#322 - Bone health for life: building strong bones, preventing age-related loss, and reversing osteoporosis with evidence-based exercise | Belinda Beck, Ph.D.

28:58Well, let's start with the low -hanging fruit, which is diet. Anybody could argue that a balanced diet is important for everything to be healthy. You need all the nutrients that we've known about for years, and the same can be said for bone. That means, particularly, and there are some minutia, but the most important one, obviously, is calcium. The amount that you need throughout your life does vary, but by the time you're a teenager, you probably need about 1 ,000 milligrams a day of calcium, and you need the vitamin D to go with that. Otherwise, you can't absorb it from your gut. So making sure dairy is by far the most debonant source of calcium, it's most bioavailable, meaning it's most, it readily absorbed.

29:43It's packed with calcium you can get most of what you need each day from, well let's say a regular glass of milk, so 250 mils, that has 300 milligrams of calcium. So if you had three of those you'd basically be getting what you needed. Not too many people drinking that amount of milk, although I suppose the number of bowls of cereal my son eats could possibly be approaching that number. But there are sources who are cheese and yogurt. And then there's the discretionary foods. If you eat a lot of ice cream and cream, that sort of thing you can get from there as well. But we wouldn't say yogurt and cheese and milk are the best sources.

30:21I mean 750 ml of milk or milk equivalent is probably less than most kids are consuming. Yeah, I would say so, particularly as they move into their teenage years and and probably getting more conscious about weight and thinking that they might be drinking diet soda instead of a milk drink. And it doesn't matter what the fat content of the milk is, I assume. I mean, for the vitamin D, it probably does, but does it matter for the calcium? Well, low fat milk actually does have more calcium in it, just by virtue of the fact that if you take the fat out, you can fit more calcium in. Give more volume.

30:57And plus you can buy fortified milk. We have physical in Australia, which has more calcium in it and I'm certain you guys fall to buy a lot of your foods and I believe you do put vitamin D in your milk. So it's nice to get both but by far the easiest way to get vitamin D is the sun and converting it in the skin. We in particular Australia is we are white people living in a black people's country. We have a very high rate of skin cancer here, the sun is extremely strong. So we're quite scared of the sun, we cover up, we slather ourselves in sunscreen hats, sunglasses the whole bit. And to the extent that we've actually set ourselves up to have vitamin D deficiency, and particularly in Tasmania very south, there's a high prevalence of vitamin D deficiency.

31:45So it's important to figure out when is the safe time to be in the sun and ensure that you get a little bit of sun because it is by far the most efficient way to get your vitamin D. Never go even close to getting sunburn, but you don't have to get sunburn. In Australia, we should be able to get our vitamin D requirement for 10 a .m. and after two, possibly a little later if you're in a really hot area. In Hobart and Tasmania, in the middle of winter, you would need to stand shirtless for an hour and sun to get what you needed. So then you've got to start thinking you're possibly about supplementation.

32:21What level matters, I don't think any of my kids have ever had a vitamin D level checked, although in an adult we do this all the time. Is there a level beneath which you would say we've got to be supplementing you if you can't do better than this with sunlight? The problem with vitamin D is that nobody can agree. There are two schools of thought. There are two levels that have been published and people will die in a ditch over those. If you've got smart people feeling that strongly about two different levels, it tells me that nobody really knows. What are the two levels that people are dying over?

33:0030 is probably one of them, right? 30 seems to be one of the cutoffs. 30 is, I believe, is the deficiency cutoff, 30 nanograms a little later and 50 years considered sufficient. So in between that you would have insufficiency, but other people say it's 75. So because this isn't really my area, I don't want to go out on limb and say which is which, they're easily searchable. There's been a lot of research done, probably it's dropped off a little now as we've discovered that hypodosing with vitamin and D is not safe and increases falls to get somebody's vitamin D up quickly. You have to hypodose.

33:41So people have sort of moved away from vitamin D as a strategy to prevent osteoporosis. It's really important that you try to encourage people to be sufficient and so possibly they will need a supplement of a certain dose. That's going to depend on the person and all manner of other things. I mean, most people are going to require a supplement to be above 50. I do. I mean, I live in Texas and our sun is a lot like yours. And I'm in the sun every single day. And I don't even put sunscreen on anything but my face. So my arms and legs, I'm not shirtless usually, but my arms and legs are constantly exposed.

34:23And I think if I'm not supplementing vitamin D, I'm lucky to be above 40. I do supplement with 5 ,000 IU daily and that takes me to 50 to 60, which again suggests I'm probably okay, but it's not uncommon here in the US to see people unsupplemented easily being in the 30s that's not uncommon. Was there a reason that you started supplementing? Did you have any symptoms? You have a brain. None whatsoever. However, I literally supplement for no apparent reason other than some loosely held belief that I'm going to be better off at 55 than 35. It's more the precautionary principle. It's more that I haven't found any compelling evidence that I'm worse off at that level and there may be benefits to it.

35:16I don't feel immensely strongly about it, but again, I'm thinking about this through lens of children where I would worry more about supplementing a kid because it's harder to measure vitamin D levels in them. You don't want to go and poke them for blood all the time. You would hope you could get it all from milk, dairy, and sunlight. I guess it would be my point. Yeah, that would be my recommendation. You know, the other thing is too vitamin D assays notoriously dodgy. So from one to the next, you may not get the same results. So I don't know, I've never had my measured. I track my bones to make sure they're doing okay.

35:57And that's how I choose to manage it. And I think as you say, it's just going to have to be whatever your tolerance, whatever your belief is. It's pretty much get as much education as you can and probably follow the guidelines that make the most sense to you. Oh boy. Okay. So we got calcium, which I think based on that, what you said earlier, I think most people are going to struggle to get that much in without being deliberate. So that's something we have to pay attention to sunlight. And then of course with sunlight probably comes another very important part of it, which is if you're getting sunlight, you're outside.

36:29And if you're outside, hopefully you're playing. And if you're playing, you're hopefully doing something good for the bond. So do you ever get asked the question, Hey, are there certain sports that are going to be better than other sports is running better than swimming is weight training. Okay. For teenagers, even younger, like when do we start thinking about at least doing pushups and things like that that might also put a little bit more into it, jumping sports versus non jumping sports? How do you think through all that stuff? You hit the nail on the head. It absolutely is extremely important, the type of loading you're doing for bone.

37:03So if we're talking about heart lungs, mental health, metabolism, virtually anything is better than nothing. In fact, anything is better than nothing for bone too. But if you really want to make a difference, get most bang for you, but then you absolutely are looking for high load activities and they include things that include jumping and landing and strong muscle movements. The other thing that is probably important is variety and variety within the sport and across sports. So we do tend to find that runners, for example, who have only ever run less protected from bone stress injuries in their running career than people who grew up playing basketball and volleyball and tennis and running.

37:50So that variety, if we come back to Wolf's Law, has probably made the bones adapt in a more robust shape to make them more resistant to loading in all manner of ways and also to loading in one direction. So my recommendation to parents is aside from giving you kids the building blocks being enough calcium and exposure volume dear every day, then use those building blocks by getting them outside every day. I mean, I know the guidelines don't necessarily say every day, but every day is what you're aiming for. Because if you tell people every day, then you may get four days. And of that exercise, you want it to be as vigorous as possible.

38:35Swimming isn't going to do it. Walking isn't going to do it. You need something that is just much more dynamic varied and will impart a high strain on bone and a strain is a measure of deformation. So you're trying to make those bones bend because it's the bending that is coming back to my PhD and what I was trying to solve. It's the bending that is actually forming the stimulus to stimulate bone adaptation. So a couple interesting things there. Swimming and walking obviously both have enormous benefits, especially swimming. But again, you're in a zero, not a zero G environment, but a very low G environment that couldn't have less bone loading.

39:15The other, I think, very important takeaway there is, and it's funny because I remember seeing a study that looked at this and being a little surprised initially, but I think based on what you're saying, it makes a lot more sense. The study basically showed that runners didn't have particularly great immunity from osteophenia and osteoporosis. And I remember at first thinking, God, how is that? They're loading so much, but your point is if you're just running, you're just adapting to one very not simple but repeatable movement in one direction, whereas if you're playing soccer or basketball, now you're not just running, you do run, but then you move laterally.

39:52You move backwards, you jump. There's more force because you sprint. So all of those things taken together make a bigger difference in creating the variety that you talked about within the sport and then across the sports if you play more than one. Yeah, absolutely. There was a study done at Stanford in 92, what was published in 92, by a friend of mine actually, who looked at the Stanford varsity athletes and compared them to sedentary controls of Stanford students who weren't doing anything. It was really interesting to see that if you compared swimmers, cyclists, runners and gymnasts to the sedentary controls on the scale of bone mineral density.

40:40Swimmers were lowest, then I believe cyclists were the same as sedentary controls because they're also in a weight supported activity. Runners were slightly higher and gymnast we know off the scale. Now this was an observational trial, it's subject to all of those selection biases that observational trials are not trial, it was a study that are subject to, for example, you're likely to have people who are lighter, so they have lighter bones who are good at swimming because they float better, so it makes them faster. So there's that bias, they may already have had lighter bones. But on the other hand, at that time, I think they were doing about six hours of training a day in the pool.

41:22And that was actually unloading their bones. So it's amazing to me because the muscle loads that are occurring during imagined swimming, 50 meters of butterfly, you know there's some big muscle forces, but it's not enough. It's weight -bearing loading that is important, and we know this because of how much bone people lose if they go into microgravity. So it was swimming, sedentary runners and gymnasts in that study? Cycleists too, I believe, and they're the ones who were the same as the sedentary control. So I don't want anybody to take home that any of these activities are bad. They're great for virtually every other tissue.

42:01It's just that swimming and cycling and even running are not going to marketly increase your bomassin. The comment about running, when we go for a run, it feels like we're pounding the pavement, but actually the loads you're putting on your body are not that great. And particularly runners that we would consider to have good technique who are running quite lightly. Yeah, their feet are actually dissipating a lot of the load, the connective tissue in the feet and the muscles within the feet are really a big part of the shock absorption there. Well, that's how we evolved, you know, with these amazing archers.

42:36And, but also remember, when you land your ankle is either flexion and extension, or weird at the ankle, but at your knees will flex when you land and your hip as well. So you've got all these shock absorbs in the whole way up. So that is dissipating the load. The same thing does happen. You do dissipate loads in gymnastics, but But when you watch those Olympic gymnasts do their tumbling runs and they land from one of those crazy tumbles boom on the floor, they are loading their bones like crazy. So not only are they getting these enormous forces that are stimulatory to bone, but again, this self -selection effect of gymnasts, the ones who had bones like iron to begin with probably were able to remain in the sport because they weren't getting injured.

43:22So there is that observational study, you know, there are VC caveats with the outcomes, but I think there are lessons to be learned from it. Yeah, and there's another study I saw that expanded that and added other sports to the mix. And the other sports I remember it talked about that were also very, very high were football, meaning American football, jiu jitsu and powerlifting. Now, again, my take on that is, I mean, power lifting is really obvious, right? It's the definition of literally lifting the heaviest weight imaginable. Football has the confounder that if you play football, you're also lifting weights.

44:00So it's probably just as much to do with how much weight training goes into playing American football as opposed to the actual active playing football itself. I would argue that that has benefits from a bone perspective. We could certainly talk about the disadvantages it has as well. And then Jiu -Jitsu is interesting in that not doing it myself, but two of my three kids do it. And so certainly spend a lot of time watching it at tournaments. But again, a lot of force being put on bones. There is a lot of bone deformation in Jiu -Jitsu just based on how hard they're tugging and contorting and stuff like that.

44:37To me, the big takeaway here is not that we should look at the sports that do the most for bone density and say that's what we need to do. We should ask the question, what is it about that sport that's doing so much for bone density? And how can we replicate that? Because of course, you could also argue that most gymnasts, I assume, have quite a lot of problems orthopedically later in life, just based on the nature of the sport. Again, the question is how do we reproduce it? Fortunately, I would say that a lot of athletes today, such as runners and cyclists and swimmers are probably spending more time in the weight room today than they were in 1992.

45:15The early 90s was really an era when swimming was kind of a six hours in the water every day sport thing. And I think today they're spending actually a little less time in the water and they're probably spending more time on dry land. And my guess is if that study were repeated today, I wouldn't be surprised if we found some improvements in the ultra endurance athletes. the takeaway as a parent is diversity of sport and load bearing. A hundred percent. And I think because my other area of research is bone stress injuries, I do talk to coaches of swimmers and that's exactly the advice we give, get them out of the pool, get them cross -training and get them lifting weights.

45:56You didn't ask just before you mentioned what are the benefits and how early should we get kids doing weight training? And for years, people were very scared of that. The girl knows. They'll stunt their growth, yeah. And there is no evidence of that. And I don't know where that even came from. I mean, people talk about, oh, you'll compress their growth plates. Why? That doesn't make any sense. It just takes a lot to do that. I'm not necessarily saying that you should be loading kids up with enormous weights. There's no need for that. But there is certainly nothing to suggest that you shouldn't do resistance training when you're a kid.

46:36I would say the only reason that you wouldn't do it is if they didn't like it because the thing you don't want to do is discourage a child from being active throughout their life. So the best thing you can possibly do is whatever that child loves to do. And then if that happens to be something that doesn't include particularly bone loading, then just try and add that stuff in. and don't force it down if throat otherwise. It's very counterproductive as those of us with children night. I'm really glad you brought that up. I was gonna ask you and I got a little distracted, but I think this is one of those myths that just drives me bananas.

47:11And we've looked, I mean, we have tried and tried and tried to find the evidence that suggests that kids can't lift weights. And we're coming up empty. We're just coming up empty. And so hopefully folks listening to this are also realizing And I think as a parent, the easiest thing you can do, especially if you have some equipment at home that you can use to exercise is Just have your kids come in the gym with you when you're lifting weights That's what we do and never once have I said to my kids. I want you to lift weights It's just hey, we're gonna go in the gym and I'm gonna lift weights and you can do whatever you want And look there's not much else to do in the gym They're gonna start picking stuff up.

47:52They're gonna start copying you. So anyway, I think it's helpful The great opportunity to teach from technique because that's what's going to mess people up, not just kids, if they're not doing it right. You don't want a kid just going over and trying to do a deadlift and not doing it right. So there's your opportunity, teach from a young age, do a beautiful deadlift. There is one of the most useful exercises they can do their entire life. Yeah, I'm glad to hear you say that because my little boys are so competitive with doing kettlebell dead lifts now, I have to hold them back because as you know, once they start to try to go really heavy, their technique actually kind of breaks down a little bit.

48:29We'll talk about another kind of sensitive area with kids that I'm sure you get asked about a lot, which is invariably some kids will have asthma or they'll have other conditions that require the use of corticosteroids either inhaled or systemic. And I know that we see this in our practice when adults come in and we're surprised to see in an otherwise healthy person, astonishingly low bone density. And of course, through our history, we realize, oh, you took prednisone for this many years of your life. So I know that nobody out there, no physician out there, no parent out there, takes it lightly.

49:06But is there any guidance you can provide as far as the minimum effective dose or maybe is there some comfort you can provide to a parent that says, hey, an inhaler for asthma used at this frequency is not going to impact the long -term bone health of a child. There's no evidence because we haven't got long -term data as far as I'm aware. And again, not really my area, all I can say is, got a co -steeroids should be minimized as much as possible throughout the whole life. If anybody, child or adult is able to manage their asthma just with Vendolan, which doesn't seem to have any negative effect on bone.

49:52That is what I would be recommending. Try to stay off steroid inhalers if you possibly can. If you're on high doses, try to titrate them down. See, if you can manage in other ways, I don't want to terrify people, but really this is abundantly clear that corticosteroids are the enemy of bone and the longer you're on them the more damage they do. They're life -saving for some people. So you have to go on them and then just get off them as quickly as you can once your respiratory condition has calmed down. And of course, if you are in a situation where you must take them and add high doses then you absolutely would probably need to But absolutely probably, you would really need to consider some bi -medication to counteract that.

50:41That's what I would be recommending for adults. Maybe the lesson here for parents again is if your child requires being on corticosteroids, well, presumably they really require them. I don't think any doctor takes that decision lightly. But it might just mean that's all the more reason to double down on the other things we talked about, which is if your child is on corticosteroids for a medical need, Then let's make sure that that's the kid that's getting 750 ml or 24 ounces of milk a day and they're out in the sun every day and they're lifting weights and they're doing diverse sports. Because again, let's take everything else and stack it in their favor so that when they come to see their doctor in their 40s, the doctor will on the one hand realize, oh, you were on steroids as a kid, but hey, low and behold, your bone density is actually okay.

51:33You haven't been as impacted by it as possible. Are children more susceptible to corticosteroids because they're in a developmental phase or are adults equally susceptible? In other words, does it affect kids more because it's affecting them on the way up or does it affect adults equally because it has just as much of a down impact on them in the maintenance phase? That would be very much stepping out of my line to answer that one. I don't know the answer to it. But all I know is they're bad at any age. Okay. We've got a pretty good primer on what parents need to be thinking about with kids. So now let's turn it back over to the adults.

52:10So we're talking about men and women in their 30s and 40s. So for most women, they're still on the positive side of estrogen balance. Beyond what we just said for kids, is there anything you would add to that as important tools as a person enters middle life. It's actually exactly the same. You've got to maintain your diet and levels of exercise because your bones need those two elements to maintain. So in the old days, we, I'm sure you can picture in your head the trajectory of bone growth, plateauing and loss. And the mantra was, this is inevitable. That's what bone aging looks like. For years, I've been saying, that's what sedentary behaviour looks like.

52:59That's what the sedentary effect on a skeleton is. I believe that if you maintain your levels or increased your levels of physical activity, friendly bone loading from the time you were 20 until the time you died, I would be willing to bet that you could go a long way towards maintaining that plateau. And the master's athletes' data seems to support that. So if you look at those data, you'll see that BMD is maintained in master's athletes as long as they're maintaining their activity. There may be a slight loss, yes, but that's probably because the loads that they're able to produce in their physical performance also reduce.

53:41But this is an atrophy effect. This is not a genetically programmed aging effect. and I know that there are many people around the world who would argue with me because I don't have much data aside from the master's athletes long term data, but it's almost impossible to collect those data because there's a lifelong studies and I would be dead before the study would be finished if I started it now. This is a very provocative idea, but I'll give you an example of where there are two arguments I would offer that suggest you could be right. The first is when you look at spontaneous activity and movement of people as they age, you see a very similar pattern, which is a relative plateau preservation of not just activity, but lean mass, followed by a deterioration, suggesting that as lean mass goes down, movement goes down, activity goes down, and then it feeds back on itself.

54:42It becomes a vicious cycle on a way you go. So, again, as you said, it could be that what we see as a quote unquote physiologic decline of bone loss is not that it's rather a proxy for muscle loss and reduced activity. The second point I would argue, again in favor of this hypothesis, is something that Luke Van Loon, I don't know if you know Luke, but he's a protein scientist and I had him on the podcast recently and he shared something that I thought was fascinating. I've always taken it as a given that anabolic resistance occurs due to aging. Because of course, we see it clearly with aging. But he discussed some studies that demonstrated that anabolic resistance was most exacerbated by inactivity.

55:26And this was done on the cast studies. So you take a given individual, you cast one leg, not the other leg. Before you do that, you run the amino acid isotopes through them. You do this exercise for two weeks. you take the cast off, so you have an atrophy leg and a normal leg, you do the same amino acid, isotopes, and low and behold, there's like 40 % or 50 % antibiotic resistance on the leg that was in the cast. This is not because they got older in two weeks, it's because they were inactive, and they lost muscle activity. If that's true, it really suggests that we shouldn't accept antibiotic resistance as an inevitability of aging, and I'm quite inclined to think your hypothesis could be correct here, which is if you just don't stop the movement, if you just don't stop the exercise, this decline of BMD might be far better than what the actuarial data predict based on sedentary behavior.

56:21I 100 % agree with you. It sounds like a village people song. Don't stop the movement. You only have to look at those beautiful studies that have shown MRIs of Master's athletes, calves compared with an age -matched person who's not active. He's also compared with a young person's calf. The young and the masters look identical. The muscle volume and quality, there's no fatty infiltration and the subject is virtually non -existent. Whereas you look at somebody's same age as the master's athlete who's not active and you've got this shrunken down little psychopathy -naked muscle belly, fatty infiltration and a big what of sub -Q fat you could select anybody from the population and you can make the data look like what you want it to and by comparison of those age groups, although the same age, but the appearance of that master's athlete muscle essentially confirms what you and I both saying this is a sedentary problem.

57:22This is not an age problem. And of course, this comes back to the problem with it. A lot of people will say, well, who cares? I know that 60 % of the population will not do enough physical activity to maintain that. So we need to invent drugs that will do the same thing. As far as I can tell, I never say never, but I think we will struggle to ever find a drug that will be able to replicate the action of exercise, physical loading on muscle and bone. because you can't replicate the stimulus and know any drug that is found to work, probably will still need exercise for it to manifest its benefits.

58:01Yeah, and there's another deeper issue there because as you know, and maybe the listeners as well, there is an enormous interest from a pharmaceutical standpoint in anti -sarcophonic drugs. You know, as it stands today, obviously we have anabolic steroids and they're They're very efficacious, but they require the training stimulus. As you pointed out, you can give a person all of the testosterone in the world, but if they don't train, they have zero benefit, virtually zero benefit, you know, slight benefit. Of course, the Holy Grail is, can we give agents that can cause muscle growth, even absent, the profound training stimulus that is needed in other regards?

58:43I always say, well, the answer is maybe, but will it be functional muscle? And to that extent, will it be functional bone? So even if a drug like BIMA or an IGF1 agonist or some of these other drugs or molecules that are being touted potentially increase muscle size, it's not clear that they're going to increase strength, function, and bony composition. So yeah, it's just the nature, I think, of our species. We really love shortcuts. We do. If we can take a bill, why would you expend any effort? And that's, unfortunately, the gene, which is going to be all -undue in terms of healthy aging. Right.

59:24That actually got us very far when resources were scarce. That was a very, very helpful gene in a resource scarce environment. Let's talk a little bit now about this menopausal transition. It's right up there with death and taxes in terms of inevitability. It's an area that I have become intensely interested in because I view it as one of the great tragedies of the past 25 years is this very popular study done the Women's Health Initiative, which was published in the early part of this century. And really came to, in my view, a very erroneous conclusion, which basically scared an entire generation of physicians and women away from HRT.

1:00:06And as a result of that, not only has there been an unnecessary abundance of symptoms associated with menopause, but I think the real hidden tragedy has been the larger epidemic of osteopenia and osteoporosis in a group of women who may have otherwise received estrogen as they went through menopause. Because so I know that your area of expertise is not in the hormone side as abundantly as it is on the training side, but is there anything on the hormone side that you want to talk about beyond what we've already discussed, which is the important physiology, the important role estrogen plays specifically in managing the role of osteoclasts in bone remodeling.

1:00:48And I assume that most of the women and men, presumably the women, of course, for the purpose of this discussion that are coming into this clinic, are they mostly postmenopausal Yeah, the majority would be post. We have thousands of people on the books. That number of people who are not post -menopausal is still substantial. So I think the years that we've been open and we've been open almost exactly nine years now and awareness has grown in the community about us. People who are not post -menopausal but are aware that either they have low bone mass already or that mum or dad or granny or grandpa had low bone mass, they want to prevent it.

1:01:31So it's one of the happiest things that has happened that people are realizing that pre -menopause is the time to start taking care of this issue. So we do have a proportion, but of course most people don't have any idea what their bone health is like until they aren't a have a first fracture or they go through menopause and they have a savvy enough GP who says, we need to get your baseline dexa. Let's get you started and all of a sudden, yyx, I have either osteophenia or osteoporosis, a way you go to the bone clinic. You said something very important there, which you and I take for granted. I think it's very important to reiterate for the listeners, for the female listeners in particular, which is you don't want to wait until you're into menopause to replace estrogen.

1:02:16You have to do it during the pre - and parimenopausal stage to get the maximum effect. And again, this is something that I think not enough women are being educated on. And as such, even if they know, oh yeah, I've kind of heard that estrogen matters and this might be a reason for me to consider HRT as part of my decision matrix, they might think, well, let me go through these two miserable years of paramanopause, wait till I'm completely a menoradic. My estradiol levels are unmeasurable and my FSH is through the roof. And now we should start doing it. No, it turns out that there are data that suggest that they've actually lost quite a bit of bone up until that point.

1:03:01Which again, to me is it's so preventable. I hope that women listening to this are sitting with doctors who can help them through that transition. I'm sure many people listening to us have had a dexascane. So when you get a dexascane, let's put aside the body composition part of it where you see body fat and lean mass. Sometimes when you get a dexascane, it shows you total bone density and it says your total bone density z -score is this and your t -score is that, but it doesn't give any segmental information. It doesn't tell you about the lumbar spine or the hips or the femurs or anything like that.

1:03:40And if you look closely, it might even give you a number in grams per centimeter squared as an actual number. Do you want to just help people make sense of what all those numbers mean? Why, for example, is it grams per centimeter squared, not grams per centimeter cubed as a density? And maybe explain to people the difference between their z -scores and their T scores and if anything can be understood from the total body Z score and T score or if we must be looking at segmental. I know there's a lot in there but have at it. Okay. So, dual energy X -ray absorbed geometry is a low dose radiation tool, much lower dose than an X -ray of your chest where the name describes what it's doing, ascending to energies through the body in a way to determine the density of the tissue that's going through.

1:04:31Now, it is a misnomer. It is an aerial density, which is a contradiction, because it is a planar view. The X -ray source is underneath, and you lie on the bed, and the detector is in the arm above. And it is a projected image of this two -dimensional density. They call it aerial bone mineral density. because without going into too much detail and I may screw it up, not being a medical physicist, the method of measuring is looking at what is detected according to the density of the material. So it's not volumetric at all. If you want a volumetric density, you have to look at a three -dimensional method of measuring.

1:05:15So you can also get bone marrow content and area from the same scan and they're derived from this density measure. So they talk about it in grants for centimeter squared because it's an aerial measure. So the answer to the question about total BMD, bone density, that is the amount of bone that you're observing from a whole body scan. And normally if your doctor wants to know if you have osteophenial or osteoporosis, they will send you to the radiology clinic and they will do a standard spine and hip scan. better normal ones from which you would diagnose those conditions, not a whole body scan.

1:05:59The only reason you would do a whole body scan is if like us, we wanted to look at body composition because we're interested in lean mass. I wouldn't use the value, the BND value that I get from the total scan as a marker or as any index for osteophenial osteoporosis because the who definition was actually based at the hip. In fact, it was based on femoral neck. We've moved away from looking at femoral neck as the standard and we look at total hip now because there can be quite a bit of variation of femoral neck because of the way that you analyze it. So osteoporosis should be really diagnosed from hip BMD according to the definition of the World Health Organization was that a T score of minus 2 .5 is definitive osteoporosis, but a T score between minus 1 and minus 2 .5 is osteopenia or low bone mass.

1:06:54Now that's essentially a T score is a standard deviation. So what is that compared to? Your value is compared to a reference database and the T score is actually comparing in your score to what they call a young normal. It depends on the site and that does vary, but let's just say it is roughly a 20 year old between 20 and 30 of the same race and sex. So a 52 year old woman is going, let's say a 50 year old white woman, her value,

1:07:35her average BMD value of a white woman age 20. That's the T score. The Z score is comparing your value to someone the same age and sex. So compared to the average BMD of a 52 year old white woman. So that is if you're looking at the plot and you have the average score goes up like we were talking about it. It doesn't go plateauing and then it begins to go down. So your score will be plotted on there, age 52. If you went straight up to the average value, that is what your BMD Z score is being compared to. So it's a standard deviation from there. The T score is being compared to right at the start of that plot.

1:08:26The reason why they give us these two values is because it's thought that at any stage of your life, If you are two and a half -stand deviations away from the amount of bone that you probably started with, then you are at increased risk of fracture. And obviously the problem with that is the fact that you could have started higher or lower than that average and most of us did. Few of us are actually average. But the Z score gives us information about where you lie in relation to your peers, how normal that is. the Z score is normally not as scary as the T score because you will have lost some time.

1:09:09Yeah, the way I try to help my patients understand it is that, as you said, like I always give them an example, right? Like if your Z score is zero, you're at the 50th percentile of the population. If your Z score is one, you're a full standard deviation above the mean. So what's that? You're in the 85th percentile if I'm doing the math correctly. And obviously, as you said, the T score is always going to be lower because we're comparing you to a perfect standard. We're comparing you to that super healthy 20 to 30 year old. So what we say to patients is, look, we want your T score. If you show up with a decent T score, your T score is zero and your Z score is plus point eight.

1:09:52We say the win is keeping that T score where it is and watching the Z score go up because over time, we want you being better and better and better than your age matched peers because they're going down and we're going to hold you plateau. And that means we can't improve you relative to the T score, although I'd love to hear in your experience what you're finding there, but we can improve you relative to your peers. Yeah. It's a good example. And yes, you're right. We can't improve at his school. Let's get right to it because this is going back to the outside of this discussion. I learned about you.

1:10:30I don't even know how. I think I was like literally just watching stuff on YouTube and somehow saw a clip. It's probably many years old from local news in Australia highlighting you talking about the Liftmore study. And there's just something like if you look at the things that I can get sucked into on YouTube. It's car videos, F1 videos. There's this world that just sucks me in, but I'll tell you another one of the things that sucks me in. Videos of elderly people lifting weights. I can go down that rabbit hole. I mean, it's ridiculous. You show me a 90 year old woman deadlifting and like I could watch that for days.

1:11:14It must be that the algorithm knows that. It served you up to me. So let's talk about the Lift More study. I suppose around about 2013, I got to a point in my research career where I looked around and thought the exercise guidelines for osteoporosis are get your kids jumping and running and playing as much sport as possible. Keep doing that for as long as you can. But then when you get osteoporosis, So stop doing all that and just prevent falls. So you don't break. So are we done? Is this the best we can do? This is lame. All my animal research experience had told me that even with very low bone mass animals, if you load them, they can grow bone.

1:12:00The only reason we hadn't been doing that in research is because we were terrified of hurting someone. And so it seemed to me we hadn't really tried. and at the risk of hurting somebody, we decided to do it. So we had three physiotherapists on that trial, including the PhD student who ran at Steve Watson. We decided to do a brief because bone doesn't need a lot of loading. You don't need to run a marathon. You just need to do one sprint to get those bone cells stimulated. So we had twice a week, 30 minutes, four exercises, and we wanted them lifting heavy. So it was 85 % 1 RM. We used compound movements.

1:12:46This needed to be an efficient project. We wanted to involve as much muscle as possible. It needed to be weight -bearing. And we wanted something that would transfer to really useful daily activities. So clearly a squat in a dead left was going to be fundamental. These are fabulous compound movements that they tick all those boxes. And these are not on machines. This is with free weights because you want to engage as much of those other systems and capacities as possible. We're trying to improve balance because we're trying to stop people falling. So, away we went. Ideally, we wanted it to be 12 months because you do need a fair amount of time to be able to detect change on DexA because DexA ionizing radiation picks up mineral.

1:13:29So, you can't just measure new bone, which would be the osteoid, unmineralized. You need a full period of time to allow for a full remodeling cycle and mineralized bone. Because it was a PhD project, we couldn't afford a full year for each person, so we just made it an eight -month intervention, which I was confident would be enough to detect a change. We did really comprehensive, bone and functional measures at baseline. We recruited about a hundred people, randomly allocated them to this high intensity resistance and impact training. Exercise research is really hard to blind to your participants and blinding is so important in clinical trials.

1:14:09So we had to not tell our participants which was the intervention that we thought was going to be effective. We just said if you got randomized to this low intensity home program, we were trying to see whether that worked too. Of course we knew that that was not going to work because we've got years of experience to know that that is not going to improve bone, but we gave them things like walking, stretching, somebody wet lunges and toe raises and things that would potentially improve their balance. So we weren't completely ripping them off. So then we had eight months of this intervention. It was supervised.

1:14:44Sorry, once again, Belinda, you said the treatment group was 20 minutes three times a week? No, 30 minutes two times a week. Yeah. Maximum group size was eight and we recruited post -menopauseal women. So we were looking for people we advertised for over 60 but I think we did recruit one person who was 58 because she had been through menopause when she was young and they just needed to be well clear of menopause. We didn't want to be fighting that withdrawal of estrogen phase and they needed to have low bone mass so they needed to be at least a T score of minus one at either the spine or the hip.

1:15:24So away we went and I have to say we were looking through our fingers for a little bit and we were so incredibly conservative to begin with and just being very careful that we weren't hurting anybody. It became abundantly clear very quickly that we weren't hurting anybody. In fact, we were making people feel a lot better. Let me just ask you about that because the video which we'll link to in the show notes, It's even though it was just a local news segment. It was just really inspiring. I think there were women there that were at some point basically able to pick up their body weight. Am I remembering that correctly?

1:15:59Like literally these women were deadlifting their body weight. Yeah. How did you even train them to do this? These women showed up to this study and they're probably told it's an exercise study. So they think, great, I'll be doing pool jogging or something. and then you drag them into a weight room with Olympic bars, how did you even go about getting them to do this safely? How much resistance was there on their part to the fear of weightlifting? I assume prior weightlifting experience was not an inclusion criteria. Well, they could have had it, but they couldn't have been doing anything in the past 12 months, because you know, bone is a use at all, is a tissue.

1:16:38So they needed to not be already doing this. We told them what the basic exercises were. So these had to be people who were willing to do this. We never throw somebody straight into lifting something extremely heavy and certainly nobody would have expected that we would end up with people lifting their body weight, certainly least of all us. We just did it very systematically. You start with a broomstick and you make sure that people's technique is good. And I have to tell you, we had people with fractures. So they had existing chifuses. And you know what a chifotic curvature looks like in a deadlift position.

1:17:18This is not a pretty thing. But as long as they have an extensor moment, it was okay. We don't want people flexing and lifting weight because then we're putting them at risk of fracture. But it's all in the coaching. And it's the reason why it's so important that the person who is coaching somebody with osteoporosis knows what they're doing. They can't just be a strength and conditioning coach, although that really helps. They have some clinical training, so because people come to you in a clinic with not just osteoporosis, but pelvic floor dysfunction, frozen shoulder, spondylalysis, if they're to go, near away, you've got to be able to manage that.

1:17:59A many of those conditions were actually screened out of the lift more study because it was the first time we were doing it. We didn't want to have to manage all of that. But I just put it out there because it's something I want to remember to talk about. So it was all about just systematically training them in the technique and then gradually increasing the load. And a lot of people think of older people and particularly older women and particularly postmenopause are women who the assumption is they go completely Lupi through menopause, which is not true. They think about old people as completely incapable, incapable of doing stuff and incapable of learning, but old people are you and me who just kept living longer.

1:18:42We have the capacity to learn and older people are perfectly capable of learning how to do a deadlift in a squat. It might be pretty ugly to start with, but they get better and as they get stronger, they get even better. I just love it so much. I cannot, for people listening and not watching right now, just the grin on my face listening to you talk about this. It just warms my heart. I just agree with all of that. I think that one of the saddest, I think misconceptions people have is that once they get to a certain age, it's too late and they sort of accept their fate. And oh, I have this chifotic spine.

1:19:22And And I guess I'm just going to spend the next decade of my life doing nothing. And studies like this demonstrate that that's not the case. I'm looking for some of the other kind of soft stuff as you think about the evolution of this study. I mean, what else did you notice in the subjects? What did they tell you? How did this translate into the rest of their lives? Because obviously you as an investigator are looking for something very specific. You want to probably understand how much muscle mass they put on, what their bone density did, how much their T -score has changed. But were there other things that you learned about these women as the study went on that spoke to their quality of life?

1:19:56Undoubtedly. And for them, that was the most important thing. And that is what made me want to open the clinic. This is our quality of life issue. It turns out this is not a bone issue. I'm a bonehead. I care about what their BMD scores did. But the reality is comments like, oh my God, Linda, I can see my shoulders in the mirror again because their posture changed. When you do a clinical trial you measure height and weight as the standard baseline how to describe your population. Who knew that we would actually be citing height as an outcome because the control group shrank whereas the intervention group grew a little.

1:20:37Of course they didn't grow but their posture improved to the extent that they were taller at the end of the study and the difference between groups was significant. It was only half a centimeter, but hey. That's in eight months. Yeah. If you like, soft outcomes, people saying my husband is hiking the cocoda trail and I just thought I was going to be cheerleading. I can go with him now. I've got this incredible strength. I've basically got my life back. I can get into the garden and I can push the wheelbarrow full of potting mix around now and I don't feel like I'm going to break. I can lift my grandchild again.

1:21:13I can get my own shopping out of the car. It's all about independence, quality of life. Measure quality of life as well and at the clinic it's pretty obvious that that is something that is improving. So what did you find after eight months with respect to muscle mass, bone density and the other sort of clinical metrics? We ended up with a net benefit of a bit over 4 % at the spine that equated to about 3 % improvement I went at the spine in BMD and about one and a half were one and a bit lost in controls. I would say that this program definitely has the biggest effect of the spine. That is a good thing because one of the places that fractures most frequently at the hip, it was a real head scratcher.

1:22:01When I first looked at the results, we had something like a 0 .6 % improvement at the femoral neck and I'm thinking, these women deadlifting and squatting 70 kilos, How can that be? We ended up with a significant difference because the controls lost to 1 .5%. There was a net benefit, but I couldn't figure it out. Luckily, I have some 3D hip software, which allows me to re -analyze my 2D BMD data from DEXA and look at the changes in geometry. From that, you could see things like cross -sectional area of the femoral their cortical thickness and so on. When you look at cortical thickness of the total femoral neck, there was a 13 % net benefit in the intervention group.

1:22:51And if you looked specifically at the lateral femoral neck cortex, there was a 27 % improvement. So it turns out that if you were jostling at BMD from DEXA, it would look like this kind of lifting only has a maintenance effect how they hit. But actually what's happening is it's changing the geometry, it's making it stronger by making the cortex that cortical bone thicker and more resistant to bending. So that was another of those fantastic moments where I had only just got this software and was just in time to show this really novel outcome. I think that's such an important point by the way. And given that But most of us clinicians don't have access to that.

1:23:38Can we, in your opinion, rely on the stabilization of the Z -score or the improvement of the Z -score, the stabilization of the T -score is a win if we're in that situation. So we have that patient who comes in at a minus two. You get them on a strength training program. They're putting on muscle mass. The Z -score gets better, but the T -score does not. You still say, look, you're probably winning, even though you don't have the radiographic tool to document the cortical bone thickening? Yeah, if you can maintain bone mass at the hip, the bone mineral density, yes, that is absolutely a win. Don't get me wrong, there were some people who probably the largest game we had at the hip in the lift more study was about 6%.

1:24:18So there were some people who improved BND, but yeah, on average, it's something that you don't always see. The important thing I think for people to understand here is even if going on this type of a training program, at best maintained you. Let's assume even the cortical thickening was maintained. There's two important points to consider. The controls are having the floor dropped from underneath them. So that gap between what you would be doing and what you're doing is widening, even if you're not getting better. So the fact that you're even getting better slightly is mind -boggling, but even if you don't, the gap between where you are and where you would be as enormous.

1:25:02The second point is your fall risk is going down dramatically because you're putting on muscle mass and to the very important point you made, you're using these free weights and you're improving your balance. So you have more muscle, more balance, more motor control. The likelihood of falling to get in the position that you're going to break a bone is going down so much. So when you add to the fact that oh and by the way, cortical bone is increasing by 13%. This is just a win, win, win, win, win across the board. And show me a bone drug that does that. If you look at our functional outcomes, we had back extensor strength, leg extensor strength, and then we had tandem walk, timed up and go, sit to stand, vertical jump.

1:25:49And we also measured chifosis. All of those things improved, but especially low extremity strength and back extensor strength. Now people think, oh, back extensor strength, yes, it's just making them stand up straighter. There's no just about it. If somebody has kifosis and their posture is such that their vision is angled downwards, they've lost that proof for all vision for say when they're walking to their car at the shopping center, which is not the comfortable environment, perhaps a little kid runs out in front of them and And they haven't seen them coming. And that's when a fall can happen on a hard supermarket floor, walking outside their own home and the neighbor's dog runs out.

1:26:33They don't see it coming. They get a fright in the fall. So posture is actually really, really important to fall risk and risk of fracture because we know pretty much half the time you fall you're going to fracture. I would add something even more to that, which is we have a couple of folks in our practice who are really forward thinking in their understanding of the role of vision in brain health. And we know this is true with auditory stimuli as well. So we know that hearing loss is a risk for dementia because it's reducing sensory input to the brain. And we would argue that you see the same thing with a reduction of visual input.

1:27:10So a reduction of visual input is a reduction of cortical stimulation, cortical meaning brain cortical, and that's also increasing problem. So in addition to everything you said, which is this increased risk of falling as vision is getting narrower, you're also reducing brain input. And I think you run the risk of also exacerbated or accelerated degeneration of the brain. So yeah, I agree with you completely. It's not that you just reverse chifosis. That's a really big deal to get somebody looking up and forward. The other things that I'm sure you saw were improvement in grip strength. So there's another benefit because you can't deadlift without grip strength.

1:27:51For women's picking, 70 kilos off the ground, think of how strong her hands are and think of the implication of that on mitigating fall risk. You think about that person walking down a flight of stairs. Now imagine the grip they have on the handrail as they confidently walk down the steps. You think of the devastating injuries that people can have of any age, but certainly older people when they can't hold onto a handrail and then they don't have the leg strength to stop themselves. Just to reiterate this point that we can't make enough, which is yes, there are some really interesting and exciting drugs on the horizon for the management of this.

1:28:28Yes, pharmacology and endocrinology play a very important role in managing these things. I would argue estrogen more than any other drug out there, but none of these things compare or should ever be thought of as a substitute for what you're describing. No, that's right. I briefly mentioned the tandem war consent to stand and timed up and go and could jump in all of those things are risk factors or predictive of your risk of falling. So yeah, we do know that improving those things reduce your risk of falling. You're quite right about grip strength. I do as much of this lifting as I can, but I'm frequently I've just been to Europe for a month in the US for a month and my lifting falls away so I come back to the gym and go to lift again and whereas my muscles, my major lifting muscles may be okay but I end up on my last set, I am just holding on to that bar and my fingertips because my group strength goes so it is absolutely part and parcel.

1:29:26This is why these Olympic lifts are so incredibly helpful because they are compare movements using virtually every muscle in your body, including if you're frowning. Like you're doing it. So, Belinda, there's no chance that anybody listening to us at this point would call into question the value of this type of intervention. So, now the question is for virtually everybody listening to us, they don't have access to you and they don't have access to your clinic. What would be the advice for the men and women who are coming to this discussion or people listening to this who want to send it to their parents or loved ones who really are showing up and are in the same state that the women were in at the beginning of your study?

1:30:11How can we take that person, provide them with the safest environment to go forth and conquer? Because again, if you're saying all you got to do is 30 minutes twice a week of of this very, very specific type of lifting protocol, which is, again, very straightforward in concept. Obviously in technique, it requires execution. How can they go about doing that? Who would you recommend they see what type of individual to coach them? So there's levels to that answer. And without turning this into an advertisement for Aneera, which is what the program is called that we deliver through the bone clinic, we get that question all the time.

1:30:52The minute I open the bone clinic, everybody wanted the program and the problem is I didn't want to initiate an avalanche of fractures for people doing the program and hurting themselves. So we decided to license it and provide that program to physiotherapists, what you guys call physical therapists, and a credited exercise physiologist, all their equivalent. And we have license. There's probably about 60 in Australia at the moment and a growing number overseas now, it's just starting to take on in the US, an academic, it's not a salesperson, I don't sell, there's people come to me and that's how they get it.

1:31:30The training for that is a very comprehensive six hours online, you must have these qualifications to do it and then you're ready to deliver it to your patients in your clinic as long as you have the gear and they've always got access to me and a lot of supportive information to do that safely. The reason I want physios and EPs to deliver it is because they have that background information that I was telling you about that clinical training that allows them to look after the millions of different comorbidities that are going to come into their clinic. So tell us again, Belinda, just to make sure everyone's hearing this and we'll link to it in the show notes.

1:32:08But what's the name of the program? Where can somebody go as an exercise physiologist or a physio to become accredited in this program? A Neuro is the name of the program and they just need to Google a Neuro Academy. O -N -E -R -O. That's right, yeah. Okay, we'll link to it. Yep. And they can read about. This is not something that the patients go to. This is something that the trainers go to to become accredited. So if a person is listening to this and they want to be trained, can they go to that site and find out where the accredited people are. Yeah, we'll go to the Bone Clinic site and we host a map.

1:32:50And if you zoom in on your area on that map, you will see a little red tag. If you click on the tag, the contact details of that O 'Neill provider will pop up. Now, as I say, at least in the US, not a huge number of them at the moment, but the demand is so incredibly high in the US. really the best thing that you could do if you were in that situation and you wanted to go to an O 'Neill RoboVider is go to your local PT or Kinesiologist exercise physiologist, some equivalent and say okay you need this program, here's the website contact Belinda and I can get them licensed and make a way they go.

1:33:30For me it's research, there is a way for them to contribute to our research program, I give them access to our database, I'm really interested in making sure that this works not just in our hands and so that part of my research. But for them, of course, it's a revenue stream, so it is a win -win for them. For the patients who cannot convince anybody to do own euro, then the next best thing would still be to contact the bone clinic. We can do a telehealth appointment with them and give them our very best advice for a program that they can do either at home or at a gym. If they don't want to do that, then the next best thing they can do is just go to the gym and get some gym program.

1:34:14Just anything is better than nothing and start lifting weights and try to get some supervision because if you've got a T -School of mine is for, I'm not comfortable with you training by yourself. So even if you're not doing a neuro gets somebody to look after you. So those are the sort of three levels. If you can, find an o neuro provider, do supervise a neuro. If you can't call email the bone clinic and we'll do a telehealth appointment and get your program that you can do, which would be the very best that we can come up with that you could do unsupervised. And then the next level down, just get yourself to gym with someone supervising you and do some weights of some kind.

1:34:54I guess I'm going to add a fourth one, which is I've been to the Gold Coast many times. It's absolutely spectacular. I think a trip to Australia is never a bad thing. Maybe scrap the telemedicine visit and just take a two week vacation to the Gold Coast and get some time at the clinic maybe. We'd love to see you. Action of the clinics in Brisbane, I live on the Gold Coast because that's where the university is, but the clinic is just out of the room. Well, Brisbane's gorgeous as well. But, Linda, this has been excellent. I'm just so excited to make sure that everybody out there who's listening to us has access to this type of information.

1:35:28I think this is a remarkable demonstration of the power of exercise. And, you know, people hear me say this all the time and I'm sure they're sick of hearing me say it. It is the most potent drug available. I am a very pro -farm guy, but there's just no denying the evidence. there is nothing that a pill can do to touch the benefits of exercise. This is about as pointed as an example as you will see. And I love hearing about how in such a relatively short period of time these women had such a dramatic improvement in their quality of life. It's such an exciting story. It's really had a greater impact on their quality of life than I can think of any other intervention than a healthcare provider to demonstrate.

1:36:13So anyway, thank you for your work and thank you for, like I said, getting up early this morning to share it with us. That's fun pleasure. It's lovely to meet a kindred spirit. Thank you for listening to this week's episode of The Drive. It's extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members. And in return, we offer exclusive member -only content and benefits above and beyond what is available for free. So if you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of this subscription.

1:36:48Premium membership includes several benefits. First, comprehensive podcast show notes that detail every topic, paper, person, and thing that we discuss in each episode. And the word on the street is, nobody's show notes rival owners. Second, monthly ask me anything or AMA episodes. These episodes are comprised of detailed responses to subscribe questions, typically focused on a single topic and are designed to offer a great deal of clarity and detail on topics of special interest to our members. They'll also get access to the show notes for these episodes, of course. Third, delivery of our Premium Newsletter, which is put together by our dedicated team of research analysts.

1:37:29This newsletter covers a wide range of topics related to longevity and provides much more detail than our free weekly newsletter. Fourth, access to our private podcast feed that provides you with access to every episode including AMAs, Sons, the Speel you're listening to now, and in your regular podcast feed. Fifth, the Qualies. An additional member -only podcast we put together that serves as a highlight reel featuring the best excerpts from previous episodes of the drive. This is a great way to catch up on previous episodes without having to go back and listen to each one of them. And finally, other benefits that are added along the way.

1:38:08If you want to learn more and access these member -only benefits, you can head over to peteratiaemd .com forward slash subscribe. You can also find me on YouTube, Instagram and Twitter, all with the handle peteratiaemd. You can also leave us, review on Apple podcasts or whatever podcast player you use. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor -patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk.

1:38:46The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay an obtaining medical advice from any medical condition they have, and they should seek assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously. For all of my disclosures and the companies I invest in or advise, please visit peteratiamd .com forward slash about where I keep an up to date and active list of all disclosures.

1:39:32I'm going to do a little bit of the same thing. I'm going to do a little bit of the same thing. I'm going to do a little bit of the same thing.