How to Stay Mobile, Independent & “Unbreakable” As You Age with Dr Vonda Wright #588

33:46And if you live 50 % of the time, you will not return to the home that you came from because you don't have the functional strength or you can't get up from a chair anymore. So bone is, that kind of fracture is not only a personal pain, it's a family and social dilemma. What do we do with mom, right? Do we hire a full-time caregiver? That's expensive. Do we have her move in? You know, in some cultures, and I'm Chinese, in my culture, that's what would happen. I mean, my parents live with me because that's just what we do. But in many cultures, that's not what you do. You find a place for your parents to live.

34:27Well, if you find a place for your parents to live, that is prohibitively expensive, many places. And so in the United States, you must use your life savings to pay for that at the rate of$5 ,000 to$15 ,000 a month until you're a pauper. And that's when the Medicaid, who wants to be in that situation? the difficulty is wonder is that i mean as you as you were talking there i got flashbacks to when i qualified as a doctor so my first job at the royal infirmary of edinburgh in 2001 when i came out of medical school was as a junior house officer which is what we called it back then in the orthopedic wards oh at the royal infirmary and i can still remember i think the first two months of my placement was doing orthopedics.

35:18And I just, I can just remember the ward and it was mostly women, frail, older women who had neck of femur fractures. And I didn't know then what I know now. Of course I was junior doctor just came out of medical school, but I can look at that now, you know, through a different lens from everything you just shared, why it affects women so much. This is huge. But how do you get a woman in their late 30s, who is in what you call the critical decade, which you can perhaps explain in a moment, to actually care about this neck of femur fracture that they might get at 75? Because that seems like, oh yeah, whatever, you know, I'm still active, I can still pick the kids up, and I can still see my girlfriends at the weekend.

36:09And, you know, how do you get someone in their 30s or 40s to care about those bone density implications later on in life? It's difficult, isn't it? It's so hard because there's a temporal disconnect. There's this banking idea. I learned it from my bankers that they experienced called temporal disconnect. On average, they cannot get the average person to save$10 for their pension, right? It's the same in health. I cannot get people motivated in their youth for their old age. So for the women and men in the critical decade, which I call 35 to 45. I love that. Is it just for women though? Or is it for men as well?

36:53No, it's for men. It is time to get your proverbial health standards in check. Because if you build a lifestyle where you're eating a non-inflammatory, high protein diet so that you're able to build, or if you're eating at all, many women decide not to eat enough. We can talk about that. If you've got your food down, and it doesn't mean you can't live and have an occasional, you know what, I had a piece of chocolate before I walked in here. I'm not talking about austerity. The standards of nutrition, a muscle building practice, a cardiovascular building practice, it's a lifestyle to you. It is not a burden if that's just the way you live.

37:33the critical decade is the time to get that in order before you lose your hormones right for women once you hit your mid-40s now you're adding that burden that we already discussed yeah it's almost as if we can kind of get away with things until our mid-30s right so yeah there are health promoting things to do but even if you don't do them you'll skim by you still seem to get by or a lot of us do in our 20s and early 30s. But then there does tend to come a point in most people's lives where it's like, wait a minute, if I don't pay attention to this, there are consequences. And of course, hormones are one of the big reasons for that.

38:18I can't get this idea out of my head about how do we get people to care about their bones early on in life and build that foundation to protect them later on in life. And I know from hearing you speak that you do DEXA scans with a lot of your patients. All of them. Now, interestingly enough, in the NHS, the National Health Service here in the UK, it's not that easy to get a DEXA scan, right? You have to meet certain criteria. Yeah. But let's just flip it. If we were designing something from scratch and going, okay, bone health is important, but we need men and women to really focus on their bone health early on in life.

39:00Yes. Teenagers in their 20s, in their 30s. How are we going to get them to do that? Oh, well, what if every single 20-year-old got a DEXA scan and then we could show them this is the state of your bone health? Is that a good idea? Is it a flawed idea? How would you put all that together for me? I think in this day and age, data drives people. And so I have proposed that we get a DEXA scan, which measures bone density, which is the mineralization. And if it's available where you are, which it is in the UK and Australia, when we're getting them in the US, an ultrasound, which tells bone quality.

39:46and here's why that's important. Every time you take a step, the bone will bend a little. When you put more pressure on it and it bends too much, it'll break, right? So we need to know the quality of the bone. You tell that with a REMS ultrasound scan, which are available here. We should have that in our critical decade. We peak out at 30, let's get it between 30 and 40, just like you get a mammogram so that we know where we're starting. Because here's the deal. If I get these scans on people and I find 30-year-olds with very bad bone because they've never built it, well, then we can do all the things to build better bone, including hormone optimization, jumping around, muscle building, a smart high-protein nutrition, because research finds that you need, for the best fracture prevention, a 10-year lead.

40:45It's okay to start these things when you're 55 or 60, but it's better if it's your lifestyle. Is it like an MOT? Well, I don't know if you have MOTs. An MOT is something we have in the UK. So if your car is over three years old, it has to undergo an annual MOT. Exam, yeah. Okay, so to check that it's roadworthy and if there's anything problems with your tires or, I don't know, the wipers, you know. Ironic that we do it for cars. Yeah. We do it in the United States when every year we get our new tag and you have to have an emissions test. Yeah. Yeah, ironic. So what I'm thinking is, I think I heard, did you say you've seen 24-year-olds with osteopenia?

41:28Oh, yeah, completely. Okay, so this is alarming, right? And this perhaps goes into the more societal piece over what conditioning women have been exposed to for many years and what women think they need to do in order to look a certain way. But why is it, I mean, do you remember that 24-year-old with osteopenia? Why did she have poor bone density in her 20s? I've given this a lot of thought. And the first thing I'm going to say is that we think of osteoporosis and bone health as a disease of old ladies. Osteoporosis is a disease of young ladies that manifests when you're old. You begin this problem when you're young.

42:09And why is that? Well, number one, still, despite all the progress we've made, women are still taught to be teeny tiny and take up no space and not eat a lot of food. Women think that they're going to be healthiest if they don't eat a lot. And even though we've made progress, I am not against GLP-1s at all. They have some profound metabolic effects, but I fear that we're tipping the needle back to skinny is better without using those with high protein and lifting practices. And we can talk about that. But the mantra that women must be skinny and not eat leaves many women with not enough materials and maybe not menstrual cycles and estrogen production in their youth.

43:00So that's number one. Number two, on the other side of the coin, we have had 54 years of rising equality in women's sports. It's the World Cup right now, right? The Rugby World Cup in the world. And we've got great athletes. But what happens as a sports doctor, I'll tell you that if you're burning 10 ,000 calories a day as a woman on the soccer pitch, on the football pitch, that you have to replace that with something besides gummy worms. And you have to eat that many calories. And that's just not the culture of women to have training tables like it is for men. So maybe you're not eating enough and you're little.

43:42Maybe you're exercising so much and not replacing enough. And then the third reason I think we're seeing it is everybody's a digital native right now. Gone are the days. We were not digital natives. We did not grow up with a cell phone. It came later in our growing up. All of our children now are scrolling despite our best efforts for long periods of time. We are no longer safe just to send our kids out to play for hours and hours. they're more sedentary so they're not bashing their bones and building bone so you get to the peak building years not having built peak bone and then so that accounts for the 20 year olds and the 24 year olds i had a physics phd student who was skinny fat meaning she was thin as a rail but she was sedentary and she did not have lean muscle mass and nor did she have high bone density I have athletes in my clinic who are trying their best, but they're amenorrheic, meaning no periods for six to nine months because they have relative energy deficiency.

44:49And with low energy, your body goes into survival mode and doesn't produce. I mean, your body doesn't want you to have a child when you're starving, which is what your body thinks you are. And so it doesn't cycle. I mean, that makes so much sense. Yeah. And I guess also one thing we're seeing across many countries now is a rise in eating disorders. Yes, in boys and girls and men and women. But of course, if you're a woman and you've had an eating disorder and for a period of time have not been properly or adequately nourishing your body for whatever reason, which of course we need to sensitively address, that's going to have an impact.

45:32Yeah. It's quite interesting that I think you mentioned there was a PhD student in her 20s and she was thin, skinny fat, I think you described it. And she was performing well, right? So what's interesting about that for me is that that individual probably thinks life's fine. I'm skinny. I'm the way I want to look. I'm able to study, but perhaps my lifestyle without me realizing it has neglected my bones and as you say of course you know the kids today are digital natives and it's something my wife and I are constantly talking about with our kids I mean my daughter's 12 and she got into netball about three years ago and so she probably plays five times a week and I'm delighted because she enjoys playing her friends are there so there's this big social component.

46:26I'm thinking, actually, you know what? If I think about netball through the lens of bone health, there's a lot of impact, a lot of jumping, a lot of speed. I think this is good. Multidirectional jumping. Perfect. Yeah. And I'm thinking this is good, right? Because there's a social component for her. And as a side effect, she's getting all of this great movement in. I think the difficulty for me would be as well if she wasn't internet ball actually you know i know a lot of parents face this if their children don't enjoy a particular sport they could hear a podcast like this and think well hold on a minute what are my kids actually doing to build their bone density i mean they go to school they come back they're on screens or whatever it might be i mean this is surgeon, isn't it?

47:19It's critical. And to that, if a parent is recognizing that their kid isn't playing netball or my youngest daughter was a ballet dancer, she's not in the studio 20 hours a week. I am a firm believer. And I say this with the most love in my heart for mothers and fathers. I am the mother of a blended family of six children. So I get raising children. from a very youngest age, kids will do what we show them. So if you want healthy children, you must be healthy yourself. They will grow up knowing that juice will rot their teeth and is bad for them. They will get down on the floor with you and play on a foam roller.

47:59And I don't say that in any kind of judgment. I say that with the reality of that many children in my life and now three grandchildren who will do whatever I'm doing. So if we want healthy children, let's show them. So if your daughter's peers don't play this sport, which I think is just so fantastic, maybe it becomes a family affair. Yeah. And it becomes what the family does. We do some kind of fun thing together that, oh, by the way, just happens to involve jumping and running and walking. Hey, kids love jumping and doing that stuff. Oh, playing. They don't necessarily need to know that when you jump, you're putting sheer force through your bones and the osteoclasts are getting stimulated.

48:46And like, sure, some of them do. Maybe my kids have heard that from me. But in general, like kids like to jump around. And, you know, when I'm advising adults right now, one of the things when we're talking about building better bone is I'm encouraging people to jump. And when I'm talking about the cardio that I prescribe, I'm asking them to sprint. Well, when we think of the passage of time, we were talking about this earlier, people give up one thing at a time and don't even realize they're doing that. And the fun play activities that kids just do, like jumping and running that are so healthy, they give up one at a time.

49:25But if it's a family affair and it's just what our family does, maybe they won't give it up as soon and it'll get the parents back into those behaviors that will build their bones going back to this idea that women and men age differently yes i'm really interested as to what happens when a woman gets pregnant oh because i know that can have an impact on bone health and breastfeeding can as well so can you just talk us through that because again i think it's empowering to realize the impact of those things and therefore what we can do on the other end. Completely love that you brought that out because if we talk about that bone as a lifespan pursuit, we just talked about the young women.

50:11Then when women enter their fertility years, when they're choosing to have children, or if you don't, bones are still of concern to you. But during pregnancy, we are building a baby from ourselves. The baby's not eating itself. The baby is eating the mother, either through the nutrients coming in, or if there's not enough from her muscle, from her bone. It takes about 500 milligrams of calcium a day to build a baby. Where are we getting that? We're either absorbing it from the gut and then passing it to the baby, or we're resorbing the mother's bone. And just for people who don't know what resorb means?

50:46Yes, it means that the way bone works, just as a bone-building primer, how bones work, Our bones are constantly doing something called remodeling, meaning taking a little bit away, building a little bit up. It's two different cell types. The osteoclast with a C is taking bone away. And then you use all the minerals that you've harvested. And then the osteoblast, B, blast, is building bone. And in normal circumstances with enough hormones, that is a pretty equal process. Homeostasis, balance. Those are all synonyms. If your body requires more than you're able to build or replace, you will get in bone deficit.

51:30That can happen during pregnancy if we're not getting enough nutrition. The mother's body will prioritize the baby and resorb what it needs, regardless of what happens to the mother, such that there is a phenomenon called the osteoporosis of pregnancy. It's a documented medical phenomenon because women can lose a significant amount of bone density. Now, here's the good thing. Our bodies know this is going to happen. And we are designed to rebuild that bone post-pregnancy. But only if we eat enough. Mothers get busy. Sometimes they don't have time to take a shower, let alone eat, right? Pile on top of that breastfeeding.

52:14Now, I always like to have the caveat based on responses I've got that I am all for breastfeeding for women who choose to do it. I breastfed my youngest child for a year. I think it was that important. Where are we get? Again, it's the same argument. Where are we getting the nutrients from? It takes 500 milligrams of calcium a day to make enough milk for a baby. We're going to take that from our bones. So every time your baby latches on, in addition to drinking water, we have to be thinking about replacing our calcium, our magnesium, our phosphorus, so that we don't end up in deficit. Because now with women, millennial women delaying childbirth into their early 30s, mid 30s, we're entering the critical decade, right?

53:02So we have less time to build bone back. And then what if we're having children more rapidly at an older age? And so we may never have time to build back. I just want people, women to be aware, right? Because you can correct that. But if you never correct that, and then we've already talked about what happens in perimenopause, losing 15 to 20 % of your bone density. Do you see how this can add up across a lifespan such that it is even more common for women truly in their menopause years? At this conference we were at, I had many women come up to me afterwards and say, you know what? I thought I was doing everything right.

53:46They're doing all the lifestyle things. But they go and get this DEXA scan or this REM scan and they're osteopenic or osteoporotic. and they're so disappointed because they thought they were doing everything right now. Well, they may be, but maybe they didn't build enough bone in their youth. Yeah, it's so interesting. You know, as you're talking, I'm thinking about my wife. So my wife breastfed both of our kids, which is what she wanted to do and she was able to. I recognize that not every woman can. Or wants to. But let's say there was four years of breastfeeding. Given what you've just said, that's four years where my children, our children, were taking whatever they needed from my wife's body.

54:37That's right. And potentially leeching her bones for calcium. It sounds terrible when we say it like this, doesn't it? In order to sustain theirs. That's right. Right? Now, you know, in the context of you just saying what you said, which is at this conference we were both at this weekend in London, we're both speakers at this conference, wonderful conference. So many women said, I thought I was doing everything right. I didn't realize there was an issue with my bones until I got the DEXA scan. So without knowing anything about my wife, would you say, actually, that's someone who might be a good candidate for a DEXA scan?

55:15I'm going to order it for her myself. Okay. So you think it's not important because - I do. What is the downside of knowing where we stand? Yeah. Because it might serve as motive. We might find out she's perfect. Yeah. Good for her. We're going to keep going on the course. We might find out that there is an opportunity to get in front of this before she's 55. This is the time to find out. And that's what I want people to do is find out. So here are all the reasons. I mean, there are dozens of risk factors for osteoporosis besides loss of estrogen and aging. But if your mother is shrinking, you know, my mother used to be as tall as me and now she's down midhead, right?

56:00If your mother is shrinking, if you notice you're shrinking, if you thought smoking was cool and smoked at any time in your life, smoking is poison to bones. If you had an illness, a chronic illness, where you were required to take a lot of steroids from asthma to cancer or any of the autoimmune diseases, there are dozens. Or if you had a fracture after 20, fracture is the number one predictor of future fracture. These are all risk factors for osteoporosis and poor bone health. those are reasons to march into your doctor and say i have a risk factor for a bad bone and i want to know if you were skinny fat your whole life if you have recovered from a from a eating disorder that these are all reasons we do not have to sit idly by and cross our fingers and hope yeah that our bones are going to be okay at 65 when finally a dexascan or will be paid for you know i think we also have to look i i'm i'm sort of semi-familiar with the healthcare system in america but of course i know the uk one much better yes i'm really off the view these days that the nhs our national health service cannot and will not be there for all of these issues it simply cannot pay for all of this stuff for everyone that's right and i think we're sort of waiting for this time where it gets funded well enough whereby all of us can have this I don't think that's coming and I don't say that because I want it to not be there yes it would be great if all of this stuff could be funded but I think at some point we have to start recognizing that the NHS is going to be there and it's going to be fantastic at some things acute problems or I shared with you we were just from the fracture clinic this morning because my son fell a couple weeks ago, well, four and a half weeks ago, broke two bones in his wrist.

58:03We got great care from the NHS. They x-rayed him, put him in a cast. We've gone and had a review. That stuff I think the National Health Service is fantastic at. But I do think, and of course, not everyone can afford this. But if you're someone who's concerned, it may be that we have to take this into our own hands and go, actually, what is the cost of me not doing a DEXA scan? Because you outlined it before. What if it's 72, you're with that break, and then it's your kids who are having to decide, are we going to put mom in a home? Are we going to pay for care? Are we going to decimate all the life savings?

58:41Whatever it might be, these are real things that are happening. And it's just going up, up, up. So this whole idea of cost as well, it goes back to what your banking friends were saying, right? We can't really see it. I don't know how much a DEXA scan is here. Let's say it's 200 pounds, right? And of course, not everyone has 200 pounds, but we don't see it where actually that 200 pounds spent could literally save you tens of thousands of pounds in the future. Exactly. So I always encourage people to do exactly what you've said. Like, Well, I have a comment about your health system and my health system in the United States.

59:22I have come to understand, even based on the way we bill, the job by and large of the U.S. health care system is to get you out of the hospital alive, to make sure you don't end up dead in the hospital, and to take care of acute problems. There is not the time. I'm a practicing surgeon. My practice is a third in terms of volume as it was because I am trying to take whole person care. But the average doctor in a fast running clinic does not have that luxury, right? So it sounds like here and in the U.S., we're just doing acute care and catastrophic care. And I think people are responsible for their own health.

1:00:03I think we can't leave all the decisions to a clinician or all the prevention to a clinician. So this is one example. For instance, I encourage people in the United States, you can get a DEXA scan for about$99, which is not a zero fund, is not a zero number. but think of how much we spend on a cup of coffee at Starbucks and I'm not zeroing out Starbucks, but the fancy coffee that I no longer buy there costs$7 and 18 cents. If I do that every day, that's a DEXA scan. Can we please stop piddling away and just save it for a month and you'll get yourself a DEXA. And I realize that that may be a privileged thing to say, but every single person has something and save it for six months.

1:00:50But let's say, let's even say that someone cannot afford that, right? Let's go to the practical things because one of the, you know, I went for a walk this morning, I was thinking about, there's so much to cover from your book and I thought we'll never get through it all. But I thought we must go into bone health because I think bone health has been undervalued. Completely. And even I've heard a lot of your interviews and I think there's, it's easy to focus on you know muscle and the strength training and the vo2 and that's all great and we're going to get to that but i do think bone needs to be raised in our awareness so i really wanted to make sure we we focused here a lot of this book is talking about the incredible benefits of movement and of course you have this wonderful acronym face right which is Brilliant.

1:01:40Flexibility, mobility, aerobic activity, carrying a load, and equilibrium and fast speeds. But if we simply look at it through the lens of bone for a minute, and yes, for people who can get a DEXA scan to see where they're at, great. Even if you can't, or you won't, there are things that you can do to improve your bone health, right? So when it comes to movement, what kinds of things can we do that will directly improve the health of our bones?

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1:04:12Yes, let's just assume you're losing bone density. Let's make it a given. That is a good place to start. Men and women are going to lose bone density. But here are the top things to do for your bone. Number one, optimize your hormones. So estrogen is so critical for bone health in the regulation of these two cells I was talking about earlier that it will help rebalance the breaking down of bone and the building of bone. Number two, building muscle. Number three and often forgotten is the E of the FACE acronym, equilibrium and foot speed. because you may be fine sitting in a chair. You may be fine walking around.

1:05:01But if you lose your balance, our neuromuscular pathways controlling balance start to degrade in our 20s, such as you reach for something, you lose your balance, you topple over. In our 20s. Yes, but it can be totally retrained. And we can talk about that. But we have to reestablish our balance so that we don't trip over our dog or our rug or just try to pick something up and fall over because you'll be fine before you fall. And then you have the fatal fall or the, you know, your child has had a month and a cast. It takes three months for an adult to heal a fracture because of our biology. Think of the inconvenience of that, even if it's a minor fracture.

1:05:42So retrain our balance. And number two in that F-A-C-E equilibrium is the long forgotten foot speed, meaning we lose our type 2 muscle fibers, which is our fast twitch fibers. And so I train people in speed and agility. You know, it's all those things we see athletes doing, hopping over cones, jumping over little hurdles. Even I was teaching a U.S. celebrity how to do toe taps and heel taps and then alternate them really quickly because we lose the neuromuscular coordination that helps us jump over our work bag that sits by our desk and trips us every day, right? We may be fine until we lose our balance and fall down.

1:06:33So we can't forget to do that in our general mobility, but specifically for bone if we're talking about it. Yeah. See, it's interesting. Things like swimming and cycling are fantastic aerobic activities but I say personally my own life over the last years I've really been thinking about weight bearing activities and if I have limited time to move and I'm making more and more time to move as I get older I'm let's we'll come to strength shortly but in terms of more I guess what you would call in inverted commas aerobic activities I really focus on walking and running. Yes. Don't get me wrong. I like cycling.

1:07:19I like swimming. But I'm thinking, yeah, but those things are not really putting load through my joints. They're not. Right. So they're great, but they're not loading my joints. Whereas walking and running are literally putting pressure through my joints. So I personally am prioritizing those as a sports medicine specialist, as an orthopedic surgeon. What's your take on that? I agree. I am not against swimming. Great for aerobics. Yeah, for sure. I am not against cycling, aerobics, and building butt core and hips muscles. But if you're concerned about building better bones, not only is walking fine, it produces about 1.5 times body weight with the steps.

1:08:03Running is fine. About two and a half times body weight. To build better bone, we need four times body weight. Okay. So if we really want to get after it, we're going to jump. And we're going to jump at least off an eight-inch step because that will produce four times body weight and impact. Because this is the way bones work chemically. The biomechanical impact of you landing hard on both feet from an eight-inch height and then jumping up straight in the air and landing again, that biomechanical impact becomes, through little channels of fluid in your bone, biochemical signal that tells the building cells, oh, I better lay down more bone.

1:08:49She's jumping around again. So the impact becomes the biochemical signal to build bone. but it has to be intense enough. So when you jump off, when you're running, I would stop and jump up in town 10 to 20 times, or you can do it all at one time, three days a week. You can spend 10 minutes jumping in multi-directions. I just posted reintroducing hopscotch to the world, right? Right, because it's multidirectional play jumping. So that's what I would add. And there are lots of studies to substantiate that. In fact, one that I published in this research group looking at what kind of activity, number one, answering the question, can we maintain our bone density by being active across a lifespan?

1:09:40The answer to that study was yes. the subsequent study was well okay what kind of activity maintains bone density best and it seems logical but we were studying the the senior olympics which is olympics for people over 50 we found not surprisingly that the jumping sports like volleyball basketball because of the impact maintained bones better than the swimming, the running, the badminton, the bowling. That's really interesting. Isn't that fascinating? And just a point to clarify. So many people these days are jumping on trampolines or on rebounders. Now, what's interesting on those, of course, there's give when you land.

1:10:25So I'm guessing that you're saying no, no, you must make sure it's against a hard surface. If you have a choice, if you are not so arthritic that you can barely move, please impact on against a hard surface. That being said, NASA has some good evidence that when they bring astronauts back down from the space stations, they use rebounders. Right. You know, and it can be beneficial, but all things being equal, if you can jump on a hard surface, jump on a hard surface. Yeah. Okay. I love that. And of course, skipping ropes are brilliant as well for this. Oh, skipping, just skipping on a track. I mean, that kind of impact, getting your knees up really high adds some impact.

1:11:05Okay. So let's zoom out again and go, well, one of the themes of this conversation is this idea, the central idea from your book that our body doesn't fall apart with age, it falls apart from neglect. You've spoken about the hormonal changes that happen in a man's life and in a woman's life and why in that critical decade, 35 to 45, particularly for women, hormones fall off a cliff and it has a consequential impact on multiple aspects of our health brain heart musculoskeletal system whatever it might be yes and we've just gone deep into bone health yes the impact on bone health and the sort of things that we can do to help improve it okay but then if we just take that broader theme in general about how we don't have to age with frailty we can age with vitality.

1:12:00A big part of your book is around movement. I think chapter two is literally making the case for movement. So could you make the case for movement? Explain to us why? We've all heard that exercise is good for us, but just build that case for us about movement. Why is it so important that we move in a variety of different ways, particularly as we get older? Yeah. So if we have hypertension, high blood pressure, there's a pill for that. If we have diabetes, metabolic disorder, there are a variety of pills for that. If there is heart disease, a pill for that. But there is one pill, one activity, one set of skills that treats everything and that is movement baseline.

1:12:54In fact, it is so critical in so many diseases that, I wish I had made this up, I didn't, but there's a professor out of Columbia University in Missouri in the United States that coined the word sedentary death syndrome. It is the 33 chronic diseases that we die from, including heart disease, that are directly impacted by the amount of movement we do. So how does that work? So let's just take skeletal muscle contraction movement. Skeletal muscle contraction produces a cytokine, a hormone called irisin that is directly related to glucose metabolism, insulin resistance. I've already talked about the way the bone talks to the brain and the muscle and the pancreas.

1:13:47So anytime we're moving our body, it's not just locomoting us, it's changing us chemically on the inside. When I recommend people sprint at the end of their cardio workout, literally get your heart rate way up, that will change the number of mitochondria, which are the powerhouse units in our cells. It will help stimulate the division of something called satellite muscle stem cells, which are called satellite cells. Mobility in the form of exercise causes the transcription and changing of body molecules of more than 9 ,800 molecules every time you go out for a run. It's signaling your DNA to express the genes that you need to stay healthy.

1:14:40it's just fascinating that that one modality mobility can change us at a cellular level it can change us at a tissue level here's an experiment we did in the labs with my partners that I had at University of Pittsburgh mobility is actually the fountain of youth for our stem cells so what the experiment was this we took little old lady mice a little old lady mouse is two years old. She's old. She's just sitting back in her cage waiting for her next meal. So we sampled her muscle and we took out a few of her little muscle stem cells. And what did we find? We found that her muscle stem cells in sedentary living were dying.

1:15:23Dying cells, it's an active process. You turn on something called programmed cell death. They were dying. They had lost their round plumpness, healthy cells around like a grape. They were more like a branch. They were spindly. And they were no longer reproducing or producing growth factors. That's what these little old stem cells were doing. Then we took these girls, and I spent a lot of money buying mouse treadmills. It's unbelievable how much mouse treadmills cost, but I bought some and we put these girls on the mouse treadmills and they were just like the rest of us. They didn't want to run, but we encouraged them to do so.

1:16:02So twice a day for two weeks, we ran these girls on treadmills and then we resampled their stem cells. The spindly dying stem cells were now plump like grapes again. They were producing growth factors. They had turned off programmed cell death. So the simple act of mobility changed our stem cell function and rejuvenated it. It was a signal to these mice bodies, these murine model that we're not dead. We're living in it. So down to the cellular level. And that's what I'm trying to explain to people in the book and give them. I mean, I think my readers are smart. They need to know why, not just go do this program.

1:16:46We can change our mitochondria. We can change the expression of our genes. We can change the amount of inflammation in our body by regulating glucose metabolism and insulin sensitivity and really have profound changes of the hallmarks of aging by simple activities that become how we live, not just programs. Yeah, I love the bit sort of halfway through the book where you move on to the next section where you've covered exercise in detail. And there's this beautiful chart where you've got listed all the time bombs of aging, DNA change and damage, mitochondrial dysfunction, senescence, fuel gauge malfunction, and stem cell exhaustion.

1:17:31And then you cross reference that with different kinds of exercise. and basically you follow that chart you go wait a minute if you do this hybrid training program that you outline in your book you are basically going to make sure you've hit every one of those six yes so all of the sort of physiological changes in your body that are driving aging in a perhaps unhealthy way or a faster than needed way, hybrid training targets them all. It's very, very inspiring, isn't it? It is. You can hit all the boxes by doing this very simple lifestyle. You're obviously such a passionate proponent of this. You're really worried at 47 and what the hell was going on with your body and your brain.

1:18:23and you've really turned things around where, you know, I saw you at the end of the day in London, you probably had a jet lag, whatever. You were on fire on stage, your passion, your energy. I think that's why you're having such an impact in the world. It's not just what you're saying, it's how you're saying it. So I guess my question to you is at this stage in your life, are you able to share with us what a typical week of training or movement looks like for you? And I appreciate that may not feel achievable for someone who's about to start, but I wonder if we could start off with what you do and then we can perhaps wind back to someone who's never done any of this before where they can start.

1:19:08Yes. And number one, I want people to give themselves grace. Because sometimes when people say what I'm about to say, they're like, oh, I could never. It's not about that. Start where you are. And I'll give you the example. I'm on a book tour right now. I am really busy in different time zones. So I am not doing everything that I would normally love to do. And I'm going to give myself grace. It's the period of life and not judge myself for it. But ideally, this is what I do. I have a flexibility and mobility practice, meaning I am trying to stretch out my tendon, ligaments, and muscles nearly every day.

1:19:52This is where I don't do Pilates or yoga, but if you do, this is where that comes in to be marvelous. I do a dynamic warm-up every day, which gets every joint, every set of tendons and ligaments around my major joints moving, right? So daily flexibility and mobility. 10 minutes? You know, it's just a series, and it's outlined in the book, The Dynamic Warmest. It's just a series of 10 things that if I do the inchworm motion, it warms up my ankles, my knees, my hips. If I do hamstring extensions, it gets my hips and my knees. First thing in the morning? Is that when you tend to do it? No, I do it before I work out.

1:20:34Before you work out. I put it all together. yeah that's interesting and the only reason I ask is because I do mobility every day but it's part of my morning routine so I'll get up yeah I'll at the moment I'm really into meditation so I'll meditate and then it's in my living room which has got a carpet on the floor so it's straight afterwards I'll probably spend five ten minutes just doing a whole variety of mobility exercises I always feel like it's waking up all of my joints for the day ahead so you do it before you work out I do it first thing in the morning. It doesn't really matter. Yeah, some form of mobility to keep all the joints moving.

1:21:10That's right. And then when it comes to, and we'll just use this acronym that you mentioned, F, that's F. A, aerobic. I used to be the marathon running, middle distance, getting my heart rate into middle zones all the time, as so many people did. I now use an 80-20 method. 80 % of the time I am in lower heart rate base training heart rate zone, which is very metabolically efficient. It helps my mitochondria be flexible with what fuel source I'm using, whether it's protein, carbs, or fat. And it burns more fat than the middle distance, middle high intensity exercising that I'll talk about in a minute.

1:21:55So 80 % of the time. So that is three hours a week, broken up into 45-minute sessions. I choose to do mine either by walking home from work, which is two and a half miles, or I have a treadmill in my room upstairs. So four 45-minute sessions a week in what's typically these days called zone two training, which is basically low heart rate training. And I came to that based on the research of Inigo San Milan, who is a physiologist for the Tour de France. He has a lab in my building, so I use his method. And I have the privilege of having my lactate threshold, which is telling me where my heart rate is, done with finger sticks.

1:22:37If you can't do that, then you can estimate it. Many wearables estimate it, but you could take your age, 181 minus your age will give you a range. of heart rate. But you also, and you do share this in the book that for people who don't want to get that technical and don't want to do lab testing, it's basically a lot easier than you think. Oh, it's brisk walking. It's brisk walking. It's basically where you can still talk. But if there was a person on the phone chatting to you, they would also know that you were working a little bit. Yeah, you would be breathless. Yeah. Yeah. And by the end of doing that, I break a little sweat because I can feel my metabolism revving up.

1:23:17So you try to do about three hours of that a week. That's correct. And that's when I listen to podcasts or I learn something. So it's relatively, in inverted commas, easy training, relatively. You're burning fat. It's good for your metabolic flexibility. The other thing, which I think a lot of people don't realize about that form of training, is that it doesn't spike your cortisol. Right. And which is just incredible. I had Professor Stephen Seiler, who's also the same ilk of Inigo. Again, Stephen's one of the world's leading sports scientists. And I think he might have coined the 80-20 training term, I think, from when he observed it in a lot of elite athletes.

1:23:56Exactly. That's what they do. Yeah. But again, he was just showing me when he came on the show that actually you don't see a cortisol spike. So it's easy to recover from that stuff. That's right. Because you share in the book, actually, that in your younger years, you went all in on high intensity interval training. Because I'm impatient. Yeah. And actually, you were sharing a lot of the research book where actually as you get older, you don't want to be doing that five, six days a week. It can actually start to be counterproductive. Well, because it's not low intensity enough to allow for recovery.

1:24:30And it's not high intensity enough sprint intervals to really change physiology. So my office is in this gorgeous performance center, and I see class after class on the indoor football field of medium-intensity circuit training where people are out there busting it. They are working really hard, but they're not high enough to be sprinting, and they're certainly not in a low heart rate cortisol state. And so what happens is they don't get the results they want. They're working hard. They don't get the results they expect, and they're injured a lot every three weeks or so. And then they have to take time off, and their brains go crazy because they don't have the dopamine spikes.

1:25:15So 80 % low heart rate. And then twice a week, I sprint. Sprinting is not running on a track like Shaqiri Richardson. Sprinting is a heart rate function, meaning getting it up as high as it can go, your own personal heart rate can go. So, but you do that for very short bursts, for 30 seconds, complete recovery, whatever that takes you. It takes me two to three minutes, four times. That sprinting is so good for your muscle-derived stem cells. It's so good for your mitochondrial function. And it's high enough heart rate that, frankly, it's great for your brain. you feel like kind of a pardon me but badass when you hop off the treadmill after sprinting right so that's how i do my cardio um so hold on 10 to 15 minutes maybe of this dynamic warm-up so mobility and flexibility on most days most days three hours of this low intensity aerobic training either walking home or on a treadmill.

1:26:26Twice a week, you're doing SIT, sprint interval training. After my walk. After your walk. So your walk is warming you up. So I'm totally warmed up. Totally warm before you start sprinting. That's right. And what I love about this is it's kind of echoing, particularly on this SIT point, what Stacey Sims said when she came on recently. I have some female friends and family members in my life who I would say are active, who walk regularly, but don't do sprint interval training. Can you make the case to me and hopefully then to them, why, yes, walking and being generally mobile is very good, but why would you say that they're not getting the full benefits of movement unless they're having this stimulus to their system?

1:27:28You know, it's just not intense enough to signal the metabolic pathways to cause the muscle satellite cell replication and the burning of fat that you get for sprinting or the mitochondrial division. But if you want a purely, purely aesthetic reason, in my own life, and in that of the people that I care for, it is the sprint intervals and the heavy lifting that recomposes you to lean. Because if we're trying not to be skinny fat, but lean, it is the sprinting and the lifting that will get you there. Because working out in the middle zone is not going to get you lean. Interestingly, that's why we have a lot of great marathon runners, but they have a lot of fat mass, right?

1:28:26You actually said in the book, actually, I found this very honest with you. You were open saying, listen, I was doing the baseline cardio and I was doing strength training, but it was when you added in the sprint insfor training that you really saw the change in your body. And you shared in the book that at that time, you think that is what got you down to 22 % body fat. Absolutely. I went from, when I was writing this book, I had come off the time when I gained 20, 30 pounds during perimenopause, which was unheard of for me. I was an athlete. And so I had always been so thin that I didn't have, I had 90 % body fat.

1:29:06What's that hard for you? Gaining that weight? Yeah. Oh my God. I was at the critical decision point of whether I buy a new wardrobe. Could I still fit into all these things that I had invested in and a certain size? Or was I going to have to do what so many women decide to do, which is get the next two or three sizes up? And I just decided, I know the science. I am worth the investment. I'm going to get this done. And so I did. and over about a six to nine month period, using the things you're asking me about is how I cite in the book. I gained eight pounds of muscle. I lost all this body fat.

1:29:45I was leaner and aesthetically, I loved it. And you know what, that goes up and down. That's why give yourself grace. I'm on a book tour now. I'm not doing four or five days a week, but I will again when it settles down. So the sprint interval training is 30 seconds of something. Something. It doesn't have to be literally sprinting. It could be the battle rope or... Or vertical or the alpine thing or the rowing or... Something as fast as you can. Yes, to get your heart rate up. 30 seconds. And then what do you do? Completely recover. So I'll give you my example. So I do this on a treadmill. To do base training on a treadmill, I currently do four to five incline, four to five speed.

1:30:32And that will keep my heart rate about 130. When I am done, then I punch this treadmill up to 11. Now, I'm not a very tall person. So for me, I'm just trying not to fly off the back of this treadmill. But I'm moving so fast that my heart rate goes up over 180. And I can sustain that for about 30 seconds. Then I'm grabbing the side rails and I completely turn the treadmill down to two. And I just walk. And it takes me two to three minutes to get my heart rate back down to, and I start again when I'm about 140. And then I punch it up again, and I'll do another 30 seconds. That's how it goes for me.

1:31:14And what, how many 30 seconds? Just four times. I mean, that's not that much, is it? It's not terrible. You can do anything for 30 seconds. And once you've done two, you're like, okay, I've only got two more. Yeah. And you do that twice a week. Twice a week. And I think the final part is resistance training. Yes.

1:31:35So I think all kinds of resistance training can be helpful, but it depends what your goals are. So I often have women tell me that they've been instructed, and I often say flipply, put down the mamby-pamby pink weights. Well, okay. So if someone has handed you a three to five pound weight and said lift it 30 times, that is good for endurance. You will fail after 30 times of lifting a very small weight. If your goal is endurance, fine, you do that. That's not our goal in midlife and beyond. That is not going to help you live independently. If your goal is purely hypertrophy, which is what we tend to do when we're younger, looking at our big muscle mass in the mirror and damaging our muscle enough that we grow and recover with bigger muscles, that is a failure range of 10 to 15 reps times four sets.

1:32:29There's nothing wrong with that if that's your goal. My goal in midlife is not to have the biggest muscles. Now, do I build muscle? Yes, I do. Can I get lean? Yes, I can. Our goal in midlife and beyond is strength and then power. Strength to be able to get up off the floor. Power not to trip, to be able to catch yourself, to have some fast twitch muscle, right? So strength is built with higher weights, lower reps. And you probably heard this from Stacey Sims. We agree on many things. So that means a rep range of three to six. Now, I've been a clinician a long time. I have found I cannot give people ranges.

1:33:13It's too confusing. They want to be really good instructions. So there's no confusing. So the rep range that I work around myself and with the people I work with is four reps to failure, four sets. Now, listen, if you're starting from the couch. It may take you six months, nine months. It may take you getting lifting lessons so that you're hinging correctly. That's how you move your hips. You're stacking your joints. You're giving your tendons and ligaments time to adjust. But once you get there, we're going to lift heavy, which is low reps, four sets, so that you fail at that high rep. That is in the four compound lifts, meaning a compound lift is using multiple joints.

1:34:01So upper body is some kind of bench press. It's some kind of pull, like a pull up. For the lower extremity, it's some kind of squat and some kind of deadlift. That's not all you do, but that's the basis for what you do. So on a lift day for me, if we're talking about my lift, when I'm lifting four times a week, I'll do two to three leg days and I'll do a one to two arm days depending how the week goes. So if it's a bench press day, I'm going to do four sets, four reps heavy. Here's what it looks like. I can do it four times. I may be able to do five, but I'm not doing six without dumping the weights off because it's just, that's when I fail.

1:34:49And then you support that with the single lift, single muscle lifts, biceps, triceps, lats, delts with slightly higher reps, eight to 10. And then core any day of the week, right? So I usually do one body part. If it's a Saturday and I have hours that I can kill in a gym, then I will do both cardio and lifting on one day. yeah yeah well thank you for sharing that bondage it's very insightful to hear what you do yeah what about a woman who might be listening to this and is thinking well well no i'm on board with what you're saying i realized that i need to take ownership of my health and i need to move more than i currently do yeah but i can't stand gyms sure right if they say that to you what do you say to them?

1:35:40Well, if you're literally starting from the couch, then body weight will work for you initially. Learning how your body moves. And I put that in the book. I put a start program in the book because I realized people are starting from different places. If you're ready for heavy lifting, which we will all get to eventually, and you cannot stand a gym for whatever reason, then that probably means you're going to have to buy a rack for your garage because or okay let's or unless you want to lift with logs in your backyard or filling up five gallon buckets of water and carrying it around it's harder to get 45 pounds of weight in your garage without actual racks of weight but i guess you could do for example you know you're almost tripping up like me on the way into the studio these sandbags i have right yes you could so a sandbag depending on how much weight is in there of course is heavy yeah you know so one thing i'll often do is you know get the sandbag on your shoulder and go up and down and then sprint up and down the garden throw it up in the air reach to pick it up again uh i also try and do that a lot when my kids are around so yeah they see it and often i go oh daddy can i can I do it?

1:36:56So I'm like, yeah, yeah, sure. Funny enough, I have bought two more. And I've actually put the right amount of sun in for your weight. Not that I try and tell them that, but they just happen to be there. But that's like when we separate movement into all these different things, right? I think for people like you and me who are super motivated around movement, that works. But I think for some people, I don't think they're going to necessarily go, well, I'm going to go to the gym three times a week. I'm going to do this two times. I'm going to do this. So I guess I'm trying to make sure that these core principles, which you write about so beautifully, I want to make sure that people listening actually take action, even if they can't on the gym.

1:37:43So listen, I will take anything except sitting around. So if you will never go to a gym and you do not want to buy a rack for your garage, okay, I'll take a lot of planks. I'll take sandbags across your waist with bridges. That's great for your butt. We just can't do five pounds. We're going to have to get a lot big sandbags, which you can. I'll take you doing pull-ups on the bars in your backyard, your children's bars in the backyard. I'll take that. I'll take you climbing your stairs with your 40 pound sandbag on your, I'll take anything except sitting around. But what I've outlined is this, is just things that scientifically and with the people that I serve work to build muscle, to, to increase cardiac health.

1:38:34But literally I'll take anything other than sitting around. Because I know if anybody tells you just to sit around or rest to feel better, they're literally telling you to go die in a corner. Yeah. One of my favorite pages in your book is page 27. And the reason why is that on page 27, you have three beautiful images. And they are MRI scans of people's thighs. Yes. Do you want to just talk us through those three images? And again, on the YouTube version, I'm going to try and pop that up on screen because I honestly believe that seeing those images will directly motivate someone to change their behavior.

1:39:22I really do. Certainly for me, I'm active, but I'm looking at that going, I need to be more active, right? Because I want a muscle like that when I'm 17. And that was the intent of this picture series. And when I submitted the paper for publication, one of the reviewers said, ah, the picture's unnecessary. And I said, this picture is so necessary, I will not publish with you unless you publish it. So here it is. I'm glad you did. Yes. Because it wouldn't have had the impact just reading the words. No, it wouldn't. No. So what the picture shows is if you imagine going to the store and buying a ham, like for Christmas, and it has a bone in the middle and the muscle surrounding it, that's what a slice with an MRI through a human thigh looks like.

1:40:06So imagine this round slice with perfect muscles. You can tell that there's gorgeous lean muscle like a flank steak across the top of the bone. Gorgeous lean muscle in the back, your hamstrings, with very little peripheral fat, you know, the pinchable fat on your leg, very little of it. When I looked under a microscope, the 40-year-old triathlete, and it wasn't just one picture, it was a whole series of people, but there was very little fatty infiltrate, or we call that marbling, you know, very little marbling. So essentially, if you have to summarize that picture, the 40-year-old triathlete was a flank steak, lean.

1:40:52Then in the control group, we had people that had sat around for a variety of reasons for 35 years. Listen, the central picture, you can barely tell their muscle. You lost all your muscle architecture. You lost muscle volume. They're grossly infiltrated with fat. You can see the white streaking. And there's a thick rind of peripheral fat. I call that a Wagyu beef. It's like the marbling you see in a Wagyu beef. But that is not the story. The story is the third picture, which is a slice of a 70-year-old triathlete who, if you didn't know better, you would think I just took the next slice in a 40-year-old thigh.

1:41:35Beautiful architecture, Gorgeous retention of muscle mass, very little fatty infiltration, and very little peripheral fat. And here's the beautiful thing. When we tested the strength of these people, we did not find a statistically significant decrease in strength until mid-60s. So what this tells us, this study was trying to answer the question, can we retain our lean muscle mass with recreational type exercise across the lifespan? And the answer is yes. Yeah, it's remarkable that you cannot at first glance tell any difference between the MRI of the 40-year-old triathlete and the 70-year-old triathlete.

1:42:18And it goes back to what you said at the start, right? The bit I quoted to you. What we call normal aging is actually normal aging for stressed out, undernourished people who are not intentionally building muscle. this shows very clearly that if you stay active right and you prioritize movement in your life you can have very similar muscle architecture in your 70s as you can in your 40s yes it is so so inspiring to see that yeah and it's also actually at the same time on one hand it's inspiring. And on the other hand, it's depressing. It's depressing how many people have that middle image, how many people in their 70s have lived a sedentary life and have got this horrible muscle architecture.

1:43:12And here's the reality. People think that that just affects their muscles. No, that affects every single system in your body. It even affects, as you all know, your cognition. Yes. This person in the center that I've described has osteosarcobesity. Let's break that down. A person who has a lot of fat surrounding all their muscle is obese by definition. a person who has lost their functional muscle they have low muscle mass they have lost a lot of their good function that is sarcopenia which kills people plus if you look at the bone the study was not looking at bone but the bone in this picture is very brittle looking it has a very thin cortex that's osteoporosis you can have each one of these in isolation but what I find by taking x-rays of hundreds of people's legs a month is that people present with obesity plus low muscle mass plus low bone density.

1:44:18And it's not one plus one plus one. It's one plus one plus one equals, I'm making this up, but a million because of the crosstalk between organs. Yeah. I want to get to hormones shortly. Before we do that, though, I just want to finish off on movement. Yeah. And I want to talk about VO2 max. Okay. Right. Because again, one of my other favorite chapters is this almost self-assessment chapter where I know we mentioned DEXA scans before and what people can do, but you go through the kind of self-assessment process that people can do on themselves, even if they don't want to see a doctor or pay any money for anything, which I think is really, really awesome.

1:45:01But in terms of really trying to get this idea through to people that what you do in your 20s and your 30s and your 40s impacts your 70s, your 80s and your 90s. I love the way you've described VO2max and the frailty line. So could you just outline what is VO2max? What is the frailty line? And therefore, what are the implications for us in our lives? VO2 max is the best measurement of your overall fitness. It's cardiovascular fitness. It actually measures oxygen diffusion, which means passage from the blood in your heart to your lungs, and therefore measures how fit you are. The higher your VO2 max, the more fit you are.

1:45:51And now endurance athletes like Tour de France athletes, they're just genetically specimens. I mean, and their VO2 max is just outrageous, like 95. Most people for their fitness level to be great, it's considered in the 50s to 60s of this measurement. Um, what happens is with time and disuse, our VO2 max will decline 10 % a decade. And so you may think, okay, great. I'm not trying to be an endurance athlete. Why does that matter? Because there is a line which you have cited, the fragility line where you are too frail. You have so little fitness. You cannot take care of yourself. meaning once you have so little fitness, you cannot get up from a chair by yourself.

1:46:46You got to live with somebody or you got to move into a home. So our goal is to never pass the fragility line. So if we're going to lose 10 % of our VO2 max, if we don't reinvest in it, now we can build real, but let's say you're not going to make the effort. You will lose 10 % per decade. So if you start out with a low VO2 max in midlife, say 30, 25, take 10 % away per decade, at some point in your life, you are likely to pass the fragility line and not be able to get up from a chair and not be able to take care of yourself. For men and women, the line is 15 to 18. So we, you know, grade is 50.

1:47:28If we pass 15 to 18, we're not getting up from a chair and living independently. We can work on that by a different type of exercising protocol called the Norwegian protocol, which is going as fast as you can in an aerobic activity for four minutes and then recovering, but only for four minutes. And by using the Norwegian protocol one time a week, you can build your VO2 max. So it's not that all hope is lost if you find yourself in midlife with poor fitness. But again, it's like bone. You're starting behind the eight ball. Yeah. I guess the central message there is, is that although it's not inevitable that we're going to become frail as we get older, it is inevitable that there are going to be some changes in your body.

1:48:24Absolutely. And that's the normal process of aging. And of course, there's many things we can do to improve things. We can stay active. We can do it in this kind of hybrid type training regime that you're outlining, which is going to reduce the rate of decline. But there is going to be some decline. In your 80s, you're probably not going to sprint as fast as in your 20s. Yes. And when I describe this, it's not because I'm a Pollyanna that believes there's never going to be a decline, but I have plenty of individual patients and populations that I've studied. When you invest in your health and mobility every single day, you're going to age in a different way.

1:49:06Now, what happens if you didn't start until your mid-50s? There are also now more anecdotal examples all over the internet of people who have started in their 60s and 70s and made profound changes in their body composition, in their health. I think I've heard Inigo Sammolan talk about someone in their 60s who started to do zone 2 training in their 60s, but maybe six hours a week of zone 2 training. And now in their late 80s, they're, I think, breaking world records. It's amazing. It's remarkable the body's capacity to change. Yes. But I guess the summary point of that VO2 matter stuff for me is that there is going to be some decline.

1:49:51Of course. As you get older. There is something called the frailty line. and therefore, and you actually have a table in the book which shows people this, but you can actually just back plot this and go, actually, if you want to be living independently in your 80s, you're going to need a VO2 max of this. Therefore, in your 40s, your VO2 max should probably be in the region of this. It's like a DEXA scan. Let's find out where we are. If we need the motivation and you're coming in with a VO2 max of 25, when you're 40 or 50, we get a little bit of work to do, but it's not inevitable. We shouldn't use it as I'm.

1:50:33I'm never going to do it. It should be a motivating factor. So FACE is a great acronym. There's loads there we've covered. And of course, the book goes through in detail. And of course, anything is better than nothing. There's perfection. And there's also make progress in where you are. Let's not talk about hormones. Okay. Because right at the start, Vonda, you You mentioned how there's a precipitous drop in estrogen for women in perimenopause. In your book, you also make the case that to you, estrogen is the elixir of longevity. Does it necessarily follow then that all women need to replace their estrogen?

1:51:17Here's how I position this. I believe that every woman is a sentient being with agency to make her decision. But I insist that that decision be made based on facts and not fear. And here's what I mean. Prior to the 2002 Women's Health Initiative study, which was a study done by the National Institutes of Health in the United States, more than 40 % of women in the US, I don't know the European numbers, but 40 % were optimizing their estrogen by replacing it because of the known effects it has on bone and muscle and heart and brain. After the Women's Health Initiative was published with the data that has been now strongly refuted as a travesty, the current number is between 2 % and 4%.

1:52:17Not because estrogen is bad for you, but because of the fear that was released from that study that made a blanket statement, which turns out to be nuanced and not true, that you will have a high incidence of breast cancer. You can't put that genie back in the bottle. generations of women still today come into my office and when i start talking about it they just automatically say i can't do that it causes cancer to which i have to walk back well here are the data you are free to make your own decision so if we go to that data do you mind if i name the one piece of data please take your time this is really important i know people listening are going to want to know your perspective on this Yeah, so the Women's Health Initiative was designed, and a lot of good work has come out of it, but not this piece of work, not this particular question.

1:53:15The question initially was heart disease as it relates to giving hormones. Now, at that time, because of when it was, the hormone they used was conjugated equine estrogen, which is a synthetic form, or which is a form that comes from pregnant horse urine. Now, what we're talking about when I advise people to consider estrogen replacement, we also have the options of transdermal using patches. So it's not only these pills made out of horse's urine. But in the WHI, they were asking the question, does estrogen replacement increase cardiovascular disease? So they recruited older women. The women in this study were in their 60s on average.

1:54:07Here's the data that they found. They stopped the study early, called a press conference. Dr. Rousseau, the head of the study, called a press conference from reading about that time and talking to people who were actually there without consulting the study group of other doctors and announced that the study was being stopped because estrogen caused breast cancer. Here are the data. In the women who did not take estrogen, the incidence of new breast cancer diagnosis was 3 out of 1 ,000. 3 out of 1 ,000. For the women in the study group who were given estrogen and sometimes synthetic progestins if they had a uterus, The incidence was 3.8 per thousand.

1:55:01So the difference between control group and study group was 0.8 women per thousand. Less than one woman per thousand was subsequently diagnosed with breast cancer. Now listen, I am not making light because one is one. One woman is one woman. I was nurse. I get it. I was taken care of in my youth, women struggling with this. But for one woman in a thousand, estrogen was taken away from generations of women, just blanketly taken away. And in this same study, there was no increase in cancer deaths. So instead of making this blanket statement, which has now affected women for generations, from which we have a high incidence of frailty in women and suffering.

1:55:59For what? So I think every woman gets to make her decision. If 0.8 is enough for you to not want to be on it, that's your decision. But I personally and the women I take care of, I value my brain too much to let it starve to death. I value my heart too much to allow myself to develop 30 to 40 % more microvascular disease. I don't want to lose any more bone than I've had to lose. and I feel like myself again because my brain is back. I am stronger than I've ever been. And it is all the things I'm doing, but it's also because I've given my body back what it's always had, which is estradiol, which is the compound our ovaries make, progesterone, because I have a uterus.

1:56:50And once we're settled out on that, I often discuss testosterone use with women because the reality is women make more testosterone than we make estrogen. It's a hormone, not a male hormone. And so I think every woman has the right to make those decisions. Yeah. Thank you for sharing that. It's really interesting for me to hear your own experience. And of course, that's of many of the patients you've seen over the years yes and yes the fallout of the whi study has had huge implications across society and particularly for women for a number of years now

1:57:37going back to the start of this conversation when you were explaining that estrogen declines so every woman is going to have a decline in estrogen it's inevitable And there are estrogen receptors all over the body, including the brain. So help me understand this from your perspective, that on the face of it, that would imply that all women would benefit from estrogen supplementation. At the same time, I think if we look around the world, we see clearly that there are certain communities around the world where women don't seem to report the same number of symptoms through menopause and that there are women in their 70s and 80s who seem to be thriving having not replaced their estrogen and again this I've seen so many women and have their lives transformed once they start taking hormones.

1:58:44But I find that interesting to go, what is it? It's a struggle, what is that? What is going on? Because also you mentioned before about how women, if you're breastfeeding and you're not careful about replacing those nutrients, you could be losing a lot of your bone structure. And as you were describing that, Vonda, I was thinking about the modern world and in particular the modern Western world where actually now women are having to do so much. Now, you know, there used to be a time in many cultures and even in Western culture where women would be supported during pregnancy and in the early years, right?

1:59:24While they were breastfeeding, the family would support them. Actually, this is a time where we need to really take care of the mother and the baby, make sure the mother has time to rest, that we're also, do you know what I mean? I do. I've read about it in books, but I've never seen it in my life. Exactly. And of course, it's very hard now in the modern world where people are often not living near their parents or their family. Often two parents in a two-parent family are working. There's a pressure, particularly in the United States, for women to get back to work really, really quickly. So I wonder, and I have this question in my head all the time.

2:00:00What is going on? Is it that in those other cultures, yes, we think they're doing well, but had they been given Easter and they would be doing even better? Or is there something about the stress load in our modern Western world, which is exacerbating these issues? I don't know. And I just want to put it to you very respectfully. Have you thought about that? because I can't quite square the circle there. I think there are a lot of factors. I love this conversation. When we talk about longevity, women are winning that race. In most countries, women live four to six years longer than their male counterparts.

2:00:41So in terms of sheer numbers of years, women win that race. But women suffer longer. Women are used to feeling pain such that women come to my office and without provocation. They say to me, you know, I didn't want to come here today because I have a really high pain tolerance and like a badge because we have pain in menstruation. We have pain with childbearing. We have aches and pains when we lose our estrogen and our whole body hurts and they can't get out of bed. We just assimilate that as the natural course of having two X chromosomes. And they say, I didn't want to come. I have a high pain tolerance, but I just couldn't take it anymore.

2:01:20So maybe some of what we're thinking of, well, we never used to feel menopause is just the natural acceptance of pain in women. Another part of it could be the modern stresses that we have. We don't live in the, at least in Western world, we don't live in the same kind of community that we used to. You know, we don't, many times we don't live with our parents or live in close proximity, right? Right. I'm going to tell you for sure that when I left home at 18 to go to university, I was gone for 22 years, not continuously. I saw my parents, but I never lived with them again. And I falsely thought that when I had my last child at 40, I used to say stupid things like, oh, it doesn't take a village to raise a child, blah, blah, blah.

2:02:15I was so wrong such that when I had her at 40 and my parents retired and moved, that community of support was the only way I could have gotten it done. So I see what you're saying about the stress and the increased inflammation that comes with that, that leads to pain and more brain loss and more bone loss. Maybe that's what we're seeing. But even in very supportive cultures, maybe women are just used to suffering. and don't want to mention it or there's a lack of understanding of what's going on. Because it doesn't mean that frailty doesn't exist. I see it in every culture that comes to see me because I live in a very diverse community.

2:02:59Every elderly woman I see is frail. I love that. I love that perspective. And I love the fact that over the last few years there's a whole number of powerful, strong female women like yourself, like Stacey Sims, and you know Lisa Moscone, Louise Newsome, you know Anita and Mukherjee you know loads of people who are trying to raise awareness of the importance of female health and actually we put up with stuff for ages we don't need to anymore and perhaps as a man it's harder for us to see things like this because you know my experience of the world is through a male body sure right so I can hear about the stuff that women have had to put up with and women have put where I can try my best to empathize.

2:03:45I think I'm pretty good at empathizing. But of course, I don't know what that's like because I'm not a woman. Right. Well, I think for this understanding to become common, to reach a critical mass, we must have the collaboration of the men that we work with and live with. I think the message will be spread more easily so much that, you know, my poor husband, I drug him onto my own podcast so that he could talk to the world about what men need to know, to understand the people they love, to prevent midlife marriage failure after 25 years. Because unless we understand what's going on, you may don't understand why your normally placid wife is suddenly enraged and has a fork in her hand aimed at you.

2:04:39Or there has to be an elevated understanding. I love chatting to you. I really do think this book is fantastic. It's such a thorough and well-rounded practical guide for someone who wants to empower themselves and take control of their health. One that we've not really gone into, which is when you arrived today, I sort of shared was one of my favorite things in the book is there's a chapter on mindset and a chapter on resilience. And just to sort of bring this conversation to a close, in the mindset section, you talk about a vision statement and why you think it's really important for every woman who goes on this journey to have their own vision statement.

2:05:26What's your vision statement? You know, I have a vision for being able to do what I want to do when I want to do it at all times. It doesn't matter if I'm my age now or if I'm 97. I want to have that independence because if I'm that independent, then I'm going to have the fullness of life that I've worked for my whole life. I'm going to have the fullness of relationship in an equally giving relationship. I won't be just taking, you know, my children, hopefully I'll be giving back as much to them as as they're giving to me in my old age, right? And so I just want that independence. And to have that vision, it takes active pursuit now.

2:06:14It's just not going to happen. And all the visions that, and this is what I teach people, have to be based on your values. Who are you? What do you want to be? What do you really value in life? And from that, you can build your vision. Because otherwise, if you don't have that, these are just six-week programs. These are just more things to do without the end purpose. Yeah. The book is called Unbreakable, A Woman's Guide to Aging with Power. And right at the end of this conversation, which I have thoroughly enjoyed. Oh, thank you. For that woman who has been listening, who your words have sparked a little bit of interest.

2:07:00They have started to see themselves differently. they start to go well wait a minute yeah vonda's right actually i have neglected myself i have put everyone else first i've not looked after my bone health i've not looked after my physical health i've never done anything for me but now i see vonda why it's so important for that woman who hasn't done much before but wants to get started what are your final words to her what I want you to know about this whole process and this book before anything else is that you are worth the daily investment in your health you have worth that means that you can focus on yourself you can prioritize these things ahead of everyone else you love and serve because you are worth it you are created and made and have value until you believe that you will continue to neglect yourself Wanda thank you so much for coming on the show my pleasure

2:08:12really hope you enjoyed that conversation do think about one thing that you can take away and apply into your own life and also have a think about one thing from this conversation that you can teach to somebody else. Remember, when you teach someone, it not only helps them, it also helps you learn and retain the information. Now, before you go, just wanted to let you know about Friday Five. It's my free weekly email containing five simple ideas to improve your health and happiness. In that email, I share exclusive insights that I do not share anywhere else, including health advice, how to manage your time better, interesting articles or videos that I've been consuming and quotes that have caused me to stop and reflect and I have to say in a world of endless emails it really is delightful that many of you tell me it is one of the only weekly emails that you actively look forward to receiving so if that sounds like something you would like to receive each and every Friday you can sign up for free at drchatterjee.com forward slash Friday 5.

2:09:19Now if you are new to my podcast you may be interested to know that I have written five books that have been bestsellers all over the world, covering all kinds of different topics, happiness, food, stress, sleep, behavior change, movement, weight loss, and so much more. So please do take a moment to check them out. They are all available as paperbacks, ebooks, and as audio books, which I am narrating. If you enjoyed today's episode, it is always appreciated if you can take a moment to share the podcast with your friends and family or leave a review on Apple Podcasts. Thank you so much for listening.

2:09:56Have a wonderful week. And please note that if you want to listen to this show without any adverts at all, that option is now available for a small monthly fee on Apple and on Android. All you have to do is click the link in the episode notes in your podcast app. And always remember, you are the Architect of your own health Making lifestyle change is always worth it Because when you feel better You live more