured her hip on one side. Guess what? This past year, she fractured her femur. She hasn't walked in a year.

Dr. Doug Lucas: [00:46:09] Yeah.

Cynthia Thurlow: [00:46:10] She is now dependent on using a walker to get around her home. They've had to be very conscientious about removing rugs and anything that she could trip over. This is someone who is cognitively sharp as a tack, but is limited by this physicality piece. I think for a lot of individuals, it's like our frailty toolkit starts in our 30s, 40s, and 50s. It's not waiting until we have that first at-risk fall, and that includes things like fracturing your wrist.

[00:46:39] It was interesting. Last year, I was at a business event. I was in between two physicians leaving this event, and my shoe got caught in a tree root, and I came down on my elbow. I ended up developing a sprain, which is not a big deal. But I remember both of them looked at me and they're like, "Are you okay?" I was like, "Yes." I was like, "Other than my pride."

[00:46:57] But I realized if I were just another statistic, that would have been the first of a series of frailty falls, which then leads to fractures and I went to physical therapy for six weeks, which will probably make you happy as a former orthopedic surgeon, which was really helpful. Every single woman that was in there with me, because it was all hand and wrist and elbow injuries, every single woman that had surgery because of fractured radiuses, which is one of the wrist bones, were middle-aged women or older. Every single one, no men.

Dr. Doug Lucas: [00:47:26] The number one risk factor for a fragility fracture is a previous fragility fracture.

Cynthia Thurlow: [00:47:31] Yep.

Dr. Doug Lucas: [00:47:31] Right? If you have one fracture, you are at risk for more and it's a downhill slide. You painted this story of your family member so well, because we see the loss of independence as the number one thing that I fear for my patients. Yes. Actually, a third of them will die, but that's actually not what I fear for my patients because so many of them are still relatively young, like you said, cognitively sharp. They have goals. They want to be the grandparent for their grandchildren or parents for that matter, depending on their age. Right? Yet they have this fracture. Hip fractures are notorious for this. 60% of people that have a hip fracture will not return to their previous level of independence. Of the 40% that isn't in that 60%, 30% of them are dead.

Cynthia Thurlow: [00:48:11] Yep.

Dr. Doug Lucas: [00:48:12] That leaves 10% that are "okay." And even those 10%, I mean I can think of one, maybe one patient and she was in her 50s, she was super young and she had a hip fracture and she bounced up and checked out of the hospital early. She was like ready to go. But other than that, everybody's life has changed. This is why we have to talk about it early and I think we really need to be looking at bone health as a biomarker of health span, not as a disease of the elderly.

Cynthia Thurlow: [00:48:38] Walk us through what it's like when you got called in the middle of the night to come in because grandma fell and grandma probably had a whole bunch of comorbid conditions on top of it. So, we probably in Cardiology had to clear her in the middle of the night. But like walk us through what that is like, a typical bone-related fracture. When you're going in as a surgeon, setting that up for someone who has osteoporosis versus who does not because it makes them much more complicated when there’s a very-- like, it happened with my family member, she is so osteoporotic. They were like, "It's like duct tape and bubble wrap," is what essentially they were jokingly saying, "that’s how we're going to put her back together, her femur."

[00:49:16] Walk us through what that's like as a surgeon and what the typical-- like let's just say average surgery, length of time under anesthesia, how long they're in the PACU, then they go to the floor, then they're there and they have physical therapy. They probably go to rehab.

Dr. Doug Lucas: [00:49:30] Yeah.

Cynthia Thurlow: [00:49:30] It's not just a short little surgery. It is a lengthy recovery.

Dr. Doug Lucas: [00:49:34] Well, so what’s funny is it is a short surgery, generally the surgical piece, and this is what I joke when I see them. I try to keep it light. But the surgery, my part, takes 10 minutes.

Cynthia Thurlow: [00:49:46] I'm a carpenter.

Dr. Doug Lucas: [00:49:46] If we're doing a traditional-- you know, if we're putting a nail in, or whatever you want to call it, putting pins in, as people say. But if we're doing a traditional surgery, it's fast, which is good, because the risk of the anesthesia is the real risk of that surgery. If you're doing a general anesthetic, if you're going to try to do it under spinal, which means they're going to make you numb from the waist down, which then has other risks. The cardiology people hate the blood pressure risks associated with that. [Cynthia laughs]

[00:50:10] The surgery itself is quick, but let me back up and go to what happens before that. This is why we need to avoid it. So, If someone trips or-- I hear this story all the time. Most people don't know this, they actually just turn and feel something pop and then fall. Fragility fractures can lead to falls, meaning that your hip actually broke before you hit the ground. That happens all the time. And so, that happens. Hopefully you're not alone, because I can tell you trying to crawl somewhere with a hip fracture is excruciating. Right? How do you get help? You should know. Like you said, you did all the things. Clearing out the carpets, dogs, they cause falls and fractures. All of these things start to matter if you have frailty. Let's assume you actually can call somebody. Right? Or somebody sees you fall and you get care quickly. If you don't, you could be laying there in excruciating pain for a long time.

Cynthia Thurlow: [00:51:03] Rhabdo.

Dr. Doug Lucas: [00:51:04] Right? Then, you hopefully you get quickly taken to the emergency room. You're going to sit in the emergency room. Emergency rooms are not fast for hip fractures. There's data, and I support the data, but there's data that says that I don't even have to come in the middle of the night to fix your hip fracture. In fact, as an orthopedic surgeon, it is standard of care for me to do it the following day for a lot of reasons. Daylight hours, you get better outcomes, it's clear. But that means you're going to sit in the operating room overnight. You're not going to be able to get up to pee. You're not going to be able to have them slide a bedpan. They're going to have to stick a tube in your bladder. Right?

[00:51:38] A lot of these women, especially this age group, never used HRT because of the WHI. Right? They have vaginal atrophy. They have chronic UTIs. Like they're just set up for a disaster. Then you're laying in that bed overnight. You finally get cleared by Cardiology in the morning. Thank you. [Cynthia laughs] Right? I love the Cardiology clearance. She is moderate-to-high risk. Thank you. I do that.

[00:51:58] And so, we go to the operating room. I do my 10-minute surgery, but it takes an hour to put her on the table again. She's in pain. Hopefully she's had pain medicine. We do the surgery, we get it lined back up. It's a small incision, it's like an inch long with a couple of little poke holes, and I'm done.

[00:52:16] If they have osteoporosis, though, sometimes we don't get good fixation. Meaning, like, it's as you described it, like would you say duct tape and band-aids? I like to say it's more like sticking screws in marshmallows. If you ever want to try this, try screwing a screw into a marshmallow. You can do it, but when you get to the end and the head is at the edge of the marshmallow, it just spins. That's what osteoporotic bone feels like. In order for us to heal fractures, we need stability. You have to have stability. If you can fix it in a way that it's stable, you can get them up and moving faster. The worse their bone is, the less likely you're going to be able to do that. Like your family member, you're going to say, "Okay, now you can't walk on this." That's what kills people. Right? If you lay in a bed-- Actually, I had a family member, my stepmom just passed this month.

Cynthia Thurlow: [00:52:58] Sorry.

Dr. Doug Lucas: [00:53:01] What killed her was laying in bed, not being able to move, not being able to eat. Right? This is what-- it was a really quick downward spiral, thankfully, but that's what kills you. So, we need to get you moving. I need to fix you with better stability so that you can weight bear and a lot of times we can't if you have poor bone quality. So, you get into bed, you might be laying there, you've got a tube in your bladder. Hopefully your pain's controlled once it's stable. But you have all-- I mean, you bled a ton into your thigh. That's really uncomfortable. Anesthesia is really hard on the brain.

[00:53:30] Then you start the recovery process. Most people with a hip fracture are not going to go home. They're going to go to some kind of an assisted care facility. Right? The care in those places, they're doing the best they can, but it's miserable. The food is miserable, the quality of care is low. They're trying to get you up and moving, doing the best they can. But you're going to spend a lot of time in bed. You're going to have skin breakdown. The likelihood of developing a urinary tract infection is really high. Needing antibiotics. Then when you start stacking all these things, then that's the downward spiral. That's why the mortality rate is so high. That's why the loss of independence is so high, is once you-- if you don't have enough metabolic reserve, you don't have enough muscle reserve, once you shut down your body, even for a couple of weeks, it's really hard to get it back.

Cynthia Thurlow: [00:54:14] Yeah, I mean your body is essentially catabolizing what little muscle you have left. What I typically saw was the patient that had underwent surgical repair plus or minus she ends up septic because the urinary tract infection then goes into her bloodstream. She probably over the course, and I'm saying "she" because more often than not, it was little old ladies this happened to. She might have had evidence of having a minor heart attack. Then we're all on top of her and then she's getting more medications added to what's going on. We're determining “Do we need to do a larger workup, do we send grandma home? Does grandma go to rehab?”

[00:54:54] Grandma never goes back to where she was before. That is a catastrophic, not just loss of independence, but this is someone who might, prior to that issue and that hospitalization might have been driving to the senior center, might have been independent enough to go to the grocery store by herself.

Dr. Doug Lucas: [00:55:14] My mother-in-law is-- I mean, she's a primary caretaker of our children. Right? She does all of the afternoon pickups, driving kids back and forth. I mean she is active and if she were to break her hip-- because I know her body habitus and I see what happens with that body, sharp as a tack mentally, but she would have a hard time recovering.

Cynthia Thurlow: [00:55:34] Yeah, well, I mean this family member that I've alluded to, it's been heartbreaking because she loves to day trade. She knows what's going on with politics and she knows what-- you know, down to the penny, what's in her bank account and her investments. I mean she is so sharp that it's heartbreaking for me as a clinician and as a family member, seeing that happen for her, because she used to be a fairly independent person and now that has really gone by the wayside. Like, she used to enjoy cooking. Standing up at a stove when you're dealing with a walker is not ideal circumstances.

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