Introduction

Dr. John Neustadt is a naturopathic physician, founder of Nutritional Biochemistry, Inc. (NBI), and a #1 Amazon best-selling author in the field of osteoporosis. He's back on the podcast to talk about his newly expanded and updated book, Fracture-Proof Your Bones — and what it really takes to protect your bones if you have an autoimmune condition. We cover everything from why your bone density test number is not the whole story, to the surprising ways your gut, your medications, and even your social life are shaping your bone health right now.

Episode Highlights

Why Bone Density Tests Miss the Full Picture

A bone density test is useful, but it only tells you about the mineral quantity in your bones — not whether you'll actually fracture. The numbers can be misleading, and most doctors and patients put far too much weight on a single score.

• Bone density tests only predict fractures in about 44% of women with osteoporosis and 21% of men
• Every major medical association has concluded that fracture risk depends largely on factors other than bone density
• Despite this, clinical conversations still revolve almost exclusively around that one number
• The FRAX fracture risk assessment on your bone density report gives a 10-year fracture probability — if it says 10% risk, that also means a 90% chance you won't fracture

Bone Quality: Why Collagen May Matter More Than Minerals

Bone is a living tissue made up of far more than just calcium and minerals. The protein and collagen content of bone is what gives it strength and flexibility — and it's almost entirely ignored in conventional care.

• There are 180 to 200 different proteins in bone, including collagen
• Collagen strand for strand is stronger than steel, and healthy collagen is also flexible — allowing bone to absorb impact without breaking
• As we age and collagen degrades, bones become more brittle and fracture risk rises
• Focusing only on mineral density misses a major part of what makes bone strong

The Gut–Bone Connection: How Inflammation Destroys Your Skeleton

Gut health and bone health are directly linked — and for anyone with autoimmune disease, leaky gut, or chronic inflammation, this connection is critical to understand.

• 90% of the immune system lives in the gut; when it becomes inflamed, inflammatory cytokines (like IL-1 and IL-6) can enter the bloodstream and travel to bone
• These cytokines activate osteoclasts — the cells that break down bone — accelerating bone loss
• Conditions like Crohn's disease, ulcerative colitis, IBS, and celiac disease all elevate fracture risk through this mechanism
• In some documented cases, osteoporosis has been the only symptom of celiac disease
• People with autoimmune disease face a 200 to 400% increased risk of fracture
• Malabsorption from gut conditions also causes nutritional deficiencies that further deplete bone health

Medications That Are Silently Damaging Your Bones

Many commonly prescribed medications have bone-damaging side effects that most doctors aren't warning patients about. A medication review should be a standard part of any bone health conversation.

• SSRIs (like Prozac and Lexapro) activate osteoclasts through serotonin receptors on bone; for every 19 women taking an SSRI for 1–5 years, one is expected to break a bone
• Glucocorticoids (like prednisone) destroy collagen, reduce bone mineral density, and weaken muscles — increasing fall and fracture risk; about 50% of long-term users are expected to fracture
• Proton pump inhibitors (PPIs) and other common medications also carry bone-damaging effects
• A study found that approximately 75% of patients hospitalized for hip fractures were taking a bone-damaging medication in the three months prior
• Ask your doctor and pharmacist for a medication review specifically looking at bone health impact

Diet, Ultra-Processed Foods, and Getting Enough Protein

When it comes to food and bone health, it's about your overall dietary pattern — not any single food. There are two things most people need to focus on immediately: cutting ultra-processed foods and eating enough protein.

• Ultra-processed foods become dangerous above roughly 10% of daily calories — yet 60% of the American diet currently comes from them
• These are not just "bad" foods — John describes them as chemically manufactured environmental toxins
• Food packaging itself leaches plasticizers and hormone-disrupting chemicals into what we eat
• The Mediterranean dietary pattern (plant-forward, whole foods, lean proteins) is well-supported by research
• A practical protein target: multiply your body weight in pounds by 0.6 to get your minimum daily grams of protein
• Eating too much protein (e.g., 1g per pound of body weight) can crowd out the vegetables and fiber your microbiome and blood sugar depend on
• Your taste buds adapt — as you reduce ultra-processed foods, naturally sweet foods like fruit will start tasting sweeter

Social Connection, Oxytocin, and Your Bones

This one surprised me — but the research is real. Your social life actually has a measurable impact on your bone health, and the biology behind it is fascinating.

• People with close social connections have lower risk for osteoporosis and heal faster after fractures
• Just like serotonin receptors, there are oxytocin receptors on bone — specifically on osteoblasts, the cells that build new bone
• Osteoblasts actually produce their own oxytocin
• Women with osteoporosis have been found to have lower oxytocin levels than women without it
• Activities that boost oxytocin — massage, petting animals, hugging, meaningful connection — may all support bone health

Routine Labs That Can Reveal What's Happening in Your Bones

You don't need expensive or unusual tests to get a clearer picture of your bone health. There are a few standard labs that, when interpreted correctly, can reveal a lot.

• CBC with differential: the neutrophil-to-lymphocyte ratio is associated with elevated bone loss — elevated neutrophils signal active inflammation
• Serum ferritin: this is the most sensitive indicator of iron status; low ferritin is associated with osteoporosis
• Standard lab reference ranges for ferritin (sometimes as low as 10) are far too broad to be clinically useful; John recommends targeting above 50–70
• Many patients have ferritin in the 25–30 range but are told they're "normal" — even when they're symptomatic

Exercise, Balance, and the One-Legged Stand Test

Falls cause 95% of fractures, which means your stability and strength matter more to fracture prevention than most people realize — and there's a simple 10-second test that tells you a lot about your risk.

• When stability was factored alongside bone density, bone density alone predicted only about 5% of fractures in people under 70
• The one-legged stand test: try standing on one leg for 10 seconds
• About 95% of people aged 51–55 can do this; by their 70s, less than 50% can
• Those who cannot pass the test have over an 80% increased risk of dying
• The expanded edition of Fracture-Proof Your Bones reviews clinical trials on different exercise programs and their impact on fracture risk

Notable Quotes from this Episode

A bone density test only predicts 44% of women with osteoporosis who will fracture — 21% of men. Every medical association that's looked at this data has correctly concluded that fracture risk depends on factors largely other than bone density.
Dr. John Neustadt

There are 10,000 chemicals that are approved for use in food in the US compared to 4,000 in the European Union. Most of those have never been studied for their toxicological effects. These emulsifiers and other chemicals — in animal studies — change the microbiome when they're consumed.
Dr. John Neustadt

Bones as an organ is the largest organ by weight in our entire body. If your bones are getting weaker, if the bone density is going down, if the bone quality is decreasing, it really is an indication that your longevity and your health span are decreasing as well.
Dr. John Neustadt

A woman's risk of an osteoporosis fracture is equal to her combined risk of breast, uterine, and ovarian cancer. And if you are a woman with osteoporosis who fractures, there's up to a 36% chance that you're going to be dead within a year.
Dr. John Neustadt