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Why fracture risk—not bone density—should be the real focus
In this powerful Part 1 conversation on the Stronger Bones Lifestyle Podcast, I sit down with Dr. Nick Birch, a former spinal surgeon from the UK who has become a strong advocate for rethinking how we assess and manage bone health.
Dr. Birch is the physician who first introduced me to REMS technology in 2023—an ultrasound-based tool that evaluates bone strength, not just density. And that distinction changes everything.
Because when it comes to your bones, the real question isn’t:
“What’s my T-score?”
The real question is:
“Are my bones strong enough to resist fracture?”
The Tyranny of the T-Score
Since the 1990s, women around the world have been conditioned to believe that a DEXA scan is the gold standard of bone health. We’re given a T-score, compared to a 30–35-year-old reference population, and then assigned a label: normal, osteopenia, or osteoporosis.
But here’s the problem.
Bone density does not equal bone strength.
Dr. Birch shared something that deeply impacted me. As a spinal surgeon, he relied on DEXA scans before surgery to determine how to anchor screws into vertebrae. But time and time again, the scan would suggest “good bone,” and when he went in surgically, the bone would be soft, gummy, or structurally weak.
That disconnect between the scan and the real bone in front of him raised serious questions.
If density alone predicted fracture risk accurately, then all women with osteoporosis would fracture—and women without it would not. But we know that’s not true. Nearly half of fragility fractures occur in women diagnosed only with osteopenia—or even normal bone density.
So what are we really measuring?
How We Got Here
Dr. Birch walked us through the history of bone densitometry and how the DEXA scan became deeply embedded in medical culture during the 1990s. Once Medicare reimbursement began and pharmaceutical treatments entered the market, a system formed:
Test → Number → Prescription.
And that framework has remained largely unquestioned for decades.
But what if the test itself isn’t measuring what truly matters?
Structural engineers don’t test airplane wings by measuring density alone—they test strength, flexibility, load tolerance. Bones deserve the same standard.
Enter REMS: A New Way to Assess Bone Strength
REMS (Radiofrequency Echographic Multi Spectrometry) uses ultrasound technology to assess bone strength at a deeper structural level. Instead of just calculating mineral density, it evaluates microarchitecture and quality—providing insight into true fracture risk.
This is where bone health is headed.
It’s not about abandoning DEXA entirely—it’s about expanding our understanding and demanding better tools that reflect reality.
Functional Medicine and Personal Responsibility
One of the most meaningful parts of this conversation was how Dr. Birch, like many physicians of his generation, has evolved. After decades in surgery, he shifted toward a more functional, whole-body perspective.
Diet. Movement. Hormones. Nervous system regulation. These are not “alternative.” They are foundational.
We are not powerless passengers in our bone health journey.
We are participants.
My Takeaway
This episode is not about fear. It’s about awareness.
We deserve better tools. We deserve accurate assessments. And we deserve a bone health model that goes beyond labels and prescriptions.
Your bones are living tissue.
They respond to lifestyle, stress, hormones, and movement.
And it’s time we measured what truly matters: strength.
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Frequently Asked Questions (FAQs)
Oxalates, also known as oxalic acid, are naturally occurring compounds found in many plants, vegetables, and fruits. They are part of a plant’s defense mechanism against predators and can be found in high concentrations in foods like spinach, rhubarb, beets, nuts, chocolate, tea, and certain beans.
Regarding bone health, oxalates can bind to minerals such as calcium in the gut, forming calcium oxalate. This compound is not easily absorbed by the body, meaning the calcium that could have been utilized for bone strengthening is instead excreted. This process can potentially lead to lower calcium availability for bone health, which can be particularly concerning for individuals at risk of osteoporosis or other bone-related issues.
However, for most women, dietary oxalates do not pose a significant threat to bone health, especially if their diet is balanced with enough calcium and they do not have a history of kidney stones.
Your gut is crucial for stronger bones for several reasons:
- Nutrient Absorption: The gut is where most nutrient absorption occurs. For bones to be healthy and strong, they need a variety of nutrients, particularly calcium, phosphorus, magnesium, and vitamin D. A healthy gut efficiently absorbs these essential nutrients from your diet and facilitates their transportation to the bones.
- Gut Microbiome and Bone Health: Research has shown that the gut microbiome (the community of bacteria living in your intestines) can influence bone density. Certain gut bacteria help in producing short-chain fatty acids (SCFAs) like butyrate, which have been shown to promote bone health. SCFAs can enhance the absorption of minerals necessary for bone strength and play a role in reducing inflammation, which can negatively affect bone health.
- Hormone Regulation: The gut helps regulate hormones that are involved in bone metabolism, including insulin, thyroid hormones, and sex hormones like estrogen. For example, estrogen is vital for bone density, and gut health can influence estrogen levels through the enterohepatic circulation, where estrogens are processed in the liver and intestines.
- Reducing Inflammation: Chronic inflammation, which can stem from poor gut health, is linked to many conditions that compromise bone strength, such as osteoporosis. A healthy gut helps to reduce systemic inflammation, protecting bones from inflammatory damage.
- Immune System Modulation: The majority of the immune system is located in the gut. An imbalance in the immune system can lead to autoimmune conditions, some of which affect the bones. Maintaining gut health helps to ensure the immune system works correctly, protecting against autoimmune reactions that could impact bone health.
In essence, maintaining a healthy gut contributes significantly to stronger bones by ensuring the effective absorption of vital nutrients, regulating hormones, reducing inflammation, and supporting a healthy immune system. Therefore, a diet rich in bone-healthy nutrients, prebiotics, and probiotics, along with lifestyle factors that promote gut health, is key to maintaining strong bones.