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The Dr. Hyman Show
Women 40+: Become Unbreakable (The Midlife Muscle Fix) w/ Dr. Vonda Wright
01:05:00
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Coming up on this episode of the.
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Dr. Hyman show, women and men age differently. Women are already winning the longevity race. We live 4.5 to 6 years longer than our partners, but we do not age well for women. I call 35 to 45 the critical decade.
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Double board certified orthopaedic surgeon Dr. Vonda.
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Wright is a recognized voice on performance and longevity. Bringing pro level science to women's everyday health.
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Take us down where we were, where it went wrong and what we have to do now.
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Historically, the research dollars that are allocated to things that predominantly affect women over 40 is about 1 to 2% of the total research dollars. And yet women over 40 are 25%.
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Of the population created a six week protocol. You talked about strength as the antidote declining. What about the role of hormones? What about the role of food? What about the role of the strength training and other exercise to be unbreakable.
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C
Subscription starter kit VONDA welcome to the Dr. Hyman Show. So good to have you. Followed your work for a while and I just think you've got a lot of good things to say.
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B
Thank you so much for having me.
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C
Plus, it's really cool that you're a woman orthopedic surgeon because there's not that many of them. I think you said 6%. My daughter just got into orthopedic residency at Dartmouth, so I'm very proud of her. There were 900 applicants for four spots and she got one of them and was the only woman. So it's funny because a lot of the bone issues really relate to women predominantly and men get affected too. But it's, it's interesting that that's how it's such a man's profession. But, you know, one of the things I sort of want to dive in is as, as you've sort of written this new book, Unbreakable, which is out now, you, you kind of dive into this aspect of women's longevity and health. What I found in studying longevity is that, and I think you've seen the same thing, is that as we get older, we seem to see a progressive decline in health and function across the population. And so we've come to accept this as normal, as just a completely normal phenomena that there's not much we can do about. I was so inspired when I was younger by this book, which you kind of hinted at when we were chatting before. The podcast called Growing Old is Not for Sissies.
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B
Yes.
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C
It was a photography book about older athletes, men and women who were really phenomenal athletes who actually often started late in life and were able to gain a lot of function and gain a lot of strength and gain a lot of mobility and gain a lot of health. And so I kind of like you to start out by helping us unpack, you know, what is happening in the field of women's health, particularly around aging, menopause, and the consequences that happen as a result in terms of their overall health, in terms of frailty, muscle loss, bone loss, because you talk a lot about osteoporosis and hip fractures, but what doesn't get talked about enough is muscle loss or sarcopenia. And that, that to me is a bigger problem.
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I was so inspired by those books early on when, when I first read them, I was still in my residency, that when I returned to the University of Pittsburgh, I set out to prove that this common conception of vitality to decline didn't have to be inevitable. Because, you know, I was thrilled to be surrounded by so many brilliant researchers, part of big NIH studies who studied populations and said these things. But what do we know about our population? 70% of people do. No form of actual exercise or food is medicine, right? They're just throwing it in the garbage can of the body, right? And so I started studying masters athletes. You had to be 40 and above, you had to be competing, but you could not be a pro. And in summary, 15 years of research, we found you can keep your muscle, you can keep your bone, you can keep your brain. We can revitalize stem cells with simple things like chronic exercise. So now I hold the opinion that while aging from the moment of our conception to the minute of our death is what happens, it's the most natural part of living. Aging poorly can be influenced. But what has happened in the national conversation is when we think of longevity, principally because most of the writers have been men, we view it from that standpoint. But men and women age differently. Men start to have a decline in their testosterone, and the hallmarks of aging gradually put them through a decline with, if you, if the new paper came out last year, two blips at 44 and about 60 of more rapid decline. And women also go through normal aging. If we take bone, for instance, normal aging is about 1% decline for men and women from about 30. However, that is not the whole story for women. For women, beginning and now we think earlier. I call 35 to 45 the critical decade, early 40s. We have so few eggs left, we are not producing the estrogen we once did. And our aging becomes rapidly increased. So how does that manifest? Well, frankly, women are already winning the longevity race. We live 4.5 to 6 years longer than our partners, men, but we do not age well. We may suffer for 20 years because of the precipitous decline in our estrogen. Every tissue in the body, from brain to muscle to bone, heart, have estrogen alpha and beta receptors. And when estrogen is no longer sitting in those baskets, all the beautiful downstream protein transcription, all the things estrogen does, doesn't happen. So women and men age differently, but so little research has been done on women specifically. Less than 1% of all research dollars are spent on women over 40 that we have so many answers. You know, I'm excited for your daughter. She can help me bring musculosal aging to orthopedic surgeons. Right. I'll recruit her.
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C
Yeah. Hopefully she's got a mind of her own, so she'll do whatever she wants. Maybe you can talk to her. I think the point you bring up is really important because I think what we see is normal aging is really abnormal aging. And especially in women, become frail, unable to function, fall easily, break hips. And you know, I think the data, you might correct me on this, but I think the mortality rate for a broken hip at a year is about 50%, meaning if you have a hip fracture, your likelihood of being dead in a year is 50%. And that, that's pretty scary. And it's something that is really preventable.
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It is.
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And it's something that we talk about diagnosing and treating, but it's still poorly done. And what's even more poorly done is diagnosing and treating muscle loss. And I, and I wonder if you could kind dive into the way in which, you know, this, this sort of transition that happened in medicine from being fanatical about giving all women hormone therapy at menopause to it being something that was thought to be harmful and dangerous and was stopped. And this all happened in 2002 when the initial data from the Women's Health Initiative came out. And I was practicing medicine then at Kenya Ranch and I was seeing women between the ages of 45 and 60 who were all in this kind of period of time. And it was chaos because all of a sudden you had all these women who were stabilized on hormones and then they got off the hormones and they had severe symptoms and, and the long term consequences of this study, I think, you know, have done women a disservice. And I think there is a recent conversation from the FDA commissioner, Marty McCary, who's a friend, about how we, we really got it wrong on the Women's Health Initiative and we really vilified hormone therapy and we might want to reconsider it, especially around, you know, bone health and sexual health and brain health and many other things. I'd love you to maybe sort of unpack that a little bit and kind of take us down where, where we were, where, where it went wrong and what we have to do now, what we should be doing for women now.
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B
The women's Health initiative was a big NIH funded study. It had a study group headed by a Dr. Rousseau and many of the other research living and participating. One participated, Joanne Manson in the FDA panel that I did a couple weeks ago. And so that study was meant to answer a question about cardiovascular disease. So it used conjugated equine estrogen plus or minus a progestin, looking at the outcomes question of cardiovascular disease. But it was stopped early. Oh, and because it was going to look at that, it recruited women in their early to late 60s. These were not young women, these were not perimenopausal women. So the study was stopped early. And a press conference was called before, if I understand this correctly, from talking to the actual participants, before the study group was even consulted about the data. So it got out ahead of time. And the statement was made that estrogen causes breast cancer. And the 40% of all women prior to that statement that were on menopause hormone therapy were removed either by themselves or by their doctors to the tune of today, it's estimated that less than 4% of all women now this many, 23 years later, have decided to do menopause hormone therapy. But what did the data say? What was the pivotal data that scared the holy bejesus out of generations of women? And if I were a baby booming woman, I would be so angry right now because they're the ones that really missed out on this because my generation, the Xers, you know, we're, we're the ones driving this. So what happened was the, the study showed that without estrogen, the, the diagnosis of breast cancer was three out of a thousand. So envision a auditorium of a thousand people. Three were diagnosed with breast cancer without estrogen on hormones. For the group, the study group with estrogen on board, 3.83. 3.8 minus 3 is less than one woman per thousand. Additional diagnosis. We change an entire culture of medicine for. Let me finish, let me finish my thought because I don't want people.
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And that's, that's what we call absolute risk. Yeah.
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I do not want people to think I do not value breast cancer and I'll tell you why. But less than one per thousand. However, there was no increase in death from breast cancer from that study.
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Was there an increase in heart attacks and stroke as well from that group?
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From background? Well, they were very old women. We don't know what was old.
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And we just point out to people is that the hormones that they picked were the ones that were popular at the time on patent, that were pharmaceutically kind of incentivized that actually we're not like your body's own hormones. Right. The horse estrogen and the Provera, which is basically makes women gain weight and grow facial hair and become depressed. So there are. There. There are real substantial differences in the way these hormones affect you. And they basically just sort of canned all the hormones and said, as a group, they're harmful, rather than being nuanced about the conversation in terms of how they affected women's health.
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Absolutely. And we have yet to recover, because I am not well. Number one, I want to clarify. I am not saying that the risk of breast cancer, the scare of breast cancer has to be totally negated. I'm just saying it has to be nuanced. Right. I mean, I started my career as a cancer nurse, and so. So I am. I am really conscious of what women go through. But to represent the data in that way has done damage to several generations of women. And we, Most of us agree on that at this point. And how do we backtrack and how do we. For instance, we were at the FDA with the main reason. I was talking about bones, but with the main reason of giving data for Dr. McCrary to remove the box warning on vaginal estrogen, which has nothing to do with systemic absorption. Right. And yet all the warnings are put on that package insert with no evidence. Right. So that's what we were trying to do with. Hopefully, there'll be a reexamination going forwards, because that's what we need.
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C
I think that's important, Rhonda, because I think, you know, women deserve to have optimal medical care, and they deserve to have their symptoms not dismissed, and they deserve to be treated proactively for things that can catch up with them when they hit their six, seven, eight decades. And it's just not happening in medicine. It's really unfortunate. So you're an orthopedic surgeon, but you're also probably involved in thinking about how a woman's hormonal health should be regulated and managed and.
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B
Absolutely.
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And how it affects their bones and their performance and their. Their brain function. I mean, I think. I think there's some newer data that if women start hormones early, after, during menopause, rather than waiting, like, say, 10 years, that it will be very protective for their brain. And Alzheimer's, which is. Which is important because a lot of women, more than men, get Alzheimer's in the heart and their heart. Yeah.
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And data exists from the European osteoporosis group that we actually. To protect our bones in Late age probably need to be replacing our estrogen for 10 years, so we can't start it at 65. It's better if we address this in perimenopause and Never lose the 15 to 20% of bone in the first place. Because as we started this conversation, bone loss for men and women is part of aging. I mean, 2 million men in the United States, I wrote this paper in 2006, have osteoporosis. So it's not just a disease of women, but women rapidly decline to the tune of 40% will have osteoporosis. If you have osteoporosis, one in two of you, me or your daughter, will have a fracture. If it's a hip fracture. 70% of all hip fractures are in women. And the minute, the minute you snap your femur, it infers the death percentage. You know, I've read 30%, and that 50% never return to pre fall function, meaning you can't live in your home. So that means you get a full time nurse, you move in with your kids, or you go to a nursing home. I mean, those are decisions that we can get in front of Mark if we do it early enough. Right? The critical decade, 35 to 45.
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And so, so if you're, if you're listening and you're a woman, you're wondering, okay, well, how do I avoid all this stuff and what do I do? And you know, I know that, that women's strength training has become more talked about. My friend Gabrielle Lyon has talked a lot about this, and I think, you know, she's got more muscles than I do. This is something that is not part of the medical conversation. I didn't learn about it in medical school. I don't know about you, but most doctors, I don't think, learn about sarcopenia, what it is, how to diagnose it, what implications there are for it. It's not just muscle that's moving around your skeleton. It's such an important metabolic immune organ that regulates so many things, even your brain function. So can you kind of break down this whole concept of sarcopenia? What is it and why is it important? And what proactively can women do to not get it? Because ultimately, if you want to age well, this is the key.
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So sarcopenia is one of the hallmarks of aging, which talks about the natural decline in the volume, strength and function of our muscle tissue. Because to your point, muscle is not just what we see in the gym mirror moving our bones around. Muscle is a metabolic organ, secreting proteins. I mean, one of them. If we take irisin, for instance, it's a protein being secreted by the muscle. It has an influence over bone density. It has an influence over turning white fat to brown fat. If you look at a protein muscle transcribes for called gallonin galanin, goes right to the brain and helps with mental resilience. So muscle has so many functions, but over time, it's estimated that we'll lose 3 to 8% per decade. After 30, if we don't do anything about it. Right. If we just sit like a lump, like a mushroom, we will lose it. So sarcopenia is actually a functional description of absolute muscle mass. How fast you can get up from a chair. Not just absolute. You know, are you. Do you have any muscle? It's how fast you can use it. Because when you can't get up from a chair, that's one of the main reasons people end up in nursing homes. 70% of all nursing home residents are women, right?
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C
Yeah.
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And so we can start ahead and rebuild muscle through lifting. And I'll describe to you how I like the women I work with to lift and feeding our muscle. Because I find most women, and I'm a whole person pod, I talk all about this to every woman. I mean, it doesn't really fit in 15 minutes insurance companies give us. But I talk about this to everybody. We have to feed our muscle to build it, because we can, at every age, we can get in front of it. So how do I like women to lift? Well, I think we need to define what we're lifting for. Right. Because I get a lot of comments about, about how I prescribe lifting, because no matter what we do, we want to lift a failure. So if we're lifting for endurance, say we're just trying to build endurance. We choose the lightest weight and we lift it 25 times until we fail. Right. I had a woman come into me a couple weeks ago who was instructed to do that. Well, that's gonna build endurance. That is not gonna help you not fall down or get up from a chair. The other kind of lifting we do, and I did this for years in midlife, is hypertrophy. Right. We're trying to build muscle, and you will get stronger, but that takes rep sets of between 10 and 15 reps to failure. But when I talk about what are we lifting for in menopause and beyond, we are lifting for strength and power. Because what do I want to do? Well, I don't know about you, but when I'm 97. I want to do what I want, when I want it. What? I don't want to have to ask my neighbor for help unless I want to. I need to be strong to get strong. We lift heavier weights, fewer reps, because it does two things. Number one, at first, it re recruits the neuromuscular bundles. Right? One nerve innervates a muscle fiber bundle, and it recruits all those to fire together to be stronger. And after you re coordinate neuromuscular pathways, then you will actually build muscle strength. Right. When you have done that, and we are interested in lifting for power, it means strength through time. Because when I leave my red bag on the side of my desk and I get up too quick and I don't have the fast twitch muscle, the ability to be strong over time, the explosiveness, I'll trip and fall and I'll have a fatal fall sometimes. So power is added with a little bit of tempo lifting, which is a different way to lift than we typically do in our youth.
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C
So how is that you're saying that the Hypertrophy is like 10 to 15 reps to failure? What you're talking about is different is.
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B
Three to six is the range.
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I have three to six reps, three.
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To six reps to failure. So what does that look like?
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C
That's very low.
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B
It's very low on my bench press. And it's not all we do. I'll explain myself. But for instance, on the four power lifts, the push, the pull over the upper body, push the pole, the squat, the deadlift of the lower body. If I can lift four reps, I may be able to push out a fifth, but I can't do a sixth, for instance. Right. That is what I mean. And the question that comes up is, but wait, wait, wait. What if you already have osteoporosis? Can you load like that? Two answers. Number one, not tomorrow. It takes a while to build up the resilience in your bones, your tendons, your muscles, your ligaments. But yes, you can build up over six to nine to 12 months. And Dr. Back did a study called the Liftmore study that showed even women with frank osteoporosis could lift heavy five reps, five sets under supervision, and not break. So yes, you can lift heavy, even.
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C
With bones, but you have to do five sets of like, low reps. Yeah.
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B
There'S a range, but, you know, it's.
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C
A lot of reps.
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I've been taking care of people so long, I feel I found that I can't give them a range. I need to give Them instructions.
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C
Exactly, exactly. But how about the risk of injury? Because you know, I think when you think about lifting heavier, there's a bigger risk of injury, right?
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B
Well, not necessarily, but I understand why people say that. When we're doing really high reps with bad form, when we're doing high reps, 10 to 15 with form that's questionable, which is what I see all the time. My office is in the performance club in Lake Nona. You may have been there on your trips here. I see some of the worst form I've ever seen. And it's not just here, it's everywhere. It's ballistic, it's bad form. It's not, it's not a well aligned. That's what causes injury. When you are taught to lift with great form and you do it methodically, we're doing fewer reps so that's less wear and tear. We're doing it carefully. So can there be energy? Energy injury? Sure, of course. It's how I make my living. Does it manifest injury? Not necessarily.
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C
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- [24:17]
A
Even certain thyroid hormones.
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C
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- [25:26]
A
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C
Listening to this and you're a 60 year old woman and you've never been in the gym before. You've done cardio, you've done aerobics back in the 60s, I know we all did it 80s you've done, you know, you've played tennis, you exercise, but you've never been lifting. Is it too late if you've gotten a significant amount of muscle loss, it.
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B
Is never too late because our body is meant to respond to the strategic stress we give it. And I have lots of anecdotal examples, not only people that I've seen people in social media. This book that we keep referring to aging is not for sissies time and time again but that takes consistency over time. So I have this friend, let's answer this question directly. I have this friend named Susan, she lives in Tampa who during COVID she was 63, she was 51 pounds overweight, probably 51% body fat and she was just sick and tired of feeling sick and tired. So she took the time over Covid and she walked, she ate protein and she went, she got a digital program, she learned how to lift and it took her a year to really learn how to lift in a powerful way. But over the course of 18 months she lost 51 pounds. She grew so much Muscle. She started competing as a powerlifter. I mean, and I can show you her pictures online now. She is not the same woman. But you know what it did, most importantly, Mark? It gave her a new, hopeful lease on life. Because when you are sitting in a state of dis health and everything hurts and your brain is all muddled, there is no hope. But then when you see your body responding to even the small things that build one on top of each other, I think that's the most critically thing important that she did.
- [28:17]
C
Yeah, I agree. I mean, I think, I think it's. It's so underestimated the power of that. And for me, I, I always recommend it to my patients. But I was, you know, a skinny guy. I loved running, I biked. I didn't really think weightlifting was necessary. I could do yoga, Pilates, I would get strong from that. And I, and I kind of told myself a line of, basically. And I, I didn't really like the smelly gyms. I was intimidated. Like, you go into Gold's Gym in Venice and it's like all these guys with giant muscles and I'm just a skinny guy. I'm like. So I, I basically didn't start Till I was 59, and I was sort of shocked at what happened to my body at 59 years old.
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B
Yeah.
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C
By just doing steady, consistent training on a regular basis over time.
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B
Yeah.
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C
Profound. And I, I don't know if you know this, but I had recently had a back issue and had a spinal abscess and had a fusion and was pretty sick and lost like 20 plus pounds of muscle because I didn't have any fat to lose.
- [29:15]
B
Yeah.
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C
And at 65 years old, I've literally been able to gain all that back, plus some because I've been more religious about being in the gym. And it's been just a shock to me to see at 65 what the body's capable of in terms of recovery, repair, and building back. Not even what I had, but more than I had. And I think that's something that was sort of a lesson that most people don't think is possible. It's like, oh, you know, I'm older, I haven't really done it my whole life, and I'm a little intimidated. But what you're saying is, no matter when you think of it, you know, it's like people say, when should I take my vitamins? And say, when you think of it, when did you start, when did you start strength training? Like, you know, it's never too late. And I Think that's an important message. So you have to learn how to do it right. I think that's what you're talking about. It was form as opposed to doing it in a ways that they can injure yourself.
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B
Some of the. Just finish on that. The original research I read when I was starting our 15 year research project was done by a researcher named Maria Featureone, who did research in 90 year old men living in a nursing home. And she put them through chair exercises and over six weeks they increased in function 150%. Now a lot of that was by retraining neuromuscular pathways, but it goes to show us there is never a time so.
- [30:33]
C
So take us through. Like you, you created this six week protocol. You've talked about strength as the antidote, declining you, you recommend a series of assessments and tests to look at mobility risk. What, where should people start in terms of diagnostics? And also what about the role of hormones? What about the role of, of food? What about the role of, of the strength training and other exercise to be unbreakable.
- [30:53]
B
So when people come to me and want to talk about their longevity and, and all the things that they read, many people come to me with health. That is fine. Air quoting fine. They're not optimized. Their labs are not amazing. They're living midlife labs with hyperlipidemia, maybe some insulin resistance, but they want to skip ahead. And this is natural. I mean gadgets are cute to all the biohacking and longevity things that are research influenced but not evidence based. So my approach is always to start by optimizing health. And for me that is understanding the organs, understanding inflammation, understanding how the body moves. I do a movement assessment with 360 degree cameras. We do lactate threshold on a treadmill or bike to look at where your heart rate is in the zones. Because I work in a place with all the bells and whistles, so I can do those assessments. And when we are optimized, then we do the other things. But then how do I optimize them? Well, we, when we talk about activity, you can talk about nutrition, but when we talk about activity, we already talked ad nauseam about weightlifting. So I use an acronym called face. I've always used this. Again, I'm a clinician. My patients need cues, right? So F, A, C, E are all the things we need to think about. So F is flexibility and joint mobility because none of us are trying to become the shuffling old person hunched over with very limited range of motion. So our tendons, ligaments and muscles need to be stretched out to optimum length daily. And that's where Pilates and yoga is a fine practice. It can't be the only practice, because the natural history of collagen fibers in the musculoskeletal system is to increase their covalent bonding and to become stiffer with age. And that's why.
- [32:45]
C
Tell me about it.
- [32:45]
B
Yeah, I know you went through a hard time. So that's F. A is aerobic. You know, I was a runner. I did marathons. I was all into the orange theory thing. Working in that middle heart rate that was neither metabolically optimal nor was it pushing myself like I was going to die right now when I prescribe, and this is good for injury too, I prescribe base training and sprinting. Heart rate. Sprinting. It doesn't have to be physical sprinting, it can be rowing, climbing. And that's based on the research of. Again, I work in this miraculous place. Anigo San Martino, who trained Tour de France cyclists. It's his protocols we use to say, you're going to work at base training, which is lower heart rate. And then twice a week you're going to.
- [33:34]
C
Is that what they call zone two?
- [33:35]
B
Yeah, I hate to use that word because sometimes in social media it gets the wrong thing, but yeah, base training, zone two, it's the heart rate and we actually test it. So I'm not guessing. We test with a finger stick where you convert from metabolizing fat to metabolizing carbohydrates. And that's called your lactate threshold. And it's that heart rate I aim people for because that's where your mitochondria are most flexible. They can use any substrate then, right? And then we start sprint. And then when people have optimized like that and want to move on to peak performance, that's where I add in VO2 max training, because that's hard, right? So F, A, C, C carry a load. We've talked about it, but E is something I talk about a lot now. Equilibrium and foot speed. I teach people to balance because it's the fatal fall that'll kill you. And I teach people foot speed. Speed just like our speed. We have a speed coach. We're training Olympic athletes to sprint faster. We're teaching mere mortals who have lost their. Their type 2 muscle fibers to move their feet faster. Whether they're the 50 year old woman who comes to my retreats or you're the 60 year old guy who wants to summit Mount Everest for the last base camp for the last time. I Have all comers.
- [34:57]
C
So that's kind of the fitness part, right? So it's.
- [35:00]
B
Yeah.
- [35:00]
C
So all the flexibility, aerobics, carry a load, equilibrium, equilibrium, balance, all that super important. And that's a great way to think about fitness because it's not just about cardio fitness or strength training. It's about flexibility. It's about balance stability. And I think stability training is really important. I noticed actually, you know, I started doing more stability training and, you know, I find it easier to dance around rocks when I'm going down a hill. Like when I was younger, I could just like run down a hill and I was less able to do that. But when I started working on that core strength and that stability, it really. That's the thing that makes people fall. When you, when you fall like a tree in the forest and go boom, that's when you break something. You know, like when you fall and catch yourself, you're not going to break something. And you can't catch yourself if your reflex or slow if you're not, you know, strong, if you don't have core strength. So all that's really important. Important. There's other pieces that have to do with. With women's health that's really important beyond exercise. Right. So the full health span blueprint, which is really a systems approach to dealing with their diet, with hormones, with, you know, other things, supplements, maybe. So what do you think in terms of the other pieces of longevity and health for. For aging?
- [36:12]
B
I would like all people in the critical decade, 35 to 45, to read enough about menopause hormone treatment to make their decision ahead of time. So the minute they start experiencing the most common things, they immediately go and they start. Now. I'm a firm believer that we are all sentient beings and we get to decide. But I refuse to let you decide based on fear. You must decide based on facts. And this happens every day in my clinic. It happened Monday in my clinic. I ask a woman had she considered menopause hormone therapy and she says, no, that causes cancer just like that. And I had to take the time to. So, number one, we must make our hormone decision. Not only estrogen, progesterone, testosterone, not only systemic, but vaginal estrogen is known to decrease the incidence of UTIs by more than 30%. Women. Women die of UTIs and they're preventable. Bladder infections, of course, bladder infections, not to mention all the sexual health benefits. And that is not absorbed. Every woman, no matter what your health history, can have that also. I mean, I'm as vain as they get. I like it on my face.
- [37:26]
C
You put it on your face?
- [37:27]
B
I do. You know, I'm almost 60. I'm as vain as they come. If I'm going to lose 30% of the collagen in my face, I'm going to help those girls out, right? It's not absorbed systemically. So that's what I mean. We have to consider all avenues as step one, in addition to the exercise.
- [37:45]
C
Well, let's talk about the hormones for a minute. I mean, there's different versions of them, right? There's the Premarin, which is a pregnant mare's urine, which I wouldn't recommend. But then there's the natural or bioidentical hormones. And it comes in pills, it comes in patches, it comes in gels, it comes in creams, it comes in vaginal rings, it comes in vaginal tablets, vaginal cream. How do you, how do you advise people to think about these different approaches? Should you do, should you do oral, should you do topical? Because you're saying you put it on your face, it doesn't get absorbed, but it, it does get absorbed through your skin a bit like that's why these.
- [38:20]
B
But the dose is so low, it doesn't, I mean, studies have been done. The dose is so low that it doesn't cause a bump systemically. Those studies have been done. So let's take a, let's talk about systems.
- [38:31]
C
And when you take it by mouth, it goes through your liver and you take a lot more of it and then you get this big, big effect.
- [38:36]
B
First, let's talk about synthetic horse, mare, right? They're gathering a variety of estrogens from pregnant horse, mare versus what does bioidentical really mean? I mean, it's kind of a marketing word, but it means that the estradiol molecule that is synthesized for medicinal use is the same that our body makes. Let's just to clarify that then route, right. Premarin comes as a pill. Estradiol systemically can come as a pill, but then it has first passed through the liver. Most of us prescribe it as a patch because it's FDA approved. We know what you're getting. And then sometimes people have it compounded. But then when we compound in a compounding pharmacy as a cream, you have to be very careful that that pharmacy is as has a high quality product because it's being stirred in a batch. Right? So but that is systemic. When I'm talking about vaginal estrogen, it's estradiol, but the dose is so low that it does not elevate systemic levels. And studies have been done testing blood levels with vaginal insertion of the cream of the pill, of the, of the little plastic thing called invexi. Now, vaginal rings which are put around the cervix are such high dose that they are absorbed. So the, so the nuance is in the dose that you're giving. The same for the face. The, you can put estradiol and a cream on your face, but the most common ones are estriol, which is one of the three kinds of estrogen. And again, the dose is so low it's absorbed, but not systemically. And we know that from studies that measure blood levels.
- [40:26]
C
So this really, you have to work with a doctor who's able to navigate this space, who's knowledgeable and isn't just going to give you the standard treatment, which is permanent Provera. And it's customized for each individual depending on what their issues are. If they're having hot flashes, if they're having low libido, if they're having sleep issues, if they're having brain fog, if they're having vaginal dryness. There's different approaches and I think it's important for them to understand that it's not just a one size fits all treatment and it's really customized. And that something I, I think I've learned a lot from my, my own patients and how to, how to do this. So in terms of other things that, that are include like food or supplements, you know, how do you think about those in terms of longevity, in terms of women's health and long term healthy aging?
- [41:11]
B
I find that women in my generation and older were raised in the time where aerobics was king queen and we were taught to not eat. I question women in my clinic and I find that many of them have coffee for breakfast, they have a salad for lunch, and they may have dinner with a couple glasses of wine. They share a bottle of wine across the table. So that adds up to less than 1,000 calories and less than 60 grams of protein. And so we're not feeding this miraculous engine that we are. Right. And so when I teach about nutrition, it's often starting with macros. What are we actually eating? Let's track our food and prove to you that you're under eating. Because women in my generation and above are afraid of gaining weight. We've been so conditioned, right? And they bought into the muscle weighs more. Well, muscle does weigh more, but you'll be leaner. Muscle is nature's sphinx.
- [42:06]
C
You look better you look better, your.
- [42:08]
B
Clothes will fit better. And isn't that what you want anyway, Right? So we started talking about macros. We educate what a protein actually is. I answer the questions that, no, I aim for 130 grams of protein a day because I'm a muscly girl. I'm short, but I'm a muscly girl. It's not a high volume of food. When you have a chicken breast the size of my hand, it's lean, has 40 grams of protein and it's not even 200 calories. Right. So that education is critical. So I focus on protein. I'm one of those people that you must have enough protein, your carbs should be high fiber. We're going to cut out the simple sugar. We're going to cut out all the white stuff we eat that you talk about all the time. And then I'm not an enemy of fat, but it has to be good fat like avocados and healthy fats for us in a balanced way. But I find that there's so misinformation and we live in a society. I don't have to tell you or your listeners with this over processed garbage can approach. It's a lot of re education.
- [43:12]
C
It is. I think it's important and I think, you know, there's so much involved in women's health as they get older in terms of the quality of their diet, in terms of the role of alcohol and how it's increased the risk of breast cancer, in terms of the gut health and microbiome and that's role in hormone metabolism and the role, like you said, of protein and muscle mass and metabolism and the role of higher doses of starch and sugar as we get older, more problematic for us because we become more insulin resistant. So there's a whole cascade of things that women should think about. Any supplements, you're like, you got to be on this. I mean, women think, and I still think this is really striking to me because women are like, I need to take a lot of calcium and my doctor says I need to take 1500 milligrams of calcium A day. And he gives them a prescription for 1500 milligrams of calcium, not realizing that's the total dose for the entire day. And it less matters what calcium you take in and how much more than how much you put out. Like, for example, in Africa, they consume probably 300 milligrams of calcium a day, but they retain, retain the calcium and they have no, no osteoporosis there in the women Partly because they're African, but partly because they just don't, they don't lose the calcium. Whereas we may take in 1500 and we lose a lot. So I think the whole idea of supplementation with calcium, vitamin D, can you talk about that? Because I think it's gotten a bit confusing for people and I still hear doctors doing this and I think it's actually dangerous to prescribe that much calcium. So I'd love to hear your opinion about that.
- [44:42]
B
I don't prescribe calcium at all. In fact, I teach people what foods have calcium in them. Because if I can help my people eat dairy or salmon with the bones in it, or sardines or mushrooms that have calcium, it's not that hard to get 12 to 1500 milligrams of calcium in your food if you're eating a whole foods diet. For specialty diets, sometimes it's harder. But when we take calcium thinking that we're building our bones or we're not going to fracture, A, it doesn't work like that, and B, it's not the density of our bones that prevents us from fracturing, it's the quality of our bones, the tensile strength, meaning every time you step on a bone, it bends a little. And if our bones are brittle because the inside of our bones are weak, we're more likely to fracture. And calcium is, is mainly in the cortex. So I don't prescribe calcium. I teach people how to get it from their whole foods. If we do need to supplement, then there's a couple whole food supplements. They come in little wedges. They're fun to eat, but that's just how I choose to approach it. I think people need vitamin D for their immune system, for their brain. It does help absorb calcium, but I'm not sure it does much for its bones. I mean, big, big meta analysis have been done by orthopedic surgeons, frankly, in China who did. Yeah, I don't remember six figures, high five figures of people and found that there was no difference in fracture risk between those on calcium, on calcium with vitamin D or nothing. So I think I do prescribe, I do prescribe vitamin D because when I measure it and it's low, I think it does a lot of other things in the body. But I don't do it principally for bone.
- [46:32]
C
Yeah, Some of the data is kind of confusing because it seems like vitamin D alone may not do that. When you give calcium with it, it may help a little bit. It does cause soft bones. Right. If you get osteomalacia with no vitamin D alone. A lot of people are very low and that can cause bone aches and pains. And a lot of people have aches and pains and they go, probably see you for these aches and pains. And that can be often low vitamin.
- [46:52]
B
D. I love that you, you brought that up because we don't talk about osteomalacia at all. You're the first person that's ever brought that up. The difference between bone density, the minerals and the tensile strength, the softness, osteomalacia. I love that you brought that up because that's what matters. Right? That's what really matters. So I have a very short basic supplement stack until people get optimized. And we're doing the whole longevity things. So vitamin D for the other things. I like Omega 3s. I think they have great anti inflammatory, great for the brain. Magnesium, frankly, for sleep, it helps. It's a miracle for me. But it's also important in about 300 enzymatic pathways in our body. I take mine at night, helps me sleep with the progesterone, helps me sleep. And then you know what, I have been optimized. And so, so now I'm really interested in my senescent cell load.
- [47:49]
C
Those are zombie cells. Those are inflammatory cells that accumulate as we get older.
- [47:53]
B
Yeah, they're spewing out cancerous cytokines. And I've worked with a researcher in Vail named Johnny Huard for 20 years, and he has measured the decrease in load with a simple supplement called fisetin, which comes from berries. And I'm not saying it's the end all be all, but he's one of the few labs that has collected data that we can think about and read about. Mark?
- [48:16]
C
Yeah, I mean, fisetin comes from strawberries, but it's really basically kills these zombie cells which accelerate inflammation for sure. You know, you talked about the foundations and I think it's important because people get all excited about this or that supplement or this or that biohacking technique. And if you don't get your exercise, your diet and your sleep and stress and relationships sorted, the rest of it is just window dressing up drain you. But then, but then it can give you a marginal benefit if you do those things in addition to everything else. So it's not like they're bad. It's just that you can't take a pill and hope you're fine. It's like taking a statin and then going eat at McDonald's and think you're going to be fine. It doesn't work like that.
- [48:53]
B
I wish it did, but not no way.
- [48:58]
A
If you're fasting and worried about losing muscle mass, you're not alone.
- [49:01]
C
Here's the challenge.
- [49:03]
A
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- [50:32]
C
So so when you when you think about kind of practical sort of approach for women's health and as they age, what are the diagnostics that are sort of non negotiables for you when you're, when you're evaluating women and where they are in their health trajectory, where they are in their longevity journey and hormonal assessment and what, what are the things you think about whether imaging or lab testing or other testing as soon as a.
- [50:55]
B
Woman is done, if she chooses to have children or if she doesn't? At 40, when most women have not yet entered the throes of perimenopause, I Want a bone density test or better an ultrasound called rems which tells us bone quality so that we know what we are before we lose 20%. Because I do that on everybody. Mark and I have 22 year olds with porous bones because they never laid down enough bone or people don't understand the osteoporosis of pregnancy or lactation, which our body is equipped to handle, but only if done right. Right. So early, by 40, let's see what our bones are doing. When you get your mammogram, you know, let's get a, let's get a body composition to know how many, what percentage fat we are and how much muscle we have. Not to be judgmental, but to give us an opportunity to know what to fix. Let's draw the basic lab panel. Know what our organs.
- [51:57]
C
So just for the bone density, it's a DEXA scan for the body composition. In other words, how much muscle and how much fat and where is it. You can also use exactly the same machine.
- [52:06]
B
Yes. It has to be software program. Yeah, it has to be. You have to ask for it in a different way or you're only going to get fine and hip hop. But you can also tell bone quality by an ultrasound which is not widely available in this country as it is in Europe. So those are.
- [52:22]
C
And then you're mentioning labs.
- [52:24]
B
We need to look at our full lipid and advanced lipid panel. We need to look at our fasting glucose, our insulin, our home ir. We need to know about our metabolic health. Right. We need to do our cardiac labs, the genetic proportion and those that are acquired. And if you've never had it done, we need to have it done. And if they're high, then you and your cardiologist. I don't know how you feel about this. I'm not an expert in it. But you know, there are ways to look at your calcium if you're really.
- [52:54]
C
High in the coronary calcium score. Yeah.
- [52:56]
B
To see where you are. And we need to look at your ferritin and what your blood cells are doing and your energetics. I think those are baseline. And yet when I'm preparing people for surgery and I say, let's talk about your medical problems. I know you've come up against this. I am often told you don't have any medical problems. I say, when was the last time you had a conversation with a doctor besides me? Right. Just because you haven't been diagnosed, maybe you don't know. But I think all of those around 40 are critical. But you know what else, Mark? Tell me what you think about this. I see so many midlife men coming into my clinic all of a sudden they're doing everything they think they should and they're popping multiple tendons or they're exhausted, or they just don't have the energy and they can't perform on the basketball court. And I measure their testosterone.
- [53:50]
C
Yeah.
- [53:51]
B
Because a normal Testosterone range is 250 to 1000. But we don't know what you were when you were 30. So I tell, I have four sons. I'm like, guys, let's go measure it. Now we know what to correct to.
- [54:05]
C
Well, you know, I, I'm very focused on diagnostics early and often. And that's why I co founded a company called Function Health. And we do all those things you mentioned and more nutritional status, hormonal status, thyroid status, and obviously the advanced lipid testing, metabolic testing, toxin testing. And, and you find so much going on in the population that's just ignored or missed or not checked until they have some serious disease. And, and being ahead of the game is always more important. You can still, you know, at any age when you start, you can still make amazing progress. And I've had people, you know, in their mid-60s or 70s who've really reversed their head. I mean, I just had a patient, 73 who finally lost like 100 pounds and is exercising 107 straight days in the gym and is eating healthy and taking a supplement. Supplements. I'm like, what? Took him a minute to get there? But that is possible for the human body to recover. And you know, I think we want to make sure you, you don't kind of wait too long. And the, the imaging is important. We do, you know, full body MRIs, but also you can get a body composition on MRI, you can get even bone density on an MRI. And that can really tell you what's going on with your, with your whole system. And then you can really get a sense of where you are because most people don't even know. And it's much easier to be proactive than reactive in terms of the amount of work you have to do to change something.
- [55:27]
B
Yeah.
- [55:28]
C
So, and your, your, your work also is really interesting because you focus on also what research needs to happen and, and where, where are we missing the ball here? Women's health research has been traditionally neglected and, and where do you see the real needs being to answer the questions that have to get answered? Because we don't know everything yet.
- [55:46]
B
We know very little, Mark. And the reason is that historically the, the research dollars are out that are allocated to things that predominantly affect women over 40 is, is about 1 to 2% of the total research dollars. And yet women over 40 are a quarter of the 25% of the population. And so I think almost any question that has only been studied in a, in a population of men and women or population of men, which is the way research is largely done, needs to be redone. For women, for instance, and this, some of this has been done. We need to go deeper identifying cardiovascular disease in women. Men present clutching their chest. Women present with microvascular disease. And let's really figure that out. Let's figure out in a dose response way how much we can improve bone density in a woman with. Because that's what people want me to tell them. How much do I have to do? Tell me the recipe. And I can't tell them it's this or that because the studies haven't been done or autoimmune disease affects women at a much higher rate than men. So there's so much research. But you know what I've been calling, I speak for a lot of women's groups calling the philanthropic women in this country to do. We're going through the great wealth transfer and I think that it's unreasonable to expect that all research dollars are going to come from the nih. There's too much work to do. And so we do a pretty good job with funding cancer research, children's research, maybe heart research. But I'm actually I make a call like at the. We were talking about the Milken function we were both at to philanthropic women benefiting from the great wealth transfer to set up funds to fund women's research or because less than 2% of all venture capital is spent on, on products for women. There's so much work to do and it's unreasonable to sit back. If we, if women want to be powerful and, and lead, then let's lead not only with our ideas but with our, our finances in a mission driven way.
- [57:54]
C
That's a very good point about it. I mean I think there's a lot of wealth transfer happening and there's a lot of need for research that's beyond what the government can provide. And I think there are a lot of answers that we don't have yet about aging, about longevity, about women's health and much more. So I'm excited about where we're going. In terms of your work, what are the things that you're most excited about coming down the pike?
- [58:16]
B
I'm really excited if I can help change the National Zeitgeist. From the inevitability of vitality to frailty, that's work worth doing. And that's been really my whole career. Knowing that as an orthopedic surgeon, by saving mobility, which I do by putting metal in bones, or by doing fascinating surgeries, what I'm actually doing is saving people from the ravages of chronic diseases. Because if you can't walk, you're going to get sedentary death syndrome, right? You're just going to die from sedentary fat burst, right?
- [58:48]
C
Okay, wait, you just, you just said something there. That was a big, big sense. Sedentary death syndrome?
- [58:52]
B
Yeah.
- [58:53]
C
Never heard of it.
- [58:54]
B
Oh, my God.
- [58:54]
C
What is it?
- [58:55]
B
I wish I had made it up, but Frank Booth made it up. He was a professor at Columbia in Missouri, and I met him when I was straight out of my fellow fellowship. Sedentary death syndrome are the 33 chronic diseases that are negatively impacted by sedentary living by the 20 hours a day we sit on our butts working or sleeping. The simple medicine of walking, getting our heart rate up, lifting weights, I mean, the. The evidence is irrefutable, can change the trajectory of your health. And if not, it's sedentary death syndrome for you. And I see it everywhere. In airports. I see it and I have this, you can hear it in my voice, this desperation to change the national zeitgeist. So I'm going to keep doing the work I've done for 20 years from a. From a technology standpoint. I did some of the original work at University of Pittsburgh on platelet rich plasma. I drew my own blood, spun it off. I am excited about harnessing the power of our own biology in regenerative medicine. I'm going to be the first to tell you, having had my own stem cell lab, we haven't figured it all out yet. We don't know the cell surface markers, we don't know the dose. We don't always know how to prevent things we don't want. But I think we'll get there. I truly believe in the power of our own bodies. And so in my own clinic, I use those autologous products, meaning I draw blood from you and I pull off those things. But now, surgically, for knee surgery, most of the time, I do not make any incisions because our technology is so amazing that I now do knee surgery through needles. It's called nanoscope. We can do so much that we used to make big incisions for through tiny, tiny needle. So what does that do the recovery is faster. There's no anesthesia, which mucks up our brain, and that people do not need narcotics. So for me, as an orthopedic surgeon, that is really exciting to join the longevity work, to the regenerative work, to the technology.
- [61:01]
C
That's really kind of a beautiful painting for the future of medicine, which is bringing together all these elements of, you know, foundational lifestyle of medicine with some of these renewal regenerative repair techniques that are using innovations like stem cells or other innovations, and I think they can be very helpful. It's still a little bit the Wild west, but it's coming along. You know, if you're looking at kind of a, you know, woman who's. Who's like out there thinking, you know, geez, I don't know, I'm overweight, I haven't exercise, and I'm just sort of frustrated and I don't know what to do. And I'm in my maybe 50s or 60s, you know, where do I start?
- [61:40]
B
I'm going to start you really simple. Because people easily become overwhelmed. I'm not negating anything I've said, but for a person you've described, it can start as simply as going back to our root mobility. You learn to walk at one, you are going to go back to your roots, and you're going to walk every day at a brisker pace than you're used to. And you're going to do it after your biggest meal so that metabolically, you're sucking the sugar out of your blood that you just ate. Whatever you ate, you're increasing your cardiovascular health. And you can do it. I mean, you know how to walk, number one. Number two, when I start going down a nutrition pathway, I can get people nodding their head about the protein and about good fats. But you know what, Mark? It's like taking someone's first child to tell them that we cannot eat added sugar. And this is how we're. And. And, oh, my. It literally is an addiction. And I understand it. I gave up sugar when I was 47. And you literally stand in front of the pantry not knowing why you're there, because your brain is looking for a hit, right? But. So I would start with those two things. And once you do that for seven days, you have a streak and you gain confidence that you can do something. And then we can get into the more complicated things, because people. I mean, I've been taking care of people for a very long time, and they get overwhelmed and confused and discouraged and stop. So that's why I Start so simply.
- [63:14]
C
And your book Unbreakable lays all this out, right?
- [63:17]
B
Oh, my gosh. Great detail.
- [63:19]
C
It's a woman's guide to aging with power, which is. I love that. I think, you know, we just have to reshift our mindset around aging to see it as a time of vitality and energy and high function versus just frailty. And I just want to close with this guy I met. It wasn't a woman. It was a guy I met who was 95 years old. And I met him at this lunch thing at my parents house years ago, and he was jumping around the room, super spry. He had a girlfriend that was 20 years younger than. Than him.
- [63:55]
B
Good for him.
- [63:56]
C
I'm like, what's your secret? Yeah. He's like, well, whatever I did yesterday, I do today. If I played singles tennis yesterday, I played singles tennis today. And I think that's a very powerful message because if you don't actually do those things that put those investments in every day, you will decline. And the older you get, the faster you decline. So when you're young, if you don't exercise for a month, you can get away with it because you've got all this hormonal and other tropical perfect support. If you don't do that when you're 60 or 70, it's a steep, rapid decline and then, you know, it's a long way back. So I think it's possible I've experienced it. I didn't want to experience having to come back from that. But I could tell you that with little dedication, a little science, and a little determination in the right understanding of what to do, that anybody at any age can get strong. My father was 79. No, sorry. He was 89. 89 when I got him a trainer for his birthday because he couldn't really get up out of a chair.
- [64:58]
A
Well.
- [64:58]
C
And I was like, oh, God, here we go. And dad, you need to get a trainer. And he. He did. And it was amazing to see the gains he made at 89 years old. So it's never too late to get young.
- [65:10]
B
I believe that absolutely. Every day.
- [65:12]
C
Well, thanks so much for being on the podcast, Fonda. I look forward to seeing you on the circuit. We're going to be in Saudi Arabia together. It'll be fun and keep learning from each other. And I wish the best of luck. And everybody check out your book Unbreakable. It's available wherever you get your books. Amazon. And where else can they find more about you and your work?
- [65:32]
B
You know, two places, both on Instagram. Where I post every single day, education and life stuff. And my website is Rvonda Wright. Dr. Vonda. Right. It's easy. Just google it.
- [65:45]
C
You'll find me amazing. Well, thank you so much for being on the podcast and I look forward to seeing you soon.
- [65:52]
B
Thanks so much Mark. Bye Bye.
- [65:54]
A
When it comes to supplements, you only want the best for your body. The kind with the highest quality, cleanest and most potent ingredients you can get. That's exactly what you'll find at my supplement store where I've hand selected each and every product to meet the most rigorous standards for safety, purity and effectiveness. Effectiveness. These are the only supplements I recommend to my patients and they're also what I use myself. Whether you want to optimize longevity or reduce your disease risk, or you're looking to improve your sleep, blood sugar, metabolism, gut health, you name it, doctorhyman.com has the world's best selection of top quality premium supplements, all backed by science and expertly vetted by me, Dr. Mark Hyman. So check out Dr.hyman.com because when it comes to your health, nothing less than the very best will do. That's Dr. Hyman.com d r h y m-n.com if you love this podcast, please share it with someone else you think would also enjoy it. You can find me on all social media channels at Dr. Mark Hyman.
- [66:45]
C
Please reach out.
- [66:45]
A
I'd love to hear your comments and questions. Don't forget to rate, review and subscribe to the Dr. Hyman show wherever you get your podcasts. And don't forget to check out my YouTube channel at Dr. Mark Hyman for video versions of this podcast and more. Thank you so much again for tuning in and we'll see you next time on the Dr. Hyman Show. This podcast is separate from my clinical practice at the Ultra Wellness center, my work at Cleveland Clinic and Function Health where I am Chief Medical Officer. This podcast represents my opinions and my guests opinions. Neither myself nor the podcast endorses the views or statements of my guests. This podcast is for educational purposes only and is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided with the understanding that it does not constitute medical or other professional advice or services. If you're looking for help in your journey, please seek out a qualified medical practitioner. And if you're looking for a functional medicine practitioner, visit my clinic, the Ultra Wellness center at ultrawellnesscenter.com and request to become a patient. It's important to have someone in your corner who is a trained licensed healthcare practitioner and can help you make changes, especially when it comes to your health. This podcast is free as part of my mission to bring practical ways of improving health to the public. So I'd like to express gratitude to sponsors that made today's podcast possible. Thanks so much again for listening.