Prevent BONE LOSS in Midlife - Before It's Too Late

Today we're going to be talking about bone loss as we age. Why this is something that we need to critically pay attention to. This is so important. And how we can prevent further bone loss. I'm going to ask questions about can we reverse it? What do we need to be doing? How does strength training play a role in. Here, I've got Dr. Vonda. Right on. I've been so excited to interview her. I've been waiting for a while for this interview. She is a practicing md, a board certified orthopedic surgeon. So of all, all of the guests I've had, this woman knows exactly what's going on here because she's operating. She's operating on us in midlife. She's seeing what's happening. So thank you so much for being here, Dr. Vonda. I can't wait to dive into this topic.

Oh, Natalie is just my pleasure.

So I want to back up a minute. You are a surgeon, and when I heard you on another podcast, I heard you on my friend Chalene's podcast recently, and what really stuck out to me is you said you can see a difference cutting into bone. So sometimes it literally cuts like butter, sometimes it's not. You actually see what's happening as we age when we've not taken care of this. Can you talk a little bit about that first? What are you seeing?

So you're right. I have the rare opportunity of actually physically feeling the structure of bone. And so I'll give you an example. For instance, when I fix someone's rotator cuff. So the rotator cuff are the small muscles that lift your arm like this. They're connected right here on the top of our humerus, which is our arm bone. And it looks kind of like this. So I bring over the rotator cuff and I need to connect it back to bone. So what we want to happen is that I need to use a drill to get through the edge of the bone into the bone to put a little. A suture anchor is what they're called, to hold the muscle down. Now, in healthy bone, I do have to use a drill. In unhealthy bone, I can just push the anchor in.

Wow.

And it's literally when I say her bones were like butter, it's the difference between trying to cut a frozen slab of butter and a melted slab of butter. And when we do that, it sinks my heart. Because not only does it mean that the anchors I put in have a bigger chance of pulling out, but it means that that woman is. Is likely to be one fall Away from a fracture.

I think in my age group, specifically I'm 53. A lot of my listeners are around my age. I'm younger, some older. We're at that age where we're having scans and we're starting to see osteopenia or signs of bone loss. And I don't know that a lot of my friends connect the dots. They say, oh, I'm seeing a little bit of this, but they're still feeling active, they're still feeling strong. They don't realize what this is leading to. Can you talk about that?

Do you want me to describe what happens when you have osteoporosis as an older?

Oh, that would be a great, fantastic both actually, what happens then and what about these early signs why we might not be feeling things? What do we need to be aware of?

Okay, so I'm going to talk about the future first. Okay, talk about now. So I think all of us can think of someone in our lives. I like to call this person Aunt Minnie. I don't actually have an Aunt Mini, but you can think of a person in your life. A woman in your life is shrinking, right? She used to be as tall as you are, but now all of a sudden her, she's up to here, she's shrinking. You can probably also think of a woman in your life who has fallen and broken a hip. 70% of all hip fractures happen in women. I'm going to just tell you the statistics. When you fall and break your hip, 50% of the time, 50% of the time, you do not return to pre fall function. Whether that means you don't live in the house, you raised your children, you cannot drive your car anym, you can't get up and go play pickle like you always did. You do not return to pre fall function. And here's the statistic that is horrifying, but I am not trying to be horrifying to you. I am trying to wake you up. 30% of the time, if you fall and break your hip, you will die. So I know. And it can happen to anyone. And when I get a woman, our Aunt Minnie, your mother, your grandmother, and I'm going in to take care of them. Here's who I see and this is the future I see for women in frailty today. This is why I'm so passionate about it. That's why we're trying to build unbreakable women. This is why frailty is the enemy. When you fall and break your hip and I'm called to your bedside, there you are laying in the hospital bed in those horrible blue gowns that open in the back and you're in pain. Broken bones are very painful, number one. Number two, many times you are incontinent because no one is bothered to tell you that you need vaginal estrogen to combat the gynecourinary syndrome of menopause, and therefore you're incontinent, and therefore you may have a bladder infection. Number three, many times the women who break their hips have such bad hearts. Heart disease is the number one killer of women that it is hard for the medical doctors to clear them for 45 minutes of hip surgery. And then the fourth thing I commonly see is that the women who are this sick sick are either momentarily demented, meaning the stress is so big in their health right now that their minds aren't working, or they're frankly have Alzheimer's. I am not trying to be alarmist. I am trying to wake women up to the reality of the future for one in three women who end up so frail you have to go live in a nursing home. That is the future that I am trying to prevent. So what about today? What about the 40 year old woman who is just entering perimenopause? What about the 51 or 52 year old woman who is freshly menopausal and now postmenopausal? The fact of the matter is that many women in our generation believe the myth and the lie that we grew up with that you had to be this big, that you had to be really skinny at all costs.

The commercials were if you can pinch an inch and pinch a cab. And yes.

Yeah. Oh, I had forgotten about the whole pinch an inch. I'll show you my inches right now. And I'm as healthy as healthy gets. So we were raised to be thin. Well, thin does not mean lean. We can be skinny fat, meaning we are composed mostly of adipose tissue, which is noxious to us if we didn't eat enough and we didn't pound our bones. Sometimes we never laid down enough bone. So I see many younger women, late 30s, early 40s, who already have osteopenia. And how do I know? Because I get a DEXA scan on every bone, buddy. Especially if their mother's shrinking, if they have had a fracture, if they smoked, if they had an autoimmune disease or for some other reason, they had to take steroids, for instance. If you have any of the risk factors, I get a DEXA scan. I find that many women in their 40s, definitely in their 50s, already have osteopenia, which is low bone density, or osteoporosis, which is frankly, bad bone health. So insurance will only pay for your DEXA scan when you're 65, which I think is a travesty because by then you're already postmenopausal and have already lost an additional 15 to 20% of your bone density. So I think every woman should either pay for a DEXA scan themselves or get their doctor due to their risk factors, pay for one in their 40s. Just so we know where we are.

I have a lot of questions based on. That's a lot to unpack there. I just had a DEXA scan and I was so scared to have one because I thought, okay, I feel like I'm doing all the right things and what if it shows something? Fortunately, at 53, mine was great bone quality, but that doesn't mean I'm in the full clear. I believe the reason mine was good, despite having an autoimmune and having other things, is because I've been in the fitness space for a long time. I've always worked out. I've lifted or I haven't actually lifted weights. We're gonna talk about that. I've done a lot of body weight that was intense, like pull ups, chin ups, things like that. And also because I'm on hormone replacement, but I wanna unpack those things because you talk specifically. Let's start with the weight bar wearing stuff. You talk specifically about lifting heavy and this is something I've avoided until I heard your interview. Literally, you changed me in a second. I thought I was doing it with the body weight stuff and I thought, oh, nope, I'm. I listened to that and I said, I am going to start lifting heavy, which is new for me. At 53, I want to. I'll talk about that first and then I want to get into the hormone replacement side of things and how that's preventing and helping.

So I think a lot of us are in your boat. In fact, I've written at least three fitness books many decades ago where I really was a huge proponent of functional lifting, which is body weight, which is using kettle bells and a variety of bands, which is not terrible. Listen, I'd rather you do be doing something than nothing. But here's what happens when estrogen walks out the door. We lose the anabolic stimulus, which means anabolic means building so stimulus that we have had our whole lives. And so we must have strategic stress to stimulate muscle protein synthesis. Mamby pamby pink weights that we lift 20 to 30 reps is never going to cut it for us. I think a lot of women either were never taught to lift or didn't want to get big. Air quote big like they see bodybuilders. Well, I'm going to assure you to get big like that takes decades of dedicated lifting. You are not going to grow muscles to that level without dedicated work at that. What we want you to be is lean. We do not want you to composed of mostly adipose tissue. So I always say muscle is nature's Spanx. If you want everything to be held in together, do it with your muscle, not the camouflage of spank. It's not that I'm against. I frankly like Sarah Blakely, but I'm just saying we have this false hope. You can look, feel a certain way. When we can look or feel a certain way by building the muscle, that is not only going to hold us together for the way we look, which is fine. I'm as vain as the next person. But is metabolically superior to fat, right?

So is it specific, the muscle, like having the muscle on, like I'm muscular. Is it specific that or is it the action of like the lifting heavy? I heard you sharing about, like when you're actually lifting heavy, how that works your ligaments and how that pulls on the muscle. So I want to understand that a little deeper too, because there's a lot of people that don't lift heavy, but they have muscle. What's the difference there? And why is the weight bearing, the.

Weightlifting part specific important Muscle acts in many ways. Muscle gives us strength to move our skeleton around, right? You can have muscle. We may see your muscle because you don't have a high percent body fat. So we may see your muscle in a person with higher percent body fat with the equal amount of muscle to you, we may not see it, right? So I have no doubt that you have a lot of muscles. But it's not just about the volume of muscle. It's the action of the muscle. Muscle pulls against bones which builds better bone. Muscle is metabolically active. It is the primary sink for blood glucose right after we eat. That's where. That's where our mitochondria are. That's where the glucose is supposed to go so that we can produce energy in our mitochondria, which are the little powerhouses of ourselves. So it's not just about looking like we have muscle. It's about being metabolically healthy. And the more muscle we have, the more metabolically healthy we are. So those are two answers. But why do we have to lift heavy? It's because we need to create enough strategic stress that we actually stimulate these processes in our body. If it's too easy, then we're not going to stimulate muscle protein synthesis. But something I don't want to forget to mention and we can come back to it. You cannot build muscle by starving yourself. If you're going to lift, you must feed your muscle growth with 1 gram of protein per ideal pound a day. And that takes a little bit of protein counting. Don't do the hard work on one end without feeding yourself on the other end because you'll just be working against yourself.

So I have some clarifying questions there. So when you said she said protein per pound of ideal body weight. So if you're 200 pounds, you're not necessarily doing 200 grams of protein. If you're working to be 140 or 1 50, that's. So it's different. What about if somebody is in weight loss mode? Do you have thoughts on that? Because I've always taught, you know, let's get our mind right, let's get the nutrition dialed in, let's start moving our bodies and then adding a lot of this strength training is kind of that latter process. Do you have a different thought process there? And where do they stand on the protein when they're just starting to first even learn to eat right? How much do they need to be forcing in of this protein to get to that ideal if they're not yet working out hard?

So I think you have to meet people where they are. And I think if your approach is to help people understand that they are worth the daily investment in their health, nothing else is going to matter until they understand. And I say this a lot, I write about this a lot, nothing else is going to matter until you decide you are worth the daily investment in your health. So until you truly believe that, you will not follow through. Because, listen, I don't believe there's. There's a sustainable thing called willpower. Willpower, meaning mind over matter, lasts about two days, right? Until a better offer comes along or you need to calm yourself, which many people do buy food. Willpower, in my opinion, is not what is going to get us to the health situation we want. It takes discipline. Discipline often goes against our immediate wants and needs. I want that bonbon. I want to sit on the couch. I want the baggage Cheetos. The discipline not to use your body as a garbage disposal is not about willpower. It's about believing that you are worth the daily investment. So that's number one. So once you believe that, how do you start? Well, literally, I know you probably start with people at all varieties of levels, as I do. If we're stepping away from the couch for the first time in history, like we're adult onset exercisers, I call them, or maybe we're glory dayers, we still can we continue to talk about what we were like in high school, okay, I'm 50, please let that go. Can we please create a new future for ourselves? But wherever you are, if you're starting out, I like to start people as easy as it gets, which is let's invest in a walk every day. You've been walking since you've been one year old, so let's not try anything hard after you've done that for seven days in a row. I always say to people, listen, if you've got one hour, if you have one hour of discipline, it must be spent on building muscle mass. I don't expect people to know how to do that. To lift heavy weights, it takes proper form. So this is when you may need to invest in a trainer for a short amount of time or the great online foundational programs that there are because nobody wants to get hurt. So it takes a little bit of education. Nobody's born knowing how to lift heavy. But once you learn how your body works and then can start lifting heavy, and I'll define that for you, that is the number one thing you're going to spend your time on. Now then once you're walking and you've learned to do some weightlifting, the next thing that we're going to add in a layer that's really going to recompose your body is I'm hesitating to tell you which one can all go hand in hand. How about we look at our nutrition next? Right, you're lifting weights, you're walking. Now let's look at your nutrition. One gram of protein per ideal pound. And it sounds like a lot, but it's not that hard. Let's give you some examples. I try to get 130 grams of protein a day. A cup of egg whites. I just had an egg white omelette with cheese and egg whites is 30 grams of protein. Yeah. If you have half an avocado with your egg white omelette, that's another seven to 10, depending on how big the the omelet.

So you're counting non animal protein too. So you're counting like what I would.

Get from everything matters. But to your point, if you're making this point, to your point, quality of protein matters, right? It is. We are most interested in the, in one of the amino acids called leucine. It's one of the essential amino acids. It's one of the branch chain in your body. Does not make it. You must get it from the outside. And leucine is highest in animal whey protein. Whey protein comes from animals you can get. So if we do the percentage of leucine, it's about 8 to 12% in animal protein. If you do not take animal protein and you could get it from vegetable proteins, it just takes more. Yeah.

And then you're getting a lot of carbs too, sometimes. So that we have another issue that.

Could happen depending what kind of vegetables you're eating. Or peas, for instance. Protein has a lot of carbs, simple carbs. But vegetable protein only has about 6% Leucine. Right. So you have to eat a lot more. But to say to those of your audience who are vegetarian or vegan, listen, look at cows and bulls. Bulls have tremendous muscle. You can get protein, but you have to eat all day. A huge volume versus animal protein. So, okay, one gram of protein per ideal pound. We then focus our carbs. I'm not anti carb at all, but I am anti simple. I am anti processed food. You must focus on fiber, 30 grams a day. So avocados have a lot of fiber. Complex carbs. For instance, at our dinners, my husband likes to make mashed white potatoes. He loves them. I don't eat those because they're simple carbs with a high glycemic index. He bakes me a sweet potato that I just eat plain with salt and pepper. It's full of stringy fiber. You can see it, right? Those are ways to address how to feed your muscle. So we've talked about walking, we've talked about lifting, we've talked about feeding. And then if we're really trying to recompose, this is the only way I've found it works in me and my and the people I care for. Hear me before you start throwing stones, ladies, you need to sprint twice a week. Now, sprinting does not mean like Usain Bolt or Richardson in the Olympics. It means getting your heart rate up to as high as you can do it for 30 seconds times four reps, twice a week. Because only with that kind of you stress, good stress, strategic stress lifting, heavy sprinting, feeding your muscle will you make body composition changes because you really care how much you weigh.

Right.

If you are lean and fit in all your, I mean, I think That's a huge motivator for people. Yeah, fine.

So I'm going to dig into this a little more because I already, I already know the questions that my audience is going to be throwing. So I'm gonna, I'm gonna throw them out here, especially people that have done my programs. Okay. I want to talk. Go back to the protein for a minute. You mentioned lucine being very high in whey protein. Are you a fan of supplementing with whey protein?

Sure. Yep.

Okay. And I want to share that is how I get my extra protein in because I find it hard to sit down, eat a lot of chicken or a lot. So I do have whey pre and post workout and that's an easy way to get. I can get another 60 grams of protein a day just from that. That's one thing. Okay. I wanted to talk about the sprinting for a minute. I used to love sprinting and I, as the years went by, stopped. I recently bought a Carol bike which is designed to. It's an AI bike that helps you time your. So it's the same idea as sprinting, but you're not on the ground running. So. But it times you to get your heart rate up, recover heart rate up. Any level can do it. When you say sprinting, do you mean any type of exercise? Are you specifically talking about actual sprints outside, like running sprint?

And you know what, you're right, I should find a different word. But sprint intervals have to do with your heart rate. You can do it on a bike like you're doing on a treadmill. You can do it on a rower, you can do it on an alpine machine, you can do it on the street. I don't care.

Actually, she's getting your heart rate up.

As fast as you can get it, you know? Yeah, for 30 seconds. And if you're monitoring it, you'll see how far high that is. Mine is about 186 and I know that I can't push it. At my age, I can't push it much higher than that. When I was younger, it was 190. That's what I. Thank you for clarifying. That's what I'm talking about.

The next thing I want to clarify there. Sorry, I'm going to dig deeper just because I already. I know how people are guests I've had on before. And then what the questions will be. Now there's also this whole idea. So anaerobic versus aerobic. Aerobic is that long with air. So you're hiking, your long walk, long bike ride. And then anaerobic is like the sprinting without air. There's a lot of talk too about it not being great for menopausal women to be in anaerobic state and do high intensity training. But I think that's still different than what you're talking about with these short bursts of sprints for a short period of time. Do you know much about that and can you talk about that? Why is there this talk about, hey, you shouldn't do orange theory, or you shouldn't do this high intensity anaerobic training if you're a menopausal woman. Have you even heard that?

So let's clarify, because there are different levels of intensity. So when I'm talking about walking, I'm talking about a heart rate that is 181 minus your age or at your lactate threshold, which is the threshold in your mitochondria, your powerhouses, where you switch from burning fat to carbohydrate carbohydrates. And as a byproduct of burning carbohydrates, you're producing lactic acid, which is why your muscles get sore. 80% of your time, you should be spent in that zone. So it relieves you from having to go to orange theory six times a week and not really getting enough stimulation to build muscle, not getting enough stimulation to really change your VO2 max. You're in the muddy middle, right? You know, I'm, I used to have a membership there. I'm sorry, guys, but what you're hearing is okay. Walking seems too easy. It's not. If you get your heart rate up to 181 minus your age, and sprinting with your heart up at 186 or the fastest you can go seems ominous. So I'm just going to settle somewhere in the middle. Well, isn't enough to do all the maximum. And it's a lot. You're stressed all the time. That's what you're hearing. You're hearing the pushback against this muddy middle. What happens when you do high intensity interval training at about 60 to 70% of your maximum heart rate? I'm an orthopedic surgeon. People do that seven times a week. Come into me hurt every three weeks because it's a lot of medium intensity, they hurt something, then they're out for three weeks, then their brain gets all upset because they're not getting the dopamine push. And so what we recommend that is completely backed by Research, is 80, 20, 80% in zone two, which I like to call base training. I don't like to call it zone two because people get all wigged out about the chemistry of it. And I understand that base training with sprint intervals, that, my friends, is what poses your body.

That makes sense. Okay, I want to ask another workout question in here, and then I have some. Then I want to go into hormones. But I've always said. And again, I want. You can correct me. I'm not. I'm not trying to be right or convince you in any way. I'm just genuinely trying to understand. I always did body weight training for years. That's what I taught. That's what I built my business on. And when I would teach body weight, I would talk about pull ups and chin ups and intense body weight stuff, planks. And that's why I was able to be lean and strong with that. However, I realized there's a difference now with actually using, like doing heavy squats, things like that. When you look at your weight training, yours specifically, what you actually do, because I know you practice what you teach, do you incorporate stuff like that or have you gone like literally strictly to actual external weights? So, because I'm not clear on this either, like, if you're building your back, for instance, could you just use pull ups and chin ups or do you have to use extra free weights and barbells and things like that? Does that make a difference?

So I power lift and pulling is one of the aspects of that. I power lift and then I lift the accessory muscles for the power lift. So just let me give you an example. Let's use. So powerlifting is a push and a pull with the upper body, and it's a push and pull with the lower body. So upper body push and pull is. Push is some kind of bench press maneuver, whether it's with three barbells or whether it's with an actual barbell. Free weights or barbells is the push and pull. You can use a variety of things for the pull, including pull ups. And pull ups are no joke, right?

Yeah.

The question is, if you can do 50 of them, is it as good as a weighted six of them with a big weight around your waist, so it's extra work for you. So push, pull those legs. Push, pull is back squats and deadlifts. Makes sense. Those are the heaviest lifts. So I prescribe those as what you can lift four times the weight that is heavy enough that you can lift four times with one to two reps in reserve. Meaning if I've got. I can't remember what the last one I think I was working out with 175 lately for my back squat. If I can do 4, 175, I might be able to squeeze out 5, but I need a spotter. That's how I gauge.

Yes, that makes sense. So it's intense for you based on that? You can't. It should be challenging.

Everybody asks me, what does heavy mean? And they say, is it £20? Is it £30? Well, £30 is heavy for my bicep. It's nothing for. Right. It's per muscle group. So. But that's how you do it. Four reps, four sets. And it's the weight you can lift with maybe one or two reps and reserve with good form. Yeah, right.

So with good form, that's where also I think some of the body weight, not maybe the extreme pull ups and chin ups, things like that, but regular body weight is learning the form first with, with body weight and then you start adding the weight. So that. So I want my listeners to make sure you heard that part too. Don't just jump into doing a crazy.

Heavy squat, you know, because powerlifting and lifting heavy is a skill like anything else. Many people, and I say this tongue in cheek, don't even really know where their hip is.

Right.

Or knee is. They come into me and I mean, if you're not in medicine or fitness or something, why would you know? Yeah, Adam, if you're a banker, an accountant, why would you know? So part of it is learning your body, learning how it moves and body weight is marvelous for doing that. And I'm not saying that there's no role for that. I'm just saying if the goal is not to become frail, then you need to lift heavier than your own body weight. Because listen, I can carry my body weight in a farmer's carry. I mean, it's not enough. Right.

That makes sense to me. That just clicked. So if you're listening, and I think most people are not in this situation, but if you're listening and 50 pull ups is so easy to you, then you have to add weight or you're not going to get that result. But if you're still working on one or two, that's still something to work on because that's huge. So do you think. So if somebody has a family, they all have their mom has osteoporosis. It's like this is their family trajectory. You see firsthand that by lifting weights, by adding muscle mass and doing this, you can literally prevent that being your genetic. That won't be your result. You can Completely prevent that. And then also, can you reverse it?

I'm not saying that in all cases we can prevent it because we stop laying down bone. We. We reach our peak bone mass at 30.

Okay.

In my experience, women at 30 are not thinking about their bones. Right?

They are not.

You know, by the time people roll around thinking about it, sometimes they're frankly osteopenic. Osteoporotic. Even young women. I get a DEXA scan on everybo. Wow. I've had 28 year olds, I've had 24 year olds. I've had a lot of 40ish people who already have osteopenia. And I'll just elucidate why I think that is. I think there's a few reasons. Number one is the skinny thing. We were just taught to be skinny. We didn't feed ourselves, we never laid down the bone. Number two, there's the. Even millennials now are a digital generation where you didn't grow up. In my generation, where my mother would say, go outside, don't come back in until dinner, do whatever, run, skip, because it's not safe now. It' a different world. So we have generations of people who have grown up sedentary. So you may be thin, but you never grew up with muscles and never bashed your bones. Or what if you were an athlete? We have now had 53 years of title nine, which is where equalize the playing field in college athletics. We have a whole generation of young women who have exercised their whole lives, but maybe they still didn't feed themselves. And they existed in relative energy deficiency syndrome and would see skip six months of periods, nine months of periods. Their body fat was always so low that they didn't have periods. Well, if you don't have enough estrogen to have periods, you're not laying down your maximum bone. And we see that a lot when we do DEXA scans in college athletes. Those are three reasons besides these reasons, why young women might not have ever laid down enough bone. So then you get into your 40s when estrogen and testosterone start to decline, because why do we go into menopause anyway? We go in because by the time we're 40, we only have 1% of our eggs left. We are born with 1 to 2 million eggs in our ovaries. By the time we go through puberty, we've only 500,000 left. By the time we get to 31, which is the end of easy fertility, we've got a very few left. And imagine by the time we're 40 and mid-40s, we only have 1% left, which means we're not making that much estrogen. So that is all the why. But let's answer the question. Can you do something to maintain a reverse course? You can consider your hormone replacement decision. Every woman that I've ever met is a sentient being with agency who can make her own choice. But I want her to make her hormone decision based on facts and not fear. Not because you read something in the grocery store, not because some old wives tale. There are very, very few reasons not to start on hormone replacement therapy, especially when it comes to your bones. Number one, make the decision. Number two. And if you decide to re stimulate your body with estrogen here, it's not a magic bullet. It's not the only thing to do. It's everything we just talked about. Lift heavy, have a jumping practice in your workouts, whether it's jumping 20 times a day, marching up the stairs like you're angry, jump roping, doing speed and agility type things. So you're bashing your bones because how do bones work? Bones work by when you bash your bones, the biomechanical energy of that is translated into biochemical messages that cause your osteoblasts, which are the bone building cells to build bone. So we gotta bash our bones so.

We can still build bones. Even though you're saying your primary years of building this is in, you know, reach your peak bone mass in your 30, if I'm hearing you correctly, you could still build, maybe just not at that same rate. Is that so?

This is what happens in menopause. Estrogen. So bone building. I always do this because as if I'm holding a femur, there are four kinds of cells and bones. But the osteoclast is the cell that breaks down bone to release all the minerals that your body needs to survive osteoclasts. Osteoblasts are the building cells that work in coordination with these to when you have estrogen. Estrogen helps control the osteoclast as does testosterone. Helps control this outof control seemingly cell the osteoclast. Without estrogen, you're still building bone with your osteoblasts still work, but the osteoclast outpaces. So you're breaking down more than you're building. So if you dampen that, they get more in equilibrium again, homeostasis again. So it's a misnomer to think you no longer build bone, you're just breaking down bone more. So making your estrogen decision number one. Lifting heavy weights, which will then pull on the bones, creating the biomechanical stimulus for bone building, bashing your bones, biomechanical to bone building, feeding yourself protein, vitamin D with K2, magnesium, so that you have enough tools to actually build the bone. You need all of those play in a consistent manner to maintaining or building bone.

So if I'm hearing you correctly, no matter where you are on your DEXA scan, which you need to know, so you know where you are, but even whether you have no bone loss yet, you're in osteopenia, or you are already osteoporosis, if I'm hearing you correctly, you still want to do these things because you can prevent. So no matter where you are. So it's not about. And I have this, and now I can't.

Okay, the question is, the advice that people get is, oh, you have osteoporosis, you can't lift weights. That's actually not true. There's a giant study, two study, two series, called the lift, more literally lift or study, which was a controlled study looking at women with frank osteoporosis under supervised lifting programs. So again, form matters, safety matters. That study found that women, even with frank osteoporosis, could lift heavy and do it safely when their form was good, when they were supervised. So, you know, here's an interesting thought. I mean, you can live with osteoporosis and may never have a fracture that ends up in the terrible destiny that I described to you if you never fall. Yeah, many times we are one fall away from devastation.

Right. What about women that are overweight? Do they have. This is going to sound weird, but this is what's in my head right now. Do they have an advantage on bone loss prevention because they're carrying extra weight on their bones?

Well, okay, so not really, but if we say they're carrying extra weight. So it's like wearing a weighted vest all the time. Okay, but here's the deal. Adhesive tissue is a noxious organ, and it secretes all kinds of adipokines that prevents bone building, that prevents laying down muscle. So, and I haven't posted it yet, but I have a picture of something called sarcobesity. So in the total volume of a X ray, that has a little femur in the middle, but the whole leg is 12 inches across, many times there is only a thin shell of muscle around the bone. So you may be carrying more weight, but it doesn't necessarily mean the sum total of your bones is going to be better. I Mean, it's very common for a person who's carrying a lot of weight and doesn't have much muscle mass to slip off a curb and dislocate their ankle. That is a very common fracture. So I wouldn't use that as any kind of safety guard.

Okay. When you talked about hormones, I know this is going to come up now, many women, and I see this daily, that many women, they're either the doctors won't prescribe hormone replacement because they don't understand it. They don't understand the, the most current research. They're still using dated studies from the early 2000s, flawed studies, or they it's somebody that has breast cancer in their family. They've had breast cancer, it's estrogen positive. So there's a lot of confusion around that. Well, I hear it, but I can't. Is there any words of wisdom you have on those topics?

Well, there's very few women who can't. Even women who have had breast cancer been treated and are now cured. Very few women of them can't.

But so many doctors won't prescribe it.

Still true. Even women who carry the BRCA gene, once they have, and many of those women decide to have prophylactic mastectomies or hysterectomies. And once those treatments are done, the data show there's literally a reason. But here's where each woman gets to have a detailed conversation with someone knowledgeable. I mean, and if you want to, I can say the resources of the people I refer to, but I want to tell people it is not uncommon for your OB gynae, your primary care doctor not to know the data well enough. And why should they? In 2002, when the women's Health Initiative study came out, estrogen was plucked off the market and all kinds of sequelae happened, including doctors were no longer taught about menopause or to prescribe hormones. It's not that your doctor doesn't want to talk to you about it. They were never trained. Right. And so unless they have, like I have gone back and completely re educated myself, they just don't know. So I think they're being honest with you and saying, I don't know how to do this and I don't want to do this. It's nuanced and complex, but you should never take no for an answer if it's something you really want. And there are a variety of online telehealth sources staffed by menopause trained doctors. There are a variety of menopause clinics now. And so I think the resources are becoming more available. But just because someone has said no to you is not the end of the story.

I do believe that we talked about mindset a little earlier, earlier that what you believe can come to fruition too. So if you are in the belief set that I can't take this because of that, then until you adjust that belief set, you might have a problem with it too. And I wanted to add that vaginal estrogen could be more localized solution. I would imagine if you're. That might be a starting place with your doctor, maybe the vaginal estrogen. Do you have any thoughts on that?

I do. Let's talk about all, all the places you can put hormones.

Okay.

And what they affect. So. And let's start from the top of our heads. So listen, our skin and our face skin period, but will lose 30% of its collagen during the perimenopause transition. Oh my goodness. I started doing this about five years ago. Before now it's common and now they're actual products. I thought if I am. And at the time I started this when I was 47. At the time, about 10 years ago. @ the time I couldn't find someone to prescribe for me either. So I got compounded estrogen, which I now do not recommend. But my reasoning at the time was, wow, if I'm putting this on my leg skin, what if I put a little dab on my face to preserve my collagen? So now there are studies that show that using compounded facial estriol or estradiol can preserve collagen in your face. It's such a teeny tiny dose. It does not get absorbed system systemically. So whether or not you want systemic estrogen doesn't matter. You can still put it on your face. The same is true for vaginal estrogen. Vaginal estrogen. Why do we need vaginal estrogen? Well, because I think your women can handle this information. Your labia, your labia minora, your vagina shrivel up and act without the presence of estrogen. And that's why sex becomes so painful. If your sex is painful. And so vaginal estrogen only acts locally. It is not a systemic application.

It's not going to help your bones. It's not going to help. It's just going to help that bones.

It's going to help the gynecourinary syndrome, menopause. But why is that so important? Because it also helps prevent prolapse of your bladder and bladder infections. About 15% of women have recurrent Bladder infections, which leads to antibiotic resistance and can lead to death.

Wow.

That's a second application. So facial and gynecourinary. Then when we get to the systemic estrogen, you can take oral, which is the oldest type. You can have transdermal patches.

That's what I do.

And you can do pellets. Now, most of us do not recommend pellets because A, it's painful, B, it's expensive and doesn't have to be, and C, it gives you a giant dose of estrogen and testosterone that you cannot titrate. Most of us recommend transdermal estrogen, which we can titrate up and down, it's just twice a week. And that does work systemically. The advantage of transdermal estrogen over oral estrogen, which is the oldest form, is that for oral estrogen to work, it passes through your liver, which is where the risk for blood clot, although low the risk for blood clot, arises. So transdermal does not carry that risk because it bypasses the liver. So those are all the places that we can use estradiol.

Now, I know someone, if they've not been listening to my podcast and this is the first episode they're hearing about this, someone's going to say, well, I'm on synthetic birth control pills. Doesn't that count? And that's not the same. Could you speak into that?

Well, synthetic birth control pills are 10 times the dose, because if you need birth control, well, then you need 10 times the dose of estrogen that you're going to use for menopause type care. So there's a dose difference, there's a formulation difference. Transdermal estradiol is identical to what your body's molecule is. It just happens to be made by pharma, but it is identical. Most birth controls, and there are so many different kinds, are not identical to what your body synthesizes. And sometimes they're mixed. So they're different. It's not wrong, they're just different. But it depends what your goal is. If your goal is birth control, menopausal doses are not going to do for you.

Okay.

Right. You need.

I haven't. I have another question. That is. I don't know if this is your expertise or not, but I'm sure you have an opinion on this, so I'm going to ask it because this is a hot topic lately. Glps. How is that affecting muscle and bone?

Where are there. Well, here's. Let's talk about weight loss in general, because we're so Fixated on the number on the scale. And what I want people to be fixated on is their body composition, what their percent body fat is, which should be less than 28% for women and, and for health to be healthy. 19 to 28%, 24 is better. And their muscle mass, not what's on the scale. I am a little person, I am 5 4, but I weigh a lot because I am very muscly. And so you have, if you're using BMI or just weight, very muscly bodybuilder type people will be obese by those standards because of their ratio of muscle to height. Right.

I want to just real quick, but I want to say something about that body, that number that you just said. Because people look at me and think I'm leaning my, on my DEXA scan I was 25% body fat, which is not the lean that people think. So I wanted to point that out because someone might look at me and say, oh, you're like, you look like you're 12%. But I was 25% on a, on a DEXA scan. And you just said you want to be 28% or less, which tells me a lot of people are definitely not at that 28% or less.

No, not lean for a woman, like dangerously lean is 19 or below. Right. So where periods start to be affected. So 25 is great. But what we don't realize is that the average, like you look at a woman, you're like, oh, she's a middle aged woman, maybe she's three pounds overweight. She's probably 41% body fat. Right. Which means she may not weigh 200 pounds, but she's got a lot of body fat. Right. Which is metabolically unhappy.

Right.

So I don't really care what you weigh. What I care about is your percent body fat and if you are building muscle. So I forgot the question.

Okay. GLPs, because there's a lot. And I want to bring this up. Yeah. Because I've had a lot of guests on about GLPs not just for weight loss, but also in the discussion of microdosing it for metabolic issues and for blood sugar. So I don't know how much you've, you've dove into that, but I think this is a really important topic because GLPs are not going away. And I think when used incorrectly or too much, it is rap. Creating rapid weight loss. And it's creating that problem that we saw from the 80s and the 90s of the too skinny and losing muscle. And I'M assuming that's going to affect our bone. So that's where I wanted your opinion and share on that.

Yeah. So weight loss, when you just do especially rapid weight loss, multiple studies have shown that you're going to lose equal amounts of fat and muscle. So your scale is going to go down whether it's GLP1 or not, especially GLP1s. Because the way GLP1s are most effective, honestly, is it stops the food talk in your brain. It gives you control over that nighttime where your willpower has lasted all day and suddenly at 9 o' clock at night, you just cannot resist the Cheetos or whatever second dinner you're having. That is what my patients tell me GLP1s do best for them is cuts out the food top. What if that's all you're doing? Well, 50% of the weight you're going to lose is going to be muscle. So the way to prevent that is to do what we've talked about. Make what you do eat high in protein, not just trashy food. Right? Number one. And make every calorie count in a healthy way. Number one. Number two, you have to lift weights so that you don't lose muscle. And I think people are doing it successfully, but it's just not this. Listen, I don't think I was about to say I don't think people are lazy, but I think people are programmed at a genetic level to live in min max, meaning we're going to get the maximum out of the minimum effort. The minimum effort is just to lose weight rapidly via a pill and not try because they're after some scale result instead of a health result. Does that make sense?

Yeah. And I'm, I actually am a fan of GLPs for some people. I think some people really do struggle metabolically like I. So I'm not against them, but I am all for the education around it that you've got to do it the smallest dose possible for you. You've got to be upping your protein, you have to be lifting weights, you have to be doing all of these other things or you're just creating a different problem. I want to circle back to where we started with for a minute because I just want to make sure I've really honed in on here. You said a few things about bone loss and, and the problems of not addressing this. And I want, and it was at the beginning of the episode, so I want to, I want to revisit that a minute because this was the main reason I wanted to have you on is bone loss in our aging process. What are the things that that's going to create if we don't address that? I want to talk about those negative things because I want people to really understand. This is not about just motivating yourself to go work out or eat more protein. This is a huge health crisis. If you don't address this, you are.

One fall away from dead, period.

That's intense.

I'm going to say the data again that I quoted to you. One in two women. If it's just you and me in a room, maybe not us, but it's two average women in a room, one of us is going to have an osteoporotic fracture in our lifetime. Those are the data. 50%. Those are long time data. There is no question. I can't imagine why we don't know that 50% will have a fracture. Well, here are the bad things about fracture. If it's your hip, which 70% of all hip fractures are women, 50% of the time you will be so damaged you will not return to pre fall function. And 30% of the time you will die. But what if it's not your hip? What if it's your wrist? What if it's your ankle? Bones are excruciating when they're broken. In likelihood, you will be decommissioned for three months. It takes adult bone three months to heal. Sometimes they don't heal at all because they start with such a bad place. Sometimes they only heal when we do surgery on them and use metal plates to put you back together. Imagine the pain you're going through. Imagine the disability you're having. You can't drive sometimes. You can't take, take care of yourself. You certainly can't work out. And then we know, we know that. Let's say you're in bed for a week. You can sedentary because you're hurt. Studies show you can lose up to 9% of your muscle mass. Wow. One week in bed, which we know makes you metabolically less healthy, which makes your brain less healthy, right? For women. Let's talk about this a little bit. For women, when we have low muscle mass or we haven't got control of our insulin insensitivity, that happens in midlife with menopause. And we live in a pre diabetic state. How many of you out there have been told by your doctor, oh, your fasting glucose is a hundred, you're pre diabetic. Just do a little better with your exercise, okay? What they don't tell you is that normal fasting glucose is 75 to 85. If you are living at 100 and technically pre diabetic for every point above 85, if you don't correct it, you have a 6% chance of developing diabetes. So if you live at a pre diabetic fasting glucose of 99 or 100, you have a 90% chance of diabetes in the next 10 years. Number one, that's bad enough, but number two, diabetes predicts Alzheimer's. So what happens if you fall and break your bone and you're embedded and you lose 9% of your muscle mass and then it just feeds your insulin and sensitivity and your pre diabetic becomes more diabetic and you do nothing about it because someone has just said to you, oh, you're a little pre diabetic. It becomes this snowball.

No, it's a rapid aging decline. It's a whole. That's what that creates. Yeah, you single handedly convinced me to change a lot of things. I mean, honestly, it was your talk that I heard that had me go back to wearing a CGM that had me going, I need to lift heavier. I need to look at my fiber, not my, just protein. I mean, I think I was teaching it and then I was like, but I was getting slack on myself, you know, with things like. So you really woke me up to that. I'm so grateful for your work and what you're sharing and you know, I.

Just want to remind everyone it makes it all worth it because you have such a ripple effect in your community. I mean, that's the kind of thing that changes generations of women.

Well, I love what you're doing because you're more than, than just a surgeon. You know, you're, yes, you're an md, you're a surgeon, but you really, I love how you took what you were see in the or what you're seeing with patients and you've really made it your mission to educate women and how you're practicing what you preach. Quite frankly, I don't think I would let a surgeon touch me. And at this point that is not looking like they live the part because I think they need to have this understanding like you do. And granted, I will say, you know, it always seems that the orthopedic surgeons are usually the fit ones or at least they, they got in that field because they were fit. Who knows? But you know, I really appreciate the work you're doing and that you do practice what you preach. And we're going to, in just a minute when we, when we wrap this episode, we're going to stay on and let my live. 360 guests ask you questions. But before we do that, where can people find you? Where do you want them to learn more? Where can they go? I know they're going to have a lot of questions and want to go deeper. Where do you want me to direct them?

Yeah, you know, I want everybody to go the place I am every single day, which is Instagram. I can only maintain one place, and it's Instagram. And I talk about these themes a lot, so if you're not there, please do that. And then sometimes people want to work with me individually, which I. I mean, I am a surgeon, but I do menopause mentorship. I a longevity doctor. And I. People come and spend three days with me in a program called Precision Longevity. So Instagram and then reach out to me. I'm easily accessible.

Where are you located?

I'm in Orlando.

Orlando. So people can go to Disney with their family and then they can go visit you.

Three retreats a year. We have women come down three times a year for boot camps. It's a boot camp. Yeah, it's the wrong word, but it's an immersion on. I call it Midlife Mastery.

I love it. I love that. Well, thank you so much.

Pleasure.