The Overlooked Side Effect of Weight Loss with Sue Shapses

James Hill:

Welcome to Weight Loss And, where we delve into the world of weight loss. I'm Jim Hill.

Holly Wyatt:

And I'm Holly Wyatt. We're both dedicated to helping you lose weight, keep it off, and live your best life while you're doing it.

James Hill:

Indeed, we now realize successful weight loss combines the science and art of medicine, knowing what to do and why you will do it.

Holly Wyatt:

Yes, the “And” allows us to talk about all the other stuff that makes your journey so much bigger, better, and exciting.

James Hill:

Ready for the “And” factor?

Holly Wyatt:

Let's dive in.

James Hill:

Here we go.

Holly Wyatt:

Today, we're talking about something that might make you rethink about your relationship with the bathroom scale, about weight loss. Jim, what if I told you that some of the popular weight loss strategies that we talk about on this program could actually be setting people up for fractures later in their life.

James Hill:

Well, I'd say that sounds exactly like the kind of unintended consequences we love to dig into on this show. You know, Holly, there are so many ways that losing weight can improve health, better blood sugar control, lower blood pressure, reduced joint pain, on and on and on. But maybe there are some potential downsides that we don't talk about enough.

Holly Wyatt:

That's exactly what we're going to be exploring today. Many people don't realize that their bones and their weight are having a conversation. I like thinking about it that way. Most of us have no idea what they're saying to each other.

James Hill:

And to help us eavesdrop on that conversation, we have Dr. Sue Shapses joining us. Now, Sue is a real expert in this area. She's Professor of Nutritional Sciences at Rutgers University. She also has a dual appointment in the medical school there, and she's a leading expert in the relationship between body weight, nutrition, hormones, and bone health. For more than 30 years, she's been at the forefront of research that explores how weight loss strategies, both intentional and unintentional, affect skeletal strength, fracture risk, and long-term health outcomes. Her work has shaped how clinicians and scientists think about protecting bone during weight change.

Holly Wyatt:

And what I love about Sue's work is that she's not studying bone density or bones in isolation. She's really looking at the full ecosystem, looking at the hormones, body composition, metabolism, aging, and she's helping us understand what actually protects bones and what quietly could put them at risk.

James Hill:

Sue, welcome to Weight Loss And.

Sue Shapses:

Thank you.

James Hill:

Before we dive into the details, maybe help us connect the dots. Why should weight loss and bone health be part of the same conversations? What do people need to understand right out of the gate?

Sue Shapses:

That it's really good to lose fat, but it's not really good to lose bone or muscle.

James Hill:

I love it. I love it. Lose the fat, but don't lose the bone.

Sue Shapses:

You got it.

James Hill:

Is that a problem? Do people lose bone during weight loss?

Sue Shapses:

It is a problem, and it's considered a side effect of weight loss. A side effect that we don't want.

Holly Wyatt:

I don't think we talk about it a lot. We're starting to talk more and more about losing muscle when you lose weight. And the GLP-1 medications have really maybe put a spotlight on that a little bit more. But I don't think we're talking about bone as much. So maybe we just start out by telling us what is kind of optimal bone health? What do we want? And then how do we figure out if we're losing it or not? Or we have enough of it?

Sue Shapses:

Optimal bone health starts with a DEXA scan, which is the dual energy X-ray absorptiometry instrument, and going to your physician to say, I want a bone density scan. It usually is not recommended until older ages. So in order to get this scan, you would have to say, I'm at risk because. And some of the reasons you could be at risk is if you have a family history if grandma our grandpa had osteoporosis, or you just don't have any very little calcium, such as very little dairy in your diet. There's a variety of reasons that you could get a bone density scan, but the bottom line is getting it before menopause in women is not that helpful because in general, you are not losing any bone before menopause in women and before age 60 or so in men. The bone loss that occurs with weight loss is much greater if you're older than if you're younger. And we looked at young women in particular compared to post-menopausal women, and the risk of bone loss was minimal in the younger women. And I bet you, you know the reason why. So I'm asking you guys a question.

James Hill:

Hormones.

Holly Wyatt:

Hormones, yeah.

Sue Shapses:

Hormones. Estradiol levels are quite low. And they even go low in men as they age. And that's very important for bone health. And a lot of people just think it's all about testosterone for men, but really it's estradiol too.

Holly Wyatt:

So it sounds like this is something that you need to be specifically looking at after menopause, or if you're kind of in a unique situation where you're not getting calcium or maybe you've had frequent bone breaks in the past or a family history, maybe a strong family history of that or some other reason. But in general, it's really menopause is when we want to start looking at it in females. And then what was the age for men?

Sue Shapses:

I said 60 or older, but let me qualify what you just said, because indeed it is a good summary of what I started to say. Now let's add in the factor of severe weight loss. Everybody at every age should think about their bones if there's more severe weight loss. And in the past, we were always thinking of bariatric surgery for extreme weight loss. And we all know now that the GLP-1 medications are causing just as much weight loss, causing, I'm saying causing, resulting in a wonderful amount of weight loss in many situations, but indeed that would raise the risk of possible bone loss. And I say possible because we have not studied this adequately yet in the bone field.

James Hill:

So, Sue, I want to dive deeper into that with the new meds in a moment, but am I right in thinking that bone is a little bit like muscle and the first part of your life, you're sort of building it up and you may reach a peak And then it declines as you age. And so it's a natural sort of thing for a decline. And both in muscle and bone, what you want to do is to have that decline be as minimal as possible. Is that correct?

Sue Shapses:

I can say that's mostly correct. The difference between the muscle and the bone, and no one phrased it quite like you just did, so I'm thinking of it differently. Muscle, we have a lot of evidence that it starts to decline with aging. With bone, it can stay the same for a very long time. It does not necessarily decline in a very rapid, you know, not a rapid way. I mean, muscle doesn't decline rapidly, but muscle we've tried so hard and we've studied it so well. With bone, it's pretty stable. Whatever causes it to finally decline, yes, it starts to decline, especially in women and older men, older men too.

James Hill:

And then the other thing I think I'm hearing in what you say is if you're older, the risk of losing both muscle and bone is probably, you probably need to worry about it more than if you're younger and trying to lose weight.

Sue Shapses:

I would say that in general. Yes.

James Hill:

Not that you don't have to worry about it some with the younger people, but I've always thought, Sue, with muscle, I worry about older people really losing weight in general because from the look-ahead study, one of the things we found is when older people lost weight and regained it, they actually regained less muscle than they lost. And I wonder if there's a similar thing maybe going on with bone.

Sue Shapses:

There is a similar thing going on with bone. And in fact, I have a great statistic that I probably can't say the exact statistic to you, but look ahead, the same study found that in those individuals who lost weight, they had a much greater risk of fracture later on in life than those who lost weight and were not successful or tried to lose weight and had no regain. The successful weight loss losers were at risk of fracture.

Holly Wyatt:

Yeah. And I think that's going to bring us, we want to talk about kind of the quality of bone and strength of bone in just a minute. But I want to back up for a second and make sure our listeners, because I know what some of them are thinking. Okay. As I get older, I need to think about it. But she also mentioned rapid weight loss or a large amount of weight loss. Any numbers that our listeners might want to think about if they've lost weight this quickly or they've lost this much weight that puts them at higher risk. Is it 10 pounds or is it 100 pounds?

Sue Shapses:

That's so great that you asked that so we tend to say that there's about a one percent bone loss with a 10 percent weight loss when it's moderate weight loss and when it's women over 50 and men over 60. It's small in comparison to the metabolic benefits of losing excess weight. So we don't want to forget that, that it's very small. I want to go back to the look ahead study and just mention the numbers. It is that they confirm that weight loss of only 6% to 9% that's maintained over a decade increases the risk of fragility fracture by 39%. I think that's an interesting number just to keep in mind. But going back to the question you asked, Holly, would you mind asking it again if I didn't answer it?

Holly Wyatt:

I think you answered it. But this number that you just talked about. So six to nine percent weight loss, which is not a huge weight loss. That's how I would say a moderate weight loss is producing this big increase in fractures. Explain what you mean by a fragility fracture, though.

Sue Shapses:

Oh, that's osteoporosis fracture. And so we call it fragility fracture as opposed to being in a car accident where it's a traumatic fracture. So fragility fracture will happen when you fall and the young person who falls doesn't fracture, but the older person fractures because their bone mineral density and quality is already compromised.

James Hill:

Holly, I'm getting the sense here that we have not focused enough on bone. I mean, some of this stuff is amazing. If you get this with 9% to 10% weight loss, now these meds are producing 30% weight loss. So, wow, is there a reason to be concerned here?

Sue Shapses:

Look, we have a lot of evidence from the bariatric patient, but in a sense, we were attributing a lot of that to malabsorption of calcium, right? Because their GI tract is partially removed and there's malabsorption of many nutrients, including calcium. And indeed, it's partially due to the extreme weight loss. They have a higher risk of fracture with this extreme weight loss. And we've known that for many years.

James Hill:

Should clinicians who are prescribing these weight loss meds be regularly monitoring bone density?

Sue Shapses:

I think it's a great idea. It costs money to do medical procedures, so we can't recommend anything unless it's evidence-based. Right now, we don't have evidence-based for the weight loss medications and carefully measuring bone, but it's not that expensive to do DEXA and maybe some bone markers in the blood.

Holly Wyatt:

I'm an endocrinologist, and I'm going to admit that because I've mostly focused on individuals with obesity and overweight, I really, for the majority of my career, did not see a lot of osteoporosis. If anything, people with a higher body weight tend to have higher bone density, not a lower bone density. And so I almost felt like I didn't get practice in osteoporosis because my patient population was overweight. And when we would do bone densities and research or studies or whatever, it would actually be the opposite. And so is that true? Do you start with more bone density before you lose weight? Does having extra weight increase your bone density?

Sue Shapses:

That's a great question because that's how I started in the field and I'm studying obese people and we and the clinicians are saying, we don't worry about bone for this population. The bone is a lot. And I said, that's true. Let me study this population anyway. And I told all our people in the weight loss studies, this is the great part about your condition. You have great bones, but we need to study them during weight loss. Well, guess what? There is a lot of bone, but the quality of the bone is compromised.

James Hill:

Ah.

Sue Shapses:

Especially in the person with a BMI greater than 35, we notice that bone quality starts to go down after that point. Now, maybe that's related to the fact that people with a BMI, more severe obesity at 35, are not moving as much. Maybe their diet is not as healthy. There's a variety of reasons that can cause poor quality bone or lower bone density or a risk of fracture, let's say it that way. So yes, people with obesity who have high bone mineral density, don't be fooled by it. We did a study where we looked at, after we found out their fracture risk actually was greater in the lab, what we did is we looked at bone quality in our obese population. One way to look at bone quality is to look at something called trabecular versus cortical bone. Trabecular bone is the Swiss cheesy bone. It's more metabolically active. The cortical bone is the denser bone that we have. If you tap your femur or your thigh or your tibia, you'll know that that's the hard bone on the outside. And what we saw is that obese people with greater bone mineral density by DEXA measurements had lower cortical bone than the leaner people. Yes.

James Hill:

This is important, Holly. This is important. And Sue, I keep looking at analogy with muscle because I think what we're realizing now, it's not the amount of muscle, it's maybe the function of the muscle that may differ.

Sue Shapses:

Yes, I keep hearing that in the muscle field. And in fact, you should know that most of the osteoporosis and bone field has gone to call themselves musculoskeletal disease, because we realize that we really want to address both muscle and bone together. So maybe the muscle people will start looking a little bit more at bone together in their studies.

James Hill:

I love it. Where two fields that are separate don't need to be separate. They need to be working together.

Sue Shapses:

That's right.

Holly Wyatt:

They need to be because it works together. And when you study them separate, you don't get the whole picture. And we see that over and over again. So I love that analogy. We are starting to look at it's not just about the muscle. It's the function of the muscle. It's the strength of the muscle. We're doing other tests, not just looking at the total amount of muscle, very similar to bone. We're not just looking at the density or the total amount of bone. We look at it a little differently. It's about your fracture risk, but I like that.

Sue Shapses:

Right. We look at fracture risk, but we always were so dependent on this bone mineral density alone to predict fracture risk. So now we're going beyond that. It started with something called FRAX, F-R-A-X. Are you familiar with that, Holly?

Holly Wyatt:

Yes, I am familiar with that.

Sue Shapses:

So it's in the DEXA instruments now because it's so helpful because there was some low bone density and young people getting their bone density done. And we were trying to tell them, no, you don't need to go on medication. You're young. You're not going to fracture. So that was about not reaching their peak bone density or being a small person with slightly lower bone mineral density. So the FRAX, as you know, Holly, it also includes estimates of fracture based on age and family history and glucocorticoid therapy and all sorts of other factors that are included. And then you get a good estimate of fracture risk. Now, we have gone beyond that. Back to the muscle function, the bone quality, so, now we're starting to measure bone quality in the field to better understand fracture risk and really delve into who is at risk and what bones, no matter what their bone density is, is not as high quality bone. So obesity is one of those. Now, they're really studying the patient with diabetes and fracture risk. It's a big field of study. And I always look at that field, which is my field, by the way.

The department that I'm in is the Division of Endocrinology in the medical school. So I think a lot about endocrinology. And they're doing a really great job. There's a lot of new studies to show that the bone quality in the patient with diabetes is compromised. And I always go back to the patient with obesity, with or without diabetes, and say, we've got the same thing going on here. And I'll stick with obesity because that's my focus, but my colleagues are thinking a lot about diabetes and there's similarities between the fields, of course.

Holly Wyatt:

Jim, I think now, I think we've alerted people to something that they may not have thought about.

James Hill:

Holly, this is a paradigm shift. I mean, literally, what we've been saying is you're obese, you've got more muscle and more bones, so you don't need to be concerned. When you lose it, you're sort of going back to normal. But what we're hearing is, wait a minute, you might have more measured one way, but you might have muscle and bone that's not functioning as well as in a non-obese person. That is really a paradigm shift.

Holly Wyatt:

And weight loss can make it worse.

James Hill:

Ah, weight loss can make it worse. So the big question, Sue, that all our listeners want to know is if I'm losing weight, what can I do to minimize loss of bone mass, loss of bone function?

Sue Shapses:

Okay. Can I step back for one second and just talk about the patient with obesity? Why do they have poor bone?

James Hill:

Yes.

Sue Shapses:

So, with the obese patient, the hypothesis is that maybe the high-fat diet is a problem. We have shown that high-fat diet compromises bone in translational studies. We were able to clearly show that. And high-fat diet, even in a person who's not obese, compromises the bone. So that's one factor. Some people talk about the low vitamin D levels in patients with obesity as a causative factor of poor bone quality. Maybe. I'm not sure. We don't really have good evidence for that. And then the other factor that we already spoke about today is that possibly being more sedentary is a factor for poor quality bones and obesity.

James Hill:

Oh, wow. We could do a podcast on each one of those three, Holly. This is great stuff. Let's go back to the high-fat diets because one of the things that, as you know, in the nutrition field, we've argued about diet right and left. Do you want high-fat, low-fat? I think what the evidence suggests is the weight loss can be similar on all of them, but beyond weight loss, I've always been concerned about how high-fat diets may influence other aspects of health. And what you're saying is it might influence bone function.

Sue Shapses:

Okay. I'm going to say something that I'm not sure about, but I always say to the people who really like their high fat diet during weight loss, you know, used to be the Atkins diet, but now it's everyone's diet of high fat to lose weight. When there's high fat and there's negative energy balance or weight loss at the same time, there currently is no evidence that it's worse for bone, okay? So I don't want to venture into that area, but I will venture into high energy intake. You know that the mouse that's on a high-fat diet is always gaining weight. Well, we know that compromises bone. We, in our own studies, were able to show that even if you don't gain the weight and they're weight matched, the bone is compromised. What we have not shown is during weight loss, whether or not this high fat diet compromises bone.

James Hill:

Yeah, it's always a conundrum because weight loss itself is so positive that sometimes it might mask some of the negative effects that might go along with diet composition.

Sue Shapses:

Exactly. And that's why I still am convinced that the high-fat diet, it has to be doing all of these same effects, but it may not be able to get there.

James Hill:

It's countered by the positive effects of weight loss.

Holly Wyatt:

And weight loss is short term. You're not going to lose weight forever. Your body's going to fight back. We know that. So it's really when you're in either regaining the weight or in weight loss maintenance where you might see this effect because of the length of time you're exposed to it, too.

Sue Shapses:

That's right, Holly. That is well said. And that's why I always tell people that I don't care if you're a normal body weight. If you're having a high fat diet and you don't gain weight, people are just always so focused on weight alone. You're doing something negative to your body and you should keep that in mind. And in particular, I know bone. So I say, here's the example that I can give in what we've studied and what I know about. And indeed, we know that a high-fat diet and the inflammation that we think is the causative factor affecting bone also negatively affects many other aspects in the body.

James Hill:

So, Holly, I've got to jump on her third point because, you know, I love that.

Holly Wyatt:

I knew it. I always thought you were going to go straight there, but I knew you were going to come back.

James Hill:

I'm getting there. But exercise and sedentary lifestyle. Talk about how movement affects bone health.

Sue Shapses:

Well, there's a lot of good studies on this, and I would tell you that it's pretty clear at this point that exercise is good for bone. And we know that it's good for muscle. What's good for muscle is usually good for bone. How about that?

Holly Wyatt:

There we go.

James Hill:

I like that. I like that a lot. We've tied muscle and bone together.

Sue Shapses:

Yes. And so resistance exercise in particular, and certainly in the older population, is especially good for bone during weight loss and probably without weight loss, I can say too.

James Hill:

But being sedentary which is something that's pretty common in everybody in our country can actually lead to some impairment in bone health, potentially.

Sue Shapses:

Absolutely. And our field overlaps a lot with arthritis, by the way. So, bone and cartilage. We also know that without movement, the arthritis gets worse. And I thought I'd bring that up because if we're talking about older people, oh, but I have arthritis, I need to sit, it feels better. Well, the more you sit, the worse it's going to be and clinicians know that, but patients need to be reminded.

Holly Wyatt:

So it sounds like high fat diet, low vitamin D, which lots of people have, we're seeing that more and more again, and then you combine being sedentary. It's kind of creating a trifecta that even without weight loss, may be really having that negative impact on your bone. You may be setting yourself up for problems, especially as you get older and you start to maybe lose some of that bone and you kind of put all that together. So I'm going to bring us back because I know what our listeners are saying. Okay, you've convinced me. I wanna do something. What can I do? And maybe we can think about in general, but also what can I do if I wanna lose a little bit of weight and preserve or protect maybe my bone.

Sue Shapses:

I am very happy to talk about that. That's the main area that I look at and study and think about. So, no problem. I just wanted to make sure we addressed obesity by itself. Okay, what are the reasons why you lose bone during weight loss? One of the reasons is that your food intake is declining and sometimes your micronutrient intake is declining most of the time, especially calcium. Calcium we're almost more concerned about even than vitamin D in this field. Vitamin D is important. You need to get adequate amounts, but large quantities that people are taking, it's not going to do the the job. We'll talk about specifics in a minute. Less weight bearing could be enough a reason for bone loss. Although there's a great study that was just published by my colleague and it was pretty cool. She added best, weighted best.

James Hill:

I was going to ask you about that, but go ahead. I love that.

Sue Shapses:

There was no effect of adding the weight back. And I have to say I'm not so surprised because that's not the mechanism that I thought was the main one causing the bone loss. But I'm more of a metabolism person and a nutrient person. So I thought maybe I was biased, but now there's a little bit more evidence that that's probably not the main reason. And if you think about six to 10 percent weight loss that we were talking about that often occurs with moderate weight loss and what most people do on their own without medications, the fact that there was bone loss, that's not a lot of weight. That's much less weight on your bones. Okay, so we're moving on beyond that. Well, calcium absorption, I said decreased calcium intake. The most amazing finding is we found that there was a decrease in calcium absorption during dieting. And why do I say that's amazing? The reason it's amazing is I've always known that during fasting, the body accommodates and tries to survive. Pregnancy and lactation, there's a compensation, right? But during moderate weight loss, intentional weight loss, we actually decrease our calcium absorption.

For whatever reason, which I could tell you afterwards if possible, reasons which related to estrogen again. Estrogen actually plays a big role in calcium absorption and you decrease your estrogen levels with weight loss, which is usually good, right? It lowers the risk of cancers, the estrogen, the high estrogen levels. So it's often a good sign to decrease your estrogen, but it affects bone and it affects calcium absorption. So we have not only a decrease in calcium intake during energy restriction, but a decrease in calcium absorption. So that combination is not good. And people really need to make sure they're getting at least 1.2 grams of calcium a day. And I would say maybe even 1.5 grams of calcium a day during weight loss in particular.

Holly Wyatt:

Anything you can do to make it absorbed better or any type of calcium that would be absorbed better. I'm really focused in on this absorption because it's opposite what I would have thought. I would have thought if anything, we would increase absorption, not decrease it. But if we're decreasing it, is there any way we can help our body absorb it better?

Sue Shapses:

Well, you can make sure you have adequate vitamin D. And indeed, we actually did a study on that and showed that you can get into calcium balance if you have adequate vitamin D. So we had a study where we used a little bit higher vitamin D, certainly than the recommended intake. So, now we're getting into numbers of what you should take during weight loss. Maybe 1.5 grams of calcium, and maybe we had 2,000 or so IU per day of vitamin D. You could take that combination you're guaranteed to be in positive calcium balance or not negative calcium balance.

James Hill:

Very practical advice.

Holly Wyatt:

Yeah. Like that. What else? Anything else that help protect this bone when we're losing weight? We've said weight loss has so many positive effects. I don't want to people to be scared to lose weight but we do want them to be smart about it. And is there something that they… so calcium, vitamin D, and then I am going to guess, movement?

Sue Shapses:

Yes. So slightly higher calcium and D than if you're not losing weight, but this is if you're really a successful weight loser. If you're just losing and then not really losing, it's not a big deal. So yes, anybody who's a successful weight loser. Who's a successful weight loser? Someone who loses one to two pounds a week would be considered successful which I think a lot of us use in the field. Another component you asked about, exercise. Resistance exercise makes a big difference. It doesn't fully prevent the bone loss, okay. But there is yet something else. And that is… I want to talk about cortisol. So I just want to remember that when we go back to it. But cortisol levels rise during weight loss. And if you have adequate estradiol, meaning younger women or younger men, that's one of the reasons why there might not be as much bone loss. Okay. All right. Finally, I'm getting to the topic that I think you guys know very well in the muscle field. Protein intake. How about that?

Holly Wyatt:

There we go. Yes.

Sue Shapses:

So protein intake has been shown, and indeed in our own studies, that it can attenuate bone loss during weight loss. In this particular study, we wanted to go for 30% protein intake, and indeed most people cannot achieve that continuously over six months or a year. But they can achieve a 24% bone to protein intake. And we were happy to get that. The other group had 18% protein intake. And we saw a difference in bone loss at multiple sites, including the radius, the wrist area, the spine, and the hip. All of those are considered the fragility fracture sites for osteoporosis and fracture risk. So that was a really good thing to find. Now, not all the studies showed that, but when I looked at some of these other studies, the compliance was terrible. They never achieved a differential in protein intake. I think you, again, must be familiar with this concept of compliance to the diet or to the intervention.

So one study found that, everybody was taking 24% of their protein. There was no differential between the two groups, and they found no difference between the groups. It's very hard to control people to lose weight and then to have two different levels of protein. And I learned that for the first time doing that study. But it showed a difference, and there was a meta-analysis to show, yes, it seems that there is a beneficial effect. So I said 24%. Get at least 1 to 1.2 grams per kilogram protein per day.

Holly Wyatt:

So, Jim, here's another parallel to muscle, and I did not know this.

James Hill:

I was going to say, Sue, we've done some podcasts on muscle and really talked about the combination of resistance training and protein. Both are good on their own, but the two together are really good.

Sue Shapses:

Well, that sounds great. I am not sure we've done a combination of protein and exercise. I'm sure someone has done it. I just am not familiar with it. And I'm familiar with a lot of studies. The muscle field is, I would say, more advanced than the bone field, but it's been around for a long time. It's a great interest to people.

Holly Wyatt:

But in this case, it's calcium, vitamin D, protein, and perhaps resistance training as the stimulus maybe to prevent it.

James Hill:

[34:40] I love it, Holly. All the things we recommend.

Holly Wyatt:

Yeah, this is good.

James Hill:

This is fantastic.

Sue Shapses:

I have another thing to tell you.

James Hill:

All right, tell us.

Sue Shapses:

It's slightly off the topic of bone, but it gets back to protein. We just looked at, retrospectively, all our people that were in our studies for these bone studies. And we said, oh, let's look at the medium protein intake. And those with the lower protein intake were closer to 15% protein intake. And the ones with the higher were really closer to 18 to 20%. Well, there was such a differential in lean body mass loss, which you guys would not be surprised about. What was so interesting is diet quality was influenced. The diet quality of the people with the higher protein intake was much better than those with the lower protein intake. Maybe this doesn't surprise you, but there were lots of vitamins and minerals that were better. They had less sugar in their diet. They had less salt in their diet. It was very interesting to see that if people pay attention to a slightly higher protein diet during dieting for weight loss, it has this other beneficial effect. And we think that effect is very good for bone. So that is why I bring it up.

James Hill:

Wow.

Sue Shapses:

That was a paper published in obesity just two years ago.

Holly Wyatt:

We've got several listener questions. Some of them we've covered, but it might be good to kind of go back over them because this is what people are wanting to know about. So Sarah, she's, I asked for their age because I thought that might be important for this, for these questions. She's 45 and she just started a GLP-1 medication and she's losing weight rapidly. She's very excited. And she wants to know, should she ask her doctor for a DEXA scan now? She's 45 or should she wait?

Sue Shapses:

So when you say now, that's after the weight loss, right? She's already lost the weight.

Holly Wyatt:

Well, she's on it right now, it sounds like.

James Hill:

During the weight loss.

Holly Wyatt:

During the weight loss, um, you know, she's 45, so I don't think she's had, I assume she hasn't had a DEXA, um, and she's losing weight. Should she wait till she finishes losing weight? Should she do it now?

Sue Shapses:

It's better to wait until afterwards because it's in flux right now, possibly. If you think about bone, it takes at least six months for a bone modeling unit to turn over. So we never do studies, we try not to do studies in the field that are less than six months to one year as the minimum. So she's in the middle of bone turnover. She'll never know what her bone is if she takes the density right now. She could have taken it before she lost weight. And there's some artifactual concerns with high adiposity over the bone so it might not be as accurate. She can take her bone density after the weight loss. Once again, she is younger, so she hopefully will not lose as much bone as an older person who's losing dramatic amounts of weight.

James Hill:

So ideally, Sue, would it be good to get a scan before you start losing weight and then get another one afterwards?

Sue Shapses:

You could, but we're not exactly sure what it would mean because that is the research that's missing in the field right now. And so what we like to do is really understand beyond DEXA what it means. Because let me tell Sarah this. We measure something called aerial bone mineral density with this bone density scan that your physician can do. And indeed, it has limitations compared to this volumetric bone density that we can do with research tools and CT scans. You don't want to do that. There's a lot more radiation associated with it, and it's still in a research mode. But back to the question, should she get a DEXA scan? Well, if she's at risk for other reasons, it's very hard to justify insurance paying for a scan at her age.

Holly Wyatt:

I think the point that was really different than when we do DEXAs, like during weight loss, it's the six-month period, this kind of need to wait for the bone, which for muscle and other aspects that we do DEXAs sometimes to look at or to look at change in fat mass, that's not the case. So that's something to differentiate between looking at changes in muscle versus looking at changes in bone. There's a little bit timing difference.

Sue Shapses:

There's a big timing difference because I said six months to one year.

Holly Wyatt:

Okay.

Sue Shapses:

It's really different.

James Hill:

Okay. Here's one, Sue, from Tom, who's age 50. My wife has me lifting weights and drinking protein shakes to protect my bones during weight loss. Is that overkill or is she right?

Sue Shapses:

She's right.

James Hill:

Figures.

Holly Wyatt:

There we go. That's all we need to say. She's right. I like it. I like it. Should we do one more?

James Hill:

Yeah, one more.

Holly Wyatt:

Okay. Mike is 52. He lost 60 pounds last year. So nice, nice weight loss there. Then he broke his wrist in a minor fall. Could those two things be related?

Sue Shapses:

They can be related. It's very hard to to say too much when i don't know his body weight and his height and BMI to better understand this but there are men with osteoporosis and we cannot minimize that. 20 years ago it was all the women. It's grandma, that's who we care about. Well, we care about grandpa too and not even grandpa. He sounds like he's much younger than that, or could be younger than that. So we're very concerned about men at this point, and we know that they're at risk of osteoporosis, and a fracture is one of the fragility sites, so indeed he could be at risk, and he should have a DEXA by now. That's a good reason.

Holly Wyatt:

Yeah, I agree with that, and I think that's important. I didn't want to leave the men out or feel like they were being left out of this discussion.

Sue Shapses:

That's right. And 60-pound weight loss is dramatic. Dramatic, as we all know. And maybe his bone was compromised if he had that BMI greater than 35 to begin with.

Holly Wyatt:

All right, Jim, is it vulnerability time?

James Hill:

It is. You want me to go first?

Holly Wyatt:

You go first.

James Hill:

All right, Sue, we like to ask questions to make our guests a little vulnerable. Has there been a moment in your career where something you discovered made you change your own health habits?

Sue Shapses:

Well, what I'll tell you, I could tell you something else, but I want to tell you a story where it changed them and changed them back. When I was learning about the calcium, I realized I had very low calcium intake. And I started taking supplements, you know, the usual about 1.2 grams per day. They have these supplements that are 600 each. Well, what we learned along the way especially with the women's health, besides it making me very thirsty and becoming dehydrated, that's a side effect of taking calcium supplements. The Women's Health Initiative found that when you take 1.2 grams of calcium supplement per day, you're at higher risk of kidney stones and possible vascular mineralization that they didn't really show. It's really kidney stones was the main one. So I said, wow, I am not taking this much calcium. And indeed, we know that if you get that much calcium in your diet,

1.2 grams per day, it's not a problem. There's none of these calcium side effects. It's when you're taking supplement on top of your diet. So it turned out in the Women's Health Initiative, they were taking 2,100 milligrams of calcium a day, combining supplement and diet. So everybody has to remember that we have these minerals in our diet and not to just take supplements as, oh, I have an RDA, a recommended dietary intake of 1.2. Let me take it all as supplement. So calcium is one of the good reminders of that, that you can easily go overboard and reach the upper limit of intake, which is two grams per day.

James Hill:

Okay.

Holly Wyatt:

My question, and I think you kind of answered it with this was, was there ever a time when something challenged something you previously believed and you, and you went back and you just said, I'm guessing now you stopped the supplements and then maybe you started it again, or you said that there was something that kind of changed. What changed for you?

Sue Shapses:

Oh, well, the Women's Health Initiative results changed my view on that. And I also knew that I didn't need to take 1.2 grams per day. I just take 200, 600, because I get a certain amount of calcium in my diet. And everyone needs to remember that if they're older, in particular, there's about 300 milligrams of calcium in a multivitamin. So that's another source of calcium. And adding it all together, we don't want to take too much. What else was shocking to me? The high-fat diet that I mentioned to you and its bad effects on bone. A recent study, this is a mouse study that, vitamin D deficiency causing weight gain. We saw that vitamin D deficiency caused the weight gain as opposed to an obese person where we always believed that the vitamin D was being absorbed by the fat in the body because vitamin D is a fat-soluble vitamin. This was an interesting finding because we saw that anyone who's vitamin D deficient possibly is gaining weight for that reason.

Holly Wyatt:

We'll have to do a whole episode on that, Jim. That just opened up a whole... The listeners now are already emailing us. I already know.

James Hill:

All right, Holly. Want me to take a shot at summarizing what we've learned?

Holly Wyatt:

Yes, please.

James Hill:

And I will have to say, I've learned a lot on this episode.

Holly Wyatt:

Me too.

James Hill:

The things I didn't know about bone. The things that I learned is that if you're obese, you might have more muscle and denser bones by the way we measure them right now, but we may not be measuring the right things. We may need to measure muscle function and bone function. So that is a big wake up for me. The other thing we learned is there are things you can do if you're losing weight to minimize loss of bone amount and function. And those are making sure you get enough calcium and vitamin D. And for calcium, I think the recommendations are somewhere around 1.5 grams per kilogram. Is that right, Sue?

Sue Shapses:

For calcium, it's one gram per day for those under age 50 or 70, depending on male and female, and 1.2 grams per day otherwise and older.

James Hill:

Okay. And about 2,000 international units of vitamin D. So the combination of calcium and vitamin D?

Sue Shapses:

Yes. And the recommended intake is 800. I must say that. I was on the guidelines committee. But for weight loss, maybe 1,000 to 2,000 is better.

James Hill:

Okay. So the calcium and vitamin D, resistance exercise, and protein. And protein, you probably want to do more than the recommended dietary intake of protein. You probably want to increase that protein. Above 25% or so if you're trying to lose weight?

Sue Shapses:

We've seen that 25% is good enough, or at least one gram per kilogram per day.

James Hill:

Okay. So there are things you can do, Holly, to minimize loss of bone during weight loss.

Holly Wyatt:

Yes, absolutely. And it sounds like there's some individuals that getting a DEXA scan and being able to look at their bone over time is good. But I really learned that you don't necessarily want to do it when you're actively losing weight. That six to one year window. It's a little bit different. I think about being able to get a DEXA during the process. And this really made me think about getting a DEXA either before when things are maybe more stable or after the process might be a better time to look at the bone density using the DEXA machine.

Sue Shapses:

Holly, as a physician in the field, I want to add one more thing to that, and I think you know it, that if someone has a low bone density, It's helpful to wait and see if they have a low peak bone density versus being a bone loser. So they wouldn't get a DEXA scan again for at least a year to find out, “Oh, this was my peak bone density. I'm actually not losing weight, bone at this time. I'm just a low bone density person.” And that often goes along with smaller people who happen to be women oftentimes.

Holly Wyatt:

Yeah, you need the two data points.

Sue Shapses:

That's right. That's right. And there's trabecular bone score, TBS. I just have to say that because that's included in the DEXA scans in many of the offices now. And that looks at bone quality. So it goes beyond density.

Holly Wyatt:

Yes.

Sue Shapses:

That's all.

James Hill:

Sue, this has been a fantastic episode. You've certainly educated me. And I know you've educated many of our viewers. So thank you so much for spending time with us on Weight Loss And.

Holly Wyatt:

Yeah, thank you. This is eye-opening.

Sue Shapses:

Thanks so much for giving me the opportunity to talk about my favorite topic.

Holly Wyatt:

Love that.

James Hill:

Okay, we'll see you next time. Keep your questions coming in and let us know the topics you want to hear. So thanks, everybody, and see you next time.

Holly Wyatt:

Bye.

James Hill:

And that's a wrap for today's episode of Weight Loss And. We hope you enjoy diving into the world of weight loss with us.

Holly Wyatt:

If you want to stay connected and continue exploring the “Ands” of weight loss, be sure to follow our podcast on your favorite platform.

James Hill:

We'd also love to hear from you. Share your thoughts, questions, or topic suggestions by reaching out at [weightlossand.com](http://weightlossand.com/). Your feedback helps us tailor future episodes to your needs.

Holly Wyatt:

And remember, the journey doesn't end here. Keep applying the knowledge and strategies you've learned and embrace the power of the “And” in your own weight loss journey.