Bone Health, Falls, Medications & Healthy Longevity | Dr Deborah Kado

0:03We were just having a bit of a giggle off air that longevity science, it really is a hot topic right now. No kidding. Right? Yeah. And so I'm interested off the top here, as a gerontologist and a geriatrician, of which we will define in a moment, is longevity science just basically a sexier way of saying gerontology? I will just say yes. Yes, probably, because at a party, everybody wants to talk about longevity, but who wants to talk about gerontology? Well, I do. That's why you're here today. Good. So familiarize us with these terms. Okay. If someone hasn't heard of a gerontologist before or gerontology, what is that the study of exactly, and how does that differ from geriatrics?

0:56Okay. So a gerontologist is someone who studies aging at any point in the lifestyle and from all different types of angles. So it could be from a biological angle. It could be from a medical angle. It can be from a social angle, philosophical, just a policy, all over the spectrum, psychology. Whereas a geriatrician is actually a practitioner, usually an MD or a DO who gets specialized training in how to provide clinical care to older adults. So to be a gerontologist or to study gerontology, there's no, it's not a specific degree as such. No, it's not. There are undergrad courses that people can take with a gerontologic focus.

1:44There are probably master's degrees that I don't know about that would be in gerontological science. There are definitely PhDs in gerontology, I think. I think a lot of people that I see who say they work in the field of gerontology are often biologists or had some sort of undergraduate science degree. And then they've chosen to study the biology of aging. Correct. Yeah. And geriatrics, so you're both a gerontologist and geriatrician. Correct. So geriatrics, if I was a medical student, what would the pathway look like for me to become a geriatrician? How long would that take? Actually, it's not too bad.

2:28It's the general, in the United States, four years of medical school training, three years of residency, or in family medicine, which is also a three-year residency. And from there, you do one additional year of training specifically in geriatric medicine. And do you think that the public have a pretty good idea, understanding of the role of a geriatrician and where they fit into healthcare and the breadth of their knowledge and role in improving the health of elderly? I would argue no. I would say actually very few, just because there's so few in the United States, for example. So just about, depending on what estimate and what year you look at, but somewhere around 7 ,000 practicing board-certified geriatricians across the country.

3:17I would also posit to say that because there's not a lot of education in geriatric medicine across our United States medical schools, that there are a lot of doctors in practice who also don't really get a sense of what geriatricians do. So sometimes what they, if they know about a geriatrician, and let's just say we're in the inpatient setting, they might call for a geriatrician's help and think that it's all for social reasons, as opposed to understanding the true differences that happen with biological aging and how that might affect both diagnoses and treatments. You said to me in an earlier conversation that we had that there are less geriatricians today, I think, in the U.S.

4:00than when you first started. That's correct. Yet, I have to imagine there's more elderly. That's correct. So what's going on there and how is that affecting clinical care? Just like in geriatric medicine, when we think about conditions that affect older people, we use the term multifactorial. There's not just one cause for why we might see a manifestation of an illness or disease in an older adult. Same idea with why there are so few geriatricians. I think one is people in medical school are not exposed to geriatric medicine because there's so few. And so an internal medicine teacher once told me, if you don't think of the diagnosis, you'll never make the diagnosis.

4:42Same thing. If you never encounter a geriatrician, why would you think to become one? So that's one. Two, I think that in previous years, it's not cool. It's like not competitive. It doesn't have some cachet. If you say, I'm a dermatologist or I'm a cardiologist or I'm a neurosurgeon, whoa, that's something special. But geriatrician, oh, yeah, that you take care of old people who are about to die. So I think it's that kind of identity of what people think a geriatrician is like. And then I think they're not the highest paid specialty in the setting in the United States. So compensation when medical school education has been increasing in costs.

5:29So I think those are some good reasons. It's built into that this kind of idea that many of us hold in society that just getting old is a bit depressive and late in life. How much can I actually do when these conditions are a result of aging? Will I be able to make a difference? Yeah. I think that's kind of the standard by which people think, right? And I think I've been really lucky in my career in that I've been able to live and watch patients over even decades how they do. And I have been convinced by them that it doesn't have to be that way. It can be, but it's not necessary. But the overriding images are such that people tend to view the negative.

6:24And they might hear someone say getting older is not for sissies because they might be facing loss of function, things that they used to do that they can no longer do, things like that. But there's a lot of positives about being able to survive into old age also. You shared a story that I heard elsewhere about an elderly man named Ralph, which seems to, you've carried it with you and it seems to have, I guess in some ways kind of influenced the way in which you see elderly people today. and perhaps gives you, I guess, greater appreciation for them as humans and able to see them as a human? That's probably true.

7:14So that was when I was age 10, and my mother took me to a local nursing home along with other students in my fifth grade class. She was PTA president, and this was an activity that we could get out of class and go to a nursing home and help residents with their art projects. And we would get to go multiple times during, say, a semester. So the person that I tended to work with was an older man named Ralph. And I didn't call it dementia at that time, but clearly he needed my help in trying to do the art projects as instructed. one of the art projects I was helping him with in a particular week I made a mistake in the steps to make whatever it was we were making and I yelled in the art room I'm getting as senile as you are and then we proceeded he didn't seem to respond in a negative way but my mom sure did driving me home at the end of the day and I think that caused me to really have empathy to really think about it from that person's point of view.

8:28And so that was a gift that my mother gave me that I think made me well-suited to pursue a medical career. Do you think we live in an ageist society? Oh, for sure. Yeah. And in what ways does that affect the people that you see clinically? I'd say culturally, depending on who that person is, the ageist society has affected their own expectations about what they might get from a doctor's visit. I think just the kind of the overall expectations that people just assume that people become infirm and lose their mind and can't take care of themselves is an expectation as opposed to not necessarily so common as we get older.

9:19And so I think those factors that seem overriding, for instance, I teach this course, I ask students, medical students, what percent of people they think in the United States who are older reside in nursing homes. And their estimates are generally somewhere in the 10 to 20 percent range, but it's really like more 2 to 4 percent long-term care. So we just have this idea because it's so kind of prevalent everywhere that that's what it looks like to get older, but it's not necessarily so. If you've been listening to me or some of my guests talk about the gut microbiome, you'll know that it thrives on very specific types of fiber and polyphenols and resistant starch, many of which the average person falls short on, despite the very best of intentions.

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10:54If you interview people who are older, how do they feel about this situation? Because a lot of it seems like it's younger people, I guess, projecting onto them about what is it like to be old? Does quality of life deteriorate? Do we have any data where someone has been followed through, let's say from midlife into elderly, and you're able to assess for them, how does quality of life change? Are they people lonely, sad, depressed, or people finding joy and are happy? And is our attitude towards aging simply a projection and not accurate? I'm just going to go to the 101 person-year-old. I don't think that that patient thinks about it in that way.

11:47I think he's just living his life. He did tell me he was a physicist when he was still working, and he did say that he bought all these books on quantum mechanics and quantum physics that he was looking forward to reading. But then when he opened one of the books, he felt like he just got through three pages and then it was done. Plus, he's had some more visual challenges. So he's seen the ophthalmologist, but they've allowed, showed him that if he uses increased light, he has certain lenses he can read, but he doesn't frame it like I'm a hundred and I was thinking about this when I was 60 at all.

12:29I think he's just living his life and he's been lucky to be pretty much disease-free. How common is that though? So there are studies that look at this and I can't give you the exact estimates at this point. I would say it's more common now than it used to be, But what's really struck me is that these things really apply to people under the age of 65, such that I have seen frailty in my younger patients where they should be thinking about this. It's not just older people. And I thought that was very prescient because it really just depends. It just is that after the age of 65, we see a greater spread, but it's not that frailty cannot happen earlier in life as well.

13:12I heard you share some other research on attitudes that I found really interesting that perhaps our attitude towards aging could actually affect our, I think it was risk of dementia. Oh, right. So that's a study that was conducted by Becca Levy out of Yale. She's a psychologist, and she went back to data from the Baltimore Longitudinal Studies of Aging. And they, for some reason, a while back when these people were in their 30s, filled out a questionnaire about their attitudes regarding aging. So this is a while back. And then in the late 1990s, I think they did the genotyping for the APOE4 phenotype, which if you have two copies, you're at a substantially increased risk of dementia.

14:01And she found that when she paired those initial surveys when these guys are 30 to whether or not they developed dementia in the end, that those who had better attitudes towards aging had a 50 % decreased risk of developing dementia many, many decades later. This was not only seen in those people who are ApoE4 positive, which is a great thing because you could see that attitude would matter for people who are genetically at risk, but it was also true for people who didn't carry the gene. So just their attitudes kind of predicted whether or not they would develop dementia later. Is that that your biology is kind of affected by your psychology, or is it that people who were more positive were more likely to engage in healthy behaviors and look after themselves?

14:50So it's a great question. It's one of those chicken and egg things, right? So I think for sure, if people have more positive attitudes, they're probably going to have more proactive behaviors for sure. So it's a behavioral thing, but there could be something else. It may not be that simple. And do you see that clinically with elderly, the more positive they are and perhaps more purpose they have and joy that they have in a day-to-day, the more likely they are to engage in certain interventions and healthy behaviors. Oh, for sure. Yeah. I was just thinking because thank you for doing your homework and bringing up these stories from other times I've been interviewed, but I was thinking about new stories to share.

15:39And I was thinking of patients who I had earlier on in my career when I was still at UCLA. And I did really have a patient who was just lovely. And then he became my patient for the next six years, making it into his mid-90s and actually suffered from worsening posture, the stuff that I study. He was somebody who got more bent over, was harder to walk as he got into his 90s and didn't have any osteoporosis. So he was one of these guys who had postural changes that was affecting his gait. And he would tell me, oh, what I like to do is I go to Costco. Because Costco, the shopping carts are not as low, they're higher.

16:23So when I can walk all around Costco, around and around Costco, and get the free samples, and have a pretty good day of it, as opposed to going to Safeway, I guess, where the carts would be very painful for him. So he was someone who had a positive attitude and was always so grateful. Every time I saw him, he made my day better. And also taught me about studies and research, like why it's so hard to show, for example, an exercise intervention makes a difference besides not doing an exercise, compared to a group that doesn't do exercise. So because of this posture, he agreed to enroll, I think he was 90, into this three times a week yoga intervention to show that, to see if yoga with back extensor strengthening could decrease his kyphosis, as we call it, this forward curvature of the spine.

17:16And he did the whole 12-week intervention. He loved it because he was a widow and all the, mainly women in the study. So it was great socialization for him. He completed the study. He came back to me in clinic and he says, Dr. Cotto, you know, I'm just really disappointed in the study. And I said, oh, why? He goes, well, no, I really, I wish it could have gone longer. I would have stayed longer. But of course, these studies have to come to an end and they're expensive to run. He says, but did you know those examiners took six weeks to have me have a follow-up visit? Do you know how much function I lost by not having that every three times a week?

17:55And now I was just recently thinking about the stories, thinking, this is why exercise studies are so hard. I'm sure the study researchers were trying to get everything lined up, but they just couldn't get him in to do the repeat measurement. So he was like, I got worse in that time. If you had caught me on that day that I finished the exercise session, you would have seen an improvement. A bit of wisdom in that. I think getting off the dating apps and into a yoga or Pilates class, gents. Yeah. When you're working with a patient, and you just mentioned then with him, I think six or eight years you said you were working with him.

18:32There's a popularized term in longevity science right now, health span. And I know that you see it a little bit differently. But I'm interested in, as a geriatrician, what's the goal when you're working with that patient? What do you think is the goal? If you were to do your job as effectively as possible, what's the outcome that that person really wants? So that's a great question. And this would be true to any geriatrician who's trained in 2026 is the goal is what's important to the patient. So that's what all the geriatricians who we teach say, you've got to assess what matters because what matters differs.

19:18So what matters to me may not matter to my patient. and that's what you should try to elicit in a patient's visits. And sometimes people have trouble just elucidating what that means for them. But that's not age-related necessarily. I think if you asked an 18-year-old what matters, they'd be like, well, you know, a lot of things matter. I'm not sure, like, what is the goal? But that's what we try to say, get the patient who's a geriatric patient to think about. and most commonly what matters to an older adult is to be able to be independent and live independently and hopefully stay in their own home i think that's the most popular um answer and then a geriatrician's job would be to try to facilitate that as best as possible to break it down and say well what is it that we should prioritize that will help you stay independent and living in your own home.

20:17Right. Yeah. And is that processed, the way that I'm seeing a geriatrician, what I'm hearing from you, it's almost like a quarterback. It's pulling all of these pieces of information from different team members together and then looking at the patient as a whole is where I can imagine if they're just having, if there's no quarterback and there's just specialists, they might not necessarily be speaking to one another and miss that bigger picture. I think geriatricians are very good at the holistic view of a person. and all those factors. So the guy who coined the term geriatrics was back in 1909, a physician, I think his name was Ignaz, in New York City.

20:55And he both recognized that older people may have specific physiological challenges as they get older, but a huge factor of that was also how social demographic factors affect how people age. So yeah, geriatricians know more about that, those aspects that make it possible for someone to live independently. They know more about what resources are, where someone can potentially, what is realistic, how much these things cost, all those things. Yeah. Why do you prefer healthy longevity over healthspan? Yeah. So the reason why I want to promote healthy longevity is because over a lifespan, people can get challenged with a health condition.

21:49So are you telling me that if you're 40 and you get rheumatoid arthritis, your health span is done because you have to go now for infusion therapies and you're at the doctor's office and it's a chronic health condition and you're at risk for all these other things, then your health span is over? I don't like to frame it that way. I think it's, you know, you have a condition, you have ulcerative colitis, which is an inflammatory bowel disease. You deal with it. It's not fun to have for sure. And it's associated risk, but can you not lead a healthy life? Absolutely. You can lead a healthy life. So that's why I call it healthy longevity, because hopefully you can live a long time.

22:28And just because you have a chronic condition doesn't mean that your health span is over. I like that. I think that's a nice reframe, right? Otherwise, you can be defined by the diagnosis. Absolutely. And sometimes people define you. So I'm thinking of another patient when I was at UC San Diego and started the bone clinic. I had this lady who had terrible rheumatoid arthritis. She was 84, and she had osteoporosis. That's why she came to see me. And I think she had limited mobility. And her hands were completely deformed. Like she probably couldn't pick up a pen very well to be able to write. She was still working.

23:08And she and I came up with a treatment plan. She continued to work. Her work was to help opioid addicted patients. And she was kind of the therapist to help them become non-addicted anymore. And she had a lot of passion for her work. She had no intention of stopping her work. And yes, she had to make special accommodations because the rheumatoid arthritis in her case was very deforming. But she didn't really complain of pain, although I'm sure there was pain involved. She just did. With your understanding of what matters most, I want to bring this back just for a moment to the current longevity conversation.

23:45Because you're working with people who are at a stage of their life where a lot of people right now that are in that are sort of optimizing longevity i mean the overall goal is to as far as i'm aware for most people is to get to 70 80 90 and be in good health being functionally independent as you're talking about because you're speaking to the people this is what they want so if you're 40 now you're likely to get to 70 80 and that's what you're going to want to right and you sort of alluded to it that that there are things early in life that will affect that. And we're going to get into what you can do later in life and how you treat patients.

24:27But do you ever get frustrated? Are there any parts of the current longevity conversation that frustrate you that are perhaps shiny objects or distractions from the things that you feel really matter, that really make a difference in terms of setting someone up to be functionally independent at 70 and 80? They don't cause me anger as much as sadness because I think there is such a hunger to try to optimize one's health. And there's a lot out there. I mean, I really don't do podcasts, but I have been recently watching some podcasts and I watch these advertisements that promise so many things. I never click on what they're going to sell you, but I listen to, they sound pretty compelling.

25:24And I'm sad because there's just so many basic things that actually don't need to break your pocketbook that you can do to help your health. But I would posit that the stress, if you don't have a place to live, an ability to get food and shelter, if those basic things, or even I would say healthcare, access to healthcare, if you have those basic things, I think you can really live a long life to be. And these are my hundred year olds who are coming through the door. So it's not like you have to have a certain amount of money to access a certain amount of preventative care so that you can catch things early, so that you can be treated early, so that you can live a long life.

26:13In fact, I think it's, I don't see that. I just see people who really focus on the importance of living a full life and feeling like they're contributing to whatever it is, is important to them that tend to have the best prognosis. So in terms of elevating that across the country, reading between the lines it sounds like addressing socioeconomic disparity is a big lever huge which is this is not new this is like world history right they're always the haves and the have-nots and if you don't have you're at a higher risk of not living a long healthy life If you have, you have access, you're going to try to optimize that and more likely to live a long, healthy life.

27:04But it's not a guarantee. And this is where the conversation, just to paint it, just to be very blunt, is where it is not as sexy. Because when you're talking about unemployment rates and housing and evening up the playing field, this is a privileged conversation. and all of a sudden that whole longevity discussion is very different to what's the latest compound, NMN or NAD, that's going to help me live an extra 10 years. Yeah. In fact, I think people, oh, don't tell me what I already don't know. Eat right, do physical activity, sleep, you'll be fine. That's boring. Tell me what's new. Tell me what I can do to extend my life by X number time.

27:54Yeah, that's what's going to sell. That's what they're going to get clicks, et cetera. But for some people, that's what they feel that they need to do. And that's okay. They can pursue that. If it makes them feel better and they want to believe the latest and greatest, that works. The only thing I would say is that, and this is getting deeper and more philosophical, is that there is something in chasing the magic bullet that allows us to escape and not sit and deal with the feeling of like, life is, it's finite, and I'm not going to be here forever. So, that is a really good point. I think that some people, and this is coming from my teaching the Stanford undergrads, and the Stanford undergrads in the class, some of them are really quite honest that death, don't even say the word.

28:53It's too frightening. It's the unknown. And so it's easier to kind of focus on the shiny objects to try to avoid death. But that, you know, I don't know. I think that unless you're thinking about like an AI generation of yourself in the future that would make you immortal, and then that's important to you, I mean, people are chasing that. So it's really, and again, it's like, what are the goals? What's important to people? And yeah, I'm sorry that it's not sexy, but it is actually true. And it brings me up to another story, if I may share. Yes. I mean, that's why you're here. In that, I think I was actually still in training at UCLA.

29:40So the government at that time, I did my training in geriatrics. And part of it was at the VA in LA. So they give you a government Ford car. You have my Thomas map. And I'm going to all these different areas all around the greater LA County to do home visits. And I was just driving past Reseda to get here. And it reminded me that on this particular visit, I went to see a veteran who was living in a home that was probably about 1 ,200 square feet, so not large. It was a family that there was, I think there were, I just saw the mom and I think four kids ranging from maybe 14 to two years old and three bedrooms with a veteran living with them.

30:27So the veteran shared the room with a 12-year-old son, and then the three other kids were in another small room, and then the parents were in the third room. And very pristine, nice house, nice, happy household, and a wonderful veteran. And I thought, these guys are, so they're racially distinct. They were not family. And yet this family brought this man, a veteran, into their house to live with them. And I was thinking about the poor 12-year-old boy. I'm like, if I were a 12-year-old boy, I wouldn't want this 78-year-old guy living in my bedroom. You could barely fit two twin beds in the bedroom, but he was very clean.

31:13The boy was so happy. And I thought, this is a happy family. Whereas I went to other addresses and 90210 type addresses and such sad families. Like no life around lonely. What's the value that you, through your experience working with elderly, the value that you feel is offered? It's the life's lived experience. and if they're willing to share that and people are willing to listen. And I honestly think that's what happened to me. I mean, I started in the field when I was in my 20, 30, well, maybe 30, and for older adults. And I think those years in treating and listening to patient stories and seeing how their lives transpired over.

32:09At UCLA, I was there from 98 to 2012, so 14 years of taking care of people over their older years. They started at 65, so some of them made it to 100. Watching that and how they made their decisions and their personal interrelationships, their attitudes, their behaviors, all of that. There's a lot of wisdom that can be passed down through observation and through giving them the chance to share and listening. For sure. We all know that fasting has real benefits, even independent of weight loss. I've had numerous scientists on the show, Dr. Courtney Peterson, Dr. Volta Longo, talk about this. But actual fasting is difficult.

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35:29For listeners of the show, Swim Club is offering 25 % off your first order when you use the code THEPROOF at checkout. Head to swimclub.co forward slash the proof to learn more. So you started at UCLA, you started in geriatrics, then you shifted to research and then back to geriatrics. What's your kind of academic work journey look like? Okay. So I started an internal medicine residency training and I decided upon getting exposed to research and I studied kind of whether vertebral fractures were associated with worse outcomes such as mortality because we knew that people who have hip fractures would, about a quarter, would pass away in the ensuing year.

36:17And we found that those who had vertebral fractures were more likely to die. And that if they had more severe fractures or more numbers, 1, 2, 3, 4, and greater than 5, that it was an upwards curve. The more fractures you had, the more likely you were to die. So that was kind of the first study question that had legs that then caused me to think, well, why are they dying? And that people who get vertebral fractures might be more bent over. And the reason why I even thought that is because I went back to the death certificates to try to figure out why are these people dying? And there was a good number who were dying of pulmonary-related causes like emphysema or pneumonia or pulmonary embolus.

36:59And so thinking, well, okay, it's compromising lung function. And then we were able to use a small subset of women who had gotten spinal curvature measured by an architect's flexi curve and show, yes, it's the curvature that was associated with increased dye. You mentioned the 4Ms. Yes. Is that the framework that you would use clinically with a patient? So we realize in geriatrics, and this is a credit to Dr. Mary Tenetti, who is in Yale and really did a lot of the early work in the epidemiology of falls. She worked with the John A. Hartford Foundation, the Institute of Healthcare Improvement, and I think a Catholic hospital foundation.

37:43Can't remember the exact name. I'm sorry. But they realized that there are never going to be enough geriatricians to take care of all the aging populations. So what are certain things that can we just create what they term age-friendly health systems so that no matter who you are, if you touch an older adult, you should be aware of what the 4Ms are, which is what matters to them. How are they moving? Are they mentating? And are you reviewing the medication list? And there's actually a 5M. There are actually 10Ms, but don't ask me to name them. But the 5M, which is getting more traction now, is multimorbidity.

38:21So really thinking about how these different conditions interact with each other. And that's something that geriatricians, because that's who we care for, are probably the best adept at doing. And the third one was mentating? That's to do with cognition? Yes, cognition. Got you. Okay. So your work in the bone clinic must hold you in very good stead given how important mobility and frailty is in this population. Yeah. Yeah, so maybe I'll go back to doing just bone clinic. Right now I'm just seeing the veterans in the multidisciplinary geriatric clinic and teaching the fellows. But I would say that was the interesting thing about being a geriatrician and then being mistaken for an endocrinologist.

39:05And then so opening my clinic to 18-year-olds and upwards is that I realized that I was actually practicing geriatric medicine principles across the lifespan, not just for those over the age of 65. So I think that's right. When you think about bone health, if your patient can't remember to take their medications, then it's the lost cause. You better assess the cognition of your patient. And people who get osteoporosis tend to be older. So that's a factor. And geriatricians will pick that up, whereas other doctors will just pretend like, oh, well, they can say hello. They can get here. They're dressed OK.

39:44Yeah, they're a little weird in their history there. but we'll just, that's not my thing. We'll just, here's your prescription. Have a nice day. See you in three months. I had a couple of conversations on bone health and osteoporosis with exercise physiologists. Oh, I know who that is. You saw those? I didn't, but I know who she is. Yeah, because we've collaborated together. Yeah, Belinda Beck and then Laura. Yes, and Belinda Beck, yes, from Australia. Yes. Wonderful work. Liftmore trial. And so we spent like a couple hours going over the principles of exercise and how do you stimulate the bone.

40:20I've always been interested in, and I think this is something you'll have experience with, I'm certain you will, how you apply those principles, which might be very easy or relatively simple to apply for a 30, 40, 50-year-old that's in good health, doesn't have sore knees, osteoarthritis, mobility issues. How do you go about applying those, the type of exercise, prescription, the evidence-based way to stimulate bone within a population of people that do have more injuries and aches and pains and joint restriction, et cetera? Well, I start where they are, but I think this would be a great conversation because I think Dr.

41:06Belinda Beck and I have been at bone meetings, I've come to her post, it's like, your patients had vertebral fractures and you're having them do these things. How are you sure that you didn't cause any injuries? And she's like, I don't know. We didn't have any complications. Wow, that's impressive. So I think for those who are at risk, it's always best to be with someone like Dr. Gian Gregorio and Dr. Beck, because this is their experience. But of course, not everybody can see them. But there are physical therapists who are very much trained and have an interest in balance and will have read their studies to be able to get a sense of what they should be doing.

41:49So for me, I start with every patient in the clinic just doing something very simple as to observing, watching them get into the room, watching them sit down, asking them to stand up. And all my trainees know I do this. And if they feel safe, and I'm standby, what we call standby assist, if they can't stand up. And if they can, and they've used their arms, then I'll probably ask them how they're feeling. And if they're feeling okay, I'll tell them, can you sit down again? And then can you try to stand up without the use of your arms? And if they do that, then pretty good. I say, how are you feeling?

42:30Are you feeling dizzy and it's like, I don't know, easy peasy, then I'll look at their stance. And if their stance is wide based, then I'll ask them, could you just move your feet a little bit closer? And then I'll keep on escalating the ask. So if they're doing it, then it will be one foot kind of slightly opposed and then all the way in front. And then I often get, are you giving me a drunk driving test? If they do that, I'll make them do it on the other side. If they can do that, then I ask them to lift a leg. And if they can do that, I ask them to lift the other leg. And if they can do that, then I ask them to close their eyes.

43:00And generally, some people, I would say, probably even in the 40s may have difficulty with any of those initial steps. And so it just makes them aware. Because if they've come to me for low bone density found on a DEXA scan, I'll say, it may not have any consequence to you. But if you fall down, you're going to be more likely to fracture. So let's focus on that. And then if they're super able to do all those things, then I'll probably just recommend the US recommendations for physical activity, including muscle strengthening. I'll talk about power. I'll talk about balance. I'll talk about aerobic and kind of doing a potpourri of those things.

43:43If they have trouble at any of those earlier steps, so the semi-stamp, then I'll probably refer them to physical therapy. So you really kind of try and find their limit in whatever domain that is, whether it's power or balance or whatever. Can you speak to our audience here who, they might be in their 30s, 40s, 50s, and they're listening to us and perhaps they have a parent who's in their 70s and 80s, so this is very relevant to them. But I think you just mentioned power. And I believe it was your research, and I think I've seen this elsewhere, that really stresses the importance of how quickly you can produce force.

44:26And why is that important for someone to be training earlier in life? And how does that connect to this whole frailty picture? Because I feel like a lot of the exercise that I see and the programming that's done that's out there is more around like slow controlled movements and i'm not sure people fully appreciate that when we're talking about falls and how how do you reduce your risk of having that fall like you said which could could create a fracture if you have the right conditions and then the downstream repercussions that you spoke to there's high mortality rate etc etc so if someone wants to get to 70 and 80 and and have good power What's the key to that?

45:11Yeah, it's doing it. It's moving, but I guess there are different types of muscle fibers, and it's the fast-twitch fibers that tend to go down with age. And those are the ones that allow you to generate short bursts of energy. So I think it's those, but I would say things that require kind of quick movement and reactivity, jumping. So how did we assess power in the study you're referring to? I think the reason why we didn't see power-related outcomes is because it was, how do you measure that? But the way we did it was with a force plate. And so we could separate the strength from the velocity and really look at the power itself.

45:54And that was the metric. While strength is important and how fast you move is important, it was really that coordinated power variable. I think what you're saying is consistent with what other guests have said on this show and Laura would reiterate. Point being that it's not just about can you slowly move the heaviest weight possible. That these other types of exercises where the weight and load might be a little bit less but you're moving quicker are complementary and additive and important when it comes to if you have a trip, can you catch yourself? And while I think being proactive about it earlier on and building muscle and strength and power is so important, I will say that it's just moving in your life, not being a couch potato.

46:48So none of my 90-plus-year-olds are the ones you see on the internet and saying, look, they're running a marathon or they're doing track and field or they're a gymnast who can still do, you know, whatever, handsprings. It's just function. And then it's also carefully curated in that you want to be smart as you move, because we do lose muscle, we do lose bone density, we may lose sight and other senses that would make us at higher risk of having a fall. So you have to be conscious of your body in space. And so I've been recently interviewed, I'd say in the past few years about why tennis is the best sport in the world.

47:33And I was thinking about that this morning because actually I saw the 79-year-old who loves to play tennis, but now has some issues with his knee. Best as in most fun or best as in longevity? Best in longevity, whatever the tennis association, they're getting a lot of mileage out of saying it's the best sport. But I was thinking because I think I saw two of my My patients were previous tennis players. Oldest was 90. I love the sport. I'm not good at it because I didn't. But anyway, so I'm not trying to diss the sport. But I was thinking if I could peg what I think based on experience of watching my patients, those who've done well, it's the dancers.

48:16Well, there's coordination, mobility, social. And memory. And memory. A lot of memory. so if i had to choose one i would say it's dancing what about musicians musicians are great too and if you are a wind instrument player you've got it hands down because you have got that lung capacity and breathing is amazing wow yeah that's protective so play tennis and take up some type of music instrumentation yeah music is interesting i love music i think any of those things that bring people joy because I think joy in itself is so healing in so many ways. Obviously, the resistance training and just moving your body like we're talking about throughout life will hopefully help reduce your risk of having the fall.

49:11And then the resistance training will help build the skeleton. So if you did fall, hopefully you don't get a fracture. But I have to imagine that also part of that strategy for you is using certain medications to improve the bone's capacity to absorb force and not break. Can you walk me through sort of current best practices when it comes to bone medications? What are the most popular ones and most effective? Well, Simon, I'm glad you brought this up because I think the bone medications, largely the bisphosphonates, have really suffered in public perception thanks to a number of sources, probably the internet, but also making the front page of the New York Times in 2016.

50:02What happened? Can you walk us through that? I think, and also the Wall Street Journal, I think it was a headline along the lines like, Fearing the Worst Side Effects, Millions, Fogo, the Use of the Number One Treatment for Osteoporosis. What was the side effect? So bisphosphonates were the first FDA-approved therapy in the United States for osteoporosis back in 1995. That was the Londonate. And in about 2008, I believe it was Diane Sawyer, if people remember who she is, she reported on the news network that on TV, because we still had TV back then, that I think it was somebody in New York just stepped off the subway and suffered a thigh fracture without falling down.

50:48And so then they started noticing that people who had been on Alundronate or the brand name Fosmax for longer periods of time seemed to be at risk of developing a spontaneous fracture of their thigh bone, which is really unfortunate for the field because you take the medicine to prevent the fracture and here's the medication looking like it's causing the fracture, which in some people it does. So that caused a lot of people not to take the medicine. There was also earlier in the, I'd say around 2005 or 2006, there were reports of what they call osteonecrosis of the jaw, where people would then be on this drug and then have a tooth pulled and then the bone in the jaw not healing, becoming what we call necrotic or dead tissue in the mouth, which does not sound fun, you know, at all.

51:44And so I think those two side effects in particular led to a downturn, people wanting to take these medications because it was very well publicized. But in 2026, what we have found is, so we'll just start with the osteonecrosis of the jaw, is the risk of that is about one in 1 ,000 people who are getting four times the dosage that we give for osteoporosis because it's also used in breast cancer survivors to prevent breast cancer from going to the bone and has been shown to improve survival. But they at that time were getting much higher doses through the vein. For the run-of-the-mill, take a pill once a week on an empty stomach with a full glass of water, they don't even have estimates.

52:33I've heard anything from 1 to 50 ,000 to 1 in 100 ,000. And being that bone practice was my only practice from 2008 until 2021, unless they had cancer, really didn't see a side effect except for one non-English speaking patient who didn't even know that they were supposed to stop it once they had this problem. But it was also treatable. So really, really rare. But it did scare the dentist as well. So that if you needed a tooth implant, nobody wants to touch it. So what we do now is we basically say, are you taking care of your teeth? Do you need any teeth pulled? Because if you do, you should get them pulled now.

53:10Go to your dentist, floss your teeth. If you don't have gingivitis or poor teeth, you're not going to have this complication. So that's one. The other one with a crazy fracture of the thigh, Rick Dell, who was an orthopedic surgeon from Southern California, Kaiser, actually looked at every single patient x-ray that came in for a hip fracture and kind of figured out who's getting these fractures, how are they related, and he did show and publish that the longer you were on an oral bisphosphate, and in this case, it was most likely Fosamax or alundinate, the first one, the more likely it would be that you would have this kind of complication.

53:48And it was really high in people like me, small Asian, thin-framed females, very high, like nine times more. So the idea is how the bisphosphonate works is by preventing the bone resorbing cell known as osteoclast from resorbing. So it's favoring the formation of the bone with the osteoblast. And so over time, that looks pretty good because you're having less bone loss. And even on a bone density scan, you'll see an improvement in bone density. But more important than looking at the density scans, the multiple randomized controlled trials showed a decreased risk of fractures of about 50%. But if you imagine biologically, if you're just going to cut, just shut off bone resorption forever, that for some people, that's not a good idea.

54:40That can lead to more brittle bone. Because the osteoclast, which is kind of breaking down bone, that process is needed for the remodeling. Yeah. And so they've kind of shut it down. And it's interesting. I think I was at a bone meeting a couple years ago where now, and I didn't even think about this, but I watched this presentation. I don't know if it was published yet, but they can look at the blood vessels. I never thought about it because they're so microscopic. But of course, blood vessels have to get all the way to the exterior of your bone. But if you eat a chicken, it looks pretty hard on the outside.

55:14You don't imagine that there are blood vessels there, but there are. But what he showed, this guy was from Germany, that I think with bisphosphonates, that blood supply for some people would get more compromised. And then if you don't have blood supply, that's when you might see the beaking. So you can see radiographic changes that are concerning for possible being on bisphosphonate too long. And so there's a physiologic reason that it happens, but not in most people, not just some people. And the good news is if you find out that you're at risk, and the way we do it clinically is if you have pain in the thigh, we now can get some bone density scanners will scan down to the thigh to look for those early changes that would make you worried, or a plain x-ray can even do it.

56:01Then you just stop the medicine and it will be fine. The risk goes down. So that's how you think about it clinically when you're managing someone that's on bisphosphonates. So say they've been on them for like a decade. Well, I probably would take them off. I would look. I'd say, what are you doing about balance? I always start with what are they eating? So we talk about diet because that matters. And we're going to get there. And what are they doing? What they're doing in terms of the physical activity, including balance. Whether they say I'm a self-defined klutz and I say that's a bad idea, let's stop that.

56:33All those things first. and then depending on what their family history is, what their personal fracture history is, then we go to the drug. And I spent a lot of time on bisphosphonates because they're still the number one drug and they're not without consequence, but every single drug that has been FDA approved since, which there are amazing tools out there, they all need to be followed up with a bisphosphonate in the ideal world. Because all of them, if you give yourself an injection every day, say with teriparatide that was FDA approved around 2002, that builds bone, or abaliparatide, which is 2017, a daily injection that also builds bone, and then romazozumab, which is two shots a month for a year.

57:18Is that Prolia? Is that the same? Oh, I forgot about this. Yeah. No, Prolia is denosumab. That was 2010, was FDA approved. That's one shot twice a year. Any of those medicines, once you stop them, you will have an increase in bone resorption. And just like exercise, if you stop exercising, you're going to lose your muscle mass. So all those exercise trials, whatever, yeah. And you can't just keep taking those bone building indefinitely. So for romazozumab, right, no. And for the two anabolics, teraparotide and abaloparotide, teraparotide, which was older, had a two-year black box warning because 70 times the dose given to rats, some of them form bone tumors.

58:08So they didn't want to have people just be on it forever. But then after 20 years on the market with no real bone tumors in humans, they removed that black box warning. So some people are taking it for longer than two years, but nobody really wants to give themselves an injection every day forever. And then albaloparotide, I think, is still two years. Which of those different drugs reduces fractures risk the most? Good question. So I think you're getting pretty good data from the bisphosphonates, honestly, 50%. But if you're really talking about like what mimics exercise the best, it's going to be romazozumab.

58:48the latest one known by its brand name, Avenity. That you see the biggest gains in bone density. You also saw in their trial a reduced risk of not only vertebral fracture, but also hip fracture. So the two daily injections, they didn't show a reduction in hip fracture, which most people are interested in. And I don't want to forget, thank you for bringing up, I put out Prolia or Denosumab, which is the once every six month injection. It's a monoclonal antibody that works to prevent bone resorption as well. And it was shown to be effective with no changes in the bone microarchitecture over 10 years.

59:29The problem is, is that when you stop it, the bone resorption starts and there's been increased risk of developing vertebral fractures after stopping. So you have to follow it up with something else.

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1:02:27You sort of mentioned before that you might take people off bisphosphonates and I have to imagine that when you get a patient, particularly if they're new and they've been seen by lots of doctors. They could be on all sorts of medications. And at least my understanding is that that can be in and of itself a risk factor for falls. Oh, absolutely. As a geriatrician in older populations, a lot, we know from large observational or epidemiologic studies that the more medications you are on, including supplements, the worse uh the worse you might do health-wise so really in fact just point blank the 100 year old i saw last week uh less than five medications no no supplements although we did give them vitamin d so you do you see some patients that are on like a cocktail of medications where over over a decade or longer they kind of been given a medication maybe it had a side effect swelling or something and then they were given another medication for that and then something else on top of that and on top of that and all of a sudden it's kind of unclear.

1:03:36Are a lot of these medications just for side effects? Or questionable indications and unknown drug interactions. I've had patients come to the bone clinic literally with a cooler full of supplements that I think I took a picture because there were 25 and I thought wow. One of them I actually referred for a bone biopsy because they were fracturing. But the bone density was fine. But I said, we have to stop these supplements because I don't know what they're doing to your body, but you're fracturing. Your bone density is fine. And I've done the secondary workup. It's not like you have some other underlying medical condition, but I really don't think these 25 supplements are helping you.

1:04:20Yeah. But that was hard because people, you know, people have to do what they believe in. Yeah. And she was clearly attached to those medicines, had a very nice cooler, very stylish. That was part of her identity. It was tough. Is that tricky if they've been prescribed those by other physicians? Oh, yeah. That is true. Because you're almost, you know, indirectly, I guess, questioning a decision that they made. And then the patient might be confused. Should I be trusting what Dr. Such-and-such is saying to me, or they go back and see that doctor, and that doctor's like, hang on, the geriatrician's taking you off that drug, I don't understand.

1:04:59Yes. So, you bring up a really good point. What do you do when experts don't agree? I had one who kept on coming back, too. I mean, I was like, you're not taking any of my advice, so why do you keep on coming back to me? She goes, no, I like having debates with you. So what do you do clinically to kind of reduce that confusion or keep the other doctors happy? Well, I feel like I'm less concerned about keeping the other doctors happy. I love to engage in conversation if people want to talk about it just to see maybe I'm missing something. In fact, I had this one chiropractor who's fantastic, who's written a big book about and has done so much research in bone, basically because he was an athlete and was surprised to find out at a young age that he had osteoporosis.

1:05:54and really thoughtful. But I think there was a point where, you know, you have to engage in the conversation, but it's okay to come up with different conclusions because we don't, I think you have to find the ground truth for yourself and what you feel comfortable with at the end of the day so that when you wake up the next morning, you know, you feel okay. And that's up to the individual. But for the patient, I just share what I think is my honest point of view. And they can either say, I think you're full of crap, goodbye. Or they can say, actually, what you're saying makes sense. And can you help me with this?

1:06:33And then we have a working relationship. And what I found through starting the bone clinic, or even at UCLA when I was in the bone clinic at an orthopedic hospital, it was really talking about what matters to the patient, and then really saying, let's come up with a plan that works, that makes sense to you. And this will include, you know, what are you eating? You know, what kind of activity are you doing? Let's come up with a medication regimen. Maybe it doesn't fit for you now. Maybe we delay it for a few years, see how you feel. If you really improve your balance, you're not having any falls, you haven't any fractures, let's get you off the medicine.

1:07:13Maybe you don't need medicines. Or maybe, you know, you just proved that you just had another fracture and we have this problem. Or maybe you have a parathyroid problem. So I send him to a surgeon for a parathyroidectomy and that really helps. So, yeah, it's an individualized plan for that person. But you've seen clinically deprescribing can improve someone's functional independence? Oh, yeah. That's one of the things that I think some of my fellow geriatricians often teach about because they will show that someone may get referred to them, say, maybe age 82. And it's just slowing down in so many ways physically, cognitively, and maybe like their own expectations.

1:07:59It's time to go into the sunset. But then they also knew them when they were 75 and they did all these things that they were so active with. So they were just wanting a second opinion. And so just a simple review of the med list and the indications and then tweaking the medications, they can become a completely different person. Are there any classes of drugs that you would say are more commonly overprescribed than others that you find yourself kind of deprescribing more often? I think sleeping aids are a big one because they're all a lot of the sleeping aids are meant to be short term. They all say it, but then people want to sleep, and so they end up long-term.

1:08:39And those are often benzodiazepines. And benzodiazepines can affect one's thinking and risk for falls. So I'm seeing that less now, but that was a big one. The other one, in the 1990s, proton pump inhibitors became over-the-counter. So a lot of people would be on, the first one was omeprazole, and they would be on that for a long, long time for reflux. So some people do need it for reflux, but there have been since studies that have associated long-term use with worsening cognition, worsening kidney function, worsening fractures in bone. They can affect nutrient absorption, right? Right. So they decrease the pH balance and the acidity of the stomach, which can affect absorption, yeah.

1:09:28You mentioned nutrition before. without us going into a two-hour episode on nutrition here. And I'm not a nutritionist, by the way. But what would you say are the biggest challenges that this population has when it comes to eating a healthy diet, getting the nutrients that they need to support that goal of functional independence? Well, that, again, depends. What I'm seeing in the veterans, actually, if they still have a partner, they're eating pretty healthy. Because I asked them what they're eating and they're like, oh yeah, vegetables? Yeah, he hated them, but they usually can find some vegetable that they'll eat.

1:10:08So it's not just meat and potatoes. Women do better than men when their partner passes away. I think that's been the lore, yeah. But like my 100-year-old vet, his wife died of Alzheimer's. Right. So there's exceptions to that rule. Oh, for sure. But on the whole, are there certain aspects of nutrition that you tend to focus on more or emphasize with the patients? Oh, for sure. So minimally processed foods, things that don't last on your shelf for more than a few months. I think when you say what are the biggest challenges, and I'm from Palo Alto, so we're pretty lucky up there. But I think access is a huge aspect.

1:10:51And if you're more homebound, it's harder to get fresh fruits and vegetables. But in general, if that's the case, because I did when I was at UCLA, I'd had some fixed income patients where we would talk about healthy fast food choices relative to others. Like, well, I don't want to name names, but just different colors on the plate. And also, instead of canned fruits and vegetables, canned, have a lot of sweets or a lot of salt, better to do frozen if possible. if you have limited means. And are you finding that it's more common you're worried about patients being overweight and consuming too much energy, or is this a population where consuming not enough energy becomes more prevalent?

1:11:37It's so interesting you ask that question because I haven't been asked in a while, but even when I was at UCLA, I think especially for women, there's this idea you get post-menopausal weight gain and then you never get it off and you're 65, 70 and you just feel like, I can't wear those clothes I used to wear. And I tell them, are you kidding? That's your insurance policy. If you end up in the hospital, they never let you eat and being skinny is actually a risk factor for doing poorly. So I have never really focused on BMI or body mass index and saying, oh my gosh. In fact, if you look at large observational studies, the optimal VMI for an older adult is probably 27, men and women.

1:12:23And that's more than I am. And if you get lower, like less than 22, that's a risk factor, broadly speaking. So I think it's more about function. I don't, it's like, can you get up from the floor? If you're on the floor and you find yourself, can you get up by yourself? I don't care what weight you are. I mean, you could be pretty heavy, and if you get up from the floor and you're super heavy, I'm doubly impressed. So if it's hard on the joints and there are other aspects, metabolically, they're not healthy, they have diabetes, that's a different subject. But just weight of itself, I'm not concerned.

1:12:59So interesting thing to think about then is the emergence of GLP-1s now. Oh, yeah. Yeah. Clearly, there's going to be some benefits from long-term health if you take someone who is obese and get rid of the metabolic consequences of that or reduce them. But equally, there's a conversation to be had about what about long-term body weight for that person and is there potential for increased frailty later in life? So GLP-1 is for diabetes and I think we could have good long-term data. We should feel reassured by that. We just don't have the long-term data to know for sure. I think the people who work in this field have reason to be optimistic, but we just don't know.

1:13:46While we're on nutrition, I found it interesting that you've also studied the microbiome and nutrient status as well as microbiome and sleep. So how does a geriatrician end up doing a microbiome study or microbiome studies? That's called opportunity. I also was getting to know Professor Rob Knight, who is a leader in the field of the gut microbiome. Microbiome Gut Project, I think he led. Yeah, the American Gut Project. It was his work, actually, and some of the regular listeners will have heard this research discussed where he looked at what predicted the greatest diversity in the microbiome and it wasn't someone's specific dietary label it was like how many unique plants they had in their diet across a week 40 40 a week yeah and then when he when i saw that from the american gut project i was like can i even name 40 different fruits and vegetables but then he said you can put in spices herbs and spices yeah and then i realized actually i am hitting 40 Yeah, it's pretty good going.

1:14:54Yeah. So the research that you did, what did it reveal? Firstly, let's zoom in on the vitamin D side of that research because I thought that was quite interesting. Oh, yeah. That blew my mind. So basically at UCSD, I was seeing my patients in the bone clinic and so many would come in pretty educated and they'd say, well, I know that I need vitamin D to absorb my calcium in my gut. So how much should I take of each? And so I thought, oh, yeah, I remember hearing another lecturer that there are vitamin D receptors everywhere in our body, and they're really prevalent in the gut. So maybe I can propose to Eric Orwell that we should measure vitamin D levels because they had stored serum.

1:15:37And then I'll get Rob Knight to help do the analysis of the gut microbiome. and we got the study approved. And what we found was Eric brought in the world expert in vitamin, not the world expert, but a very well-respected scientist in vitamin D measurements from Belgium, University of Leuven. And so he did the measurements, but not just of the 25-hydroxyvitamin D level, which is the storage form that your clinician doctor will measure, but also the 125-dihydroxyvitamin D, which is the active hormone, and then the metabolites of the vitamin D as well downstream. And what we found was that the actual storage form, the 25-hydroxy-D, had nothing to do with the gut microbiome.

1:16:24There was a flat line. But those men who had more diversity within the bacteria of their guts tended to have better active vitamin D hormones and more evidence of vitamin D flux, suggesting flexibility of the system. So that's an association, but is the hypothesis that the microbiome is directly affecting the activation of vitamin D from a storage to an active form? So it's a great question. So when we figured out how to write this paper, since they were both measured at the same time, you really can't talk about cause and effect. And so it's that chicken and the egg problem. But what we know is that they are very closely related.

1:17:06And that was very exciting. And these men, by the way, were from six areas across the United States, Portland, Oregon, UC San Diego, Palo Alto, actually, which was lucky because then when I moved to Stanford, I'm still involved with study. And then University of Minnesota, University of Alabama, and University of Pittsburgh. So from six areas across the country. So we could really look at sunlight, for example, because that was one of the things I wanted to see. And certainly the people who lived in the more sunny days per year, by the weather maps, they had higher levels of 25-hydroxyvitamin D, just as one would expect.

1:17:43But in terms of 125 across the board, there were no differences by latitude. So what it taught me was that our biology is smart, so it's going to figure out what it needs. And the men were equal across the way. And so I think vitamin D metabolism is super important for bone. But yeah, we're using a clinical marker that works, but there's still a lot more research that needs to be done. The people in that study who had more diversity and had higher levels of the active vitamin D, was that level considered, was that clinically better, clinically meaningful? That's a good question. So we couldn't look at that directly in the study.

1:18:30An interesting study, like an add-on study to that, that I'm thinking, could be to take a group of men that are supplementing with vitamin D and then randomize half of them to eating more plants to increase the diversity of their microbiome and see if that increases their active vitamin D levels versus the placebo. Yeah, that would be interesting. Actually, a good number of these Mr. Ross men were already taking vitamin D. Of course, they were participating in an osteoporosis study. So they were already kind of educated to think about their bones. So we did adjust for vitamin D's use, and actually a lot of the men, very few of them were deficient.

1:19:16So what's your, at this stage, even though it's an association, what's your kind of clinical takeaway, or how does that affect you clinically? So for bone health, actually, it's not just these data. I think I'm using data from the UK Biobank where they've really tried to figure out there's so much on vitamin D. What is it actually doing? And then the randomized controlled trials that showed no benefit in terms of cardiovascular disease or cancer or falls or fractures. And everybody's like, oh, it's the wrong study, just like the WHI for hormones. It's the wrong study. But I think that vitamin D is very important.

1:19:53And in certain scenarios, if you look at some of the work that's come out of the UK, it does seem that it's important for bone health for sure. We already know that. But it's really for those people who are deficient. And that was a big complaint regarding the vital trial, the big one. But they did measure vitamin D in 12 ,000 people. It wasn't like they, I think. So they did measure it. Maybe it wasn't 12 ,000. I think it was. It was some subset of the 25 ,000. And when they subsetted into the people who were deficient to see if there was a difference between 2 ,000 versus nothing or placebo, there wasn't a benefit for fracture.

1:20:36But I think most endocrinologists are like, well, scratching their heads. We know vitamin D is important for bone. So we still check it. And if they're deficient, we try to replete to 30 to 50 nanograms per deciliter. But apart from bone, the UK, as it convinced me, it is important in immunity. So it's not a bad thing. As long as you don't get toxic, because you can have toxic effects, some level of vitamin D supplementation is probably safe. So if not all men are converting the same amount of the inactive stored form to the active, and we're measuring the stored form, how do you actually know clinically if they have enough active?

1:21:14Exactly. And the whole reason why physicians measure the storage form is because it's stable. And the 125 will be measured by kidney specialists because most of the 125 comes from the kidney in the conversion in the kidney from a non-active form to an active form. So they'll measure it, but this kind of work really is harder to do in individuals as opposed to populations where you get kind of an average reading.

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1:22:46What were the findings in that kind of body of research on gut health that were related to sleep? Yeah, that was another fun one. So these men wore armbands for a week, which is not the gold standard for sleep. But we also had in a subset the wrist actigraphy, which in the sleep world was considered more of the gold standard for objective measures of sleep. But we had both the questionnaire, a validated questionnaire of sleep, self-reported sleep and aspects about their sleep habits, as well as this armband measure for seven days. And what we found was it was the men who had the most regular sleep patterns, meaning they tended to go to bed at the same time and wake up at the same time every day, had the most diverse gut microbiomes.

1:23:37And what I didn't mention and don't want to emphasize too much, but there are certain bacteria that are considered kind of more favorable to gut health. And those are the butyrate or short chain fatty acid producing bacteria. And we found the pattern in both studies, the vitamin D study, as well as the sleep studies. Interesting. What are the most common neurological conditions that you would be treating or kind of helping patients manage that's affecting their cognition? So that would be in the broadest class called a neurodegenerative disease, of which probably the most famous is Alzheimer's disease.

1:24:17So definitely Alzheimer's, but then there's also what we call mixed dementia. So a lot of the people who develop dementia will have underlying cardiovascular disease as well. And when you do neuroimaging, you can see evidence of small vessel disease that would be consistent with a vascular pattern. pattern. And I really think it's more, and I'm not a dementia expert, but I think it's more of a continuum that you can see. So they're kind of classic Alzheimer's, but I think there is definitely a vascular component throughout. I would say that the manifestations of how people present with a dementia are very variable.

1:24:57What are the most effective kind of tools in your toolkit that you have to help someone's cognition improve if they have mild cognitive impairment or Alzheimer's? Is that even possible? So let's just start with mild cognitive impairment, meaning that their function is pretty much conserved. So by that, I mean, maybe before they could keep a list of 10 things they need to get done in a day and it's all in their head. But now they realize they should write down the 10 things or they may get to number five and they'll never remember what six, seven, eight, nine, and 10 were. So if someone's in that form or they're still functioning because they're making accommodations to whatever it is that's bothering them, then I ask them, and I do this even advanced dementia, is to ask them to challenge their brain.

1:25:55So even with advanced dementia, are you speaking directly with the patient? Or are you speaking to a caregiver? Or how does that look? It depends. So oftentimes, there better be a caregiver because a dementia patient will not reliably remember. But I speak to the patient first, even if I know that they're not going to remember because they are my patient, the caregiver is the caregiver. So I will tell them what I think might help them. I will also give them the possibility that some of their function could improve by participating in certain behaviors. And a lot of times that's just taking a walk.

1:26:36You know, maybe it's getting off out of the couch. Maybe they tell me, oh, I read, I read. I say, great. What did you read? In fact, this happened last week when my 79-year-old was a knee replacement who played tennis. A lot of times people get very vague, but because I said, well, now you can't play tennis. So what do you like to do? And he said, I like to read. And I said, okay, great. What do you read? He looks at his wife and the wife is, by the way, 14 years older than he is. And she's still working and his caregiver. And he says, well, I like to read two magazines. I don't want to name them for patient privacy reasons.

1:27:15But then I asked, okay, well, I used to read these magazines. So I knew the two of them. And then I asked him, so who was on the cover of the last magazine? He named it. And he talked about it. And so I was really impressed because the wife was very concerned about his cognition in the past two months. And basically, he's had a knee replacement that's gone bad. And this is something a geriatrician would think. He's not just has dementia. He might just actually have a smoldering infection in that knee. It was swollen. and maybe we need to take care of the infection because maybe if we treated that, his thinking would get better.

1:27:55And by me asking just those very specific questions made me have faith. Like their neurons are still working in there. He's pretty precise. He remembers what the magazine cover was for this last, and I actually went back after, because I don't read this magazine anymore. What is the latest cover? You checked it. I checked it. He was right. And he knew what it was. He knew the person. Sometimes the presentation of mild cognitive impairment or dementia could be something else. Yeah. That's what we have to rule out. What other things, like hearing loss or? Yeah, it goes hand in hand. So sometimes, yes, sometimes some people are just not social.

1:28:36So it's a good protection to being not social. It's just not to hear. So is that dementia? Hard to know. But mood, mood is a big one. Delirium is another big one. So medication, over-medication is a big one. Yeah. Do those brain exercises, do they just slow progression of disease if someone does have mild cognitive impairment or they do have Alzheimer's? Is there evidence looking at doing certain exercises, stimulating your brain in a certain way, whether it's recalling certain words or doing a crossword, can it reverse pathology at any stage? Yeah, so that's a great question. And I actually think nutrition, physical activity intervention trials, and then these ones that try to look at change in cognition, they're really technically difficult studies.

1:29:36Because for a geriatrician, I want to care about the end game. Like, are they actually better? I don't care if they get two points better on some scale out of five scales that they've done. It's more like, how is their function improved? And so I think there probably are studies that show some benefit. I would say just anecdotally, and this is how we used to practice medicine back in the 1960s, just by patient experience, is that there are kind of two factors, right? It's like I can see learning happen from visit to visit. And, but maybe what's more important is the patient's perception of how they're doing.

1:30:16Because that's what really, I'm only there forever. At VA, we're lucky. We get like an hour, hour and a half. But for shorter patient visits, it's hard to really get a full snapshot of what someone's life is really like. Why is that more important? The perception. Like what does that mean to them fundamentally? That means that they feel better. and isn't that what a doctor's job is is to make people feel better and they feel more hopeful probably yeah for the the 50 year old listener who is fearful of developing dementia perhaps their mother or father has it what do you think are the most effective things that someone can do in midlife to to help lower their risk of experiencing that later?

1:31:08Probably to believe that that's not necessarily their destiny. What I found a lot is people, if they've lost a parent, whatever age that parent died, if they pass that age, I mean, it's like a big deal because that's kind of what I expect that I might not live because that's when my parent died. So same thing with kind of dementia is that we don't fully understand all of its causes for sure, but we do know that there are behaviors, namely number one is still physical activity, getting the blood circulating. The other thing is really believing, treating your brain like a muscle, in that you've got to exercise it in challenging you to build new neural pathways.

1:31:55And I think the research has shown that we can do that, and we can do it at a very old age. So it's really engaging the brain and not just becoming a robot doing the things that you do all along. Because that, I think, leads to constriction and then eventual loss of function faster. So to a 50-year-old, it's really engaging, living in the moment, not thinking in the future and the past, not getting overly anxious about that's my destiny, but saying, what can I do? And believing that if you do it, you could actually change your destiny to something that you want. What do you do in the circumstance where you, and I have to believe that this happens inevitably, you're dealing with an elderly person and perhaps they think their best years are past them and they don't really have a lot of purpose and joy.

1:32:52and so maybe it's difficult to find a concrete answer to kind of what matters most to that person. How do you work with that person? You know, it's hard to write a prescription for purpose. It's different to writing a prescription for medication for bone or telling someone to do a balance exercise. But when someone's lost the joy for living. I think the best thing that people can do in that case, if that's really, like, it's not a mood disorder, there's not something that can be fixed, like chronic pain that can be addressed, social isolation, if it's really something where the core is, and this happens, like, I am ready, like, I don't even know why I'm on this earth anymore, then it's from a practitioner standpoint, an acceptance of that that's where they are and giving them the validation that if that's where they are, that's where they are.

1:33:54I'm not going to change that. All right, let's land this plane. What's one thing you want to leave the listener with today from our conversation, if one thing was going to land? I think if one thing is going to land, it's, I think, just being self-aware of who you are. So I'm going to go digress a little bit, but there's a married couple from Harvard. One of them, Jerome Groupman, wrote for The New Yorker, wrote a book. And Pam Hartsman is his wife, who's an endocrinologist also at Harvard. And they went around the circuit around the early 2000s talking about a medical mind and how they compared and contrasted their experiences.

1:34:38So for Jerome Grootman, he said, I grew up in a family where there was early cardiovascular disease. And I saw how the latest inventions of the time, stints, literally saved my parents' lives. And so I'm in for the latest, the newest, the greatest medical inventions because we are at the precipice of continuing greatness and precision. Now we're precision medicine, precision health. So that's really exciting. and then Pam was like well my parents lived well into their 90s and our thing was stay away from doctors and I would rather uh you know grad um kind of go towards more just natural healing not not supplements but you know just natural healing letting the body believing the biology doing the healthy health behaviors and things like that and so I think people have to find their comfort zone of where they are.

1:35:36And a lot of the PhD scientists now in the longevity space, I mean, they really believe. So I've been on other podcasts saying I wouldn't do NAD. But, you know, really smart scientists not only believe that it's going to work, they are ingesting it or injecting it or whatever and selling it and making a profit. So we're not talking about conflict of interest in terms of profit. But I mean, I think they believe it. So at least they're doing what they're saying and they're selling and getting rich off of. But I think because of my 30-plus year in medicine and being in the aging space with Roy Walford, who believed in caloric restriction, and watching kind of the iterations, and then it's resveratrol, and then it's this and that and the other, rapamycin, that biology and aging is just so complex.

1:36:29We want to distill it in to easy bins and what can we do, but really, I know people are looking for something sexy, but if they're really looking towards a long, healthy life, I can't, I would say, figure out who you are. And maybe if that makes you happy, like injecting that stuff and you have the wheelies to do it, fine. Would I as a treating physician ever recommend it? No. well thank you deborah this has been great and and i really i value your your voice in this conversation around longevity and healthy longevity as you put it and certainly that distinction between healthspan and healthy longevity is something i'm going to walk away from this conversation with well thank you for putting on such a thoughtful podcast uh i'm learning more about the field now there you have it friends i hope you enjoyed this episode If you did and want to stay up to date with future episodes, be sure to hit that subscribe button on YouTube and follow on Apple or Spotify.

1:37:32Finally, thank you for showing up and the effort that you're making to take control of your health. I look forward to hanging out with you again in the next episode.