Dear Mark: Osteoporosis, Body Fat Gain on Caloric Deficit, and Stalling on Primal

X-ray image of legsFor today’s edition of Dear Mark, we’ve got a three-parter. First, I try to help out Karson, a guy who’s trying to convince his osteoporotic, sun-starved mother to try a few lifestyle interventions that may improve her condition without coming off as smug. Hopefully I’m persuasive enough. Next, is it really possible to gain body fat on a caloric deficit, or is something else going on? And finally, Dawn seems to be doing everything right, but she’s not losing any more weight — weight that she feels should be coming off. What can she try next?

Let’s go:

Dear Mark,

Since you have a persuasive way with words, I was wondering if you have any suggestions for my mother. My tone sometimes comes off as smug and preach-y. She recently turned 60 and her osteoporosis is progressing. Her job requires her to be at the office from 9am to 5pm and she is not able to get outside during the week to soak in the sweet sweet vitamin D. Whether it is diet recommendations or any key habits she can engage in, any help would be more than appreciated.

Thanks for all you do!


Mom, your bones are not inert slabs of calcium helpless against the ravages of time. Bone is metabolically active tissue. It responds to movement, to nutrition, to loading. They don’t wear down and lose strength due to tick of the clock, but because we stop using them.

By loading, I mean resistance training. It’s really quite effective for strengthening bones, even osteoporotic bones, especially when paired with the drugs she’s likely been placed on. And I’m not just talking about isolated machine exercises. Heavy squats, for example, have been shown to improve bone mass, bone metabolism, and other skeletal properties in women with osteoporosis. I’m assuming she doesn’t know her way around a barbell or weight room. That should change. Hop on Yelp and look for personal training gyms with the best reviews. Schedule a visit and book a few sessions with a trainer to learn the ropes. Make sure he or she has experience training older adults, particularly those with osteoporosis. It’s a common condition and many personal trainers have dealt with it. If she really likes the trainer, she should consider sticking with them. If not, get comfortable with the movements and do them on her own time at a gym or at home.

If you live nearby, meet up on the weekends for hikes. Get her moving. Start small, with gentler, flatter hikes, eventually progressing to longer ones with more elevation. No mom I know will turn down a visit from her son, even if it involves extracurricular movement. Plus, being out in nature can only help.

She’ll have to supplement with vitamin D. Sunlight is ideal, yes, and not just for vitamin D, but what can you do? Without adequate vitamin D, your bone health will suffer. Vitamin D also improves neuromuscular functionality and muscle strength, which in turn reduces the risk of falls and fractures. Aim for 2000-4000 per day and get sunlight on her days off.

Unless she’s eating lots of gouda cheese, natto, and goose liver paté, get her on vitamin K2 supplementation, stat. Vitamin D doesn’t really work optimally without adequate vitamin K2. It’s particularly effective against postmenopausal osteoporosis. Make sure her doctor knows and has ruled out any untoward interactions with medications, just to be safe. If either she or her doctor are ambivalent or skeptical, send links to the following research:

A good low-dose vitamin K2 supplement is this one.

For higher doses, try this or this.

By the way, she’d probably benefit from gouda, natto, and goose liver paté just the same. And those foods are delicious (well, natto takes some getting used to).

How’s her gut health? Is she eating much prebiotic fermentable fiber? Resistant starch? If not, there’s a chance she’s not actually absorbing all the calcium and other bone-relevant nutrients from her food. Many studies have confirmed the beneficial effects of prebiotics on mineral absorption in humans and animals and bone health in animal models. Galactooligosaccharides (a class of prebiotic fiber) increase calcium and magnesium absorption and improve bone mineral density. Both inulin and resistant starch also promote better mineral absorption.

Make sure she’s eating adequate protein. All else being equal, older adults need more protein than younger folks because they’re less efficient at metabolizing it — and not just to maintain muscle mass. Protein plays a huge role in bone mineral density, so she should eat at least 0.6 grams of protein per pound of bodyweight, mostly from animal sources (whey protein, meat, yogurt, cheese). More could help, too.

It’s never too late, and you’re never too old.

Hi Mark,

I’ve talking to some people that are claiming it is impossible to gain body fat while in a caloric deficit. Is this true? I’ve never seen any studies done and would like to know your thoughts.



Well, maybe, but you’d have to be losing a lot of lean mass at the same time. Theoretically, I suppose you could be losing enough muscle to explain the caloric deficit while still gaining body fat. In reality, people conflate caloric deficit with calorie reduction. If you reduce calories so much that your metabolism tanks, you may actually go into caloric excess.

Remember that calories in affects calories out. Too few calories and your metabolic rate drops to account for the lost calories. So even though you should be in a caloric deficit, your metabolic rate has plummeted far enough to prevent it.

Hi Mark,

First, thanks for all the wonderful info you provide — I’m reading your book now and just bought the 21 day plan book for my daughter. I’ve always been relatively fit and stable weight (<20 pound variance, other than being pregnant).  I’ve been eating Paleo for ~6 months with very few indulgences (not kidding) and can’t lose any more weight (I’ve lost 4 lbs total).  I’m 50, 5’5 1/2″, 138 lbs; need to be ~125.

Typical day for me is 3/8 cup organic heavy cream (total) divided over my 3 cups of coffee (0 carbs), 2 organic eggs, 1 piece bacon, pile of fresh spinach, 25 raw almonds, ~5 oz piece of baked fish and chicken (skin on), 2 tblsp organic coconut oil, 3-4 cups of green/red veggies and some ghee/butter (1-2 tbsp) or olive oil. That’s it. ~4-6 Corona Light beers over the weekend has been my indulgence. No sugar, no fake food, no grains.

I get at least 10,000 steps in per day, do bursts of heavy lifting, and sprints maybe twice a week. I should be making better progress; I’m super frustrated.

My next step is cut out beer and heavy cream entirely… but it doesn’t seem like I should have to?

Thanks for your time,


Your diet looks a little light in calories, protein, and (possibly) carbs.

You’re pretty active, and consistently so (lifting, sprints, 10k steps). You’re most likely deeply ketogenic, though that’d have to be confirmed with some urine or blood tests. You’re sitting at about 1300-1400 calories, which, given your activity levels, should be very hypocaloric. By most accounts, you should be losing weight, but you’re not. So: just do what you’re doing even harder and more strictly?

I don’t think so. I think you should consider switching up your program.

You’re dealing with a lot of stressors with very little relief, and those stressors increase cortisol.

Acute spikes in cortisol are adaptive, and “good,” and generally beneficial for body composition. When we exercise hard, cortisol spikes. When we rest, cortisol returns to normal and we recover from the training and come back stronger/fitter/faster.

Chronic elevations of cortisol are maladaptive and “bad” and promote weight retention and fat gain. Any stressor spikes cortisol. Exercise is a stressor. Eating 1200 calories is a stressor. Eating very little protein is a stressor, particularly if you’re sprinting and strength training and running a calorie deficit. Training hard without adequate calories is a stressor. Being really frustrated all the time about your weight and obsessing over the scale is a major chronic stressor. You add all those things up and it’s no surprise that you’re stuck.

Bottom line: your cortisol is probably chronically elevated and women in particular seem more sensitive to the effect chronic cortisol has on body composition.

From your email, I see a lot of myself in you. I was a pretty tightly-wound guy for many years, and it’s what drove me to be so competitive in my endurance pursuits, but it’s also what made me drag my feet when I knew I should call it quits. I’ve never dealt with stress as well as I’d like. My stress levels didn’t manifest as weight gain or stalls. They manifested as muscle pulls and upper respiratory tract infections and gut issues and arthritis. But I had to heavily modify the lifestyle that was destroying me. The product of that was the Primal Blueprint.

Here’s what I do if I were you:

  • Eat about 500 more calories per day. Just get more food in general.
  • Eat more protein. 2 eggs, a piece of bacon, and a 5 ounces of chicken or fish simply isn’t enough. Add another 5 or 6 ounces of chicken or fish and maybe some whey. Get your protein up to a gram per pound of lean mass, preferably. You’re training a lot and the less food you eat, the more protein you need.
  • Drop some of that cream. I like cream, but that’s nearly a half cup each day, which is too much (especially if you’re stalling). Substitute more protein, leafy greens, and (see below) small amounts of carbs.
  • Consider post-workout carbs. You don’t need a lot. You don’t need to carb load or anything. But a few potatoes, sweet potatoes, or a bowl of fruit around your workouts will only help you recover and, most likely, lose a little more fat by reducing cortisol. Increase carbs by 20-30 g until you notice renewed progress. You may find that 150 grams a day is your sweet spot on the carb curve.
  • Take a week off from all activity except for walking. Don’t lift weights, don’t sprint, just walk. Consider it a deload week.
  • Relax. Take a short vacation. Go for hikes in beautiful natural settings. Camp out, even if it’s just in the backyard. Meditate.

Another thing to consider: your body may have reached its happy place. You may simply be in homeostasis. That’s okay, and oftentimes what “we” want is different from what our body wants.

Thanks for reading, everyone! If you’ve got any input for today’s reader questions, throw it down in the comment section!

About the Author

Mark Sisson is the founder of Mark’s Daily Apple, godfather to the Primal food and lifestyle movement, and the New York Times bestselling author of The Keto Reset Diet. His latest book is Keto for Life, where he discusses how he combines the keto diet with a Primal lifestyle for optimal health and longevity. Mark is the author of numerous other books as well, including The Primal Blueprint, which was credited with turbocharging the growth of the primal/paleo movement back in 2009. After spending three decades researching and educating folks on why food is the key component to achieving and maintaining optimal wellness, Mark launched Primal Kitchen, a real-food company that creates Primal/paleo, keto, and Whole30-friendly kitchen staples.

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