Episode 379: Menopause Myths, Cortisol Belly, & The Truth About IUDs

26:30And that's why if you think about Stacey's example of what happened in two fasting periods to a man and a woman, different things are going to happen to your body if it thinks it's being in starvation. You said that men can do longer fasts. They can. They can do longer fasts and it can show to actually, you know, be something that might be advantageous for them for how their body is made might increase their focus and some other metrics. But for women, these longer periods are actually going to promote more visceral fat storage and become pro-inflammatory. And you said it a little casually, but disrupting your hypothalamus and shutting off your hormone system will cause a low estrogen state.

27:09And that's very problematic, as we've talked about.

27:18Let's start with this cortisol situation because I just had an argument. It was a discussion. The woman in my gym, very kind, very nice, and I would consider reasonably intelligent. Her coach had her do this full hormone workup when they started. So she got her cortisol tested in addition to like testosterone, a bunch of weird thyroid labs. And by the way, her coach is not a physician or a healthcare professional in any. Yeah, but, you know, that's details. And this woman's like, I'm not drinking coffee because my cortisol is high. And I was like, who told you your cortisol is high? She's like, well, I had a measure.

27:55And I'm like, when did you have a measure? She's like, well, it was in the morning and I got one lab draw. And I was like, yeah, so that's not how we test for hypercortisolism when it's not how we assess cortisol levels. It's more complicated than that. There's no current consensus on how to do it, but usually like a 24-hour urine collection, you can do a dexamethasone suppression. There's a bunch of different ways. We have a whole series on this. It's more complicated than that. I can't tell from your lab value that you have high cortisol. Oh, by the way, I'm not worried about what coffee does to your cortisol level.

28:20This is not – cortisol is not the thing to focus on for you. I feel confident in saying that. Anyway, what the hell is all this fasting stuff about and being hyper-focused on cortisol? Like is there any chance that people who are doing either intermittent fasting where they skip breakfast, don't eat till lunch, or they do some other sort of time-restricted feeding window where, you know, more calories in the early parts of the day and then they fast overnight, you know, whatever. Is there any chance that this is increasing people's cortisol to a level that is pathological? We have no data to support that claim or the claim that somehow you're going to store more visceral fat.

29:01In a calorie deficit, no less. The fasting literature is quite clear that it's not magic and that it's a tool you can use to create a calorie deficit. And it can be an effective tool for people. You have a shorter eating window. You end up eating less. You've created the calorie deficit and that works. So if there was somehow a connection between this and visceral fat, people were increasing their visceral fat over 16 weeks of time-restricted feeding, then that would be shocking. But we would have that data and we don't. It's an effective weight loss strategy if you're using it appropriately. Yeah.

29:45Yeah, it's just another tool to create a calorie deficit. does not appear to be advantageous insofar as either more people are able to achieve clinically significant weight loss with it or otherwise adhere to it. But if it's somebody's preference, I'm fine with it. But this idea that women respond somehow differently to this and their cortisol levels go crazy. And that is the cause of apparently findings that have never been documented in humans. You know, it's interesting because intermittent fasting is often billed to be like this inflammatory reducing sort of practice, you know, autophagy like increases, you're breaking down more cells that are innocent and you want to get rid of them and all these good things.

30:25It does that, but now it also increases cortisol and it's pro-inflammatory apparently to increase visceral adipose tissue. And to be clear, I think both of those claims, I think it's all BS. Like it's, it just, the stuff that happens short-term hormonally, Generally speaking to me is uninteresting from a human outcome standpoint. I feel that way about pre-training hormonal milieu. I feel that way about post-training hormonal milieu. I feel that way about when people are fasting for short periods of time. I'm more concerned about what happens long term. I think that's where most people should spend their attention.

31:01That's where they should focus their attention. But this, it's just the last claim, and I'll get you to weigh in on this. The idea that if you were a woman and you do intermittent fasting, well, you're at a high risk. Dr. Crawford said this. You're at a high risk of not eating enough. The idea that like low energy availability is going to – and it's like, well, if most people – if more people don't lose weight on intermittent fasting compared to any other sort of dietary practice, if that's what the data says, then how is there an increased risk of low energy availability or insufficient nutrient consumption?

31:34Yeah, and I think I don't understand why we're kind of borrowing from the low energy availability literature, which is a true problem that some people have. But that's we're seeing this in athletes who are doing a lot of exercise and who are probably not fueling to support that level of activity. Or maybe they are trying to stay at a low body fat or low weight for performance related reasons. And that's sort of the population that is typically affected by this. Now, the idea that most women are affected by low energy availability is just insane. Because if that were true, then, I mean, we wouldn't have any overweight women, first of all.

32:24We can say long-term fasting does increase cortisol levels. We can say that if you are doing a ton of exercise and not eating at all, then that is probably not a good idea overall for your health, for your daily nutrient needs, for performance, for a variety of reasons, right? Um, we can say if you are somebody who does have chronically elevated cortisol levels and you have been diagnosed with Cushing's that maybe you are having some changes in your body composition and we're seeing more weight around your midsection and that's your cortisol belly. And maybe there's like that kernel of truth. But we're now packaging this in by borrowing from all of these scenarios that are irrelevant to most people.

33:24And then we're saying, and therefore, no facet training. Right Doesn't make sense It's not evidence based It just like Every time the intermittent fasting Has been investigated Effectively just rebuts Everything that's being said about it Even like the late One of these More recent meta-analyses On this Show that fasting Didn't have any effect on estrogen Prolactin levels Gnatotropins Another recent study Showed that it actually Didn't really affect Cortisol as much As we would otherwise predict I mean it's just It's just dynamic There's a lot of stuff going on here So sure. I'm just rejecting it.

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35:09So the RDA recommendations of 0.8 grams per kilogram is survival doses of protein, like sitting on a chair like a mushroom. Preventing malnutrition is the goal of it. It is not for active people. It is not for living your best life people. Point eight. The recommended daily intake is point eight grams per kilogram of lean body mass. So it's low. It's very low. So the research supports, easily supports, let's use pounds, 0.86 grams per pound for lifting people. I recommend over a gram, a gram for ideal pound.

36:00Dr. Vonda Wright talked about protein intake. She said that you shouldn't be eating the RDA recommended protein intake because it's made for people who are sitting on a chair like mushrooms. Just the first time I heard that saying. So add that to the lexicon. She recommended one gram of protein per pound and then later said, no, it's one gram of protein per pound, ideal body weight. How much protein do people need? If we're talking to the general public, then I think everybody agrees the RDA is a little bit too low. So that 0.8. but when we bump it up to 1.2 1.3 that seems to be helpful there's a benefit there what does that mean for most people eat protein with each meal maybe throw in a protein shake um if if you're struggling to get a sufficient portion of protein with each meal uh if we're starting to quibble about 1.6 or 1.8 grams per kilogram, by the way, not we're not talking pounds, then you can say, oh, perhaps a slightly higher level is is better if you're somebody who's really trying to maximize muscle growth, maybe.

37:14But the idea that we would need more protein to fuel our activity because we are physically active. We're doing our four sprint interval a couple of times a week. We're not using protein as fuel. So that just completely misses the point about what is the purpose of dietary protein and how are we using it in physical activity? We're not. Yeah. Yeah. I mean, again, who is this advice to and like what's the application, right? I mean, if you look at most data we have on protein consumption in the United States for adults, it's higher than the RDA as it is right now. Depending on who you read, it could be anywhere between 0.9 to 1, 1.1 grams per kilo per day.

38:02But we just eat a lot of protein, mostly, unfortunately, through the way of like processed foods, which not great. So if you tell somebody just increase their dietary protein, most people will take that to mean like, okay, more chicken, more egg, just these generally minimally processed or unprocessed foods. which can be useful for displacing processed foods and other things that tend to be more energy dense and so on and so forth. That said, strictly speaking, most people don't need to eat that much more protein. To your point, it's an extra protein shake a day. And in fact, if I was making like this public recommendation, it's like, yeah, look, you need to lift weights a few times a week, all the major muscle groups of the body, make sure that you take a few sets for each muscle group to somewhere that feels kind of uncomfortable.

38:42You need to do two, two and a half hours of conditioning per week, whichever modality you prefer. It should be kind of hard, but not so challenging where you can't speak in short sentences and you should have an extra protein shake every day. And it's like, well, I just wrapped up five and a half hours of nonsense into something that is not only accurate, but also like, you know, public facing. So, yeah, most people would benefit from like an extra protein shake or extra serving of protein per day to the extent that taking protein up higher is would be better is either from displacing, again, ultra processed foods for people who are currently eating a dietary pattern that's rich in those or for very active, very lean, hard training individuals.

39:21Sure, higher than that. But they're not listening to this freaking podcast about protein intake anyway. So like, you know, and how how high can you go? Much higher. But saying a gram per pound, it's already a little high. And then a gram per pound ideal body weight without defining what ideal body weight is. And further, none of the evidence on protein intake is about ideal body weight. It's just total body weight. Some people say, oh, no, it's got to be your lean mass. And I'm like, where is the data on that? Like if you wanted to say that because somebody maybe is an individual with obesity, for example, and their body weight is quite high and you wanted to make some sort of recommendation, I get that.

40:01but saying that that's like the general rec for everybody, like just inconsistent with the evidence. Well, it's also not a very practical recommendation because most people don't have access to that number. We got to measure it. No, no, you got to get a DEXA. If you want to work together, you got to get a DEXA scan first and only then and a VO2 max. And we got to get your cortisol level tested too, because that's how we're going to, we're going to dial you in. You brought up an interesting point earlier that a lot of this discussion around hormones really leads to a lot of unnecessary hormone testing done by people who don't really understand why or how to interpret the results or the huge influence of measurement technique like the assay that you're using it might not it it might just make it kind of a garbage um assessment like testosterone for women.

40:49But by measuring more things and making it more complicated and presenting it as like we have this sort of secret sauce where if we have more data, then we can be more granular in our recommendations kind of misses the mark on tracking metrics that we actually do know are important. Like if you want to track your progress in the gym to make sure that you are progressively overloading, then that's good. If you're trying to eat fewer calories, then perhaps tracking your calories, at least for a short period of time, can be an effective strategy. But there are obvious things that we might want to encourage people to measure.

41:37And worrying about these acute or day-to-day hormone fluctuations, whether it's menstrual cycle or longer-term menopause transition or even shorter-term with cortisol, we're focusing on the wrong things. Yeah. Yeah, I agree. It does sound sexy. It does sound compelling, especially to the lay public. It's like, oh, this is doctor speak. I'm interested in doctor speak. And that, you know, look, I mean, medical dramas and TV shows, they're very popular. So there's something there. I get it from a marketing standpoint, but yeah, I agree. Missing the forest for the trees, and in some cases the trees are actually not trees at all.

42:19They're just mistaking them for trees. Just kind of a weird thing.

42:26We're going to shift gears now. Up until this point, the misinformation has mostly been about wasting your time in the gym or stressing you out about meal timing. But now we're moving into medical advice that could actually cause harm by scaring women away from effective health care. The viral episode made some terrifying claims about IUDs and birth control causing bone loss and essentially, quote, shutting down a woman's system. Now, to address this, I tagged in Dr. Lorraine Baraki to look at the specific claims regarding IUDs and the birth control pill.

42:58Certainly circumstances where that is the right thing to do. We've had IUDs in practice for a really long time. for the majority of this, we were only placing them in women after they had given birth at least once because of their size and being able to pass them through the cervix. Now we have different options and we are offering them to women younger, which is wonderful. However, when we're putting IUDs in the uterus of women who are really young, sometimes the progesterone dose in them is so high that it is preventing ovulation. And we are seeing young women who are not ovulating and they are not making estrogen, therefore, and they don't even really realize it because that's not disclosed as one of the main mechanisms of a progesterone IUD because it doesn't happen in enough people to effectively prevent conception that way.

43:45It works through the inflammation, the cervical mucus changes. And why does that matter? Because if you are not ovulating and you're not making estrogen, you are going to have low libido, low energy, you're not going to build your bones. during critical years, let's say the IUD lasts five to seven years, you're 18 to 25. These are some of the most critical years in your mental health, your bone health, your cardiac health, and being low estrogen during that time is going to set you up on a different risk trajectory for your entire life. And the worst thing here about the progesterone IUD is that because of the progesterone, which will thin the lining, many women just say, I don't have my period because my lining is so thin and that's a side effect of the IUD.

44:31If that same woman was not ovulating and came to me and said, I haven't had a period in seven years and I knew she was low estrogen and not ovulating, we're highly concerned about her health. But because she has an IUD, what happens? Well, that's a side effect of the IUD. No big deal.

44:55I'll start by saying that the claims made regarding the levonorgestrel IUD show a fundamental misunderstanding of how these devices work. The claim I'm referring to is that the IUD shuts down estrogen and therefore stops bone building. This is taken from what we just listened to, to quote specifically, sometimes the progesterone dose is so high that it is preventing ovulation. We're seeing young women who are not ovulating and they are not making estrogen, therefore you're not going to build your bones during critical years, referring to the ages between 18 and 25. And so just to put this in a bit of context, I will say that the key to understanding the mechanism of the progesterone IUD is its local action.

45:48The IUD releases a very low dose of the hormone levonorgestrel, and it releases it directly to the uterine lining. The hormone concentration in the rest of your body, or the systemic level, remains extremely low. How is ovulation affected by this? Well, the IUD's primary job is to create changes in the uterine lining and cervical mucus to prevent sperm from fertilizing an egg. The majority of women, up to 80%, who use the levonorgestrel IUD continue to ovulate and produce their own natural systemic estrogen and progesterone. It's also worth noting that estrogen, primarily estradiol in our bodies, continues to be produced by the ovaries during the use of ovulation-suppressing hormonal contraceptives, though at lower levels than in ovulatory cycles.

46:41Studies showed that during active use of combined oral contraceptives, for example, which consistently suppress ovulation, in contrast to this IUD, which only occasionally suppresses ovulation. Estradiol levels are significantly suppressed compared to natural cycles, but they are measurable. They do persist, and that reflects ongoing, though diminished, follicular activity. So it's a bit misleading to paint a picture that is all or none, in this case, with the production of estrogen. Now, let's address the topic of bone health in women using the levonorgestrel IUD. Because ovulation typically persists, natural estrogen production continues, which protects the bones.

47:32The studies on levonorgestrel IUDs have overwhelmingly found no clinically significant reduction in bone mineral density, even in young women in their critical bone building years, as referenced before, the ages of 18 to 25. The uterus localized actions of the levonorgestrel IUD differ from a systemic form of progesterone-only contraception, like the Depo-Provera shot, which reliably suppresses ovulation in nearly all users and is associated with temporary, though typically reversible, bone mineral density loss. The key here is systemic progesterone inhibiting ovulation and estrogen production without concurrent exogenous estrogen, as in combined birth control pills, which is protective to the bones.

48:24The next claim that I wanted to address is that the IUD could mask a serious health problem. And the quote that this claim comes from is, the worst thing here about the progesterone IUD is that because of the progesterone, many women just say, I don't have my period. If that same woman was not ovulating and came to me and said, I haven't had my period in seven years, were highly concerned about her health. The reality here is that this point is only a partial truth. The contributor in this case fails to differentiate between two very different situations that are worth pointing out. The first situation would be amenorrhea, or the absence of a period with a progesterone IUD.

49:13In this case, the IUD's local hormone intentionally thins the uterine lining, which is why most users have much lighter bleeding or no bleeding, also referred to as amenorrhea like I mentioned. When a woman with an IUD doesn't have a period, we know why. It is an expected side effect of a device releasing a low-dose local hormone. The other situation to differentiate from the first would be amenorrhea with no known cause. The example the speaker gives, a woman who hasn't had a period in seven years for an unknown reason, i.e. does not have an intrauterine device that is leading to this, to the lack of a period, is an entirely different, potentially detrimental scenario.

50:06That lack of a period signals an underlying issue like low energy availability, excessive training, or premature ovarian insufficiency, which occurs in 1-3 % of women. That warrants prompt investigation. The concern that the IUD is masking a serious, rare condition like premature ovarian insufficiency is small when weighed against the massive benefit of the IUD's extremely high effectiveness for preventing pregnancy or its use in treating pathological, life-disrupting menstrual symptoms. In short, counseling should acknowledge the masking risk, but it should not be used as reason to forego one of the most effective contraceptive methods available.

50:54The second clip we're going to watch relates to the use of hormonal contraceptives, including birth control pills, as well as other forms.

51:07The birth control pill can prevent ovulation, therefore prevent some women from being in terrible pain. If you have PCOS, they're often handed out like candy. One reason is because it will regulate your cycle so that you don't have these prolonged irregular periods, but also will decrease testosterone levels, which is sometimes a good side effect of the pill for women who have PCOS. Back to a normal level. Yeah. But if you don't have PCOS or the regular person, a lot of times your body's tissues are not responding to synthetic estrogen and progesterone the same way it does to natural. I think that's a very important point.

51:42So my niece, who competes at a national level, and she's 14, started suffering from, as she was going through her adolescence, her acne got outrageous. And she's a 14-year-old girl, started at 12 and a half. And, of course, she goes to the dermatologist, and they're trying some topicals. And then finally, as you go down the algorithm for how we treat acne, one of the off-label uses is birth control pills will lower the testosterone. Their skin can clear up. So her father, a little concern comes to me. Her mom passed away. Her stepmom had passed away. So he didn't have the mom in the house, you know, the immediate mom to talk to.

52:19And for the first time, I immediately thought of her athletic performance. Thank you, Dr. Sims. And I thought, she wants to go to the Olympics. There's no way I'm going to let her testosterone levels drop. Like, we're going to throw everything topical at this. And we finally found the right combination. Her skin looks great. She's super happy. But like the next logical thing was to put this 14-year-old, you know, on a birth control pill to get her acne under control, which is the end result. But what no one's thinking of is her athletic performance. How is it going to affect her? Training years leading into it.

52:51And her training years. Like this is critical for her. 16 is when the next trials are up for her. Yep. So that's two years from now. So we were able to get her acne under control, avoid the birth control pill. But that was nothing I'd ever thought of before.

53:10Let's tackle some of the common claims we hear about hormonal contraception, especially for young female athletes. The idea that birth control is inherently detrimental to performance, bone health, or hormonal health is widespread, as we just heard. But the evidence tells a more nuanced story. The first myth to bust, so to speak, would be that hormonal contraception ruins performance. The claim from this clip was that the next logical thing was to put this 14-year-old on a birth control pill, but what no one's thinking of is her athletic performance. And the reality is that hormonal contraception does not substantially impair or enhance sports performance at a population level.

54:04The overwhelming scientific evidence shows that starting hormonal contraception does not confer a performance downgrade. That being said, individual responses and side effects should be considered in counseling and training plans. However, it's not enough to just look at the science. We should also consider contextual factors that can influence others, including adolescents in their sports performance. Coaches, parents, trainers would do well to avoid the nocebo effect when it comes to this topic. If you tell a young woman her performance will suffer because of the pill, she might believe it and her performance could in fact drop regardless of the physiology.

54:48So I'd say that it's best to be supportive and set positive expectations, especially in the absence of any compelling data that would imply otherwise. The next myth to address here is that bone density will diminish or disappear in women taking birth control pills. And this is taken from the claim that it's no wonder I have 20 and 30-year-olds with no bone density. This is a major exaggeration. Estrogen is crucial for bone health as it helps to maintain and build bone. Combined hormonal contraceptives, which contain estrogen, generally have a neutral or even mildly beneficial effect on bone density in adults.

55:38For adolescents, the nuance is important, and that is that starting combined hormonal contraceptive soon after menarche, or the first period, may temporarily slow the speed at which the body builds peak bone mass. But to suggest that healthy women are left with no bone density is fear-mongering, and it is not supported by data. Consistent training, adequate nutrition, and avoiding gonadotoxins like cigarette smoke and certain drug regimens are the biggest drivers of long-term bone health, in fact. And the next topic to address, or myth to bust, is that combined hormonal contraceptives shut off testosterone.

56:28The combination of claims that this came from were, first, there's no way I'm going to let her testosterone levels drop. That was in reference to the adolescent niece. And we're going to shut off our testosterone because it makes us feel better. in reference to women who take hormonal contraceptives, presumably to reduce symptoms of hyperandrogenism, such as acne and excessively oily skin. That is a presumption, as that speaker referenced PCOS specifically. And the reality is that these claims are misleading because it confuses total testosterone with bioavailable or free testosterone. So let's talk about what combined hormonal contraceptives actually do.

57:16The estrogen in these combined hormonal options increases a protein called sex hormone binding globulin. That's made in our livers. Think of sex hormone binding globulin as a taxi service for hormones. The result is when you have more sex hormone binding globulin taxis, they pick up the free testosterone in your bloodstream. This means that you have less unbound testosterone available to interact with tissues like muscle, bone, and skin. This is why doctors prescribe combined hormonal contraceptives for conditions like severe acne, since unbound testosterone affects the skin in ways that lead to increased skin oil production and acne.

58:03So what is the impact on performance? Well, when women taking combined hormonal contraceptives have less free testosterone, studies actually do not show a clinically significant impact on strength or sports performance. We cannot simplistically apply male performance models to female physiology, specifically that we will run faster or lift more weight linearly with higher levels of bioavailable testosterone. own. Women are not little men, and our bodies respond differently to changes in androgens. Pivoting away from myth-busting of some of the claims made on this podcast, I'd like to emphasize the importance of focusing on the individual.

58:50Beyond the science, we have to consider the lived experience of the athlete in this case, and I would maintain that quality of life is a significant performance factor. If an adolescent is suffering from severe acne, this can have a detrimental impact on self-worth and confidence. If an adolescent is suffering from heavy or irregular periods, it can be difficult or impossible to train or compete at all due to pain, hygiene needs, or flooding, which refers to bleeding through one's clothing. Combined hormonal contraceptives can be a tool that allows them to fully participate in their sport and life without distraction.

59:34The care we provide to adolescents and adults alike must be informed by evidence and prioritize the individual's goals and priorities above all else.

59:56Huge thanks to Dr. Lorraine Baraki for clearing that up. Finally, we couldn't review a modern health podcast without touching on the elephant in the room. Zempic, Manjaro, and GLP-1 agonist. The viral clip framed these drugs as a potentially scary way out or scary alternative to the gym, talking about muscle loss, bone loss, and when they would actually take patients off of these medications. So we asked Vineyard's Dr. Spencer Nadolsky, a lipid and obesity expert, to weigh in on these claims.

1:00:26so if you give them the isempeg but they still don't go to the gym they still don't do anything else then we'll stop giving it to they won't be healthy okay i want to stop there she says that we're going to stop giving them the medicine imagine if you have type 2 diabetes insulin dependent type 2 diabetes where you're so insulin resistant that you need insulin on top of a GLP-1 receptor agonist and other medicines. And because they are not following some sort of lifestyle plan that you give them, you say, I'm going to stop giving you your insulin. That's the same analogy. Or if a patient is on a statin drug or whatever other chronic disease medicine drug, and they are not following through with some sort of lifestyle plan, you go, I'm going to gatekeep and withhold this really efficacious medicine that's going to help you regardless of lifestyle because you're not doing the lifestyle that I prescribed.

1:01:26That's bad medicine.

1:01:34Well, when I hear that it's going to help me lose weight and I've got two options. I can go out and lift all these weights, Stacey, and I can, which, you know, Vonda, I don't, yeah, it's hard, isn't it? go to the gym, I have to put my shoes on, all these things. Or I can take this injection. And lose all your muscle and lose your bone and end up like the little floating figure in Wally movie that I've talked about before. And that's my fear of just blanket people use. You're also, whether you mean to or not, giving the illusion that willpower is all you need to lose weight by what you said. I can either do these hard things or I can choose this medication, which appears to be the easier way out.

1:02:17And two things can be true at once. People can work extremely hard. Maybe they don't understand exactly what they should be doing. And that's part of what we're trying to change the discussion on. So in our clinic, it is an hour long. Now they're coming in to discuss the GLP-1 option. It is an hour long visit of risks, benefits, side effects, protein intake, resistance training, mandatory. We will follow your bone density. We will follow your bone mass. I mean, your muscle mass.

1:02:49I love what Dr. Crawford is saying right here because she's pointing out this false dichotomy that you can either go this easy way out with Ozempic or other GLP-1 receptor agonists, or you can do it the hard way, which is lifting weights. Dr. Stacy is saying, oh, you're going to lose all your bone and muscle if you take the easy way out. You got to do it the hard way. It's a false dichotomy. Of course, you can use both together. And I'd like to point out, though, that the issue with obesity is appetite dysregulation, where these medicines really help normalize and resolve that, or at least minimize the appetite dysregulation and improve the appetite regulation.

1:03:27that makes it difficult to actually do the things that people know what to do. They just have troubles doing them, such as eating a healthier dietary pattern and actually doing the exercise, especially when they're thinking about food all the time and they have a lot of weight and maybe it's difficult to do that exercise. So I like that Dr. Crawford really pointed out right here. It's like, hey, this is a false dichotomy. People need these medicines to be able to do the activities that you're discussing. it's not an either or. I want to go into this idea of bone loss with the GLP-1 receptor agonist.

1:04:03This has been studied pretty well and in fact there's some data that some of the new GLP-1 slash GIP receptor co-agonists may actually have protective effects on the bone. So there's no data to show that people are losing massive amounts of bone from using these medicines. It's a concern from losing a lot of weight in general, but there may be something protective about this co-receptor agonism that we see with at least terzepatide and maybe some of the newer drugs. There's nothing specifically about the GLP-1 by itself that seems to be catabolic about bone other than the calorie deficit. So we don't hear people getting really upset about people that just diet without exercise.

1:04:45They're saying it specifically about these medicines, which is a form of weight by recommendation. I love what Dr. Crawford's saying here as well. I do think we need comprehensive care around GLP-1 receptor prescriptions. We should be touching base with people, making sure they're not losing weight too quickly, making sure that if we can, helping them exercise. But we shouldn't also gatekeep if they can't exercise or won't or not willing to exercise, as I mentioned before. If people take GLP-1 receptor agonists and there is a good indication for them and they don't lift weights or eat in a way that we want them to, they're very likely, in fact, they're most likely, almost 100 % going to improve their health.

1:05:28So they're not going to become unhealthier from taking one of these amazing efficacious medicines with a poor lifestyle. If they don't do the lifestyle that we recommend them, they will still get healthier. Indeed, glycemic improvements, weight loss, of course, improvements in obstructive sleep apnea, liver health, and even cardioprotective nature of the drug will help them reduce risk of major adverse cardiovascular events. So I don't like this posing like if you don't do the lifestyle that we promote and you just take the drug, you're not going to get healthier. In fact, you're going to get unhealthy.

1:06:02That's not true. We want to promote a healthy lifestyle, but the reality is not everybody is going to do it. And so that's behavior change and the issues with behavior change. I will say anecdotally, I noticed that patients, once you give them medicine, and they're able to do the things that they already knew to do, but just couldn't do it before.

1:06:27And that is a wrap on our review. Look, the reason we spent two episodes breaking this down isn't to be haters. It's because when you mix valid science terms like myokines or cortisol with fear-based storytelling, it can paralyze people. If you take one thing away from this episode, you are not fragile. Menopause does not mean you stop adapting to exercise. Your IUD is not eating your bones. And if you're a woman, you can fast and not get cortisol belly. If you want to support evidence-based content that empowers rather than scares, leave us a review and share this episode. For Dr. Loren Colenzo-Semple, the Barakis, and Dr.

1:07:00Nadolsky, I'm Dr. Jordan Feigenbaum. See you next time.

1:07:13Thank you.