#214 - AMA #37: Bone health—everything you need to know

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Hey everyone. Welcome to a Sneak Peek, Ask Me Anything or AMA episode of the Drive podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to peterattiamd.com forward/subscribe. So without further delay, here's today's sneak peek of the Ask Me Anything episode.

Welcome to ask me anything AMA episode 37. I'm once again joined by Nick Stenson. In today's episode, we dive really deep into one subject, bone health. This is a topic we get a lot of questions about, but we decided to save our AMA for a time when we had accumulated enough questions that we could cover this comprehensively, which, as you've gathered by now, is sort of.

How we like to do things because.

It allows us to go much deeper.

So in this ama, we're going to cover the following.

We look at why everyone should care about bone health. In other words, why is this such a priority not just for yourselves, but also for your children? We break down what bone mineral density is, how it's measured, and how much variability exists between people between sexes, and how it changes over the course of your life. We also talk about what influences it.

Both early in life and later in life.

We look at differences between men and women when it comes to this health and why menopause has such a disproportionate effect on the bone mineral density of women. We then get into ways that you can improve bone health, from exercise to nutrition supplements and, of course, drugs. We end the discussion around what happens when we're forced to be sedentary and how you can work to minimize the damage during these periods. As a reminder, if you are a subscriber and you want to watch the full video of this podcast, you can find it on the Show Notes page. If you're not a subscriber, you can watch a sneak peek of this video or on the YouTube page.

So without further delay, I hope you.

Enjoy AMA number 37.

All right, Peter, welcome to another AMA. How you doing?

Doing well, man. The final seven episodes of Ozark dropped tonight. We're recording this April 29th interesting date for two reasons, by the way. The other thing that occurred to me this morning is that the days and dates in this year, 2022, were the same as they were in 1994. So I was like, oh my God, Today is Friday, April 29, which is the same as it was in 94. So on Friday, April 29 in 1994 was the practice day at Imola. And that's when Rubens Barrichella had that horrible, horrible accident. We can link to the accident where he basically hit the chicane and launched into a barrier and amazingly only escaped with a concussion and a broken nose. The following day, which is the same day as tomorrow will be, which was Saturday, April 30, was when Roland Ratzenberger was killed, which made it the first fatality in Formula One in 12 years. The last one being Zill Villeneuve in 1982. And then of course, Sunday, May 1, which will be the same this year.

Was when Senna died, all in 1994.

Yeah, it was at the same race. You had these three horrible accidents resulting in two fatalities in one weekend. But again, to think it's the exact same days this year as it was 28 years ago. I didn't notice that until today.

This is really off topic, but do you still have the skill that you had back in the day where you can remember what day, like day of the week a date was?

Only if I can peg it to something, but not as profound as it used to be.

I remember in meetings we used to just throw out random dates and then we would fact check it. I feel like we wasted a lot of time doing that.

Someone would tell me their birthday and I would tell them what day of the week they were born on.

On the complete opposite end of that. What we're going to talk about today is a topic that we get asked about a lot, and we've gotten a lot of questions that have come in, but we've never really dove really deep into it, which is what we're going to do today. And it's kind of all things bone health, bone mineral density, osteopenia, osteoporosis, things of that nature. And I know this is something that you work a lot with in your patients, and I know it's something that's of really big interest for people. And so our hope is that we can go through this episode and focus on why is this important? So why should people care about this? People listening right now. There'll be a subsection of them that are going to be super interested and there'll be probably another subsection who are maybe younger. They've never really thought about their bone health and they might not think it really applies to them. But our hope is, in the beginning at least, we'll walk through why they should care about this and why they should should focus on it early on in life. And then from there, we'll talk about how bone health changes as people age, the differences between sexes with men and women. And then we'll also focus on things, on how people can improve or help their bone health become better, from physical activity to nutrition, supplements, drugs, and more. And then if all that goes well, and we still have time, which is always 50, 50, on how these AMAs go. We'll also focus a little bit on people dealing with acute injuries and how they need to think about this, which I know is something that you're interested in, given your recent shoulder surgery and now you're not as active in one side of your upper body as you used to be. All that said, I think before we start going through those questions, it's gonna be helpful to set the stage a little bit, just so everyone is on the same page and the definitions and what we're talking about. So why don't we start with what are some of the types of bones we'll be referring to? Because at least for myself coming into this, I just kind of think a bone is a bone, and I don't really think much more beyond that. So why don't you dive into that a little bit?

Bone is. It's a living tissue. Okay, that's obvious. But I think it's also easy for a person to forget that and think of bone as somewhat inert. But in fact, bone is heavily vascularized. Bone is an organ that plays a very important role in a lot of things. I'm actually not going to go super deep into the anatomy and physiology of bones. I'll point out just a couple things, right? So first of all, think of a couple types of sections of bone. So we think about the cortical or compact bone, and that's what forms, like the shaft in the exterior of long bone. So if you think of your femur, your humerus, things like that, they have the long shaft and then the nubbins at the end. So the shaft of that is the cortical or compact bone. And then at the end, you have the trabecular bone, sometimes called the spongy bone. Those are kind of at the end of the bone, and there are some differences amongst those in terms of their vascularization and things like that. But again, I think for the purpose of this discussion, whenever I talk about compact or cortical bone, I'm talking about the shaft. And whenever I speak about the spongy or trabecular part, I'm talking about the end. Again, I think marrow people probably intuitively understand that marrow is important, but again, it's very important, right? Marrow is what's producing our white cells and our red blood cells. So in this era where we were thinking about a post Covid world, it's important to understand that the memory B cells and memory T cells that are going to provide lasting immunity against this virus and other viruses reside in the bone marrow. The whole purpose of being infected and then having a subsequent infection that's less devastating purpose of being vaccinated for the same reason is to have memory B cells and T cells that are sitting there in the bone marrow that can respond immediately and quickly upon reintroduction of the same antigen.

When you mention Nubbins, it made me think about your banana Nubbins and you recently posted on Twitter. You might be looking for a new profession. Do you want to let people know what your new interest is in the world of longevity?

I've been very interested in human longevity for a little over 10 years and I'm sure I will remain so. But I've at least considered moving into banana longevity because I think the opportunity for impact is huge. It's one thing if you can figure out how to take the average person from being 80 to 90, that'll have a huge impact on the world. But if you could take the average banana and go from like two days before it turns mushy and brown to 10 days, I think it's revolutionary. I just noticed I was on the USDA's most wanted list because of how many bananas I waste. So I got to do something about this.

If you solve the banana crisis and you move to avocados, they'll probably give you a Nobel Peace Prize as well. The upside is very high in this new world.

Avocados last so much longer. I could buy like seven avocados and eat them in a week. I can't buy seven bananas and eat them in a week at one a day. It just doesn't work. I think that entire fruit space is just a racket. I think bananas are a pyramid scheme. The whole thing's just total scam.

Maybe one of our upcoming AMAs will just do a conspiracies with Peter Attia and we'll just go into the world of bananas. So Peter, you mentioned earlier ago B cells and T cells. Can you walk people through what cells make bones?

This can be made as complicated or as simple as you want. Just think about osteoblasts and osteoclasts and I kind of Remember from medical school the way I used to remember this? So osteoblasts B are responsible for building bone by producing collagen, bone matrix, and mineralizing it. Osteoclasts remove bone by reabsorbing calcified bone and the matrix. So osteoblasts contribute to increasing bone mineral density. Osteoclasts the opposite. It's also important to understand this exists in an equilibrium. So we're constantly remodeling bone, adding to and subtracting from this, and basically turning over calcium. So bone is like 50 to 70% mineral. And obviously, what's the predominant mineral? It's calcium. We'll talk about that in a second. It's about 20 to 40% organic matrix. So, again, what does organic mean? Organic is carbon, hydrogen, oxygen, sulfur, et cetera. And then the rest of it is a bit of water and lipid. And again, you'll see that primarily in marrow in an adult. Like the entire human skeletal system can be remodeled in a really long cycle. It might take 10 years to turn over all of the mineral and organic content within the bone over and over again. But at the micro level, calcium balance is happening quite frequently. I don't remember the exact number. I want to say it's like 99%. But virtually all of the body's calcium is contained within bone, and therefore, bone plays a very important role in calcium homeostasis. And if anybody's taken a physiology class, they probably remember how important calcium signaling is to everything within a cell. Again, we think of these bones as structural entities, which, of course, first and foremost, they are. But remember, they're also a very important reservoir for calcium, which is another very important ion in the activity of every cell.

You talked a lot about calcium. What about vitamin D? What role does vitamin D play in the bones?

They're both very important. And again, there's two forms of vitamin D, vitamin D2 and D3. But really, when I talk about vitamin D, I'm going to mostly talk about D3, which is the active form. So what's the problem with being deficient in vitamin D? Well, again, people might recall a disease called rickets. And you see this often in developing parts of the world where people are really malnourished and they have really, really soft, sort of spongy bones. Actually, just yesterday, I had a friend over who does a bunch of mission work in Rwanda, and she was showing me a child at their camp whose legs. The child was, like, probably 5 years old. He was sitting down, and they were doing something with his Legs that you would think would be impossible to do with a human being. Basically, while he was sitting on the ground, they were able to move his foot back and forth, back and forth, and he was in no pain. But it's because he didn't have bones that were anything other than basically rubber bands. So he couldn't stand. And within, I want to say, six months of correcting his nutrition, totally normal. Amazing opportunity when you think about what happens in that part of the world and how you can fix that. But what is it about vitamin D? Well, vitamin D increases the gut's absorption of calcium. So if you're woefully deficient in vitamin D, you're going to have trouble absorbing calcium through the gut. And we're going to talk about in this podcast later about the importance of dietary calcium and or supplementary calcium. And so you can see why that becomes part of the issue. The other thing to kind of keep in mind here is the role of another hormone. And again, I'm trying to only introduce concepts now that are going to become relevant later, either through treatments or nutrition or supplementation. So I'm being a little bit simplistic. But the other thing that you can't avoid here is understanding the role of calcium and parathyroid hormone. I think most people are probably familiar with their thyroid gland sits here in the neck. It's kind of got this shape to it where it's got like two main lobes and then each lobe has two poles. Well, at each of those poles is a little tiny gland called the parathyroid gland. So you have four of those. And the parathyroid gland is really the master gland for regulating calcium levels. So low levels of calcium in the blood stimulate parathyroid hormone secretion. As parathyroid hormone level goes up, it simulates the release of calcium from the bone into the blood. Now it also induces enzymes in the kidney which then convert vitamin D into its active form to then aid and speed up in the process of reabsorbing more calcium from the diet. So all of this stuff, parathyroid hormone, calcium, vitamin D, very important to maintaining bone health. And anytime you things that disrupt that system, you're going to see disruptions potentially in the bones.

I think that was a good quick overview of what will be important for what we cover next. And I think the natural follow up to it is what is the consequence of poor bone health? What is the consequence of low bone density? Some people who will be listening to this will have already known issues of bone density. And some people have never thought about this before in their life. What would you say to those people on why they should care about this and why they should think about it?

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