If you support people experiencing osteopenia, osteoporosis, fracture risk, menopause-related bone loss, sarcopenia, metabolic challenges, or confusing bone test results, this episode will help you think more clearly about what the numbers actually mean.
Dr Ritamarie
We have a problem in bone health. We've taken one of the most complex tissues in the human body and reduced it to a number. The T score. While that number matters, it's become easy to forget what it doesn't tell us. It doesn't tell us why someone has lost bone. It doesn't tell us whether their bone quality is compromised.
It doesn't tell us whether they have muscle, balance, hormones, nutrition, and metabolic support needed to protect that skeleton. It doesn't tell us whether the person in front of us is actually at high risk for fracture.
Today we're going to look beyond the number. We're going to talk about conventional DEXA, full body DEXA, Echolight REMS, fragility score, trabecula bone score, bone density, bone quality, and fracture risk, because we as practitioners need to understand what each tool can tell us, what each tool can miss, and why no imaging test should ever be interpreted without the person attached to it.
Many people are told they have osteopenia or osteoporosis based on one measurement, the T-score, but bone health is far more complex than bone density alone.
In this episode, we're going to explore DEXA, full body DEXA, Echolight REMS, fragility score, trabecular bone score, bone quality, and fracture risk, because the goal isn't just to identify that bone density is low. The goal is to understand what's happening in the person in front of you, what factors may be contributing, and how to create a root-caused personalized strategy. The test gives us data, but the practitioner creates meaning. If you work with people who have osteopenia, osteoporosis, fracture risk, menopause-related bone loss, sarcopenia, metabolic issues, or confusing bone health results, this episode will help you think more clearly.
Even though we're talking about imaging, we're really talking about interpretation. What does the test actually measure and what does it miss? What can distort the results? How does it relate to fracture risk? How does it connect with things like muscle, falls, hormones, labs, inflammation, digestion, nutrition, and even medication history? How do we interpret the test in the proper context of the whole person?
Let's start with the standard pathway.
Someone gets a DEXA. They see a T score, and they see a word like osteopenia or osteoporosis, and they get scared, rightly so. The practitioner gets concerned, and suddenly the conversation becomes, do you need a medication? Do you need more calcium? Do you need more vitamin D? Do you need to walk more?
While those questions may matter, they just aren't enough, because the T-score is one piece of information, and it's part of a much larger story. A person's fracture risk depends on bone density. It also depends on bone quality, prior fracture history, falls, muscle mass, balance, vision, neuropathy, medications, inflammations, blood sugar regulation, thyroid status, cortisol, all the things that matter, protein intake, absorption of that protein, gut health, spinal changes, body composition, need I say more, and the ability to safely load the skeleton. That's why bone assessment needs to go beyond the number.
Let's stop for a moment and talk about what the T-score is. It compares a person's bone mineral density to the average peak bone density of a healthy young adult. It's not comparing someone to other people their age. It's comparing their bone density to the level of bone density we would expect when the bones are at their strongest. In general, a T-score of minus one or higher is considered normal bone density. A T-score between minus one and two point five is considered osteopenia, and minus two point five or lower is considered osteoporosis.
The T-score is useful, because it helps to classify bone density and estimate fracture risk, but it doesn't tell us why the bone was lost. It doesn't tell us whether the scan was affected by arthritis or positioning. It doesn't tell us whether bone quality is compromised. It doesn't even tell us whether someone has enough muscle balance, metabolic support, or other to reduce the fracture risk.
When someone gets a diagnosis based on the T-score, it should be the beginning of the conversation, not the end.
Let's talk about DEXA. DEXA stands for Dual Energy X-ray absorptiometry.
The most commonly used test for measuring bone mineral density, and it's widely available. It uses a very low level of radiation, and it's included in clinical guidelines. What it does is it gives us some important information. It provides bone mineral density measurements, T scores, and Z scores. It's commonly used to assess bone density.
It helps diagnose osteopenia and osteoporosis, and it can monitor changes over time, although it takes a while for the changes to be able to be detected. It can guide treatment decisions, and the most common sites measured are the lumbar spine, the total hip, and the femoral neck. Sometimes the forearm is measured, and these sites matter, because they're associated with an important fracture outcome and clinical decisions.
What I want to be clear is DEXA is valuable. DEXA matters. The problem isn't DEXA, the problem is pretending that DEXA tells the whole story. The DEXA scan is one piece of information about the skeleton. It doesn't tell us the complete story of why the skeleton changed.
Let's talk about T-score versus Z score. The T-score compares bone density to a young healthy adult reference population. That score is commonly used for diagnosing osteoporosis and primarily used for diagnosing osteoporosis in perimenopausal women, postmenopausal women, and older men.
The Z score compares bone density to what would be expected for someone of the same age, sex, and reference group. A T score asks, How does this person compare to peak bone mass?
A Z score asks, How does this person compare to others their age? That distinction really matters. A low Z score may suggest that's something beyond normal aging that deserves investigation, maybe it's endocrine dysfunction or malabsorption or inflammatory disease or medication effects. Maybe it's celiac or kidney disease or undernutrition, just not eating enough, and maybe it's early menopause.
A low T score tells us bone density is low compared with peak bone mass. A low Z-score compares us to others our age, so the Z-score asks, why is this person lower than expected for their age? That's a root cause question.
What can DEXA miss or distort? Well, that is several things. It measures a real bone mineral density. In simple terms, it estimates bone density in a two-dimensional way. It's useful, but it doesn't directly measure every aspect of bone strength.
Dr Ritamarie (07:51)
It doesn't measure collagen quality, bone turnover, microdamage, or glycation. It doesn't directly measure fall risk, and it can be affected by artifacts. The lumbar spine can be really tricky when they test it. The results can be influenced by a lot of things like osteoarthritis, osteophytes, degenerative changes, scoliosis, aortic calcification, compression fractures, and even positioning.
Sometimes the spine looks stable or even improved, but improvement isn't because the bone became healthier. It may be because the degeneration or calcification made the reading look denser. That's why practitioners need to look beyond the summary page and look at the individual vertebrae and look at whether the vertebrae were excluded. They need to look at the hip, look at the femoral neck, look at the changes over time, and ask whether the same machine was used each time and whether the change is greater than the least significant change for that facility.
Sometimes the spine score improves because the bone improved, but sometimes it improves because the spine got more degenerative, has more osteophytes and thickening. We need to know the difference.
Then of course, trends matter more than just a single reading. One of the biggest problems that people have with bone testing is fear. Someone sees a score and panics, and a practitioner sees a score and jumps into a protocol, whether it's drugs or something else. One test is just a single snapshot. Trends tell us a whole lot more. When possible, we want to compare the scans from the same machine or facility. Don't go shopping around. Look at whether the change is meaningful, and look at what changed in the person's life during that time. Menopause, weight loss, starting or stopping hormones?
Did they start thyroid medication or increase the dose? Did they take steroids? Did they become more or less active? Did they lose muscle mass or develop gut issues? All of these things matter. If they increase protein and resistance training, that's going to change things, too.
Did they start medication for their bones? That's a good question to ask, too. Testing always needs to understand the trigger to ask better questions. It's not about panic, it's not about shame. It's just better questions, and better questions is what we all should be doing as professionals to get to the root cause and understand what's really going on.
Now let's talk about a full body DEXA. This is an area where there can be some confusion, because full body DEXA and conventional DEXA answer different questions.
Conventional diagnostic DEXA is primarily focused on bone mineral density at key fracture risk sites like we mentioned, the spine, the hip, the femoral neck, sometimes even the forearm. Those measurements are used for osteoporosis diagnosis and fracture risk assessment; whereas, a full-body DEXA is used for body composition. It can give us indications about total fat mass and lean mass and regional lean mass.
Lean mass in the appendages, in the arms and legs, and fat distribution and visceral fat. It can give us asymmetry numbers from side to side or top to bottom. Sometimes it gives us whole body bone mineral content. This can be extremely valuable in a root-cause bone health model, because bone health is not separate from muscle health. Muscle-bone connection is one of the most important concepts we need to understand.
Dr Ritamarie (11:23)
A full body DEXA can help answer questions like, Is the person losing muscle? Are they under-muscled? Are they losing lean mass during weight loss? Is there sarcopenia? Are they carrying more visceral fat while losing muscle? All these interventions are geared towards improving body composition, but are they?
A person can lose weight and still become more vulnerable if the weight loss includes significant muscle loss. That's important, because with aging, menopause, metabolic disease, and even aggressive weight loss approaches, sometimes we're losing more lean than fat.
A full body DEXA adds some valuable context, but it's not to be confused with the two. The full body doesn't automatically replace a diagnostic DEXA. They're different tools, and they look at different things, and they may answer some different questions.
A conventional DEXA helps us look at what's happening at key skeletal sites, and it's a close-up look. A full-body DEXA helps us understand what's happening with the metabolic terrain around the skeleton and how much muscle the person has and what their body composition is. We also get to see if they are losing lean tissue or improving their resilience? Both of them can be useful. The key is knowing what questions we want to answer.
Another emerging technology is called Echolight REMS. REMS stands for radio frequency echographic multi-spectrometry. These are all hard words to say, big mouthfuls, but unlike DEXA, which uses X-rays, REMS uses ultrasound-based technology.
One of the things that makes REMS interesting is that it provides another way to evaluate bone without ionizing radiation, and a lot of people are concerned, because they've had a lot of radiation.
Echolight REMS can assess skeletal sites including lumbar spine and femur and provide information like bone mineral density, T-score, Z-score, and fragility related information. The fragility related information is super exciting, because it expands the tools practitioners may have available when assessing bone health. An important caution is we don't want to say automatically this test is better or it replaces everything else. That's not how good clinical reasoning works.
Dr Ritamarie (13:33)
There are different tests, and they answer different questions, and the more tests we get, sometimes it's better. But, we also want to be careful about over-x-raying people. DEXA uses X-ray to estimate bone mineral density, and REMS uses ultrasound signal analysis. Both can provide valuable information and both require proper techniques, so we can get a misinterpretation if we don't do the proper technique. They need to be looked at in the context of the whole person.
A REMS should still be interpreted alongside fracture histories, falls, muscle mass balance, and hormone status. All these things are important. Look at somebody's nutrition and inflammation status, what medications they might be on, and what's their capacity for movement. Are they restricted? And, the factors that may have contributed to bone loss in the first place. No imaging test is magic. I wish there was the perfect test, but there really isn't. Then, the value is interpreting the information in context with everything else about the person.
The fragility score is something that the REMS does. It's especially interesting, because it attempts to move beyond simply measuring density, thickness. The T-score says how much mineral density it has compared to reference.
The fragility measurement answers a different question. What does this information suggest about the vulnerability of the bone? Quite frankly, this matters, and people really want to know that, because how risky is it that they're going to fracture something if they fall? Two people can have similar bone density but different fracture risk. One person might have really good muscle mass and balance and strong movement patterns, and the other things like good nutrition and low, low inflammation and an ability to move confidently.
Another person may have lower muscle mass or poorer balance or multiple medications that can interfere with bone and the strength of bone and history of falls.
Those folks in different backgrounds can have a similar T-score, but a much different fracture risk. We need nuance. The fragility score isn't a standalone diagnosis, and it doesn't replace all the history and all the other things or clinical judgment. It also shouldn't let us ignore concerns on the DEXA. We have to use these in combination with each other. It's just another piece of information. Sometimes that additional information helps us to see things.
The other tool worth understanding is the Trabecular Bone Score, TBS. It is derived from the architecture of the lumbar spine DEXA image. It gives us additional information about the quality of the trabecular structure inside the bone; whereas, DEXA tells us about density. TBS gives us another window into the quality of the internal matrix of the bone.
Two people can have the same T-score but different TBS results. This may suggest differences in bone quality and fracture risk. TBS doesn't replace DEXA. It doesn't limit clinical judgment, but it can add another layer of understanding. My understanding about it is you can do it using specific software to look at the DEXA results. Not every place that does a DEXA can actually get the TBS. They have to have the proper technology to be able to do it.
We have DEXA, we have full body DEXA, we have REMS, we have fragility score, we have TBS, and each one gives us a little bit more of a picture of what's going on. The mistake is expecting one test to tell us everything. Sadly that's not true, so zoom out.
Bone density obviously is important, but it's not the same as bone quality. I'd go for bone quality any day of the week over bone density. Bone quality isn't even the same as fracture risk, because there's a lot of other things that play into fracture risk, and that has to do with balance and musculature.
Bone quality, looking at the microarchitecture, the matrix, the collagen quality, mineralization, bone turnover, micro damage, all these things are important. The material properties that determine how bone responds to stress is super important. Then we have fracture risk.
Dr Ritamarie (17:38)
Fracture risk includes more than the skeleton. It has to do with muscle mass, it has to do with strength, it has to do with balance and equilibrium, it has to do with power. All these things are super important.
It also can be related to vision. If somebody has vision loss or neuropathy, that might interfere with their ability to stay upright, and they may fall down. Even if they have some sort of issue with dizziness or an unsafe home environment or footwear. There are so many things that play into the fracture risk and the fall risk.
Even blood sugar regulation. Somebody gets woozy and starts to fall down. We need to look at all of these things, including thyroid and estrogen status and especially protein intake and absorption of that protein. We need to have people be able to move safely.
Two people with the same T score may have very different risk profiles. Somebody may have a low T-score but excellent strength, balance, movement, and nutrition. Another one may have a better T-score, but they're frail, and they fall a lot, or they have more risk for falls like dizziness, et cetera.
The bottom line is the T-score matters, but fracture risk is bigger than the T-score. Fracture risk is the bone, the fall, the force, the muscle, the medications, the metabolic terrain, all these things play into actual fracture risk.
How do we as practitioners use imaging?
The framework that I do is first start with clinical risk. You're going to ask, has this person had a low trauma fracture? Low trauma meaning it wasn't a serious fall. They just tripped, and they hit their arm against the wall, and they broke something. That's a low trauma fracture.
Have they had a vertebral compression fracture? These are very common in people with weak bones. Is there family history of hip fracture or recurrent falls? Are they taking medications that may make them dizzy or affect bone risk? Do they have an inflammatory disorder or a celiac, which will impair their digestion and absorption? Again, that affects the strength of the bone like other conditions like thyroid, kidney, diabetes, and malabsorption.
The next thing to look at is the DEXA but beyond the summary page that they give you. You want to actually look at the sites, look at the spine and the hip, look at the femoral neck and whether or not the area is declining more than another. Comparisons are important.
Third one is to compare threat trends. How is this changing over time? Ideally, we're going to go to the same facility and use the same machine, but that's not always guaranteed. We may have some skewing when we look at numbers over time that way. You always want to know what happened to the person's life? Did they lose weight? Did they start an exercise regime? Have they been on medications or hormones and developed gut issues or changed exercise? All those things are important.
The other thing to really look at and consider is body composition. If somebody's losing muscle, that matters for bone health. If they're becoming frail, of course, that matters. If somebody's improving muscle function, that matters, too.
And fifth, consider additional tools when we can. If it's available, the TBS, the REMS, the fragility score, and even the full body DEXA. Everything provides a layer. We want to look at people as a whole, not just a little part.
Sixth, pair imaging with the rest of the clinical picture, the full lab testing and looking at muscle and grip strength. The test gives us data, but the practitioner creates the meaning.
Dr Ritamarie (21:11)
We'll end with a few common mistakes that I see practitioners make.
Number one is they look only at the T-score and ignore the rest of the report. The T-score matters. It's just one piece.
Mistake number two is assuming an improved spine score always means healthier bone. It doesn't, quite frankly. Spinal degeneration, arthritis, calcification, there's lots of things, and it can affect the results.
Mistake number three is ignoring the hip. Hip fracture risk is clinically important, and hip measurements often provide valuable information.
Mistake number four is treating full body DEXA as a replacement for diagnostic. Remember, it's a full body. It's mostly looking after body composition and a little bit about bone. They answer very different questions.
Number five is ignoring muscle and fall risk. The strongest bone density measurement in the world doesn't eliminate the risk created by falls, fragility, poor balance, and low muscle tone. We have to look at the person altogether.
Mistake number six is creating fear from one scan instead of using it as information. “My density went down a little bit. What's going on?”
Mistake number seven is failing to investigate secondary causes when the bone loss is unexplained or unexpected. Somebody's losing bone faster than expected. We need to find out why. What, metabolically, is going on there?
Number eight, giving everyone the same T-score, the same recommendation. I mean, that's just protocol thinking, and we don't buy into that. Bone health requires pattern recognition, and that's why we need to move beyond protocols.
If you haven't already downloaded my little booklet, go to the show notes to get Beyond Protocols. A protocol just sees a T-score and thinks calcium, vitamin D, medication, walking, whatever your favorite intervention is.
Pattern recognition asks very different questions. Is it really bone loss or could there be factors affecting the measurement? Is the spine score reliable? Is the hip declining? There's a lot of questions that we can and should be asking, especially metabolic issues as well in terms of blood sugar and hormones and inflammation and things like that.
A lot of people are trying to lose weight, and they're undernourished. They're not getting enough protein and minerals to support healthy bone.
Is a person afraid to move when they get a diagnosis of osteoporosis? How about strength? We need to keep up our strength with regular exercise.
Practitioners need to think beyond the score. They need to think beyond protocols and look at the whole thing as an integrated whole. The scores, the bone density scores, the T scores, the REMS, plus their metabolic scores, their lab testing, their blood sugar balance, et cetera.
Bringing it all together, if you're a practitioner, the key points I want you to remember: DEXA is valuable, and it gives us important information, but it's incomplete. The T score says the bone density compared to young adults, and the Z score is the bone density compared to other people our age. Spine can sometimes be misleading, because there may be some other things going on in calcification, arthritis, et cetera.
Full body DEXA gives great information about fat distribution and lean muscle mass and all that, but it's not the same in terms of bone as the diagnostic hip and spine DEXA. Echolight REMS, fragility score in the TBS is great for looking at bone characteristics beyond bone density alone. It looks at the matrix.
There's no test that should ever replace your clinical reasoning. The most important question isn't what's the score, but what does this score mean in the context of the whole person? What's their fracture history, muscle loss, balance, hormone status, nutrition status? Are they on any medications that are influencing their risk? What is happening with inflammation, metabolic health, digestion, and movement? These are important questions to ask as well.
Our goal is to understand the person behind the measurement.
Today we looked at the T-score. We explored conventional DEXA, full body DEXA, Echolight REMS, fragility score, trabecular bone score, bone density, bone quality, and fracture risk. The bigger message is this, bone health cannot be reduced to one number.
A scan can tell us something important about the skeleton, but it can't tell us the entire story of why the skeleton changed. It can't tell us the whole hormone story or anything about nutrition, and the movement and all that. These are all critical. Metabolic health is so important for bone health, and bone is just one big metabolic organ.
What we need to have and ask is not how do we treat osteoporosis, but how did this person lose bone and what does their body need to build resilience? That's a shift from protocol-based root care to root cause care.
If this episode helped you to see bone testing differently, that's the kind of root cause thinking we explore in Beyond Protocols, because practitioners don't need another generic osteoporosis protocol. They need a way to recognize patterns and interpret data.
If you need a framework or you want to look into the framework, go and download our Beyond Protocols, because understanding how the human body works and the complexities is super, super important.
Practitioners who know how to connect the dots between hormones, nutrition, metabolism, movement, genetics, environment, and lifestyle are critical, and that's the power of what we do in nutritional endocrinology.
Nutritional endocrinology gives us a framework for understanding the communication system of the body and identifying the patterns that create health or disease. If this work we're doing inside the Institute of Nutritional Endocrinology appeals to you, reach out, and we'll talk to you about how you can get involved. We're going to teach you how to ask better questions, recognize patterns, and create personalized strategies that address the root causes, that address the upstream issues that are creating the downstream concerns.
Thanks for joining me on my quest to reinvent healthcare, and until next time, shine on.
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