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Why bone strength, consent, and whole-body health must replace the tyranny of the T-score
In Part 2 of my conversation with Dr. Nick Birch, we go deeper — not just into REMS technology, but into something even more important: informed consent, medical blind spots, and what true bone health really requires.
If Part 1 challenged how we measure bone health, this episode challenges how we think about it.
For decades, women have been conditioned into a narrow framework:
DEXA scan → T-score → medication.
But bones are not numbers. They are living, remodeling tissue influenced by hormones, digestion, inflammation, movement, and overall wellness.
And the future of bone health is not about fear — it’s about information.
REMS: More Than Density
As Dr. Birch explained, REMS doesn’t just measure density — it also measures bone toughness, which contributes to overall bone strength. The fragility score helps determine whether your bone behaves more like someone who has fractured or someone who hasn’t.
But here’s what’s critical:
It’s not just about one number.
It’s about combining:
- T-score
- Fragility score
- Lifestyle
- Hormonal status
- Nutrition
- Exercise
- Overall wellness
Bone health must be viewed holistically. A woman is not “her T-score.” She is the whole person.
The Blinkers of Modern Medicine
One of the most powerful moments in this conversation was when Dr. Birch described how, during his surgical career, he wore “blinkers.” As a surgeon, his job was to operate. Naturally, he saw problems through a surgical lens.
It wasn’t until he stepped away from surgery that those blinkers came off — and he began to see the broader landscape of health.
This resonated deeply with me.
Modern medicine often trains for depth, not breadth. Specialists know their field extraordinarily well — but the integration between systems can get lost. Bone loss is not isolated. It is metabolic. It is inflammatory. It is hormonal. It is digestive. It is neurological.
We must expand the conversation beyond one organ system.
The Hidden Risk of Polypharmacy
We also discussed something that affects so many women over 60: polypharmacy.
Multiple medications layered on top of each other can create unintended consequences. For example, a bisphosphonate may lead to reflux. Reflux leads to a proton pump inhibitor. A proton pump inhibitor interferes with calcium absorption. Reduced calcium stimulates parathyroid hormone. And the cycle continues.
Each medication may be prescribed with good intent. But the interactions compound.
Bone health cannot be separated from gut health, nutrient absorption, and systemic balance.
Informed Consent Matters
Dr. Birch emphasized something crucial: true informed consent requires presenting all options — including lifestyle alternatives.
If a woman does not know about exercise strategies, dietary interventions, hormone considerations, or newer diagnostic technologies, she cannot truly consent to a medication plan.
Education empowers choice.
And that is why conversations like this matter.
Prevention Must Start Earlier
Perhaps one of the most important takeaways is this: bone health should not begin at age 65.
Peak bone mass is built in adolescence. Hormonal health, nutrition, and movement habits in teenage years shape skeletal strength decades later.
If we educate women now, they will educate their daughters and granddaughters.
That is how change happens.
My Takeaway
The best test for measuring bone strength today is REMS — but even more important than the test is the mindset.
You are not your T-score.
You are not a prescription.
You are a whole human being.
Bone health is health.
And the more information you have, the more power you have to choose wisely.
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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.