Dr. Kim Millman, MD, PhD, began her career as an electrical engineer working on highly classified satellite projects. She eventually went on to earn a medical degree and a PhD in epidemiology and population genetics.
She now focuses on one pursuit: your bone health.
Dr. Millman is a truly integrative physician who has spent 18 years reversing bone loss at its root. After watching patients lose their confidence due to osteoporosis and being handed a lifetime prescription that did not build quality bone, she set out to find a better way.
Trained at UCSF, USC, and Stanford, she created the Integrative Bone Health Method™ and the Restore & Rebuild Healthy Bones program, helping thousands rebuild their bones and get their confidence and lives back.
Now, at a pivotal moment for bone health, she co-founded The Bone Health Academy® to train the next generation of practitioners, a ripple effect that carries her method far beyond her own practice. Through her patients, her students, and the practitioners she trains, she is dedicated to redefining bone health care.
DrRitamarie
A DEXA scan tells you that bone is being lost but tells you almost nothing about why it's being lost. Some of the most useful information to understanding what's actually happening inside the bone actually never makes it into the standard osteoporosis workup. That's a shame, because bone density, of course, is important, but it's only one piece of the bone health picture.
Bone is a living metabolically active tissue. It's constantly being broken down and rebuilt. If we want to change the trajectory of bone loss, we need to understand those processes, not simply wait for another DEXA scan a year or two later.
Today, we're going to talk about the bone health tests that are frequently overlooked, what they can tell us about bone remodeling and the underlying drivers of bone loss and how that information can change the way we approach osteopenia and osteoporosis.
I have exactly the person I wanted to have here for this conversation. Bone health is a perfect example of why this deeper approach matters. Someone gets a DEXA scan and is told they have osteopenia or osteoporosis and the conversation quickly turns to calcium, vitamin D, exercise, or medication. There's more to it than that, and it's usually overlooked in the conventional practice.
They're very important, but we need to ask a more fundamental question. Why is this person losing bone? What can we do to help get that to stop? What's their bone metabolism doing now? What has it been doing over the last X years to cause this bone loss? What's happening right now? Are they breaking down too much? Are they not building enough? Are there underlying issues like hormonal, nutritional, inflammatory, digestive, metabolic?
All of these things can interfere with healthy bone remodeling, and most importantly, what can we measure that gives us those answers? That's where I want to take our conversation today.
Dr. Kim Millman is the perfect guest to take us there. She has one of the more unusual paths into medicine that I've heard in a long time. She began her career as an electrical engineer working on highly classified satellite projects before going on to earn both her medical degree and a PhD in epidemiology and population genetics. So why bone? We're going to dig into that today, because today her focus is bone health.
For the past 18 years, she's worked to understand and address bone loss at its roots after seeing patients lose not only bone density, but confidence in their bodies. That was a problem, because it didn't address the bigger picture of their bone quality and their bone health.
She trained at a lot of cool places like UCSF, USC, Stanford, and went on to create the Integrative Bone Health Method and the Restore and Rebuild Healthy Bones Program. She co-founded the Bone Health Academy to train practitioners in a more comprehensive approach to osteoporosis and bone health, and this is so, so needed.
Kim, I'm so excited to have you here today. Thank you so much.
Dr Kim Millman (03:54)
I'm very pleased to be here. Thanks.
DrRitamarie (03:57)
Tell us a little bit more about what the heck's got your passion up about bone health and how you got into it.
Dr Kim Millman (04:04)
I would say that early on in my career, I was really struck by a couple of different things. One was that in the United States, osteoporosis and osteopenia affects 54 million people. In fact, this is more people than have diabetes, more people than have cancer, and more people with coronary artery disease. It is the number one metabolic disease in menopause among women.
This is what I saw in my practice. I would say that among the post-menopausal women in my practice, at least 30 to even 40% of them had osteoporosis and osteopenia. It was really incredibly common.
The other thing that really struck me was the absolute devastation that people had when they got diagnosed. This is something that I heard over and over again. The day I got my diagnosis, everything changed. I didn't know what I could do safely. I didn't know if I could pick my grandkids up off the ground. I didn't know if I could keep gardening and hiking and riding my bike, riding my horse, playing pickleball, or going swimming. I didn't even know if I could go grocery shopping or do laundry. I didn't know if I would end up like my aunt who was stooped over in pain. These are still my patients. “I really didn't find any satisfactory advice from my doctor. It was basically calcium, vitamin D, exercise, and medications for the rest of my life. Absolutely no one could tell me why, except for the fact that it was family history, and I was menopausal.”
These women were frustrated, and I was heartbroken by their story. What I knew was that I had to find real answers for them and so I started to dig in. I started using bone turnover markers early in my career. I researched mineral metabolism and vitamin D metabolism.
I uncovered evidence behind protocols that were truly effective and would move the needle like vitamin K and genistein. I started to put together a framework for how these root cause factors actually influenced bone health. Like for example, was estradiol mainly anti-resorptive? Did it help to reduce bone breakdown or did it build? In the beginning, I didn't know this.
I developed this kind of framework, and it took me about five years, I would say, before I felt like I had any kind of expertise in this area. It's now been 18 years since I've been specializing in bone health. About five years ago, I had this huge waiting list for my practice. I still do. It's about six months out, and I can only see people in California, but there were so many ladies that desperately needed this information.
I developed a virtual online program called Restore and Rebuild Healthy Bones. We're now in our seventh cohort, and I've had 650 ladies and men. We've had about five men in the program, and we're ready to start our seventh one. There's another 125 that are in that cohort. What I was seeing was some of them were left behind, because they needed more than the program. They needed somebody to guide them. It wasn't enough.
I joined forces with Margie Bissinger, who had many online summits, and we then co-founded the Bone Health Academy. We're now in our second cohort, and we are helping them to be able to look through this bone specific lens, have nuance, in the way that they look at testing markers, protocols, and then it's our mission to redefine bone health care.
DrRitamarie (08:35)
Wow, and it's needed. It's so needed. I hope that you're not just getting alternative practitioners to take your course, because so many conventional endocrinologists, general practice doctors, all need this information, and they're just not getting it in their training.
Dr Kim Millman (08:55)
In fact, we had a woman contact us from Anchorage, Alaska and said, we have this bone health clinic, and they have really just very rudimentary care. I would love for the PA who's working in this bone health clinic to come and take your course from the Bone Health Academy so that we can bring it to Alaska, really evidence-based root-cause care, bone health care, to Alaska.
That was pretty exciting. We are seeing regular medical doctors, PAs, MDs, DOs, and we've got a lot of functional nutritionists and functional medicine doctors as well. So it's pretty exciting.
DrRitamarie (09:41)
Well, that's very exciting, because I see it as such an overlooked area. We look at the outcome of bone loss, which is bone loss like fractures, thinning bones tested on a DEXA, but we're not really looking at the underlying physiology and metabolic processes underneath it. That's where the beauty lies, and that's where the real
solution lies, not just, “Okay, you've got this bone. Let's just take a medication and prevent it from getting weaker.”
Dr Kim Millman (10:12)
There are really a few things that really move the needle when it comes to building bone. The big needle movers are strength training and hormones and medication and a couple of other things like dealing with hyperparathyroidism, and that's breaking the bones down really fast or other pathologies.
The root cause factors are what stabilizes the whole microenvironment, and so if you don't have that, and I don't know that really, because I do things all at the same time, I don't really know that gut work doesn't really move the needle and build bone, but I don't really think that it does all that much that stabilizes. You can't ignore the root cause factors, because if you don't have stable bones, you will be in this situation that whatever you do has to be for a lifetime of work.
If you do medications, it has to be for a lifetime, because the bones aren't stable, but when you have this in play, if there is medication that's needed, it's only a short-term bridge.
DrRitamarie (11:26)
I love that. I love the fact that yes, we need medications lots of times, because people come back with their T scores of minus three. Address what the T score actually is, just so we're all on the same playing field, then let's talk about the testing and the process for helping people to really get to the root cause.
Dr Kim Millman (11:44)
Of course. Okay, the t-score is a number that is the standard deviations away from the mean. You have a Gaussian curve, and you have the mean, and that's the bone mineral density at the mean. Then statistically you have a standard deviation loss, another standard deviation loss, another standard deviation loss. Now you're at negative three standard deviations.
This is compared to a 35 year old woman, and it doesn't depend on their frame size. It could be a thin woman compared to someone like me with a thicker frame.
The negative that the scores are from zero to negative one is normal.
From negative one to negative 2.5 is osteopenia, and then from negative 2.5 on beyond is osteoporosis. I have women who are four feet, nine inches, and they're a hundred pounds, and they're being compared to me. They are artifactually going to actually look worse than they really are, so there are some statistical issues with bone density scans that actually have to be looked at.
One of the things that we're seeing now is that obviously bone strength is not just bone density, but it's also quality. We have the TBS score now, which is the trabecular bone score, and it is an adjunct statistical program that's run on the DEXA, only at the spine level, and it gives you quality.
There was a study, the Alvarado study, that showed that for 33% of the women that were shorter than five foot tall and were also lightweight, that 33% of those women were osteoporosis in the T score with normal TBS scores, normal microarchitecture.
We do know that there are definitely these statistical differences, and that has to be kept in mind.
DrRitamarie (14:09)
Absolutely. Why is that? I don't hear people talking about that. They just say, I have my negative three, negative two, negative five, whatever. Are most doctors aware of that? Is that something they have to request separately?
Dr Kim Millman (14:24)
I don't think they are really aware of it. There are other issues with the DEXA scans, too. I don't know if you want me to go into that, but I don't think that regular medical doctors are aware of that statistical problem, but it is a problem, and that's why we, as nuanced bone health experts, want to use as much quality information as we can get.
We want to use the TBS. There's something called a REMS scan, and that's an ultrasound based scan, and they have something called a fragility score. It’s the same kind of thing. It's a quality test. We want to take in as much of the big picture information as we can.
DrRitamarie (15:06)
I know about the REMS. It is a separate test. I have to go to certain centers to get it, but it sounded like with the TBS, they could calculate that from a typical DEXA.
Dr Kim Millman (15:19)
It's not available in very many places at all. In the Bay Area, you would think that Stanford and Kaiser have them. They don't. We have to go all the way to UCSF, and I'm in Las Gatos, which is part of the South Bay. It's a certain company, MediMaps, who developed the software, so the facility has to buy the software from MediMaps and then they use that to analyze the lumbar spine DEXA scores. If the company hasn't bought the software, they won't be able to offer it.
DrRitamarie (15:52)
They can't do it. It's only offered at certain places. Okay, got it, so now we've looked at the DEXA. We've looked at other things you can do with the imaging to determine bone strength, but what other tests are you doing? I know you're looking at bone turnover markers and all that. Let's talk about those.
Dr Kim Millman (16:09)
I think that the bone turnover markers are one of the most informative things that we can do. Early on in my career, I was using urine DPDs, I was using NTXs, I was using osteocalcin, and the two that I find that I've really settled on, which I find the best to do are the, C-telopeptide, CTX, and the propeptide of type 1 collagen, which is P1NP.
CTX is bone breakdown. How fast are they breaking down? Basically the higher the score, the more bone breakdown there is. P1NP is bone formation. The higher that score, then the more bone formation there is. There's a ratio of CTX to P1NP. The natural ratio is one to 10.
Let's say CTX is 350, P1NP should be 35 or more. Usually when the CTX goes up, the P1NP goes up with it. When it falls, P1NP comes down, then what you see is like with medications, the CTX will come up, but the P1NP will come way, way, way up. This is an anabolic medication or an anti-resorptive medication, CTX is here, and then the medication will bring down the CTX and the P1NP will come down with it.
That's that kind of natural ratio between CTX and P1NP.
What you can find out is that when you're looking at CTX, you really want to know what those optimal ranges look like, because the range that's given, and we see this all the time, and I know you talk about it all the time, is that this range is like this huge range, and in fact, with CTX, it goes all the way up to 1,000, and somebody could be in real trouble when their CTX is 1,000.
The CTX optimal value is 250 to 350.
DrRitamarie (18:22)
For age, is that age dependent? Just 250 to 350, regardless of whether you're pre or post menopausal. Okay.
Dr Kim Millman (18:30)
That's absolutely right. Then there's a little bit of a gray area between 350 and 400. 400 people are definitely losing bone.
Can you imagine somebody is at a thousand or 1100, and I'm like, this person is in imminent fracture risk right now. I've got to talk to them about maybe even doing some kind of bisphosphonate or some kind of anti-resorptive, for a short period of time where we can get a handle on this. We can find out why, we can figure out what else to do, but fractures are devastating.
I'll talk to my patients about doing something, but a medical doctor who doesn't have training in this thinks people are fine at a CTX of 1,000.
DrRitamarie (19:18)
There's CTX and NTX, and I used to do the NTX all the time. That's urine. How do they compare?
Dr Kim Millman (19:25)
You know, I don't even know anymore. I just haven't used it in such a long time. CTX is blood. The other thing people have to be really aware of in these bone turnover markers is they’re collagen breakdown products, because of that, you can't take collagen, you can't take bone broth, because you'll basically be measuring the collagen and the bone broth instead of measuring your own collagen breakdown products.
DrRitamarie (19:55)
You have to avoid that for a few days, before you get tested. 48 hours.
Dr Kim Millman (19:58)
48 hours. There's a huge diurnal variation, their CTX is highest in the morning, than in the afternoon, if you compare seven in the morning to two to three o'clock in the afternoon, the CTX can fall by more than 200 to 250 points. That's a huge difference.
If somebody is coming and doing their first CTX in the morning at seven o'clock and their second CTX at three o'clock in the afternoon, they're going to go, “Wow, look at what improvement I've had.” It's completely because of the diurnal variation. It always has to be done fasting, as early in the morning as possible, and done at the same point in time as possible, and then also, you don't want to do exercise, really heavy exercise, the day before, that affects the P1NP.
DrRitamarie (21:02)
When you say heavy exercise, you mean walking, running, lifting weights?
Dr Kim Millman (21:07)
Running, getting your heart rate high, lifting weights, doing some walking would be okay, but that's going to affect the P1NP and have the P1NP artificially elevated. I really honestly think that this is the biggest reason why medical doctors don't trust them.
DrRitamarie (21:26)
Because they're not getting consistent results is what you mean.
Dr Kim Millman (21:30)
They're not getting consistent results. They don't understand that they are so variable and that these are the things that affect their results. They're not informing their patients to go and do this, and then, they're like, wow, okay, well, yesterday it was 250 points different than today. How can I trust that data?
DrRitamarie (21:54)
Exactly, that makes sense. We have the P1NP, which is bone building. The CTX is the bone breakdown. What else? You mentioned osteocalcin earlier, and there's another bunch of things that I've looked at. Tell me, those are your top two, but what else do we test?
Dr Kim Millman (22:12)
I just don't even use the others, and I'm not really even well versed in them anymore at all. What I would like to talk about is how you can use the CTX and the P1NP. You can track them for any kind of intervention progress.
Let's say, one of the biggest things that I use it for, and I think this is a very nuanced way to do it, is that when I'm looking at a bioidentical hormone replacement therapy, and I'm looking at the target levels of estradiol, and I have a certain way to do this where I have targets that are bone specific, they're age specific, that's just based on the risk coming from the studies.
You can, in fact, see when a person starts hormones, their CTX might be 700. After they hit their targets, go all the way down to 350. If you see a CTX that's as high as 700, and you've worked on diet and inflammation and toxicity and all these things that you do naturally in your practice, and they're still around 700, and they're not on BHRT, it could be estrogen by itself that's doing that.
I'm looking at CTXs to determine, okay, maybe in this particular person, I want to push the target a little bit higher to get them back in the CTX range that I like.
You can use it to monitor therapies, monitor medication, monitor transitions between medications and whether or not the medications are effective, or whether your natural approaches are effective.
DrRitamarie (23:57)
Okay, assuming that we're doing these at the right time of day, and it's a good monitoring tool, how often should we be recommending people get it done?
Dr Kim Millman (24:09)
Right, so that depends on your therapy. Let's say that you're working on blood sugar regulation, which you're working on with everyone. How long does it take for you to get your therapy where you feel like there's going to be a meaningful difference? It really is therapy dependent.
With medications, it could be three months. With blood sugar, in your hands is probably three months, in my hands, it might be a little bit longer. How long does it take for you to have people's food sensitivities and their gut and their cortisol and how long does that take? CTX really kind of depends on that. I would say that at least once a year.
DrRitamarie (24:57)
At least once a year. Okay. Assuming they are on medication though, how often should it be? If you want to see, this bisphosphonate, or is this Evenity, or one of the other meds, if those are actually doing what they should be doing. And a DEXA, that's a year between DEXAs makes sense, six months maybe, because you don't really see the changes as much. How can we test in between, and should we be testing in between DEXAs to see?
Dr Kim Millman (25:25)
If the person is on a medication, in order to evaluate whether it's effective, you test at three months. I only use anabolic and anti-resorptive only for certain reasons. Let's say that you're on an anabolic, somebody is on an anabolic, and they need to transition. They're right at the end of their therapy, and they need to transition onto an anti-resorptive so that that handles the rebound. It depends on what the medication is, at what point, how you handle that transition. If it is Evenity, the transition is actually quite easy. In fact, I look at Evenity for effectiveness. It has a very short range in the very beginning when it's most effective, and that's a month. You could miss it. It's so effective that I don't even check Evenity's effectiveness anymore. It's so effective.
DrRitamarie (26:32)
Effective meaning it raises the P1NP, and it lowers the CTX.
Dr Kim Millman (26:38)
The CTX will come up with a P1NP, but let's look at this.
Let's say CTX is 350 P1NP is 35. The Evenity might raise the CTX up to 500, but its natural counterpart will be 50. Evenity will push the P1NP to 150. It's outpacing the natural one to 10 ratio by three times. That's how you kind of have to look at it. Onero Strength Training Program does this, too, where you'll see the outpacing. You might see it twice outpace a one-tenth ratio.
DrRitamarie (27:21)
The strength training being heavy weights affecting the specific areas where the osteoporosis is found. Tell us a little bit more about that.
Dr Kim Millman (27:34)
Belinda Beck in Australia, she has the Onero program, and she has got some actual clinical data that was evaluated. She's got four exercises. There's a deadlift, a squat, a heel raise, and I forgot the other one, but there are four exercises. She trains physical therapists all over the US. These physical therapists that have training programs, they actually watch a person and watch their form. They do progressive increasing weights, and they do it twice a week.
She had a clinical program in Australia called the Liftmore trial. The BMD of the lumbar spine increased by 3%; whereas, in the control group, it decreased by 1.2%. In the femoral neck, it was 0.3% compared to a negative 1.9 in the control group. That was in eight months, and I see even better than this in my practice, but I'm doing multiple things.
DrRitamarie (28:44)
Okay, so they're doing that program, and you have people, are there therapists in California that can do this with people, or is this specific?
Dr Kim Millman (28:53)
I have three people in my area that I refer to on Onero programs, and they used to be very far and few between, but now more and more are available. That is one of the things that I recommend to my patients is to do that.
DrRitamarie (29:15)
Okay, so you're not testing, so we're going to get back to the testing. The CTX you're testing in the P1NP, but you're not testing things like PTH and osteocalcin.
Let me just summarize and make sure everybody gets that the CTX and the P1NP have a 10-fold variant, the P1NP is going to be a tenth of what the CTX is. All right, so we're looking at that. CTX is 250 to 350.
Dr Kim Millman (29:54)
The optimal range for CTX, remember the optimal range is very important, 250 to 350.
DrRitamarie (32:14.155)
If we have a 1,000 for the CTX, the P1NP is 100. No, we want the CTX in optimal range and then we want the P1NP to be 10% of that. Or better, right? Better is better. Better is better.
Dr Kim Millman (30:18)
Or better. Yes. I didn't explain that very well in my class, and I've had many people, I don't understand, but the P1NP is way higher, and I'm like, that's good. That's good.
DrRitamarie (30:26)
That's good. That's good. That's bone building. Okay, got it. Three months, if they're on medication, we should be testing it in three months to make sure that the medication is actually doing what it needs to, and the same thing with the strength training program, really.
Dr Kim Millman (30:42)
Strength training, sure, and then natural therapy is like maybe six months, maybe six months, maybe nine months. It depends on what you're doing and what your experience is for the change.
DrRitamarie (30:52)
Okay, great. We'll get into another session on the therapies that you find most effective, but tell us the other testing that we should also be monitoring rather than just send them off to their annual or every two years some people get DEXAs.
Dr Kim Millman (31:07)
We have tests that are all around calcium metabolism. Serum calcium, and I'll tell you some little nuggets about calcium, too. Serum calcium is pretty misunderstood, too. PTH, which is parathyroid hormone, 24 hour urine calcium, and vitamin D. They always should be done together in the beginning to look at, and the relationship between them is absolutely important.
Here's these little nuggets around calcium. The calcium range goes from 8.8 to, I believe, 10.4. Any serum calcium that's lower than 9.2 is really too low for the body, so what happens is that the parathyroid glands, they're these little rice size glands that sit on each lobe of your thyroid. There's four lobes, there's four wings. So one, two, three, four parathyroid glands, they're your calcium sensor. When there's not enough calcium in the blood, the parathyroid glands start to secrete parathyroid hormone and that then leaches calcium out of the bones to bring the calcium levels up in the blood. We need calcium in our blood.
That's our natural defense mechanism to keep calcium in homeostasis. When the calcium is too low, that's what naturally happens. Now a calcium that is lower than 9.2, from 8.8 to 9.2, is completely normal in that range. That can cause secondary hyperparathyroidism.
The body doesn't like calcium lower than 9.2. If the parathyroid hormone shoots up, then what that means, is that person doesn't like that serum calcium so low. That's kind of the area where I find that there can be a secondary hyperparathyroidism.
I'm always, if I see an 8.8, I'm like, I better get a PTH. The PTH is on the high normal end. Maybe it's not even abnormally high, but it's on the high normal end. I'm going to go, no, that person needs more calcium. Whether that person takes calcium supplements, or they get more from their diet, we always love food first, but sometimes they need to supplement and then I can watch how they're moving together, but I want to see them together.
Now on the other end of the spectrum is the high calcium.
With high calcium, I might be wrong about this, but I think that the upper end is 10.4. Really anything that's over 10 should be suspicious of either primary hyperparathyroidism. What this is, primarily means that the calcium is just fine in the blood, but the parathyroid glands have these little adenomas, these little tumors, and they're hyperfunctioning. They're usually benign, but they're making too much parathyroid hormone. Then all of a sudden, the body is just leaching calcium out of the bones. This is really a bad situation. If the parathyroid glands were not, let's say that there was just some reason where the calcium was at 10.0, it was just there for a day or whatever. The natural response of the parathyroids would be to suppress parathyroid hormone, because you don't want to leach more calcium out of the bones.
DrRitamarie (34:55)
If you see a high calcium, you should see a lower parathyroid. When you see a higher calcium and a higher parathyroid, then we're looking at a potential adenoma or some sort of tumor or malfunction.
Dr Kim Millman (35:15)
it would be just a pressed parathyroid hormone, and the parathyroid hormone doesn't necessarily need to be outside the range. If it's a high calcium, it needs to be in the bottom end of the range. If it's a primary hyperparathyroidism, it could be just in the higher part of the range. I've seen doctors watch and wait even when calcium's are 10.2, 10.3, they kind of watch and wait, and the parathyroid is all the way up to 56. I think the top end of the range is 65. It's already kind of not making sense. This is the kind of situation where there very well could be a hyper-functioning parathyroid just sitting there.
DrRitamarie (36:07)
Interestingly enough, I remember having a client a few years back, and she had, hopefully I'm wrong, but I don't think I'm wrong. She had a parathyroid in the eight hundreds, and she'd had it for a long time. When we said to her, you have to have this checked. my doctor said, don't worry about it, because it's normal for me.
Dr Kim Millman (38:31)
Well, I've never seen a parathyroid hormone at 800, but I mean, could it have been that it was 80, because 80 would be elevated.
DrRitamarie (36:43)
Maybe it was a decimal point on the thing, but either way, it was high. It was high.
Dr Kim Millman (36:45)
It could have been that. If you see this high-ish calcium with a high or high-ish parathyroid, parathyroid hormone, it is suspicious. That's not a watch and wait like situation.
The other thing is you need to look at low vitamin D levels and that can cause a high ish parathyroid hormone. Usually the low vitamin D is like 20. It's not 30 that usually, and certainly if somebody is in my optimal range for vitamin D, which is 50 to 80, I do not like 120 like some functional medicine doctors do, because I do believe that's going to start stealing calcium from the bones, but if you're in my optimal range, that is certainly not going to cause a high parathyroid number.
There's also the 24 hour urine calcium. What that is, is that the kidneys reabsorb most of the calcium that comes through the blood, and that's their job. Any extra calcium that goes into the urine means that the kidney is not reabsorbing that.
One of the reasons would be hyperparathyroidism. There's so much calcium in the blood. It's just there's so much to filter. You see a lot in the urine. That's one of the reasons, any kind of high CTX could cause it for any reason.
Metabolic acidosis. Metabolic acidosis is when, that's probably one of the most common things, is metabolic acidosis. This is when the whole body is acidic, like a high sugar diet.
There's dietary causes, sugar, too much protein, and too much protein has to be a lot of protein, too. Like 1.6, 1.8 grams per kilo kind of a thing.
DrRitamarie (38:41)
Okay, a lot of people are recommending that, though. A lot of people are recommending it.
Dr Kim Millman (38:44)
It will raise the 24 hour urine calcium a little bit. It really will. It depends on the activity level, too. I'm usually recommending 1.2 to 1.4 and staying in the lower part of the range, but at least getting that. High intensity training can do this with lactic acidosis.
Excess cortisol, absolutely, and toxicity, and anything that's metabolically going to produce an acidic environment could produce metabolic acidosis.
One of the ways to double check that is to be looking at the pH of the first morning pH of the urine and if that is acidic.
I like it to be 6.5 and above. 5 to 6.5, I'm a little worried. Maybe even 5 to 6, 6 to 6.5 is a little gray area for me. What I do for that is, because that's the most common reason besides CTX is being high, et cetera, I like to do moderate to high dose potassium, either citrate or bicarb.
I'll do an electrolyte. I don't know if we're supposed to mention any brands. I like Optimal Electrolyte by Seeking Health. It's got a reasonable amount of potassium, some magnesium. It's potassium and magnesium that really helps to buffer that metabolic. They can recheck their urine pH and see if it's moving. The other pathologic reason is that there's kidney concerns, a kidney issue. The kidney is actually not absorbing, reabsorbing the calcium. That would be one reason as well, but I hardly ever see that.
DrRitamarie (40:43)
When you look at the CO2 on the blood, does that have any merit to you as it starts to go, like I look at below 25, it's starting to head into acidic. Have you found correlation with that and testing first morning urine?
Dr Kim Millman (40:58)
I have to be honest. I don't look at CO2 all that much. Thank you for telling me that. I always learn things from you. I'm going to put that on my radar. I'm going to start looking.
DrRitamarie (41:10)
See if there's correlations. I always like to look for a correlation between that? Thank you for sharing about the potassium, because I was just talking to somebody today who's CO2 dropped below 25, where I like to see it, 25 to 30, and her potassium came back low. We talked about supplementing and adding high potassium foods. There's always little nuance things that can be super helpful.
Before we get off calcium, ionized calcium. Do you check ionized calcium? I was taught to, if the parathyroid hormone's high to check the calcium. If slightly high, check the ionized calcium. You don't see that as being useful.
Dr Kim Millman (41:58)
I don't, I probably should. You could teach me about that, too.
DrRitamarie (42:03)
I was going to learn from you more. I just know that that's something I don't remember where I learned it, but I've learned it a while back. And osteocalcin?
Dr Kim Millman (42:13)
Osteocalcin. Osteocalcin has a biphasic nature. At one point it represents too much turnover and another point it represents good formation. I don't think it's all that reliable to look at.
DrRitamarie (42:27)
Okay, so mainly we're looking at obviously the CTX, we'll just keep saying these over and over, so it's drilled into everybody's brain, CTX and P1NP, and then looking at serum calcium, which is on every metabolic panel. Then if that is high or low. If it's below 9.2 or above 10, 10 or above, then we want to look at parathyroid to see what's going on and see if they're tracking in the same way. If one's high, one's low versus tracking the same way which suggests a pathology. Did I get that right?
Dr Kim Millman (43:02)
Exactly. It's always that relationship when you're looking at calcium, and you know that there's also magnesium and vitamin K, and I mean really I just look at dietary intake and supplement intake making sure that magnesium is in there.
They're getting enough intake, and if they're taking calcium supplementation, they need to be getting at least a half of the amount of calcium and magnesium. I like it even more to be a one-on-one ratio. If they're taking 300 milligrams of calcium, they take 300 milligrams of magnesium. I just do it that way, and I want the magnesium to be on the upper end of the range, like 2.2 and above. I think the upper end of the range is 2.4.
DrRitamarie (43:48)
And serum? What about RBC magnesium? I've done a lot of that. I've seen a lot of people whose serum magnesium looks okay, but the RBC magnesium is not. I really try to get them to be up in the 6.0 type of range with that.
Dr Kim Millman (44:05)
I don't do RBCs. I'm going to re-listen to this podcast and get all these pearls from you. There's homocysteine. A homocysteine above 15 increases the risk of fracture by 1.7 times.
I am looking at MCVs. MCV is mean corpuscle volume, and that's the width of the red blood cell. When it's high, it's B12 and folate deficiency. When it's high, I'm looking at I think 9.6 and above, not just a hundred and above. When it's really low, it can be mixed, it's a little bit tricky, but less than 70 is iron deficiency.
I always look at ferritin for iron anyway. I'm looking at a high MCV. That's a tip that it could be B12 or folate. I'm looking at a serum B12 and folate level, and then I'm looking at homocysteine. Homocysteine needs to be 8 or under for me, 15 is not good. 10 is not good enough. Of course it's not good enough.
DrRitamarie (45:19)
No, no, no, and even with women, I like to see it seven or below, ideally. Men eight or below. There's too low a range, too. We don't get into that here, but it has to do with the methylation.
Dr Kim Millman (45:29)
Two thirds of the top end of the range of methylmalonic acid could be a problem, too. A lot of people will just look at the range that's listed, but it needs to be the lower part of two thirds of methylmalonic acid. That is the sensitive indicator of B12 deficiency. It also gives you an idea when MMA is high, and you probably know this, it's potentially the MUT gene. It is the conversion of B12 to adenosylcobalamin. You need adenosylcobalamin, then that's another thing. When you're looking at homocysteine, B12, and folate, you have to get the right forms.
DrRitamarie (46:18)
Too much of the methyl is, everybody jumps right into methyl, but too much of that when they have a COMT slow, it causes anxiety, because it's not properly eliminating neurotransmitters, like epinephrine and norepinephrine. Those are all things that need to be looked at.
There's no one size fits all. We're looking at customizing. No bone protocol. Kim's going to tell us the bone protocol. There is no bone protocol. There are pieces of that that apply to individual people. When you test things, you get to see what's really going on underneath the hood.
Dr Kim Millman (46:53)
It's a framework. It's a framework.
DrRitamarie (46:56)
It's a framework. That's the word I love to use. It's always a framework of, these are the things you have to look at, but they're not all going to be applying.
Dr Kim Millman (47:00)
Then there's inflammatory pathways. I look at HS-CRP and not much more than that. It's absolutely a rule in, it's not a rule out. It can be inflammation rampant in the body, and HS-CRP looks fine.
DrRitamarie (47:16)
I've seen that in raging autoimmune diseases. Most of the time when we see it high, we're looking, but if I see it at a 0.3 in somebody with an autoimmune condition, I scratch my head trying to figure that one out.
Dr Kim Millman (47:29)
Well, I think it's probably that transforming growth factor beta and IL-6, IL-10, IL-17, especially IL-17, they're elevated. We're not checking for them, and I'm not going to go on some big extensive hunt for cytokines that are high. Mainly what I'm going to do is kind of a full body assessment on symptoms and try to pinpoint things that could be happening.
If I'm worried, then I'm going to do the same thing you're going to do. I'm going to look at the gut. I'm going to look at toxins. Knowing that somebody's inflammation is high. It's like, well, what are you going to do about it? You have to figure out why it's high to begin with anyway. You just still have to do it all, and then probably one of your favorite categories is blood sugar dysregulation.
Of course we're not just getting glucose and A1C, we're getting fasting insulin, so we can do a HOMA-IR. We're going to do a C-peptide. We're going to do a triglyceride to HDL ratio. We really know about insulin resistance, and then from a cardiovascular perspective, so there's two things that I do like right away.
There are two things that I really need to know about. I have a whole big lecture on how heart disease is related to osteoporosis and almost every cardiovascular factor is somehow related to osteoporosis. I think it's just the metabolic tie in.
DrRitamarie (49:02)
Well, nobody considers osteoporosis. We don't think about it in general medicine, as a metabolic disease. But it is. Big time.
Dr Kim Millman (49:14)
Absolutely it is. Absolutely. There are two big things that I think about that I've really got to, other than the fact that they're so related, hormones. I need to understand what a woman's cardiovascular history is, before I put her on hormones.
If somebody is getting evaluated for Evenity, I have to know what their cardiovascular risk is.
My two rule outs are LP little a, Lp(a) and CAC.
DrRitamarie (49:44
You're saying Lp(a) would be a contraindication for an Evenity.
Dr Kim Millman (49:48)
Well, I've looked at the whole picture. I'm going to get a Lp(a), and I'm going to get a CAC score, or a coronary artery calcium score. I'm going to kind of look at those two things. If Lp(a) is higher than 70, if a CAC score is higher than, I don't know, it's really hard to put a number on a CAC score.
I had a woman, and she had a CAC score of 850. We were evaluating her for Evenity. I said, you need to go and get an angiogram. She had a 90% blockage in the LAD. I was like, this would not have been a good situation. Nobody thought, nobody thought that.
DrRitamarie (50:38)
Just talk a little bit about Evenity. This is the first time I’m hearing this. A lot of these doctors who are putting people on Evenity, they don't believe in CAC scores. They don't check that. They don't check any of the cardio markers. This is a really important thing for us to be looking at before somebody jumps in and goes in. What is the issue with Evenity and cardiovascular? Tell us a little bit about that.
Dr Kim Millman (51:00)
There's a black box warning that there's an increase in heart attack and stroke. Evenity is a sclerostin inhibitor. Sclerostin is a break on bone building, because obviously, we can't have huge skulls. We have to have a break on bone building and also calcification of the soft tissues.
Within the cartilage, within the chondrocytes, when there's too much sclerostin. When there's injury to cartilage, they need sclerostin to repair, when sclerostin is inhibited, so bone building can increase.
If you've got an injury to an ACL, it's hindered by a sclerostin inhibitor. The cartilage can't heal. There's cartilage. There are chondrocytes in the heart valves so that the heart valves don't get calcified. That's what its purpose is there for. It's a sclerostin inhibitor.
If there's a heart valve repair that needs to happen, it might not repair on Evenity. If there is cartilage, or an injury, it might not repair on Evenity. There's something about the blood vessel walls. There's something about the blood vessel walls also that they might not be able to repair.
That's the whole tie in between the cardiovascular issue and Evenity.
DrRitamarie (52:40)
There's so much more I want to ask you about, and there's so much more I want you to share with everybody.
What I'd love to do is just wrap up and summarize the testing that everybody should be getting in addition to or instead of, and then let's have you back. I want to talk about your whole calcium paradox thing, which we might've talked partially about, but also about medications and when they're indicated, when they're not, and how to look at all the possible side effects that may not be well established or explained to people.
Let's just wrap this up and then we'll have you back.
Dr Kim Millman (53:22)
Let's say that somebody has an Lp(a) or a CAC score. I'm going to look at some of the Cleveland heart labs, like the lipid fractionization, F2 isoprostanes, oxidized LDL, LP-PLA2, myeloperoxidase. I'm going to dig in further, and then there's all the functional heart, all the functional labs. I use GI-MAP to look at dysbiosis and intestinal health markers, look at a DUTCH test to look at estrogen metabolism and salivary cortisol. I do food sensitivity tests, and I do a total tox test.
Basically that's just digging into all these functional markers that we do for root cause testing. I don't know that I really look at them any differently than a functional medicine doctor does, but I'm always tying them back to turnover markers.
Did my intervention help? And in what timeframe? I'm just like a regular functional medicine doctor, and what timeframe would I normally see adrenals reserves starting to improve, cortisol starting to normalize? Then I'm going to kind of look at CTXs, but I'll tell you, I shotgun everything.
It's hard to pick everything apart and really know what's working, which one decreases CTX and which doesn't.
DrRitamarie (54:45)
I think that that's a reductionistic approach if we're trying to do that. As functional practitioners, we're looking at, where is the function breaking down? I don't need to have it, well, let's do this one first and then we'll do this.
My goal is to help this person get well and feel better and avoid increased fracture risk. We are going to do anything that we find that's out of balance. Yes, we'll stagger. Yes, we'll prioritize. We don't need to have that this-for-that correlation. It's looking at all the possible things that go together and cause this.
Well, this has been an amazing presentation, and I know you had a free gift for everybody. We're going to have it in the show notes, but tell them a little bit about that.
Dr Kim Millman (55:31)
I have a deep dive in a webinar masterclass that goes through all of what we've gone through there. I'm going to have that in the show notes, and you'll be able to come over and actually watch. It's about an hour and 15 minute webinar that I think you're going to love.
DrRitamarie (55:53)
Great. Thank you, thank you, thank you. What's the best place for people to look you up?
Dr Kim Millman (55:58)
I'm at themillmanclinic.com
DrRitamarie (56:01)
Well, thank you, thank you so much for being here today. This has been an amazing deep dive into some of the bone indicators and how it connects to the cardiovascular markers and why we also need to be comprehensively looking at that.
I so appreciate you being here, and I appreciate all the rest of you guys who are listening and watching, because you're dedicated to helping people truly get to the root causes, not just continue to do DEXAs and throw medication and what's the next medication.
Our next conversation, which we will schedule, will be about the meds. How do we know when somebody comes in, and they're on a bunch of different meds, or they have been on a series of meds, which is more likely what we see, how do we know when they actually need them? And in conjunction with the natural approaches, not instead of the natural approaches.
So thank you again for being here. Thank you all for listening in and until next time, shine on..
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