A (5:37)

Thank you so much for having me.

B (5:39)

We are gonna be talking all about bone health. What are some of the pillars for great bone health? I know that there is a lot of talk, I will call it not noise, but yeah, noise, around the importance of muscle, which, of course, I'm a huge fan of. But there are other tissues that go to the gym and train with you every single time. It's not just your muscles that are lifting. Bones are lifting. You got ligaments, you got tendons, you got articular cartilage. There's a lot of things that go to the gym with you every day or, you know, several times a week. And so I wanted to maybe frame our conversation by starting off with if you are a woman, let's say you're 35, 45, and you're listening to the show because you're concerned about maybe you're concerned about body composition, you're concerned about aging well, aging powerfully. What are some of the things that we want to be considering when it comes to stacking the deck in our favor for healthy bone metabolism, healthy bone density, and bone quality?

A (6:40)

Oh, yeah. Well, that's a great opener. I could actually just speak on that for the next hour, so I'll try to make this brief. I think the biggest thing for women, especially in that age group that you mentioned, and the women that are approaching going through perimenopause, there is often a conversation around, like you just said, body composition changes, hopefully thinking about aging gracefully with strength, however you want to say it. But what doesn't get talked about is what is happening with our musculoskeletal system, specifically the skeletal system. Right. Like what's happening with your bones. And what I'm seeing in our clinical practice, which is really exclusively focusing on osteoporosis at this point, what we see is that we see women even younger than that, honestly, in their 20s and 30s, but definitely as we get later in 30s and 40s with surprise diagnosis of osteoporosis because they got screened for some who knows what reason. And I think it's much more common than women know. So as they go through this timeframe in their life when their hormones start to fluctuate, they're trying harder in some ways to focus on body composition and maybe dieting harder, exercising harder, exercising in a different way. You really have to take into context what's happening with your bones, because there's a lot of those things that you could be doing that could be making bone loss significantly worse. And if you don't know what your starting point is, then you could be putting yourself or setting yourself up rather, for a really rude awakening, potentially with even an early fracture in your 40s or 50s.

B (8:01)

So let's maybe look into some of these silent. I love that you said dieting harder and exercising harder. I think for many women, we often frame health as being as thin as possible. Like, that's what health means for women. It's like, how skinny can you be? And I completely rally against that, certainly if you've listened to, like, more than 20 minutes of any podcast in the past five years. But if we talk about what are some of the culprits that can kind of lead to. So we can. We can expand into dieting and exercising harder. I'd also like to, you know, for the mothers that are listening, I think that pregnancy and postpartum, certainly, if you're someone who breastfed, I think that these are some things that we might not necessarily, you know, equate with calcium loss, mineral loss, you know, bone density loss. So maybe expand on some of these so we can talk about pregnancy and breastfeeding, talk about how that impacts bone health and quality. And then some of the other things that you just mentioned, the dieting and the exercising.

A (8:57)

Yeah. So, yeah, let's start with. I mean, pregnancy. Pregnancy and breastfeeding is a. Just a remarkable process in general. Right. Like this amazing thing that women can do to bring life into the world. It's phenomenal, but it is hard on your body in a lot of ways. Right. And your mind and every. Every part of you. I have three children, sat with my wife as she did many of these things, and watched her go through it and experience this, you know, as close to secondhand as I can. But I see it in my patients, too, and that is that, you know, that baby will take from you what it needs to survive, and that's what they do. Right. So while you're pregnant, it is very likely that you will lose bone density. We don't actually screen, you know, we're not screening women before they get pregnant. This isn't part of, you know, the process and the journey. And I don't think that it should be necessarily, because usually what happens is a woman will lose bone density as she's pregnant. She may continue to lose it actually as she's breastfeeding, because that's also a very metabolically challenging timeframe. But then on the other side of that, the body will typically rebound. I mean, the human body is amazing, and especially the female body has the capacity to do so many things, and it generally will rebound. That bone density will come back up. The fluctuations in hormones, all the things that happen postpartum will support that rebound. We can actually talk about how that actually plays out later in life. So I don't know that it's necessarily something to lose a lot of sleep over, losing bone during pregnancy. The area where I get concerned about is if you happen to have osteoporosis before, that is an area of concern. But the only thing you're going to do differently is just really focus on the diet side, really focus on the nutrients, staying as active as you can during that timeframe. But ultimately, this is a sacrifice for every woman as she goes through this, sacrificing parts of her body so that she can bring this child into the world.

B (10:43)

Yeah. And we're not saying don't get pregnant and don't breastfeed. Like, highly Recommend Both.

A (10:46)

Yeah, 10 out of 10 on both.

B (10:48)

10 out of 10 for. Yes. For having children and being able to breastfeed them, certainly. I mean, for me, it was one of the most rewarding to breastfeed, like, to see that my body could literally make food for my children. Yeah, highly recommend. 10 out of 10. And I love the reframe there around that. Your body has the capacity to rebound from that, just by way of definition. You mentioned osteoporosis. There is another term, osteopenia, that a lot of women hear. So just by way of definition, back of the envelope, what are the differences between the two? How do we know the difference? How do we know where we are on that spectrum?

A (11:23)

Yeah, there's a lot of things in the bone health space that have, like, really, like, weird and bad terminology. So when we talk about osteoporosis, osteopenia, we're literally just referring to the T score, which is a. It's a statistical metric on a DEXA scan and a couple other types of scans out there. But it's essentially just comparing you, especially if you're an older woman, but it's comparing you to the younger version of your, you know, sex and ethnicity based population. The T score, it goes by based essentially like zero to kind of negative five is sort of the bottom end of it. And those are standard deviations. So again, it's a statistical thing, but a T score of negative one is one standard deviation below the average. And if you talk about osteoporosis, it's below negative 2.5. So if you were to draw out like the statistical bell curve, we get really geeky about this. It shouldn't be much of the population, but it is, which is why the statistics here don't really make sense. But so osteoporosis, Osteoporosis is a very clear diagnosis. The World Health Organization came up with that back in 1994. Like, this has been around for a while. Osteopenia was actually never a diagnosis though. And this is something that a lot of people get wrong, even doctors get wrong. Osteopenia is not technically a diagnosis. It is simply the range between normal and osteoporosis with a cutoff of negative 1. So between negative 1 and negative 2.5 is technically osteopenia. But again, that's not actually a term. The term we're looking for is low bone density. This is actually what it's been termed as. So it's either low bone density, low bone mass.

B (12:52)

So this is on the way to osteoporosis. Not quite there yet, but you're somewhere between one standard deviation and two and a half before we sort of get that qualification.

A (13:01)

And something I hear a lot is, and this needs to be cleared up is people say, oh my gosh, I have osteopenia, I need to be really worried about my bones. And that might be true, except that what we're really more interested in is the trajectory. Meaning it's like, did you have normal bone two years ago and now you have osteopenia? Like, that is concerning. But if you had the same bone density 20 years ago as you do now and you happen to be in this range of, you know, whatever. Negative 1.6. Yeah, it's not necessarily, you know, red flag alarms because you actually haven't lost bone as you've aged, which is really good. So we really need to be more interested in the trend of bone density rather than just a single point in time.

B (13:38)

Yeah, that's well said. And I think it's really what you're talking about is like the rate of change. Right. So what is the rate of change that we're looking at? If you've sort of been just under the normal, but you've been fine. There's no. You're less concerned about someone who has maintained the same level of bone density, let's say, over the course of her life, which is including puberty and pregnancy and perimenopause and menopause, versus, as you said, someone who has had regular to healthy, you know, nice thick cortices, like, you know, nice bone. And then all of a sudden we see a huge change in a year to five year period, let's say. So it's really the rate of change that we're looking at. Okay, so let's talk about excess dieting. This is something that honestly, every woman, every woman on the planet, myself included, I think have been subject to looking. You need to look a certain way. As a woman. Where I am most concerned certainly is with beautiful teenage girls. Right. Because we reach our peak bone density early in life and there's really not much you can do once, you know, it's like when the skeleton matures somewhere around 25, it's like, that's your height. It's like that's sort of like you can't really change it. And the same is true. And maybe I'll have you expand on this in terms of our teenage girls, once you've. And boys, once you've sort of reached that peak bone density, it's like you've put in the maximum savings into the savings account. Right. You can't really put. Put that much more in. And so, you know, we've had guests on the show talking. I've had. The one who's coming to mind is Lisa Moscone, who talks about the three Ps. It's like puberty, pregnancy and perimenopause. And she's talking about it with the filter of brain changes. Right. So the neuromusculoskeletal system. Right. And where I would maybe like for you to expand on that conversation is girls that are in and young adults and women in perimenopause who are seeing undesirable body composition changes, who are like, you know what I'm just going to do? I'm just going to fast for five days. Or you know what I'm just gonna do? I'm gonna go on whatever diet. You know, I'm gonna have 500 calories, 800 calories a day. I can't tell you how many women it's like 1100 calories for whatever reason seems to be the number that a lot of women land on, which is not enough substrate to build bone, muscle, joint, like to regenerate. So talk a little bit about the impact of excess caloric restriction in particular. Maybe we can even dive into some macronutrients and micron.

A (16:06)

Love to. Yeah, yeah. So I'll just give a little bit of my background on this because generally, I mean, as an orthopedic surgeon, like, I, I shouldn't know a lot about this, but even before I went to medical school, I was a professional dancer, so I lived in the fine arts space. My wife is a professional dancer now. She's a PhD in nutrition and a registered dietitian and she runs a weight loss company. So I've been in this kind of weight loss dieting space for a long time. Personally, my family, it tends to be quite obese. Most of my family has been very heavy most of their life. I've battled it, it all of my life. So I'm not going to say that I know what it's like to be a woman, but at the same time I do know what it's like to chronically diet as a man. And I think putting all those pieces together and then going into my clinical practice, which is probably 95% women, I see the same thing that you just described, which is most women that I see live so much of their life in a severe caloric deficit. Right. And then when I watch what they try to do to lose weight, which is, I think, getting worse, made worse by the GLP1, call it a phase, call it.

B (17:08)

We're going to talk about that. Yep, yep, yep.

A (17:10)

Because now it's just easier. Now it's just easier to be in a, in a strict and severe caloric deficit. But I will say that all of almost all the patients that come in to see me with osteoporosis, trying desperately to improve it through lifestyle and avoid the drugs. Only almost 100 of them are under eating. I mean, 100. So I see it all the time. I see it especially in our younger women that have this problem. And so like you said, if you are under eating, you cannot build. Our body kind of is always sort of balancing back and forth between sort of, you know, anabolism building and catabolism and breaking down. You, you want to do both. You never want to be in one all the time.

B (17:47)

Oh yeah, right, right.

A (17:49)

I mean, it's true, like for, I mean, I look at the, you know, the guys who are trying to be anabolic and women, you know, who are trying to be anabolic and put on as much muscle mass as possible and, you know, mainlining protein all day long and trying to be anabolic all the time, it's also not good.

B (18:01)

Yeah.

A (18:01)

And so you always want to balance back and forth, but if you lean on or if you really live in one side, especially the breakdown side, you're gonna. You're gonna lose bone, you're gonna lose muscle, you're gonna lose, you know, a lot of other things, too, and eventually you'll develop osteoporosis. The reason why this is such a big deal for women more so than men, and I think it is probably a bigger deal for men than we know. But the reason why it's so important for women is because, as you said, women and men both reach their peak bone density in early adult life, but men have a higher starting point. So men just are more protected from reaching osteoporosis. And so women are just going to get there faster. And I think, as you said with. With younger women, with adolescent girls dieting hard, especially early in life, you are missing the opportunity to build bone. My daughter is only six, so I've not lived this yet, but I have had lots of young patients, and when I was in the ballet space. Oh, my gosh. Right. I think 1100 calories is generous for what I would see these women eat. Right. Yeah. So, you know, I. It's just. It's really unfortunate because you're right. Once you. Once you reach this mid-20s, maybe early-30s, it's generally a downhill slide, hopefully a plateau. I will say that it is possible to improve bone density. It is impossible to come up from a low starting point, But I don't know that you're going to go from normal, nearly normal, and you're going to keep pushing up from there. I don't know that you can actually continue to do that. So you really have to take advantage of this opportunity. And I strongly encourage anybody who has an ear to bend for a young woman to encourage them to think of. Instead of thin is in that strong is in. Right. Be strong. I mean, I hear you talk about this all the time, Stephanie. Like, you look better with more muscle on your body.

B (19:43)

Right.

A (19:43)

It's the internal Spanx. Like, it's so easy to get distracted by. By leanness and to not recognize that really, what's more appealing is probably more muscle mass on your body. But even so, like, from a bone health perspective, it's so critical to balance back and forth between break down and build up, we have to continue to build up over time. Not all the time, but at least some of the time.

B (20:05)

Yeah. And I think for female athletes too, if you're a young female athlete, you're a soccer player, you're, you know, whatever, whatever sport. I think we also have to be educating our coaches. Even, you know, we see this is rampant in dance gymnastics where running. Yeah. So it's like the smaller you are, you know, the better your performance is. But I think that we can really make a strong argument for, you know, an appropriate amount of muscle, an appropriate amount of tensile strength, of bone density to be able to withstand like, especially with foot, like with soccer, you know, to be able to challenge someone, like you need to have good core strength and good balance and good, you know, to be able to perform at the highest level. So I think that there can be maybe a shift from appearance, which I think a lot of coaches erroneously attribute to performance and how much food we're eating. And of course, you know, we, we can talk about the menstrual cycle as well. But there's another overlay there. These younger women where they have these aberrations, they have this flux of hormones, it's up and it's down, it's pulsing up and it's pulsing down so.

A (21:10)

Well, hopefully. Right, yeah, well, right, that's right, yes. Yeah. So let me speak about the athletic population. You know, from a dance perspective. I mean, I saw this firsthand. And the problem with any fine arts, any aesthetic space, is that the leadership tends to look at the dancers, unfortunately as absolutely replaceable. Right. You've got a thousand girls who want that spot. And if that girl doesn't have the right, the right look, the right leanness, you know, she can't fit into the costumes that they have from the previous ballerina that used to wear them. You know, they will ask her, literally ask her to fit this body type, this look, and then if she can't do it, they'll replace her with somebody else. Fortunately, the sports world is not quite like that, but I do see, I see such a big problem with running. And one of my patients a couple of years ago, she was young, she was out of, she still ran recreationally, but she was a high level runner and had osteoporosis in her 20s. And so she, you know, she. And I really pushed to talk to her coaches to try to get into the long distance running space and they wouldn't talk to me. That when it's a weight to ratio activity, weight really does matter. And so those coaches, I think, are intentionally putting those girls health at risk in order to improve performance.

B (22:26)

Yeah.

A (22:26)

And so, and that leads me to talk about, you know, then menstrual cycle. So, you know, she, I, she had these great conversations with her. She's an attorney now. And so she, she's very like, she's very open about her experience and also very angry about, you know, what's happening in the space. And she was telling me that essentially socially, all the girls, if, if a girl was actually having regular menstrual cycles, that means that they weren't training hard enough enough. That means that she was eating too much food. Like they knew.

B (22:52)

You see that in bodybuilding too.

A (22:53)

Yeah, but they push it, but they push it the wrong way. Right. So they're like, no, no, no, no. Like you can't. That's not, that's not good for your performance. We have to, you know, you have to be pushing harder, which is, I mean, so sad. But there is evidence to support this idea that if you don't have a normal menstrual cycle, if you aren't cycling. There's one study I can think of in particular. If you're not, if you don't have at least five cycles of an ovulation and a regular luteal phase, then you'll be losing bone as a young woman. If you think about how many women, I mean, hormonal contraceptives aside, but how many women who are not on hormonal contraceptives, not synthetically suppressing ovulation, but don't have regular periods, It's a large percentage of the population. Right. So this is really concerning for me and why I tell all women, almost regardless of age, you should have a baseline dexa. If that's all we have access to, you should have a baseline screen for bone density. Because with all of the different factors that we are exposed to, just as humans on this planet, all the toxins, all the stress, all the bad things that are in our world, so many of us, I mean, arguably probably all of us, have risk factors for osteoporosis, have risk factors for bone loss.

B (24:00)

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A (27:40)

Yeah, and let's not forget testosterone at the end there.

B (27:42)

Oh, yes, the hero.

A (27:43)

Yes. Yeah, yeah. So, I mean, estrogen is, I mean, just if you go all the way forward into, you know, the post menopause timeframe, Estrogen is an FDA approved drug or product for the prevention of osteoporosis. So we know estrogen's been well studied all the way from the whi for all the good and the bad that that study did. But I mean, we're talking hundreds of studies on estradiol, specifically estrogens. Many, many, many studies. Dozens and dozens that I've read on bone health and estrogen. So we know very clearly what it does. It acts on both sides of the metabolism equation. So I'll just take a second and explain that. We are always breaking down and building up bone. And this is a really important point.

B (28:22)

Point.

A (28:22)

So we're always breaking down and building up bone. We as humans replace our skeleton about every decade, the entire skeleton. Right. Like the femur that you have today, Stephanie, you didn't have a decade ago. It's totally different femur. So if we're breaking down and building up that much, it stands to reason that if we can control one or both sides of that equation, how much you're breaking down, how much you're building up, we can manipulate what's happening with our bone density and quality over time. That's really good news for people with osteoporosis, but it's also really good news for those that want to prevent osteoporosis. So then back to estradiol. So estradiol works on both sides of the equation like most natural things do, which is actually really cool. So does exercise. Right. So there's so many, all these natural things that we can talk about. And so it has the strongest impact, though, on the breakdown side. So we know that estrogen, specifically estradiol, will. Will work to slow down or shut down osteoclast. That's the cells that break down bone. Osteoclast, resorption of bone. And you can see it very clearly in biomarkers in blood. It also works a little bit on the building side, but more so in encouraging the cells, the osteoblast, to proliferate from stem cells. So it doesn't make them go faster, it just helps them to be there. So estrogen is the most studied of the two. Progesterone is interesting, and it's a little unfortunate that progesterone is almost never studied alone. So in research around progesterone, we have to kind of work our way through the fact that most studies on progesterone are not on progesterone. They're on synthetic progestins. They are not the same. They do not work the same. And so when I say progesterone, I mean micronized progesterone delivered either orally or another route. But micronized progesterone is what I'm talking about. Micronized progesterone and endogenous progesterone, what you naturally produce. Both of those have an impact on bone. We know that they stimulate osteoblast, the cells that build bone. But as a standalone intervention, it's never been studied for bone health. And so it's. It's unfortunate because I have women that take it because they want to improve their osteoblast. And I think that's totally fine because there's other reasons to take it, too. Certainly not approved for that purpose. But I can't tell them to what extent it's going to be beneficial because it's just never been studied. But I like progesterone. I love progesterone. I think it's a fantastic thing to add to estradiol always, not just if you have a uterus. And that's. Those are actually the. That's the policies, the guidelines that we set up at LifeMD in my new clinical practice, where we're setting up, you know, entire women's health programs and bone health programs around this, getting away from this idea that we should only use progesterone if a woman still has a uterus to protect the lining of the uterus. There are receptors for progesterone all over the body, including the bone, including the brain, including the Peripheral nerves. So, you know, I don't like preventing women or stopping women from having that benefit by saying, oh, well, you had your uterus taken out, so you don't get progesterone. We don't play that game.

B (31:06)

Yeah, you can sit with us. If you don't have a uterus, you can still get some progesterone. Yeah. Tell us about testosterone. What does that do?

A (31:11)

Testosterone is a really controversial one. I had a. I did.

B (31:14)

It really is. It really is. Yes.

A (31:18)

So. And here's the. The thing. So I did a podcast with Louise Newman. Newson. Sorry, Newson.

B (31:23)

Yes.

A (31:23)

Yeah. And she. So she's over in the UK and she's a huge advocate for testosterone. And some of those clips really went viral. And I mean, the comments. It took me like a week to get through the comments.

B (31:34)

And they were persecuting her, I think, too, in the uk, like, totally constantly. Yeah, yeah. No, but I think her medical board, like, I think she was.

A (31:43)

I wouldn't be surprised. Yeah, she's. Yeah, I talk to her pretty frequently because we have very similar language, you know, so I'm always interested, like, what's happening. But for when, from a testosterone perspective, nothing that she says is actually controversial. What I said that really frustrated some people, especially in sort of like the. The menopause space, is that I. I was saying that there is benefit to be anabolic. Right. Testosterone is anabolic.

B (32:07)

Sure.

A (32:07)

And there is likely benefit. Likely. Notice the word there. There's a likely benefit for using testosterone from a bone metabolism perspective. None of that is incorrect. All of that is can be backed up by evidence. Several studies can back that up. Where we fall short and where this gets controversial is clinically, do we actually quote, unquote, use it for osteoporosis? And before the FTC shuts us down, note that, that it is not FDA approved for bone health for osteoporosis, but it's not FDA approved for anything, actually.

B (32:37)

So, you know, it's just HSDD right now.

A (32:39)

Well, but it's not even FDA approved for that because there's no product. The FDA approves products, not concepts.

B (32:46)

Great.

A (32:46)

Right. And so there are guidelines that support testosterone for HSDD and fsiad, but there's actually no FDA approved product in the United States. So it is not FDA approved for anything. So whenever anybody, any clinician is using testosterone, it's all off label. They're just likely using it for HSDD in conjunction with the guidelines. Fine. But we also know that testosterone does very specific things. It has been studied in Both women and men, specifically for bone health. But the studies aren't great and they're also not very clear. But when it comes to testosterone studies, we run into the same stuff over and over again with testosterone. It's true in testosterone studies in men too. In men, because this is where it's studied the most. In men. They use a very low dose. They try to bring them out of a true hypogonadal, meaning a very low level of testosterone. And their goal is to bring them just out of it. So they're not actually optimizing for sure. They're not even making them eugonadal, which is quote, unquote normal or average. They're just aiming to sort of get out of this hypogonadal state.

B (33:47)

It's like the RDA recommendation for protein.

A (33:49)

Oh, yeah, right, exactly. I mean, draw a great analogy there. And so if you do that and then you follow bone, bone, you know, bone density over time, guess what? Like, it didn't change very much. But they don't have enough testosterone still. And they're not doing the studies to look at estradiol levels in men to understand if they have enough testosterone on board. What's happening with IGF1, they're not exercising. Right. Like, these aren't the right studies to be looking at testosterone as a tool for bone health. And in women, it's even worse. Now, the studies that do exist, there is one randomized control trial and it's a very small study from many years ago using an estradiol pellet versus estradiol pellet plus testosterone. And the testosterone group did do better. But again, it's a super small study. And so we have some evidence. So for me, clinically, when I, when I talk to women about testosterone or androgens in general, we start with estrogen and progesterone for hormone replacement therapy and then optimizing hormones and perimenopause. We can talk about that, but we want to optimize estrogen and progesterone first because that's more predictable what that impact is going to be on bone. And then if they're androgen deficient, either, you know, testosterone is low or DHEA is low, or they have symptoms of hsdd, then we start talking about using androgens. But I'll often start with not testosterone. I also only have all telehealth, so I can only prescribe in about 30 states because of the controlled substance issue. So we have to have tools outside of testosterone for our patients. DHEA actually is studied independently for bone health and at relatively high doses will increase bone mineral density as a standalone intervention, too. But most women aren't going to tolerate those doses. That dose is 50 milligrams, which is a lot of DHEA. And so we use DHEA where we can, we'll use testosterone where we can for women that meet those criteria. But we are asking, we have to ask about sexual function and dysfunction in order to be able to prescribe it. But the good news is, I would bet that you've had many interviews talking about this. You know, if you were to ask a large population of women, especially those with low testosterone, if they are experiencing low libido and it causes them distress, the percentage of women to say yes is very, very high.

B (35:54)

So, as a recap, progesterone. Yeah, sorry, this is. No, this is fantastic. It's fantastic. I just want to wrap this up so that everybody. I want to make sure that everyone's on the same page. So when we're talking about estradiol, this is going to have an inhibitory effect on osteoclasts. So these are the cells that are involved in maybe bone breakdown. Progesterone has a proliferative, proliferative effect on osteoblasts, which are the bone cells that are involved in building bone up. So increasing density and then testosterone is going to. Is it going to do both of those things? Are we going to see bone?

A (36:28)

Yeah, kind of. So we think of it more as anabolic. Right. It's going to have an impact on the bone building cells. But we also know that testosterone will aromatize into estradiol and therefore it's going to have an impact on Osteo Class 2.

B (36:39)

Great, great, great, great. Okay, so testosterone sort of does both of them as well. And. And to your point, as we've said many times on the show, we need more studies, we need more research. And yeah, testosterone is used. As of this recording, there is no product for women in the United States or Canada. I think that there's for sure. There's one in Australia. I think one is coming to market in the uk, but yeah, still North America. We gotta get with the times. Okay, so I actually wanna come back to. I know we got to hormones, which obviously I love to talk about, but I wanted to come back to dieting because when we talk about excess dieting, not meaning that peak bone mass that we were talking about earlier, what are some of the things that we want to make sure that whether you are a young girl who has not reached her peak bone Density. Yet you are someone who maybe just gave birth or you're a woman in perimenopause or both. Because we know that perimenopausal women are having. We're having children later and later in life. So we have 44 year olds and 46 year olds and 48 year olds having babies for the first time.

A (37:41)

Time.

B (37:41)

So what are some of the nutrition principles that we can adhere to that are going to promote optimal bone quality?

A (37:51)

Yeah, so nutrition is a tough one for me because I have such, I think we all do probably, right. Strong beliefs around nutrition, you know, what works for us and what I've seen work for my patients. But I've softened my language significantly over the last, I don't know, four years as I've been talking with larger audiences experiencing different, you know, you know, different cultures where the things that I say are, are, you know, either offensive or not. Like they just can't, they can't take that advice.

B (38:17)

Right.

A (38:18)

And so what I've come to kind of boil this down to is just distill it down to, is that we need to consider that we have to have the building blocks. Right? So we'll start with the macronutrient protein. Right? We have to have enough protein. I've heard you say this. I don't know where you are right now with this, but for me, especially because most of my patients are starting already in a bad starting point, we really need to focus on building. So for me, I use around 1 gram per pound of ideal body weight as a target. But I also openly say, for those critics that say that that's too much. I openly say that we know very clearly in the literature that there is a threshold around 1.3 to 1.6 grams per kilogram. Sorry to switch units there, but around 1.6 grams per kilogram, there's a threshold for muscle protein synthesis. The reason why we push it north in the axis, about 0.8 grams per pound.

B (39:06)

I was going to say 0.7.8.

A (39:09)

So about 0.8 grams per pound. But the reason why I push it north of that is two reasons. One is every study on protein intake and bone health shows that those in the highest quartile or whatever, however they divide it up, those that consume the most protein, have the highest bone density always. And there doesn't appear to be an upper limit in normal populations. Right? So that's number one. And number two is most of our patients that we see with osteoporosis also have something else going on on. Right. They've got gut dysfunction. They've got, you know, low hydrochloric acid. They have pancreatic enzyme deficiency. There's, there's a reason why they're not going to be able to process and assimilate protein efficiently. Therefore, we want to overshoot it. I also overshoot it. For those that are leaning more on plant proteins, I am. I personally, and I recommend using animal proteins whenever possible. Higher quality protein. But if you don't want to, you can still succeed, and that's okay. You just have to recognize that you have to be eating more complete proteins. Look at your amino acid profile. And if I say one gram per pound for kind of an omnivore diet that's heavily animal leaning. If you're going to go more plant, you're going to have to go even north from there. And that could be another 20%, even another 40% more.

B (40:19)

Yeah, yeah, yeah. And I think the Asian for, that's really for our Asian population, right? So South Southeast Asian Asians who tend to be vegetarian. When I used to say animal protein or bust. So me, like you, I've softened my language a little bit because, you know, having beef or pork is just not part of the everyday culture there. And I think that you can get there with plant proteins, right? You just need to do your due diligence. And I think that the selection of plant proteins is also important. So you're going to have things like soy that has a relatively high bioavailability. You're going to get really good absorption with that, which is really great news for, you know, our listeners who are of Asian descent because they tend to have a lot of soy proteins in their diet. So you're going to get, you're going to get more bioavailability with that versus something like a, you know, a pea protein, something where we start to see the bioavailability, you know, drop from like 95, 96% down to like 70, 60 with rice protein, that kind of thing. So I think it is, you can still get there with plants. You just need to, you just need to be smart about it.

A (41:25)

It. Yeah, I agree. And the one caveat I have is for women that are struggling with weight, in addition to this, this is this like challenging back and forth, right? So I say eat more protein. They say, well, but now I'm consuming more calories and now I'm gaining weight, which for a lot of our patients is actually a good thing. But for women who are, who are not in a position where they're underweight, to begin with. And gaining weight is a problem for them metabolically. Then looking at what's coming along with your protein. One of the reasons why I do encourage animal protein is that it comes with fat.

B (41:54)

Fat.

A (41:54)

But plant protein tends to come with carbohydrates.

B (41:56)

Carbohydrates. Yeah.

A (41:57)

Right. And so this is, this is a difficult balance. If you're really leaning into plants but you're also gaining weight. This is a, it's a challenging combination.

B (42:03)

Yeah. So you have to just get in touch with your inner protein shake.

A (42:08)

Yeah. And ask yourself why. I mean, what are, like, what are your beliefs around food? Like, what are you willing to do and not do?

B (42:14)

Yeah, yeah, yeah. All right. So we have protein and paired with fat whenever preferable, because that's going to help with satiety and certainly that, that's great for a whole host of things. Talk to us about some of the micronutrients as well. So we Talked about protein, 1 gram, ideally per pound, per ideal pound of body weight. Talk to us about some of the micro minerals that really move the needle for bone health as well.

A (42:40)

Yeah. So everybody talks about calcium. Right. And I think it's kind of funny how calcium really like takes the stage on this. And, you know, if you go to your conventional doctor in the system, they'll say, oh, you know, do weight bearing, exercise and calcium and vitamin D. D. As if those are the only two nutrients that you need to build bone. Not that they're not important, especially vitamin D, but I was going to say.

B (42:58)

D. I would prefer the D over the calcium.

A (43:00)

Right, right. Yeah. If you're going to pick one. If you're going to pick one. But the calcium, like, I understand that if you look at the composition of bone, it is. There's a significant portion of calcium. Sure. You know, it is by. I think it's by volume at 50% protein. Again, we're talking about protein, but the other volume is minerals. And of the minerals, the majority of the minerals is calculated calcium. So it is, you know, calcium is important here. But if you, if you've ever tracked food, if not you. But your listener has ever tracked food, then you will see that you probably are not calcium deficient. Assuming that you're eating some amount of dairy, it's definitely possible to be calcium deficient. If you're again, more plant leaning. But it's. When we talk about calcium deficiency, we have to recognize too, we hear the number like 1200 milligrams of calcium as a recommendation. I don't think it needs to be that high, honestly, because if you look around the globe, not all countries are saying that. And the World Health organization doesn't say 1200, they say more like 700 or 800. So I think that probably, if you're close to that, that 700, 800, you probably don't need calcium supplementation or if you do, you don't need much. And so this becomes an issue with supplementation because so many of the supplements have a thousand milligrams of calcium. It's just way more than you need.

B (44:09)

And then is the calcium getting to where it should go? I mean, that's the question. It ends up in your arteries, it doesn't end up in your bones.

A (44:18)

Bones, yeah. So we'll come back to nutrients in food from a supplement perspective. This is a really important point, which is if you look at the studies on calcium and vitamin D and even go back again, like Women's Health Initiative, right, Like big randomized control trial, they used calcium and vitamin D. You, you do see that there is some value in doing that, but it is mostly the vitamin D. From a, from a calcium perspective, you look at calcium alone, it's not a very good intervention. So you really need to consider calcium, just as is filling in the gaps in your, in your intake of food. If you also look at some of the smaller studies looking at what happens in your blood with calcium products like calcium citrate. Calcium carbonate.

B (44:55)

Yeah.

A (44:55)

Calcium carbonate is chalk. Right. And so these synthetic forms, not synthetic, but they're manufactured forms of calcium that you are so unnatural to consume a thousand milligrams of chalk at one time, your body has no idea what to do with that. So in the calcium alone studies, you actually do see an increased risk of heart attack. So administereal. But if you even just give 400iu of vitamin D like they did in the WHI, that risk goes away. So you really do need fat soluble vitamins, vitamin D, vitamin K. Now we know more about that one. So if you're combining calcium with vitamin D and vitamin K, I think you can overshoot it some. But even then I would still encourage people to use not calcium carbonate, calcium citrate, but to look at the more whole food forms of calcium. And by that I mean either if you want to go plants algae forms of calcium from several companies that do that, and then animal forms of calcium from ground up bones, that's called hydroxyapatite. And so you actually get calcium in the form that it is in bones. And then if it's processed the right way, it actually Comes with a bunch of growth proteins that are going to actually be in the bones, and they help to build bone. There's a product that's available in both Europe and the US that looks like that.

B (46:01)

That's so interesting to say hydroxyapatite, because one of my friends is a dentist. He was on the show. He was talking about hydroxyapatite for. For teeth, which, of course, that makes sense, right? Teeth are bone. So when we're thinking about, you know, he was like, get rid. Like, ditch the fluoride. Ditch, you know, hydroxyapatite, Get. Find that in your toothpaste. And I was like, huh, that's a good tip.

A (46:20)

And also put it in your bones.

B (46:21)

And also put it in your bones, yes. What about some of the. More I won't say obscure, but maybe obscure, like phosphorus, boron. Like, what are your thoughts on supplementing with those? Or maybe finding it in the diet?

A (46:35)

Yeah. So I always tell everybody, if you're open to it, and I respect. If, you know, if someone has an eating disorder history and they're like, I can't track my food. It just would, like, make me go off the rails. Fine. That's fine. But if you're open to it, I would encourage you to track your food for at least three to five days. Be totally honest, eat the diet that you would normally eat and just see what comes up. It's not a perfect test, but it can kind of give you a sense of what you're deficient in. And I can tell you that almost all of us are deficient in things like magnesium, for sure. Maybe calcium, maybe phosphorus, depending on what your diet looks like. And the likely boron. I'm glad you brought up boron. Boron's a really weird thing. I don't know what to call it. Right. It's not really a mineral. It's not really a vitamin.

B (47:12)

Vitamin D. It's like, is it really a vitamin or is it a hormone?

A (47:15)

Yeah, well, vitamin D is a hormone.

B (47:16)

Yeah, it's a hormone. Yeah.

A (47:17)

Yeah. But boron's like. It's like none of the above. It's a really. I did a deep dive on boron for this thing that never actually went live, but.

B (47:24)

Oh, my God. Let's do the deep dive here. Talk to us about boron.

A (47:27)

So the thought behind boron is that it came from outer space. Like it didn't exist on this planet. It totally. It's so weird. And I hope I'm not wrong on this, but, man, like, I was just going down this rabbit hole and like. Yeah, the thought is, like, it came from outer space. It doesn't look like a mineral, it doesn't act like a mineral, it doesn't act like a vitamin. It is this weird thing that was given to us, I think, you know, to have specific impact on our body. And it does. And so if you are boron deficient, you will have a hard time building bone. And that's why, if you look at a lot of the bone products out there, the supplements that are out there, they have a fair amount of boron in them. And so there's even that, like. Have you heard of the borax challenge? Did you ever hear this thing?

B (48:05)

No, I've never heard of that.

A (48:05)

Oh, my God. So.

B (48:06)

Oh, the thing that you clean using the laundry.

A (48:08)

Yeah, it's a laundry detergent, right? Yeah. So, yeah. So nobody ever do this, please. But there was this whole thing. I was interviewed for this borax challenge, like the documentary, and maybe they didn't use me because I said, like, nobody ever do this, please. But basically, borax has a lot of boron in it. And so there was this trend, this, like a social media trend where people were using borax, like, the cleaner and like.

B (48:28)

Oh, don't.

A (48:29)

Yeah. Which is scary because it. The dose really matters here, and so you could really overdose yourself. So you're not going to overdose yourself with boron if you're just supplementing with like, 3 milligrams, even up to 10 milligrams. But it's kind of hard to find through diet. So the best source of it is actually in prunes. Yeah. And so there's actually. There's a ridiculous number of studies looking at prunes and osteoporosis. And I don't know. I don't know who's funding these randomized control trials.

B (48:57)

Big prune.

A (48:58)

It's big prune. Yeah, but there's. But there are multiple randomized control trials with pretty big numbers looking at prunes and osteoporosis, and it does improve bone mineral density as a standalone intervention, likely because of the boron.

B (49:11)

Wow, that's so cool. I did not know that.

A (49:15)

Yeah. Boron. It's an alien.

B (49:16)

Wow. It's an alien. It's given to us by aliens. No, but the prunes as a standalone intervention. That's wild.

A (49:24)

Yeah.

B (49:25)

So how. What are we talking about? So you said 3 to 10 mgs of boron, so what in an average, a prune. What's the do?

A (49:32)

I think it takes, and it's been a minute since I looked at this, but I think it's a 50 gram dose, which is about five prunes. It's a lot of prunes.

B (49:41)

Yeah.

A (49:42)

So here's what happened.

B (49:43)

It's still going to help your digestive system.

A (49:45)

Well, it depends on where your digestive system starts. So I did a. I did a video on this and then I got all of this negative feedback because people were like, oh, my gosh, I should eat a lot of prunes. And I think, I think everybody knows what happens when you eat a lot of prunes, but apparently not. And so, yeah, we got all this, like, oh, my gosh. I had all these, you know, digestive issues. So the prunes are not benign. Otherwise, just for the record.

B (50:05)

Okay, okay. Well, this is, I mean, this is a big takeaway for me. I didn't know. I love that it's a standalone intervention for osteoporosis. That's fantastic.

A (50:12)

Yeah.

B (50:13)

There was a time that I just trained for the mirror. My world was scales and macros and check ins on repeat. Perimenopause was really my wake up. I realized that muscle isn't just about chasing lean, it's about longevity. And strong is a love letter to your future self. That is why I built Lift. It is a strength training program for women who want capability over comparison. If you are ready to build the kind of strength that spills over into every part of your life, join LYFT today. Head over to drstephaniestima.com Lyft and join today. Okay, so we've talked about diet, some of the minerals. I'll come back to what you said earlier, again with exercising harder. I think a lot of women, you know, if you've listened to any of my. I'm a very big advocate for lifting weights with an asterisk with some nuance. As I said to you in the beginning, it's not just your muscles that are going to the gym. Your tendons are coming along, your ligaments, your articular cartilage, your bones, all of these are affected by weightlifting. And this is. I'm a huge proponent of, like, form before load. We won't get into that. But for lifting weights is not the first thought that enters a woman's mind when we say, hey, you should be exercising more. They think, I need to get on the treadmill and I need to run or I need to do some type of cardio. Because again, health has been. The way that health has been presented to women is how skinny can she get? And so we have all these cardio and so many women listening, myself included, grew up in the cardio section of the gym. Right. So how can we think about exercise, movement? And I kind of want to talk about a couple of different, like high intensity movement, lifting weights, I certainly want to talk about. But cardio interventions as a way to manipulate or augment bone health for the better. And then maybe in order to answer that question, we need to also talk about what are the detrimental interventions for bone when it comes to movement as well.

A (52:06)

Yeah, boy. So let's, so let's start cardio and then we'll go from worst to neutral because there actually isn't a true cardio. I consider high interval training different. So there isn't, there isn't really like a, you know, like a zone 4 cardio activity that's going to be good for bone across the board, which is.

B (52:25)

Even like track sprinting, something like that.

A (52:28)

Yeah. So again, high, high intensity intervals, different scenarios.

B (52:32)

You.

A (52:32)

Okay, so, but let's just start at like the worst. So there's a, there's a ton of research on this. Swimmers have low bone density. I mean, just across the board, strong association, low bone density. And you might think, oh my gosh, why? Because swing is such a hard sport and it is, and it's good for you. So I'm not saying don't swim, but think about what's happening. You're putting yourself in a low gravity environment.

B (52:51)

Yeah.

A (52:52)

Right. You're in, you're in water. And swimmers that swim, I mean, they, they're in water a lot. So you were in a low gravity environment all day long. Take that to an extreme. What happens to astronauts? They lose bone. Like crazy. Crazy. Right. So you're in a low gravity environment and you're doing resistance, but not high intensity resistance. Right. Like your arms going through the water. It's repetitive movement, fantastic exercise, cardiovascular, but you're going to lose bone. That's unfortunate. And then I would say probably second worst would be long distance running.

B (53:20)

Yeah.

A (53:20)

And you know, what's the threshold of long distance versus not long distance? I don't know. Maybe, you know, but when I see a woman who's running, you know, probably, you know, over 5, 10 longer miles a week and training or training for long distance events, I start to worry about our bone, the running itself. A lot of times people will say, well, but it's impact, right. Like your feet are impacting the ground. And that's true, except it's not enough impact. And the action itself, if you think about what you're training your body to do, because everything we do is inputs. Right? Food is input, exercise is input. And if you're, if you're considering what running is as an input, you are running long distances. And if you were to build a machine to go long distances is you would build it as light as possible and as efficient as possible. And so that machine would not have a lot of muscle on it. That machine would not have a lot of excess body fat on it. Right. And this is what runners look like. We know what long distance runners look like. They're lean and they oftentimes will have low bone mass and osteoporosis. So long distance running will do that too. And then of course, there's the diet component of that. And then the next one that kind of surprised me a little bit, but I guess it makes sense is cycling. So I was, I went through a period of my life where I rode a lot of bikes and I raced road bikes. And again, another reason why, like I had, I had low bone density as a young adult because of the ballet background. And then I went, became a cyclist after that. Cyclist, also associated with low bone density. And again, why? Well, now you are in a regular gravity environment, but now you don't have any impact.

B (54:41)

There's no impact to it.

A (54:42)

Right. You're on a machine that's made out of carbon and you're just cruising along. And again, same thing, like cardiovascular, fantastic. But what a professional cyclist look like, they're super cactic. Right. They're super lean and it's associated with low bone density and osteoporosis. So then like for the normal of us, you know, or like who are doing these things more from an amateur perspective, you have to just consider that these are probably net negatives for your bone. I'm not saying don't do them, but consider that you have to do other things that are going to be beneficial for bone.

B (55:11)

Yeah, I think with the long distance running, and feel free to redirect me here or to add to it, but I've always understood that, you know, the heel strike or however, you know, you can make the argument that heel strike is not the right way to run too, if you just stay on your forefoot. But okay, so calcaneus or forefoot strike, whatever it is, you're probably getting something like five to six times your multiple of your body weight. But to your point, if you're optimizing for long distance running, which I would say, and we'll come back to high intensity interval training or sprinting in a moment. So anything that's kind of like long where you are steady state cardio. So anything that's like longer than 10 to 15 minutes, I would start to qualify. Because you're going to, you're not going to, you're not going to pulse it up to like 100% output. You're going to be somewhere around 60, you know, 75% output. Your body is going to say, okay, so I have to get. In order to be efficient at this activity, I have to trim everything down. So to your point, I have to trim down my muscle mass, I have to trim down my fat mass, I have to trim down my bone mass. And so a lot of people will get, you know, I'm using air quotes if you're listening here, like thinner or skinnier, let's say when you're running but you're not really changing your body composition, you're just becoming a smaller version of what you were before because your body is now optimizing for being efficient at that particular exercise that you're doing multiple times a week. And so I think that it's also, maybe there's a little bit of opportunity here for nuance because if you have somebody who, let's say maybe they're rehabbing, they're coming back from an injury or they're just like not ready to do like an all out track sprint yet. It's like, okay, so let's kind of get you on the bike. Let's say, let's get you in low impact scenario where you can practice your form, you know, whatever form it is, and then we can start replacing some of that with some of the higher impact. I know, and I'm not sure if you're done your list yet. So we've done swimmers, long distance running, cycling.

A (57:08)

I'm just going to move on to sprinting next. So that's a good, good segue. Yeah.

B (57:11)

Okay, okay, good, good. So, so, and then we can kind of like move up the totem pole in terms of what's important for bone health. So I'll let you take it from there.

A (57:17)

Yeah. So then, then sprinting becomes a totally different thing and I would actually love, I'd love to dig into some of that evidence around the heel strike and the multiples of body weight. I'm really fascinated by this multiples of body weight concept because there are some commercial interests in the bone health space. This idea of osteogenic loading where we're sort of trying to hit a threshold of multiples of body weight over four, for example, but in more of like A static, less dynamic way. And the research behind it is like, it's present but not overwhelmed. And so I would love to see, like, from a running perspective, what that heel strike looks like, because I've always, and I don't talk a lot about this, but I've always thought that, like, with running, you're going to sort of be. You're going to kind of oscillate between like, 0.8 and like between 1 and 2 multiples of body weight and may. And. But maybe we're looking at different studies or maybe I'm looking at walking, I don't know. But either way, like, I think this multiples of body weight thing is interesting. When you start getting into modalities, which we can do another time or today if we have time, you know, like whole body vibration, we talk about, like, GS, like force, right? But it's also like those are two, you know, similar metrics. So anyway, I just think that's interesting because when you get into sprinting, there is a difference in the dynamics of the contraction, right? Like, you are. You're forcibly making changes to your bones. You're stressing your bones in a totally different way. And it starts to look more like the thing that we know is good for bone and does build bone, which is actually, actually impact. Like, if you were to jump off of things, if you were to generate multiples of body weight throughout your entire body. And so sprinting, like, if you look at a sprinter in slow motion, oh, my gosh, like, you can see their bones bending, right? Like, they're really stressing their bones. And maybe you have. I have not seen a sprinting intervention done on osteoporosis for sure, because I don't know how many people have osteoporosis.

B (59:01)

Well, because osteoporosis, like, don't stress yourself because your bones are so weak. It's like, that's the whole point.

A (59:07)

But I would, I would love to see what that looks like because, you know, my goal is to spread this message to especially younger audiences, you know, women in midlife and even young adults, right? Like, if you have low bone density for whatever reason and you have the capacity to do something like sprinting, and we know that it's good for bone because it's good for so many other things, right? Sprinting is such an incredible. It's such an incredible exercise to have in your, in your tool belt. So I would love to see exactly what it does. But again, it starts to push into this idea of, like, impact, high intensity and then when it comes to, like, resistance training, I'm like you. I'm a big fan. But I love the way that you said, you know what? Gosh, what did you say it was?

B (59:45)

There's other. Form before load.

A (59:47)

Form before load. Thank you. I love that. I'm gonna start using that. So form before load. And the reason why this is so big for me is that most of my audience and population and community members and patients have never lifted a weight in their life.

B (59:59)

Yeah.

A (60:00)

And now they have osteoporosis. And of course, now they're told not to do anything. Anything. But I tell them that you can't do that unless you just want to be on a drug for the rest of your life and live in a padded white room. Like, that's not the life I want for you. And so we have to teach them how to lift. So, yes, form before load. And we teach them form, and we can do that. And if you are 60 years old or 65 years old and you've never lifted a weight and you have osteoporosis, know that as long as you can move your body, you can learn how to lift weights. Totally possible.

B (60:28)

I gotta be honest with you. I am kind of getting irritated at this, like, lift heavyweights at all cost sort of narrative that we see, particularly in the. You know, you have these sort of, like, fitness influencers, menopause influencers, that are like, lift heavy stuff. And it's like, I have had. I've seen women, again, patients, 65, 70, and I have just done. Done calisthenics, like, body weight exercises with just. Just working on form, range of motion in the joint. And we have built muscle just with her using her own body weight. So, yes, heavy weights, but that is not. And I think that there's, like, a fundamental misunderstanding of what progressive overload is, because that's really what we're talking about. Like, the way that we want to build bone, the way that we want to build muscle is through progressively overloading, you are increasing the demand on the bone. You're increasing the demand on the tendon, the muscle, the ligament, et cetera. But there are many ways to do that without adding another plate, Right? Yeah.

A (61:27)

You know, and I think of influencers, and I'm like. I'm friends with Vonda. Right. Like, I really appreciate her message. Yeah. But one of the things that she says that I kind of disagree with. I mean, I'm on both sides of it. She makes fun of, like, the pink.

B (61:40)

The pink the man be pamby. She says the man, be pamby.

A (61:44)

And so, and like, I get it. Like, that's not enough. If your goal is to generate significant stress across the bone. It's not, it's not enough to build, you know, certainly big muscles. Right. But if your starting point is. Is very low, if you've never lifted a weight, I absolutely want you to have that mambi pamby pink dumbbell. Like, that's a good next step. Right. That is progressively overloading on your way up. I actually have a pair of those in my gym. I'm not kidding. Yeah, they came with my peloton, I think.

B (62:13)

You know, I think where, I mean, she and I are, we've talked about this a few times. I think where that message is coming from, but does have the potential to be construed to your point is that people pick up The Mambi Pamby 2 pound weights and then they never move on from it. Right, right. It's like, we want to get toned. You don't want to get bulky. You want to be toned. Which, by the way, is not a comment. It's a comment on the nervous system hypertonia atonia. You know, that is a comment on nerves firing, not muscles. Like you can't tone if you see your muscles. It's a question of leanness. You know what I mean? Like, your muscles are always there.

A (62:48)

Well, and you're not gonna get too bulky. I've challenged my female patients for years. I mean, for years show me that you're gonna get too muscular. And I've had one patient who stands out. She did get some pretty impressive delts, I will say. I'm like, wow, that's okay. I think it looks really good. But, but that's a lot. And, but anyway, there, there is this like progressive overload up to this idea of high intensity. But I like to use the words high intensity rather than heavy. They're both subjective terms. But high intensity is a little bit more specific and a little bit more accurate. Because if you look at the studies on like, for example, the, the Lifmore trials, the most famous one, if you're familiar with that.

B (63:25)

Yeah, yeah, yeah, yeah.

A (63:26)

So. So the Lifmore trials. Belinda Beck out of Australia, she developed this eight month intervention and it's called the high rate, and that's high intensity resistance and impact training. And I think she did a great job in creating these trials and they're some of the most well known studies on exercise and bone density. And she did a little bit of a disservice to the population though, because she chose complex, complex lifts to add into it and understand why she did it. But the lifts that she included in that intervention were a barbell back squat, a barbell overhead press and a barbell deadlift, which are great lifts. I do them. I love them. Well, I kind of love them technically.

B (64:02)

Very difficult to execute.

A (64:03)

Well, they're difficult, right? They're difficult. And so now I actually, I educate a lot on this to say like, you never have to do these, these three specific lifts ever in your life and you can improve bone density. Like so many people think, like this is the way, this is the way to do it. And it's not. Is a way, it is a way to do it. There's a lot of ways that you can do it. And then what. The thing I think that was most valuable though of the study is that she really made a point to say, look, you can do high intensity, which I believe she described as. I think it was 75 to 80%, maybe 85% of one rep max.

B (64:35)

That's what hot. That's what heavy is. It's over 80% of 1 RM.

A (64:38)

Yeah, but, but heavy I think for me, and this is where I think like social media gets crazy because I get, I sometimes I say heavy and I don't really mean heavy but like for me heavy is, is, can, can certainly be high intensity. But I think heavy people think of like this is heavy, right? Like an 80 pound, an 80 pound kettlebell is heavy, a 20 pound kettlebell is not heavy. But if a 20 pound kettlebell is 85% of your one rep max, like that is high intensity density.

B (65:02)

Correct.

A (65:02)

And so I just, I like to kind of like find the difference there because we do need to progressively overload. But, and again, going back to her study, I think what's cool is that she was using an older population with osteopenia, not osteoporosis, but they had low bone density, they were at an elevated fracture risk and she taught them how to estimate one rep max. I think that's really valuable that we can kind of use this terminology in this sort of atypical population. Right. Like most people aren't going to talk about that, that you know, to their 60 or 65 year old mother or grandmother. And so I think we can still use these tools and we use these tools to help to progressively overload people over time. And one more thing on that study that's really critical to understand is it's one of the only interventions that shows an increase in bone density with resistance training in General usually it just shows slowing down bone loss. As an intervention. What she did was the, the last two letters of the intervention. Is it impact training? Training. So she was doing an assisted pull up, pulling up onto a like a chin up bar and then dropping off the bar and landing as hard as you could on the ground on your feet. But you know, landing and generating impact through your body. So the combination of high intensity resistance and impact resulted in a statistically significant increase in bone density.

B (66:15)

Fantastic. The one thing I'll add to this, if there is anything else to add, which you've just phenomenal summarized when we're thinking about progressive overload. I know that I was saying like there's lots of other ways other than load, but I'll just name them in case listeners not aware. So we have obviously range of motion tempo. Manipulating tempo is a huge way you want to pause when the muscles and the tendons are stretched. That's one way to progressive overload with the 2 pound Mamby Pamby weights, if that's where you are right now. Volume. Right. So you can just do more sets, more repetitions and the density of the work work. You can also just if it takes you an hour regularly to do the, to do the work, you can just get it in a smaller amount of time. Like take less rest and punch out it. Punch it out in 45 minutes. So these are all nothing to do with load, nothing to do with adding on. But you can absolutely stress and you know, if you're sending a signal for whether it's hypertrophy or strength, separate outcomes. But often, you know, similar like there's overlap. Those are some ways that you can progressively overload. So this is this like lift heavy no matter what kind of stuff is, you know, it's just, I mean women are already dealing with so much in midlife in general. It's like we're, you know, we have teenagers, some of us are new moms, you know, we have career, our parents are age. There's just like, you know, there's just a lot of complexity in midlife. And so when you add on the narrative and you have to be lifting heavy or else you're not doing it properly. I was like, I completely disagree. And it's actually a way for you to fast track your way to an injury, tendinous ligament, dentists, whatever, which is going to take you just orders of magnitude longer to come back from when you're 55 versus when you're 25, right?

A (67:56)

Yeah, try 70. I know I tell people like let's progressively overload. But let's start low, go slow and don't get hurt. Number one, don't get hurt.

B (68:06)

I noticed that weighted vests did not make your list. And I asked this in cheek because I did a whole series on my Instagram about what weighted vests do and what they don't do and how to use them. Because I think, you know, if there's like, you know, if there's like a. Sometimes I remember I saw this meme once, it's like pick your personality in menopause. It's like you play pickleball, you wear a weighted vest, you know, you go to bed by nine or you know, something else. Right. Or you're on hormone therapy or whatever. So weighted vests have become really central to the conversation around bone health. I have, you know, I said this to you before we got recording, like spoiler alert. I don't think that that's what they're doing, but maybe you can speak to the weighted version vest trend. What are some of the benefits of weighted vests and what are some of the things that are claimed to be facilitated by weighted vests that they are absolutely not doing?

A (69:00)

Yeah. So I mean, let's start with the, the, the. Well, I'm going to start here. So I'm an orthopedic surgeon first, right. So I don't, I don't practice, I don't operate anymore. I'm not in that space. But as an orthopedic surgeon, what do I deal with? Fractures and joint problems. And I think it's really interesting, you know, in that space case, if I had somebody who was overweight, and this was before I knew anything about weight loss, but we knew very clearly in the literature that if you lost 10% of your body weight and you were overweight with joint pain, your joint pain would get better. Right. Just super simple. So then I think it's really ironic now I'm in this space where everybody's saying, well, let's add 10% of your body weight through a weighted vest and exercise. So I think for some of the population this is a terrible idea because especially if you are already overweight. And obesity and osteoporosis do go together by the way. Way. So if you are already overweight, adding 10% more to your body weight is likely a recipe for joint pain. And I really worry about the joints with anybody adding load that isn't short lived. Right. So like high intensity resistance training, short lived load, you're not continuing to stress your joints after you do Those, those sets or reps or whatever. Right. If you're putting on a weighted vest and wearing it all day, like you see some influencers doing, or it seems like they're doing anyway, I think that is going to have a negative impact on your joints. So. So that. That worries me. But I think there is a population where there's potential benefit, but we need to understand what the benefit is. So. So many of my patients are underweight, right? So they are underweight. I have so many women who are 5, 3 to 5 5, 95 to 105 pounds, right. This, like, super small frame. They would benefit from a little extra load on a regular basis. So I think it is, if they have healthy joints, reasonable to increase their body weight to do some exercises is. I don't like them to necessarily do resistance training with it. I really worry about injury in my patients from that perspective. I don't like them to wear them around the house doing, you know, like, whatever they're doing with the kids. I just worry that they're going to fall over and fracture something. So I'm really concerned about that now. Could they wear it walking and would that have positive benefit? Probably, right? Probably for that population to be beneficial. But let's be clear what the benefit is. Probably good for your muscle muscles. Probably good for your bones to some extent. But the study that most people will cite, when they say 3% improvement in bone density or whatever number they throw out there, that study, I think the lead author was Snow, if I remember it correctly.

B (71:20)

Yep, that's right. Good memory.

A (71:22)

Yeah. And so what they did. And you know it well. So maybe correct me if I'm saying this wrong, because it's changed over the last couple of years. I've been saying this, but in that study, it was a randomized control trial.

B (71:33)

Trial.

A (71:33)

Well, I was randomized anyway. And there was a group that used a weighted vest and then a control group. But the group that used the weighted vest was also doing other exercise, right?

B (71:41)

Yes, yes.

A (71:42)

And so. And then what was the outcome? Right. The outcome was that it slowed down bone loss. And so many studies on bone density will make these claims to say that there was an 85, 85% improvement in bone or like whatever the percent is. Right. And. But what that means is, is that there was less bone loss in the intervention group. They still lost bone. And we already talked earlier about resistance training and bone loss. We know that resistance training or exercise will result in less bone loss than no exercise and resistance training. So then what impact, if any, did the Weighted vest have in that group? We have no idea. But yet that's the study that everybody throws out there to say, oh, my gosh, it's so good for your bone. So I think we have to be very clear and realistic to say that it's definitely not building but bone. Is it slowing down, bone loss? Maybe, Maybe, maybe. But, like, of all the levers you can pull for your bone, like, this is not a big one.

B (72:34)

That's not where I would start. I'll say it that way. Right. If you have all the other verticals lined up, you're getting your protein, you're getting your boron, your alien boron, you're getting phosphorus and the vitamin D and all the things, and you're getting, you know, appropriate movement. So we're not doing the swimming all the time, the long distance running all the time, the cycling all the time time. You're doing the resistance training, the high impact or the high intensity training. Sure. I think it has a great metabolic benefit. You know, I think after dinner you want to go for a walk and slap on a five pound, eight pound, whatever. Great. The only other thing I'll add to it. You said joint pain. The only other thing I'll say is especially in menopause, perimenopause. Menopause. We have pelvic floor issues. So we have children that we've birthed. Right. So we have already a pelvic floor that. That maybe was attended to postpartum, maybe not. And then now we have kind of back to the hormone conversation that we were talking about. As we see declining testosterone and estrogen, the integrity of the muscles in the pelvic floor are changing as well, along with the skeletal muscle. So you are now having this weighted vest, and it's almost kind of like a waist trainer, even though it's not exactly the same. But you're putting more pressure on the pelvic floor when you're adding weight. So I think that that's also something to consider for as well.

A (73:53)

Y. That's a great point.

B (73:56)

I want to talk to you about one of the most important molecules in your body to help keep your energy up as you age. I am talking about nad. High NAD levels help our bodies by creating energy, maintaining healthy DNA and protecting our cellular health. But in our 30s, unfortunately, as young as our 30s, our NAD levels start to plummet. So you need to start supporting your NAD level levels now. I absolutely love a formula that just came out within the last year called Qualia Nad. It is so unique because it has all Three NAD precursors. So for my nerds, those are niacin, niacinamide and nicotinamide riboside, which supports NAD production by boosting your NAD levels by up to 50%. It is vegan, non GMO, gluten free. And if you're over the age of 35, if you want to start taking it now, this will be one of the best things that you can do for your aging process process. To learn more about how NAD can boost your energy, visit qualiolife.com better and use code better to get 15% off. That's Q-U-A-L-I-A L I F E.com better and use code better at checkout. What about if someone is, maybe someone has, they've been diagnosed with, you know, they've had to take extended corticosteroids for whatever reason and, and they sort of have to make a choice between having systemic inflammation and, or bone loss. What are some of the things that an individual might think about in terms of protecting their bone? We know that long term acute corticosteroids, it's not really gonna do much, but long term chronic use of them can certainly affect bone. And then my second question is other medications that are often given for bone, like bisphosphate, kind of thoughts on that. I have, I certainly have some strong thoughts on that too. But long term corticosteroid use?

A (75:53)

Well, actually, I'm going to generalize that a little bit and just say like there are, there are lots of therapies that can result in bone loss. And so corticosteroids, any kind of steroid over a long period of time definitely put you at risk for osteoporosis. So for anybody out there who is taking steroids and even like oral steroids, like an oral inhaler for asthma or you know, like some kind of a lung disease disease, those can do it too. So if you're taking steroids for anything, autoimmune disease, whatever it is, make sure you know what your bone density is and follow it over time. But I want to put another group in there actually, because this is a really similar, not the same population, but a very similar outcome, which is women who are past the initial treatment for breast cancer who are put on either an aromatase inhibitor. Right. Or something that is going to, some have, some have some negative, a negative, some kind of a negative, excuse me, hormonal impact over the course of the next five to 10 years while she's on that therapy. So those are kind of Two of this thing, the same areas for me where I can't tell them not to do that thing. Right. Like, they're going to choose with their oncologist in the breast cancer group to, to do or not do that therapy. And that is, that is up to them. I have opinions on it, but my opinions don't really matter. And then same thing, if a patient needs steroids, like, I can't tell them not to do that because they're, you know, it could be worsening of autoimmune disease or like, whatever it is the reason why they're taking their storage. Right, right. So we have to just accept that that is a factor we're not going to change. But what we need to do is focus on all the things that we can do. Right. So then that is a person who needs to just really nail the other pieces. So while some people might be able to be successful to say, like, you know, I do resistance training three days a week and like, I'm not that serious about it, you know, the person who has one of these big factors against them, we need to really push every lever as hard as we can. Now, one of the things that's nice about being in the steroid group, not that it's nice to be in that group, but you have the ability to still use hormones and hormones are some of the biggest tools. So that's a fortunate scenario to be in. Whereas for women, status post breast cancer, primary treatment, they're very limited in what they can do, for the most part, controversial, but for the most part. And then we have to, you know, understand that we can't use some of these more powerful tools. So you really have to start just focusing on all the things that we know are good for bone and getting really, really clear on what the biggest levers are and just pull them as hard as you can and then continue to monitor over time. Because the last thing you want to do is wait, you know, two, three, five years and then be like, oh my gosh, I lost 40% of my bone mass. And I'd see that. I mean, I've seen it. It's incredible. It happens so fast, fast. So make sure you're monitoring and then catch it quickly. And that's a great way to lead into this next topic, which is bone drugs. So when it comes to bone drugs, you mentioned bisphosphonates. I'll zoom out a little bit, which is there's really two main classes of bone drugs. There's the anti resorptive drugs. So that's the bisphosphonates, that's the phosphomax, the Boniva, the Reclass and then the Prolia also fits in that group. And then there's the anabolic drugs, that's the Forteo and the Temlos and Avenidis sort of bridges the gap between. And so the antiresorptive drugs are the most commonly used. They shut down osteoclast function again, those cells that break down bone. And then by shutting down the osteoclast, they essentially just shut down bone metabolism. So these drugs are really good at slowing down or essentially stopping bone loss. And while you could argue that, you know, should this be your primary treatment for osteoporosis? I think in general for most people the answer is no.

B (79:19)

No.

A (79:20)

But for someone who is in especially a short term treatment or a, you know, maybe not short term, but midterm, you know, a couple years.

B (79:27)

Specifically under five years, like, yeah, under five years.

A (79:29)

Like if you know that you have like, say you're on, you know, five years of tamoxifen, you're losing bone as a breast cancer thriver. Right. So if you're in that group, it's a totally reasonable time to take a drug for three to five years. So you can come out on the other end of that. Not with osteoporosis. Right.

B (79:45)

Yeah.

A (79:46)

Now steroid use is a little bit different because you, that might be indebted. Definite. Right. But even then you could still start to say, well, okay, if I have to use it and I know it's going to get worse, maybe I'll add a drug, you know, during this time where I have to use it more heavily, maybe it's seasonal, like maybe there's some kind of rhythm that you can play with there. So I think there is a time and a place for all of these drugs. And when you have something that is pushing you really hard and you can't control it in any other way, I think that's the time that we should really be considering them.

B (80:12)

Yeah, I really like your, this is a very balanced approach. I think that I share the same opinion with you insofar as I think bisphosphonates or just the anti resorptive drugs in general can be a good short term solution. So in the case that you, you know, in the example that you gave someone who's, you know, she's, you know, beat the breast cancer, but now she's on these medications that can lead her on the other side to be an osteoporotic, osteoporotic when she's done. You know as well as I do that when we use, use using bisphosphonates in particular, we see way, you know, at the five year mark and beyond this is when we start to see actually the opposite effect. You said it shuts down bone metabolism. It's like, okay, so if I get a new femur every 10 years and now I've shut down bone metabolism for half of that. You know, after that we are going to start to see things like cracks in the femoral neck. We are going to start to see cracks all through, you know, some of the big long bones and the pelvis, which is just like, you know, how can I also like, you don't want that. You do not want that. So for a short term fix, no problem. I sort of feel I have the same opinion about GLP1s. It's like, you need to lose weight. It's better for you not to be obese than obese. However, you know, kind of coming back to this, this impact on, on bone, it's like if you can't take in enough substrate, if you can't take in enough food to build your bones, to build your muscles, muscles, you're gonna lose it. Your body's gonna, it's gonna down regulate. And being skinny is not the only metric or you know, measuring stick we'll say for health. So I, I, yeah, I like this idea of like pulses where it's like, you need it right now. Let's give it to you, let's give you what you need. No problem. You need to be, you know, not obese. Let's get you not obese. But in the meantime, let's set you up with some really strong lifestyle habits. Habits where you can not be dependent on the medication because that's not how you're designed to be. And you can, you know, get your exercise, the right type of exercise we've been discussing, the right type of nutrition that we've been discussing so that you can be independent. Like that's real. You know, people talk about like, what's rich? It's like, is it money in the bank or is it like being able to go out down, down your stairs without worrying that you're going to take a fall and not being able to decelerate and crack your hip? You know, there's, yeah, that's sort of my little thank you for coming to my TED talk.

A (82:39)

Yeah, yeah. No, I mean I, so I, yeah, I appreciate that and I want to, I want to talk about the glp ones too. There was another study that just came out. I actually haven't read it yet. Somebody just passed it along to me. So I read the title, that's all I know. But basically the title was suggesting that GLP1s were good for bone health. And I've seen multiple theories on this and smaller studies, you know, like bench studies, studies demonstrating the improvement in bone metabolism with GLP1s. And I think that it is possible that because they are reducing oxidative stress, they're reducing inflammation. We know these things are bad for bone. I think it's possible that they could be good for bone. And most people who are using them are not eating enough protein, as you said. Right. So if you're not getting in the substrate, I can't imagine that in most people using these drugs that they're going to see an improvement in bone. For sure. Sure. Now we know always whenever you lose, whenever you lose mass, you're letting go of weight. Some of that's going to come from lean mass. The question is how much? And when I say lean mass, we know I mean very clearly in the GLP1 weight loss studies, they measured lean mass and we know that up to 40% of that weight loss was in lean mass. But lean mass means both muscle and bone, just to be clear.

B (83:50)

Right, Correct.

A (83:50)

And so, you know, you see this and in people who have been on a weight loss journey, a lot of times they will get a DEXA on the other end. Maybe it's for body comp or whatever. And they have osteoporosis after losing 100 pounds because they lost, they were in such a catabolic state for so long, they lost a lot of bone. So regardless of how you do it, GLP1, not GLP1, whatever, you have to maintain adequate protein. If you eat too much protein, you won't lose weight, but you have to eat adequate protein and do resistance training as you're losing weight to minimize, you're never going to shut down, but to minimize, minimize the amount of lean mass that you're losing.

B (84:25)

I would love to look at those studies because I, I, I can see theoretically how reducing systemic inflammation would, would help bone. Bone needs to be, and bone needs to be mechanically stimulated. Bone needs to be supported with nutrients. It doesn't live, it's not a sigh, it doesn't live in a silo. Right. It's part of, it's part of the endocrine, it's part of the, it's part of the body. So if you don't have Enough nutrients overall all. I can't see how it's not going to suffer. And then there's like the question of like a dosing and management issue. Right. Like you can over. You can give someone too much of it that you know you're just going to end up with an osteoporotic. There was some influencer who was on it to lose weight and she ended up with osteoporosis. She was a young, young.

A (85:05)

She's a young singer.

B (85:06)

Yeah, she was a singer. Yeah, yeah. I can't recall her name but she, it was, she was like 20 something.

A (85:10)

I know who you're talking about. Yeah, I reached out to her. Yeah. So another, another point on that. That is the dose you mentioned dose. I think that there is probably a role and we need to see better evidence on this. But at what dose do you see the systemic inflammation reduction?

B (85:26)

Yeah.

A (85:26)

Right. So like, I mean the whole topic of microdosing, like, you know, what dose do we need to lose weight? We don't know the answer to that either. But what dose do we need to reduce the inflammation? And it might be that maybe if you look at, and oh, you know what? I did look at this study a little bit deeper. It was in diabetics using it for blood sugar, not for weight loss. This is why. Right. So they weren't necessarily losing weight. So I think if you're using it in a, in a way that you are essentially diabetics because they're going to have underlying pathology, it's going to lead, likely to more inflammation. Right. So if you're using something that reduces inflammation, oxidative stress and you're not losing weight, then that can be a powerful tool. And then also if you're using a very low dose, like a quote unquote microdose, whatever that means, means if you're using a very low dose but that reaches your threshold for inflammation, then I think it could also be beneficial. And I've been playing with this myself using smaller and smaller doses of both semaglutide and tirzepatide. And I can tell you that even personally I definitely feel even a very small dose of tirzepatide, I feel less inflammation in my body, less joint pain. So I don't know what those numbers are. I would love to see good studies on this, but I do think it's possible in the future we might see, see this sort of very like quote unquote sub therapeutic according to the endocrinologists.

B (86:37)

Yeah.

A (86:38)

But a micro dose where we are seeing the impact of inflammation reduction.

B (86:41)

Yeah. And joints. I mean, this is the, I mean, if you want to talk about, like, the real flex for longevity, it's. It's good joints. Like, you can't squat if you don't have good knees. You can't do a pull up if you don't have a good shoulder or good shoulder articulation and good, you know, subscap, you know, scapular movement and all of that. So, like, the real, like, I love that there's at least some, you know, case studies and of ones kind of floating around where it's like, yeah, joint pain, you know, feels better on a smaller dose. Like, I think that, you know, time will tell in terms of some of the, some of the research. And in the meantime, we have to deal with some of the infighting between, between the people who are like, team microdose. And people are like, no, team needle.

A (87:19)

I mean, I wonder who's, like, who's doing, who's going to do this research, though? I mean, the pharmaceutical companies are not motivated to do.

B (87:24)

Right, right, right.

A (87:25)

So then how do we get, how do we get large enough studies? I think we're going to be kind of stuck with these, with these smaller studies, these case control studies. You know, I don't know, I'd love to see somebody study it because I think it could be from a chronic disease perspective. It could be massive.

B (87:37)

Yeah, yeah, yeah. I mean, there are some good regenerative. Like, I have a good friend of mine, Tina Moore, who talks about microdosing, talks about this idea of, like, it being a regenerative, like it's, you know, endogenous, like we produce it, but at really low doses can be incredibly regenerative for some of the things we've been talking about, autoimmunity and, you know, joint pain, spinal pain, all, all the things. So yeah, yeah, yeah. Time will tell. This has been such a fascinating conversation, I gotta say. Prunes, man, like, that's my big takeaway is as a. Their own intervention for osteoporosis. I love the podcast because I get to learn things and I get to learn it from brilliant minds such as yourself. Thank you so much for spending the time today with, with us.

A (88:16)

Well, thank you for having me. I really appreciate the opportunity to talk to your audience.

B (88:20)

Awesome. All right, so where can people find more about you, Doc? If they want to find out more about your work, maybe they want to work with you. They want to join trainings or anything that you might have.

A (88:30)

Sure. So we, we spend a lot of time and effort putting together social media content and long form content on our, our YouTube channel, the Dr. Doug Show. So that's on YouTube. It's also available as a podcast. And that's all, of course, free. Our community, if you want to dig in deeper and look at some of the resources that we've created, that's called the Osteo collective and that's osteocollective.com and it's a fantastic group of mostly women and a few men who are improving their bone health naturally over time. And it's a really great organization to be a part of.

B (89:00)

Fantastic. We will make sure that all of that is clickable links in the show notes.

A (89:04)

Great. Thank you.

B (89:08)

All right, welcome to the after party where I tell you what I really, really think about the episode the Good, the Bad, the Ugly and the Brilliant. And this episode did not disappoint. Y' all know that I love to talk about bones and all the other tissues that go with you in addition to muscle to the gym. And we talked a lot about bone health today. And so, as you know, if you're listening to this, so a couple of my favorite moments, probably, like the number one highlight was the prunes. Like, I don't know if you saw, if you're, if you're listening to this or if you saw my face, but I was like, prunes, prunes, What? As an independent intervention for osteoporosis. Like, that's amazing. And the whole talk about boron, like, being, you know, maybe it's, you know, not native to Earth. I thought that that was. I'm gonna go on my own little nerd safari now and try to figure out everything that I can find out about boron, because I've always known that boron, phosphorus, you know, magnesium, vitamin D, these are essential for bone health. All types of bone, whether it's, you know, cortical, bone cancellous, but like all the different types of bone, which we didn't talk about today, but that's just me nerding out with you. But boron, yeah, yeah. Super cool prunes. Super duper cool. So loved that. I really liked the explanation that he gave around the different impact that hormone has. Hormones have on bones. So estradiol being inhibitory to osteoclast, progesterone being proliferative to osteoblasts and then testosterone, kind of doing a little bit of both. Doing God's work, if you will, doing a little bit of both progesterone and estradio impact. And then of course, the DHEA conversation. And then I don't know if you picked up on it, but when we were talking about like worst exercises to best, you know, when he was like running, I was like, wait a minute, what about, what about, what about sprinting? My favorite sprinting. He was like, wait, wait, I, I'll get to it, I'll get to it, don't you worry. So we started with swimming, long distance running, cycling, and then talked about sprinting and the impact that that has on bone turnover and rejuvenation. I just love this conversation because I think that there's, there's so much misinformation online about things like weighted vests being really good for bone or taking calcium as being really good for bone. And really thinking about what are some of the interventions that we can think about for our young girls, our teenagers, so that they can reach peak bone density and then how that can really serve us over the arc of a woman's life when we see some of these, you know, proliferative hormonal changes through pregnancy, postpartum perimenopause and menopause and how, what are some strategies that actually work? And so I really enjoyed our conversation on GLP1s and the bisphosphonates like the antiresorptive drugs and the anabolic drugs as ways to maybe be temporary solutions and also getting in to place some of the main tenants that really, that really do drive the needle. Overall, like super nerdy conversation. I love it when someone can jam. Like he was, he was like talking about the lift more trials. And I was like, oh yes, let's go, let's talk about this. So really, really love someone knows their research and also marries that with clinical practice. It's like that is a man after my own heart. Because that is something that I love to do as well. I love to marry the science with the application for real life. It's one thing to talk about a barbell back squat in isolation. It's another thing to actually get someone who's never lifted weights before and get them and get them to lift weights. Right. We're definitely not starting off with a barbell back squat with one of those, with one of those individuals. We're going to get started with a calisthenic, like a body weight type of movement. So very nuanced discussion. I think that going to be something that is important for obviously I'm hoping that this was valuable for you, but if there's another woman in your life that you think would benefit from this podcast, my ask is that you share it with her with love and with obviously the intention that you can both do better together, which is the philosophy of the show. So until next time, I bid you adieu. Thank you so much for listening, as always, and we'll catch you then. All right, I All right. I hope you enjoyed today's episode and I must give you the obligatory legal and medical disclaimer here. This podcast, Better with Dr. Stephanie, is for general information only and the advice recommendations we discuss do not replace medicine, chiropractic or any other primary healthcare provider's advice, treatment or care in the consumption of this podcast. There is no doctor patient relationship that has been formed and the use and implementation of the information discussed are at the sole discretion of the listener. The information and opinions shared on this podcast are not intended to be a substitute for primary care diagnosis or treatment. In other words, guys, be smart about this. Take it with a grain of salt. Take this information to your primary healthcare provider provider and have a discussion with him or her to make the best choice. That is for you. Remember, I am a doctor, but I am not your doctor and these conversations are meant for educational purposes only.