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How to Assess Bone Health


  • There are many ways to assess bone health and strength.
  • While none of them are fantastic, combining tests creates a better idea of your overall bone health and what changes you can make to improve it. 
  • This article discusses different options and when you should talk to your doctor about getting tested.
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By Dr. John Neustadt

There are many ways to assess bone health and strength. While none of them are fantastic, combining tests creates a better idea of your overall bone health and what changes you can make to improve it. This article discusses different options and when you should talk to your doctor about getting tested. 

Physical Changes

While people don’t typically experience symptoms as their bones deteriorate, there are physical signs that can clue you into a problem. If any of the following are happening to you, it could indicate that you’re losing bone and should talk to your doctor about running some tests:1-4 

Thinning Skin: While many hormones affect bone health, estrogen, in particular, helps maintain healthy bones and skin by promoting healthy collagen. As estrogen decreases with menopause, women lose skin collagen and bone mineral density. Women with thin skin have a higher incidence of bone loss.

Wall-Occiput Distance: The occiput is the back of your head. If you’re standing with your back and feet against the wall and your head doesn’t touch the wall, it could mean that you’ve developed a dowager’s hump. A dowager’s hump is when your upper back rounds forward and can indicate bone loss. 

Weight: Low weight is associated with bone loss. If you weigh less than 115 pounds (about 52 kg), you’re at an increased risk for poor bone health.  

Height: If you’re shrinking, it could mean that you’re losing bone in your vertebrae. A loss of about three-quarters of an inch or more over 1-3 years is a cause for concern.  

Rib-Pelvis Distance: If the space between your lower ribs and the top of your pelvis is less than two fingerbreadths apart, it could indicate bone loss.  

Tooth Count: If you’re losing teeth and have less than 20 teeth.  

Self-reported Humped Back: If you notice your back has become humped.

Testing Technologies

Many testing technologies exist. The gold standard is the dual x-ray absorptiometry (DEXA) test. Others include quantitative ultrasound (QUS), computed tomography (CT) scans, magnetic resonance imaging (MRI), and, most recently, radiofrequency echographic multi-spectrometry (REMS).


A DEXA test measures the amount of minerals in bone and reports your bone mineral density (BMD). When you get one of these tests, you’ll see your T- and Z-scores. A T-score compares your bone density to a healthy 20–29-year-old (when bone mass is at its peak) of the same gender and race.  

So, if you’re a 62-year-old woman, your T-score is how your bone density compares to a 20-something woman of the same race. In contrast, a Z-score compares your BMD to the average bone density of someone of your same age bracket and sex.  

If your DEXA test results show that you’re losing bone, talk to your doctor about why. While the drop in estrogen after menopause is the most common cause for most women, up to 30% of the time when postmenopausal women lose bone, it’s not due to the lack of estrogen. It’s from external causes, such as medications that damage bone. And in premenopausal women and men, it’s up to a staggering 50%.5-8

Fortunately, there are many things you can do to support your bones and promote healthy bone density. This includes exercise, diet, getting enough sleep, and taking Osteo-K or Osteo-K Minis. 


Quantitative ultrasound (QUS) is a portable device that people might see in medical clinics, pharmacies, or health fairs. It uses radio waves to evaluate bone health. It does this by calculating three variables: bone stiffness (stiffness index, SI), how fast the sound waves travel through the bone, called speed of sound (SOS), and how much the sound waves decrease as they travel through the bone, called broadband ultrasound attenuation (BUA). The heel (calcaneus) is the only validated site for a QUS test.9-11 

Validation studies of QUS devices compared to DEXA scans have been conducted, but there is no consensus as to which device, measured variable, and cutoffs are best.12 Therefore, if you get a QUS, make sure to mention this and ask if the technician understands the manufacturer-recommended cutoffs associated with osteoporosis and also verify that the device has been validated against the DEXA scan.13 

In addition to being a useful tool for bone health screening, studies show that QUS results are associated with predicting fracture risk,14, 15 including fractures of the proximal femur (upper thigh),15-18 the vertebrae,13, 19, 20 and other sites.20-24 These studies demonstrated that the fracture risk associated with QUS results was at least comparable with other measurement approaches and, in some studies, even similar to DEXA scans. 


Radiofrequency Echographic Multi Spectrometry (REMS) is similar to QUS in that it uses sound waves. Unlike the QUS that is done on the foot, however, a REMS test is conducted on your lumbar vertebrae (lower back) and upper thigh. This is a relatively new test, which became available around 2019. Multiple studies have validated this test against a BMD test and found it to be similar for evaluating osteoporosis risk.25-27 

More importantly, studies compared the ability of REMS to predict fractures. In one observational study of 1370 women ages 30-70 years old, researchers followed them for five years and concluded that REMS was just as effective as a DEXA scan for predicting fractures.28 Other researchers improved upon its ability to predict fractures by creating a Fragility Score (FS). When patients’ bones were assessed, the REMS-based FS was better at predicting fractures than a DEXA test in both women and men.29 

The main hypothesis of the FS calculation is that fragile bones have structural characteristics that ultrasound radio waves can detect. The machine detects the radio wave patterns and compares them to a database of healthy bones in the same age range as the patient. The technology has been validated up to 90 years old. The FS value is the percentage of a patient’s radio waves that look more like a “frail” bone model than a “non-frail” bone.

REMS is a wonderful new development for a few reasons. Patients are not exposed to ionizing radiation. There are lots of patients for whom a DEXA T-score is not valid (eg, premenopausal women and men younger than 50). A FRAX is not valid for patients younger than 40, while REMS can be used for those patients. REMS is less expensive than a DEXA. It’s also portable, providing greater access to screening in doctor’s offices and health fairs.

Lab Testing

Laboratory tests provide clues about overall bone health. They can be run more frequently than bone density tests and are relatively inexpensive. These tests provide information about bone health and whether your body’s internal environment is healthy for bones or might be contributing to bone loss. Below are a few helpful ones.  

C-telopeptide (CTX)

When collagen degrades, bone breaks down, and collagen fragments are released. One of these is C-terminal telopeptide (CTX). It can be measured in the urine and serum (the liquid part of the blood). One benefit of measuring CTX is that it shows changes much faster than what can be detected on a bone density test.

The International Federation of Clinical Chemistry (IFCC) recommends the CTX blood test as a bone health marker.30 High levels of CTX indicate that bone collagen is being lost and bones are getting weaker.30, 31 A 2000 study followed 435 women ages 31-89 years old for an average of five years. The highest CTX results were associated with weaker, frailer bones. If someone also had low bone mineral density and low levels of estrogen, their bone health was even worse.32  

If your CTX is high, there are natural ways to decrease it. Both Collagen peptides and the nutrients in Osteo-K and Osteo-K Minis (MK4, Vitamin D, and calcium) have been shown to reduce CTX. In a study of 51 postmenopausal women, CTX was decreased by taking five grams of collagen peptides daily, plus calcium and vitamin D3, for three months. CTX decreased almost four times more in people taking collagen, plus calcium and vitamin D3, compared to people only taking calcium and vitamin D3. In those women taking collagen, CTX decreased 11.4% compared to 3.5% in the control group. This implies that significantly less bone was breaking down when taking collagen.33  

In another study, women took 45 mg of MK4, plus vitamin D3 and calcium daily for three months. Their CTX was tested before they started the nutrients and at the end of the study. The researchers found that taking the supplements significantly decreased their CTX.34 These studies show that Collagen, MK4, Vitamin D, and calcium support bone health. 

Neutrophil-to-Lymphocyte Ratio (NLR)

Neutrophils and lymphocytes are reported on a white blood cell (WBC) count. This is a routine and inexpensive test. Neutrophils are the most common type of WBC. Infections, inflammation, and some cancers and medications can increase neutrophils. Lymphocyte is a general term for white blood cells. It’s the total amount of white blood cells, regardless of the type.  

An increase in the neutrophil-to-lymphocyte ratio (NLR) means the neutrophils have increased, and there is immune activation and inflammation.  Pro-inflammatory signaling molecules like interleukin-1 (IL1), IL-6, IL-11, and tumor necrosis factor-alpha (TNF-alpha) are associated with increased hip fracture risk in older women.  

To calculate your NLR, take the number of neutrophils on a WBC test and divide it by the number of lymphocytes. An NLR of 3.17 or higher is associated with bone loss.35 

Vitamin D

Vitamin D should be on everyone’s radar and regularly tested. For bone health, making sure you have enough vitamin D is crucial. Higher vitamin D levels are associated with increased bone mineral density and maintain strong bones, especially as you get older.36 However, according to two studies that evaluated vitamin D levels in 11,000 people, about 40% of adults and 70% of children are deficient in this crucial nutrient.37, 38

Without vitamin D, only about 15% of dietary calcium and 60% of phosphorus are absorbed. On the other hand, with enough vitamin D, calcium absorption increases by up to 40%, and phosphorus absorption increases by 80%.39 

For optimal bone health, a person’s Vitamin D blood concentration should be 30-44 nanograms per milliliter (ng/mL). Above 30 ng/mL, nonvertebral fractures decrease by 20% and hip fractures by 18%.40 Similarly, the greatest decrease in the risk of falling is seen when someone’s vitamin D level is about 30 ng/mL, and dying from any cause was reduced when the blood level was 40-48 ng/mL.40 

But higher levels might be even better. For additional health benefits such as immune support, clinical trials, and meta-analyses concluded that an optimal range appears to be about 50-60 ng/mL.40, 41

Most healthy adults can increase their vitamin D blood level to 30-44 ng/mL when taking a daily supplement containing 1,800 to 4,000 IU (45-100 mcg) of vitamin D3.40 But to get your levels higher, you’ll likely need to take more. Multiple studies concluded that vitamin D levels increase by about one ng/mL for every 100 IU (2.5 mcg) of vitamin D3.42,43 Therefore, to get vitamin D into the optimal range of 50-60 ng/mL, you may need to take at least 5,000 IU of Vitamin D3 per day.  

It takes about five to six months to reach a steady state, at which point your vitamin D level remains fairly constant.43 Many clinicians recommend testing your vitamin D every few months to make sure it’s approaching an optimal level and whether you need to adjust the dose. 

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