What Bone Density Scans Can't Tell You About Fracture Risk | A Masterclass on Bone Health

0:00Here's something that we still don't talk about nearly enough. We're getting better and better as a society at treating heart disease, cancer and other chronic conditions. So most of us are living longer. But in order to enjoy those extra years of life, we also need to remain strong and physically capable. Most people later in life will tell you that it's not enough to simply avoid a heart attack or a stroke in your 60s and 70s. They want to keep doing the actual life. activities that they love. Moving with confidence, functioning independently. And if you've ever spoken to someone with osteoporosis or osteopenia or someone who's had a bad fall, you'll know how much this can rock their confidence.

0:43Slowly out of fear, they very often start doing less and less. Their physical capabilities and independence shrinking day by day. I don't want that for myself and I certainly don't want that for you. So in this episode I've pulled together my favorite conversations on bone health with some of the brightest and the most experienced researchers and clinicians in the field. We'll get into why fracture risk climbs as we age, whether you really need to lift heavy, and how to train so that your bones stay strong and you stay on your feet. Importantly this is a conversation about what you can do about it Because while genetics do matter, low bone density and fractures are not a guaranteed part of your story.

1:30And if you've already been diagnosed with low bone density or you've had a fracture, there's still a lot you can do to lower your risk from here. Let's get into it.

1:49help me untangle osteoporosis and kind of bone mineral density versus risk of fracture because i think a lot of people probably just think that risk of fracture comes down to bone mineral density, but there's a lot more to it. Yeah, so it comes down to like when I was talking about sort of the, your risk of fracture depends on your bone mineral density and the applied loads that you, right? So whether you break something depends on the load applied to bone and how much the bone can withstand it and other factors as well. So things that can influence applied loads, like for example, like if you fall on cushions versus concrete.

2:32Those things kind of influence it. But bone mineral density is kind of used as a surrogate measure of bone strength, right? So it's used to identify this is how strong your bones are. But it's really only kind of one measure. But, you know, increasingly it's been recognized that, you know, if you take say two people with the same bone density and one is 50 and one is 80, the risk of fracture seems to be higher in the older cohort of people versus the younger cohort of people because there may be other factors related to aging. So for example, you may be more likely to fall, right? You may have other health conditions that affect your bones that aren't, you know, that your bone strength that might not be exactly accounted for by bone mineral density.

3:19So there's a number of other what we call independent risk factors that are used in screening. And so when a physician assesses someone, they will hopefully order a bone density test, but they'll also look for these risk factors. And then they'll use a tool like FRAX, for example, where they put in the risk factors and it calculates a probability of fracture in the next 10 years. And that's based on all of the identified risk factors that are in the... Just kind of looking at what is the likelihood that this person's going to fall, and what is their bone mineral density? Not fall. The likelihood that they're going to fracture in the next 10 years based on their bone density and the presence of other risk factors.

3:56So it's like an algorithm. They calculate a probability based on eons of epidemiologic data that links risk factors to fractures. So they literally plug in, okay, this is your bone density, this is your age, this is this, and it'll actually spit out a number and it'll say your probability of fracture in the next 10 years is 14 % or 23%. And then they'll also do one for hip fracture specifically. And that's actually what's often used to make decisions around medication or other strategies for preventing fractures. So they calculate sort of this probability of fracture that's based on a number of risk factors, which includes bone density but is not limited to bone density.

4:40When you brought up that comparison between the 50-year-old and the 80-year-old, so I like this, they have the same, let's say, bone mineral density for the neck of femur. Correct. Femoral neck is what is used in the calculation. Yes. And yet they have a different risk of fracture because of all these other variables. Potentially. Potentially. I'm using one and one, but it's cohorts of people that this is based on, not one and And those other variables are, in this example, meaning that that 80-year-old, that bone is going to be subjected to greater load beyond its threshold? Because I feel like the assumption, I guess, and where I'm getting at is that, is the bone mineral density what determines how much load the bone can take?

5:27Or is there other properties of the bone? I see. Yeah, there absolutely is other properties. So bone strength is influenced by its material properties. So for example, bone mineral is kind of this beautiful composite of like a collagen-like matrix and then minerals. And so the minerals are embedded in this matrix. And so it gives it both this toughness and ability to resist tensile forces, but like tension, like pulling, right? But also good compressive strength. So it's a really nice composite material. I like to use like the example of like cement and rebar, right? Like you've got these two materials that provide different aspects of strength.

6:05So what can happen is if you have, for example, changes and the material properties, that's not measurable really with bone mineral density, right? So for example, some people who are very vitamin D deficient can develop what's called osteomalacia, which is under mineralization, right? Which is reduces the compressive strength of the bone, and then they can be at increased risk of fracture. Or with aging, sometimes bone mineral can actually be slightly hyper mineralized and that can actually influence the risk of fracture as well. Then there's the structure of the bone. So it's like not just the amount of bone you have, but how it's organized, right?

6:41The structure of it. So you can sometimes have small changes in bone structure that might not be appreciable on bone mineral density scans from year to year to year, but that can actually affect bone strength. So for example, if someone has wider bones versus narrower bones, that can influence bone strength. So there's those factors. And bone mineral density, it's actually not a density, right? Because density is mass over volume, and it's a two-dimensional x-ray. But what it is, is it's literally just the amount of bone present divided by the area in the x-ray, right? So it's an aerial bone density.

7:18It's a massive area. And so it's taking the amount of bone and trying to control for the person's body size, right? Because a bigger person is going to have more bone than a smaller person. So it's sort of trying to correct for that. But it doesn't really give you an adequate measure of bone structure. And there are structural aspects that can actually affect bone strength.

7:43How well does bone mineral density kind of correlate with the strength of a bone and the amount of force that a bone can withstand? And are there other properties of a bone outside of bone mineral density that kind of influence its bone's ability to withstand force? A hundred percent. There are. The reason why we do use Dex and we've used it and it's been so consistently helpful is because your BMD, it probably does predict about 70 % of your risk of fracturing. So I keep emphasizing it's not perfect, but it does have this very strong relationship between your BMD and your risk of fracture. We know that that's for years, decades has shown us that's the case.

8:32but when you drill down to what DEXA is on an individual basis there are definitely problems of that can get in the way of how accurate it is for you so for example it's a two-dimensional modality and that's because if you if it looks like a bed for those of you who haven't had one it you lie down on it and the x-ray source is underneath the bed and there's an arm that goes over the top. And as you scan, that moves along with the x-ray source because it detects what's coming through you from that x-ray source. So sources in the bottom, detectors above you, and it's detecting this, the density with two different energies that are going through you.

9:18And that's how it's able to detect the difference between bone and soft tissue. When it does go through the body, it's going through sort of in this single plane. So you end up with this two-dimensional projected image and that's why there are underestimations of BMD for small people and overestimations for big people because you're not getting the actual real size and shape of a bone. The other thing is you're getting the whole bone and you're not able to parse out the cortical bone and the trabecular bone that are the two different types of bone that comprise a whole bone. So the cortical bone is the dense shell around the outside and in the vertebrae that's quite thin.

10:01Most of the inside of it is that trabecular spongy bone. Cortical bone is quite dense and in long bones in the shafts and I'm sure you've seen that on a chicken drumstick, the long part, that's almost all cortical bone and it's very, very hard and dense but at the ends of long bones there's trabecular bone again. Now why that's important is because if you think about trabecular bone being all this interconnected mesh of bone, there is a large surface area of all of those struts and beams in there that is available for bone cells to attach to and resolve and rebuild. So it's a much more labile pool of bone, it's much more accessible for remodeling.

10:46So that's why many of our trabecular bone areas are affected by osteoporosis because they're affected more quickly than cortical bone which remodels quite slowly. The reason why I've gone down that rabbit hole is because DEXA can't tell the difference between cortical bone and trabecular bone. It's all, it's just going through the whole bone and it's providing an overall number of bone mineral density in what it sees, which is both of those types of bone. Now that doesn't matter in terms of its ability to predict fracture and giving us this BMD score, but if you want to know how things are changing and you want a little bit more information, probably other ways of measuring good.

11:31Now we've also got a PQCT, a peripheral computeral computed tomographer, which it's like a CT, but it's tiny and it has a small gantry. You stick your arm through it or your leg and it's able to scan through the bone and it has the scanning all the way around the bone. So it gives you an image in three dimensions and it allows you to look at cortical and trabecular bone and looking at changes in that. But it's not a very common tool used clinically. It's mainly a research tool. Belinda, has that been validated as a better predictor of fracture risk than a DEXA or is it just additive? It depends who you read, honestly, Simon.

12:16The people who sell the machine say it's better. And the people who read their research on it say it's better. And it makes sense that it would be better, but there's not a huge amount of epidemiological data to prove that. The reason why I got one for my lab is because the shape of a bone is extremely important to its strength. So this is where DEXA falls down a little. So scanning the proximal femur, which we call the hip, but it's the hip is the joint, but the proximal femur is the close end of the thigh bone. So it's what articulates with the pelvis and that's what breaks. If you have a hip fracture, it's normally the end of the femur that's close to the pelvis.

13:02And there's a, the head of the femur sits in the pelvis, and then there's a narrow neck that comes away, and then there's the rest of the bone that goes down your thigh. That narrow neck is often the place that breaks. Now a DEXA will scan all through that whole region and scan it as your hip. If you have something like we do, we have some 3D software that allows us to reanalyze that DEXA scan and look at the shape of the bone, you're able to see how, in our case, exercise acts on the shape of the bone to change it and make it stronger. And that gives you additional information that your just straight BMD doesn't give you.

13:44Yeah, that's, I mean, that's particularly interesting from a research point of view, because if there is more to the bone architecture when it comes to risk of fracture than just bone mineral density, you might miss a potential benefit of an intervention if you're only measuring the density. Well, certainly in our lift motor study, we didn't see very much of an increase in BMD at the hip after this, you know, this high intensity lifting program. And we think, what is going on? And then we looked at the three dimensions and you can see that the cortex of the femoral neck was getting thicker and wider.

14:18and if you just think about a stick you know a narrow stick or a thick stick and you try and bend one or the other you know that the thicker one is going to have more resistance to bending so the body not to anthropomorphize it too much but the body is so smart and the bones are smart they adapt exactly where it's needed to mechanical loading and they adapt in the best possible way There's not really any benefit to adding more mineral to a packet of tissue. It's much better to change the shape in such a way that it can resist bending better. And that's what bone geometry, why it's so important to measure that.

15:01If 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. That's why Dr. Will Balsowitz and I founded 38Terra, a gut health company where science meets supplementation. An independently conducted 15-day M. Scheim study found that our first product, Daily Microbiome Nutrition, or DMN for short, significantly increased short-chain fatty acid production and encouraged the growth of beneficial microbes linked to better gut and metabolic health.

15:40It's a simple daily scoop that you can add to water or your smoothie, no sugar, no fillers, just clinically backed ingredients that make your gut bugs happy. So if you want to support your microbiome in a meaningful science backed way, check out 38terra.com and use the code THEPROOF to save 20 % off your first order.

16:03I want to come to Liffmore, but just while we're here on assessment, are there any blood tests that someone could do that may act as a surrogate for a DEXA or perhaps you could see changes in blood before you see a reduction in bone mineral density? There are tests you can do. I wouldn't use them as a surrogate for BMD because whatever's going on in your blood, it won't necessarily completely reflect what status your bones are because it can change and it can change in response to various things. So because the process of remodeling the skeleton, we have bone cells that resorb bone and we have bone cells that replace that bone.

16:48And this process happens over and over throughout life all the time because the skeleton is largely a reservoir for minerals that we use elsewhere. So that remodeling process actually is really important for just maintaining the availability of those minerals to other processes other than bone. So it's not a pathological process. Remodeling is important, natural. We replace 5 % of our skeleton every year. The problem is when the bone cells that are resorbing resorb too much and the bone cells that are building refill too little. And this is basically what happens in age-related osteoporosis because that aging process, if you're not loading your bones enough, will happen that way.

17:39You get a net loss each remodeling cycle and that's why we lose bone over time. The benefit of having a blood test is that it can detect if you've got a lot of resorption happening and it can also detect if you've got more than normal formation happening. So if somebody has suddenly lost bone mass, doctors often do get a blood test and they will look at CTX for bone resorption and P1NP for bone formation and see if they are out of whack. And they also use it to see if a bone medicine is working because most of the bone medicines are anti-resorptive and they stop the cells from resorbing too much.

18:21So they do use it as a tracker, but they don't tell you how much bone you've got, just how much it's being remodeled at that time.

18:34That said, and I've kind of been going through this with my mom and she won't mind me sharing this. She loves doing her exercise and she has osteopenia. Strong family history of it on my mom's side. and I think there is an argument for even though we have those studies showing that you can still promote hypertrophy muscle growth with very high high reps with a low load I don't think that is as as advantageous from a bone density point of view do you have any comments on that we don't know conclusively and the reason for that is because we have a far less robust body of literature in bone because bone adaptations take so much longer than muscle adaptations.

19:19And getting people to stick with the study for a year and getting the funding to carry that out is tough. People who say that you need to be lifting really heavy for bone often point to the Lift More trial. And this was a study where one group of women did heavy barbell deadlifts, back squats and overhead press, I believe, and these hard landing jumps. So they were jumping up to a pull-up bar and then trying to land as hard as possible, keeping their legs as straight as possible. So that's protocol for one group. The other group did this at-home bodyweight exercise program that wasn't designed to elicit any bone adaptations by the author's own admission.

20:02So this is an example where, of course the group that was doing the heavy lifting and the jumping had a better outcome than the group that was doing this largely ineffective program. What it doesn't tell us is what if there was a group that was doing a set of 8 to 12. It also doesn't tell us to what extent was it the lifting and to what extent was it the hard landing jumps. So there are a lot of questions that need to be kind of teased out there. And when we look at meta-analyses for bone, there are some studies showing that moderate loads were better than high or low. There are some studies showing that low was effective.

20:48And there are some studies showing that jumping was effective and others showing that it wasn't. And so I think we are not really at a place where we can conclusively and confidently give really strict guidelines about lifting and rep ranges and or the inclusion of jumping. But we do know that the lifting weights is helpful and people will also encourage some form of kind of balanced training for fall prevention. And I think with jumping, there are a lot of women who are really averse to jumping. And certainly this hard landing jump with your legs as straight as possible is not an exercise that I would typically recommend nor do myself.

21:34So we need to be a bit careful before we translate that research to practically. How would you approach this if you were 65 and wanting to improve your bone mineral density? Well, the unfortunate truth is that through exercise, we probably aren't improving our bone density anymore at that age because bone mass is peaking in our 20s. So we're really trying to hold on to what we have as opposed to try to gain more. And that makes bone adaptations distinct from muscle adaptations. but certainly we have really powerful anti-osteoporotic medications that are available that are very effective for for women if they're appropriate there are also in some cases you know benefits of estrogen-based therapy on bone from an exercise standpoint we want everybody lifting weights for muscle so if we are saying well we're going to do that anyway and we know there are some added benefits for bone.

22:36It's a no-brainer for me to recommend that. And then I think we want to encourage overall physical activity. And we want to encourage moving in different planes of motion through different ranges of motion. If you're somebody who is physically active and can do deep squats and lunges, then walking up the stairs isn't going to be a problem for you. And if you are more agile, you're going to be able to catch yourself before you fall. So kind of practically speaking, I think it would be unfortunate if we found out that, oh, we need actually this whole new, completely different regimen just for bone.

23:19because then we're saying, all right, you need to do resistance training for muscle, and then you need to do this new other program for bone, and then we want to do our cardiovascular exercise as well. And so then we're making it harder for people to kind of hit all those targets. But I think we'll learn more in the coming years about exercise adaptations for bone. We just need to be patient because, like I said, you need to do a nine-month, 12-month study in order to get some quality data. Otherwise, you wouldn't expect to see any changes. Yeah. And I should clarify, when I was referring to my mom and her exercise, I would classify what she's doing as more of a moderate load, not heavy load.

24:02So it is more in that 8 to 12 kind of rep range. And at least my kind of rationale for that rep range was that it's it's enough to get those hypertrophy adaptations but also might be better for bone than doing like reps of of 30 sets of 30 we don't you know maybe we don't know but the rationale was that lower reps with a higher load could increase her risk of injury is there any evidence that would would support that that you're more injury prone if you're you know lifting a load that allows you to lift kind of three or four reps and you're at failure? I think I would never prescribe that to somebody who's new because if you, I mean, think about it, if your deadlift form is just a little bit off and you might be more likely to, for that to be a little bit off and you're lifting those really heavy loads.

25:01So in that sense, yeah, I think it is a bit riskier. The other reason not to recommend that rep range for somebody who's new is we want to practice the movements. The way we develop good technique is by practicing the movement patterns and also understanding what is close to failure. What does it mean to feel like, okay, I know I only have one left in the tank. And so that's why the rep range that you mentioned, the eight to 12 really would be my go-to for the majority of people. I think it allows for enough repetition that you're practicing and really focusing on form and getting used to the movement.

25:43And also it's allowing you to get close enough to failure and or to feel what it's like to get close enough to failure. And it's appropriate for the majority of exercises. Nobody wants to do a set of 30 barbell squats.

26:01Where do we start here in terms of thinking about the different exercises, how someone chooses the exercises and how they determine, you know, what weight they select and those sorts of things? Yeah, I think for me, like the way I like to think about it is, um, most people, if they've never strength trained before. You want to keep it, keep the exercises easy for people to learn and master. And probably you don't want to have too many exercises because then it's overwhelming, right? So I just think about like when I go to a physio and they give me, if they give me like 10 exercises, I'm going to forget half of them.

26:42And I'm an exercise physiologist and I'm not, it's going to be hard for me to, you know, quickly build in 10 exercises, you know, four times a week or whatever they want me to do them. So I'd like to be realistic. So what's like the bare minimum? So I think, okay, well, if we want to hit most of the major muscle groups, you probably want multi-joint exercises because that's going to be more efficient, right? So I kind of think, okay, well, you want to have a squat pattern. You want to have a hinge pattern. You want to have a push pattern. You want to have a pull pattern. And then some might argue You would need a press or some sort of shoulder exercise.

27:20And I actually really like carries because they're very functional. And you can actually, that is also a way of challenging balance as well, because you're incorporating mobility with a destabilizing element. Like groceries. Exactly. So I actually like to add those as well. So I would say like if minimum, bare minimum, if I wanted to start someone on a strength training program, that's kind of an easy framework. because then you can have a continuum of exercises, say, in the squat pattern, where for some people, a sit-to-stand is going to be very challenging, and that's a squat pattern. For other people, we're getting them goblet squatting with 20 pounds right away because they are stronger and they can learn the squat pattern while holding a weight.

27:57So you just wear people on that continuum, but everyone is doing one of those, each of those. The exercise you do really depends on what resources you have available to you um you know are they exercising at home with dumbbells are they in a gym or they have you know everything they need and then also like individualized um to their kind of abilities and impairments i have a lot of questions okay in terms of load and i know that we we've we've kind of spoken to this already but here on resistance training whether it's the landmine press or it's the squat how do we think about load whether someone's body weight is enough if they should be adding weight um how does that person kind of troubleshoot that at the individual level i think it really depends on their goals right so if a person their goal is to be able to to get out of a chair without using the arms for support, a body weight sit to stand practice is going to be enough for them.

29:03But if their goal is, if they're already able to do that and they want to get stronger, or they want to try to improve their bone density and maximize the stimulus to bones, then they might need something more challenging. So I think, you know, like there are going to be people, like I look, you know, my dad when he was falling a lot, like uses a walker severe arthritis like my goal for him was fall prevention and I wanted him to be you know functional in his home like I'm not trying to increase his bone density he was 90 like he's and he actually fell a whole bunch of times and never fractured anything so his bone density is probably pretty good but my goal for him was functional strength so do I need to throw a lot of weights on him no I had him doing um squats higher volume really practicing not using the arms, giving him some balance challenges.

29:52Like my goal is different there. But if your goal is I want to get stronger, I want more muscle, like I want to build muscle, then you have to, you have to walk that line of close to fatigue, right? So, and you may want, if your goal is strength, then it may be more effective for you to train at a higher percent of 1RM. Whereas if your goal is volume then you might be better to like muscle volume i mean volume of training may be more important so i think it really depends on what your goal is what about let's say a 70 year old yeah who wants to get to 90 and still be able to go up the steps still be able to walk down the road with groceries or bring groceries in from from the car um getting up and down out of seats in and out of bed all of those sorts of things and can do that right now yeah is it enough to just keep sort of training those things or do they need to do more than that kind of anticipating that they're going to have age-related changes so i would advocate that they do strength training with progressive overload beyond that for a variety of reasons.

31:11One, it gives them a bit more of a, they're able to then do those activities at a lower percent of their maximum capacity, right? So if we think about that, you said they were 70. So they're 70 and they're able to lift their groceries, but maybe with aging, their muscles get a bit weaker or their neuromuscular function isn't as good, so they're a bit weaker. and now all of a sudden they're lifting their groceries, but instead of it taking 60 % of their effort, it takes 80 % of their effort. And they don't do it or they have to take breaks because it's harder or they get someone else to do it because they can't do it anymore.

31:45Whereas if they are training at 70 and they increase their strength, so now it's only 50 % of their maximum ability, they still see that decline. They're still able to do it 10 years later. So that's the way I like to think about it is you're building that reserve so that you can still do those activities, but it's less of an effort. And you're also building that reserve of muscle that is important for your immune system and all these other things. Because you do tend to lose muscle with age, so you want to build as much as you can. So back to earlier, we were speaking about the difference between resistance training where a muscle contracts and then the tendon pulls on the bone.

32:24And that can result in the bone adapting. And then there's impact. On the resistance training side of things, thinking about that force, what I'm hearing from you is, probably a greater load so higher intensity probably better than so choosing a heavier load and doing less reps like say five reps like a lot of studies do and that load at five reps you're like close to fatigue failure is probably better than choosing a lightweight and doing 20 providing that this person doesn't have an injury and and is safely and confidently doing this exercise, that heavy load is going to be superior in terms of the stimulus it provides to the bone?

33:10I think we don't have enough evidence to say for sure that that's true. So I know that these conversations happen, and I just don't think we have enough evidence to say this intensity is better than that intensity. And I feel like the bigger problem in this world is that people are not resistance training because the barrier to entry is challenging because they find it intimidating or they're hearing these messages that you have to train heavy and that's intimidating to them or they don't want to do it. So if you ask me what the studies say, I will say that you tend to see more of an effect or I even hate to say that because it's really challenging because the studies are quite small and there's a lot of risk of bias.

33:54But I would say like more often there's more like moderate or high intensity interventions, resistance plus impact that show an effect. So yeah, moving towards that is great. And the other reasons why I tend to, and it's about difficulty level, it's not about load. So that's the other thing is people think they have to lift really heavy weights. It has to be challenging. But for some people, challenging is no weight at all. Some people, you know, they can slow the exercise down a bit and make it more challenging without adding weight. Or they can do a harder version of a bodyweight exercise. So do a, you know, a one-legged squat or a kickstand or B-stance squat without adding a lot of weight and make it more challenging.

34:37So I think people conflate load with intensity, but I think we need to think about difficulty level for the person. Most people don't think about brain health until something feels off. Personally, I'd rather look at the data while everything's functioning fine. That's part of why I use Function. It gives you access to a set of tests you'd otherwise chase across several appointments. Two markers I pay a lot of attention to, Omega-3 Index, which reflects your EPA and DHA status. DHA, of course, heavily concentrated in brain cell membranes, and homocysteine, which is consistently associated with cognitive decline risk.

35:15Both of these are modifiable, which is the point, measure, and then intervene. Members can also add on tests like APOE, the genetic test for inherited Alzheimer's predisposition, if that's something that you want to know. None of this, of course, replaces your doctor, its information, a more comprehensive view of what's going on inside you, so the conversation starts from data rather than guesswork. Check your health the way that I do. Function provides more than 160 lab tests for$1 a day and member pricing on advanced imaging. Join at functionhealth.com forward slash Simon Hill and use the code Simon25 for a$25 credit.

35:55Something I do a couple of times a year, fasting. Fasting has real benefits, But actual fasting is hard. By hour 14, you'd trade a kidney for toast. Prolon is a five-day fasting mimicking diet. Plant-based soups, snacks, and drinks that keep your body in a fasting state while you're still technically eating. It came out of Walter Longo's lab at USC's Longevity Institute, built on 25 years of research with more than 40 clinical trials behind it. The mechanism here is what interests me. This program has been designed to trigger autophagy, the cellular cleanup process that won the Nobel Prize in 2016.

36:33Their trials also report reduced biological age and fat loss with muscle preserved. Those of course are studied outcomes rather than guarantees but the research base is more serious than most of this category. For me it's the closest thing I've found to a longevity intervention with real clinical work behind it. Five boxes labeled by day, you simply open the box and follow the directions. Ready for your own reset? For a limited time, Prolon is offering listeners 15 % off site-wide plus a$40 bonus gift when you subscribe to their five-day program. Just visit prolonlife.com forward slash the proof.

37:11That's P-R-O-L-O-N-L-I-F-E dot com forward slash the proof to claim your 15 discount and your bonus gift prolonlife.com forward slash the proof if someone wants to get to 70 and 80 and and have good power what's the key to that yeah it's doing it it's it's it's moving but i guess there are different types of muscle fibers and it's the fast twitch tiders 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?

38:03I 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. And 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?

38:57and while I think of 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 so none of my 90 plus year olds are the ones you see on the internet and saying look at 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.

39:49So you You have to be conscious of your body and 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. 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 some 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 patients were previous tennis players. Oldest was 90. I love the sport.

40:27I'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. Well, 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. It's amazing. Wow. Yeah, that's protective. So play tennis and take up some type of music instrumentation.

41:13Yeah, 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. And then the resistance training will help build the skeleton. So if you did fall, hopefully you don't get a fracture.

41:47Are there certain injuries that over the years have surprised you where surgery hasn't led to better outcomes? Let's back up a little because you mentioned injuries, right? Like I say all the time, most joint pain or tendon pain in grown adults is not due to an injury, right? You didn't sleep wrong. You didn't, you know, that milk wasn't too heavy coming out of the fridge. Our tendons and joint structures were engineered in such a way that if you don't maintain them and exercise them, move them, run them, strain them, they're going to let you down. And one of the ways they're going to do that is they're going to start to hurt.

42:33Then there are those of us who exercise a lot and we hurt ourselves. So we overdo it. Very few of the people that we see in the office fell off a ladder, fell off a roof or got hit by a car. Is the evidence looking at whether conservative or surgical intervention leads to better outcomes clearer when we're talking about acute injuries? So injuries from sport versus more of the chronic injuries or chronic damage, let's say, or aging that you're talking about? Yes and no. Most of the studies that have been done have been done on routine meniscus tears, routine rotator cuff tears, you know, a 50-year-old walking to your office with no history of injury.

43:16There are no clear studies that demonstrate if you fell off a ladder and ruptured your rotator cuff, there are no clear studies that you'll do better with surgery. The issue becomes there are significant consequences if we wait two or three months to see if you do fine without surgery because the root channel cough will change in those three months and it may significantly compromise your ultimate result. I want to get to the biology of tendons and joints and come back to what you were just speaking to with regards to aging. Before we get there, have you ever performed surgeries and then And then years later, as time has gone by and there's more evidence accumulating, perhaps you have more experience with patients and realize that if you had those same patients today, you might treat them differently.

44:06Oh, yeah, of course. All the time. Most of the surgeries that I do now, I did far more of in the past. And what are those surgeries that you would do today where you would say, these are the ones where there is the clearest evidence that we should do surgery and patients will get a better outcome than managing conservatively or waiting? Sure. So one example is a root tear. It's a type of meniscus tear. The meniscus is only attached to two points front and back of the knee, and they're called roots. And typically the root on the posterior back aspect of the inner side of the knee is the one that ruptures.

44:46And those knees tend to go downhill pretty quickly. And they develop stress reactions and stress fractures if you don't address them and fix them. And to your point that if you took the same scan to 10 orthopedic surgeons, you might get four different pieces of advice or recommendations. If we think about a listener now who maybe has some type of issue, joint restriction, pain that they're wanting to get on top of, what is it in your eyes that makes a good orthopedic surgeon? And how can someone discern between one that is practicing based on the best evidence that we have and one who perhaps isn't?

45:26It has to feel patient-centric to begin with. Every injury or issue tends to have a personality. The same type of tear is going to behave in 10 people in 10 different ways. You know, are you a tennis player? Is it your dominant arm? What's your medical status? Are you diabetic? Is your A1C 12? These all need to be taken into account when we're looking at a person. And you have to be examined. That sounds strange, but our physical examination can be very revealing, especially in joints like the shoulder where you can miss a frozen shoulder because you saw a rotator cuff tear on an MRI and just proceeded down the surgery route.

46:16So there's a clear situation where you're going to make that person worse if you miss the frozen shoulder on exam. So hopefully you're asked a number of questions, hopefully you're examined and then your imaging is taken into context with your history and your exam to come up with a reason for either surgical or non-surgical management in the person sitting before us. Talk to me about knee osteoarthritis. How often are you seeing people that have knee osteoarthritis, whether it's patellofemoral or tibiofemoral or both? Five times an hour. It's incredibly common. Whether it's the cause of pain, that remains to be seen, but I will see it on an x-ray or an MRI all the time.

47:04The most common cause of arthritis is aging. So you see an older demographic and it's going to show up. So what do you see on an x-ray or an MRI that is indicative of arthritis? So the x-ray is going to show a decreased space between the femur and the tibia. You're also going to see the bone of the tibia and the femur become more dense as that space narrows. That's a process that we call sclerosis. You can see swelling in the knee or an effusion. And then you start to see bone spurs where the bony anatomy of the joint is going to change. And then the bottom of the femur has two condyles and they're typically curved.

47:52As arthritis progresses, they tend to flatten. So the changes are pretty obvious. MRI can be far more sensitive because it can show structural change within the cartilage itself. It can show inflammation within the bone. It can show inflammation within the synovium, which is the lining of the knee joint. or the capsule, which is just deep to the synovium. And so it can give us more information about the severity of the arthritis or whether it's painful, but x-rays alone usually work to show it. I sensed you being somewhat deliberate or careful with the wording decreased space. And I think you've written about bone on bone being quite a harmful three-word phrase.

48:42Yeah, I mean, it's an awful phrase, right? You know, I run with people on weekends who have bone-on-bone arthritis in their knee. And, you know, the one I'm thinking of, he's my age and bounds over mountains and hills and rocks and roots. He's not disabled. So there are so many studies that show that your x-ray findings do not correlate with your symptoms. Same goes for the lumbar spine and the lower back, et cetera. So for some reason, the words bone on bone really strike at a patient's heart. It makes them very nervous. And as I alluded to before, they went to an exercise class. Some of them might stop.

49:31I can't. I have bone on bone. Or they need to lift weights for osteoporosis. I can't. I have bone on bone. Or I need a knee replacement because I have bone on bone, which of course is not true. You might need it if you're bone on bone and have severe pain. But the finding alone, you know, so a lot of doctors online came back at me when I wrote that and said, why? We're just being descriptive. I'm like, no, you're not. You can say severe grade four arthritis or severe arthritis you don't have to say bone on bone what good is that doing language matters and and ultimately if it's causing people to give up exercise and there's evidence that exercise can improve someone's outcomes with osteoarthritis which is what people really care about right they you care about can i do the physical movements or activities that i want to do and can I do it pain-free or with less pain, then I think that we have to be responsible with the language that we use to describe someone's condition.

50:37I agree with you fully there. Is the evidence on exercise for someone with osteoarthritis, would you say that's a strong body of evidence that says, look, if you have knee osteoarthritis, doing this type of specific exercise is likely to be net positive for you? So for the most part, yes. There's a fair amount of evidence that supports that. And there have been times when I've had patients lined up for surgery. And there was one time in my practice when we had a lot of financial problems in the U.S. with the collapse of the finance system. And a lot of people were afraid of losing their jobs. and they were signed up for surgery and held back.

51:26And we started them in physical therapy. And when things lightened up, a lot of them didn't need the surgery. Same thing happened around COVID. You had a lot of people scheduled for surgeries. And when the ORs opened up again and we called them, like, actually, you know, I did the exercises that you sent me and I'm doing pretty well. I've taken creatine daily for years now on a plant-based diet you start from lower muscle creatine stores than someone who's eating meat so it's one of a few supplements that I feel really adds something to my diet and the evidence on strength and power is about as solid as it gets when it comes to supplements with emerging data on cognition which raises a question that most of us never ask do we actually know what's in the creatine that we take every day the category has exploded and most brands have competed on flavors and formats rather than the quality of the creatine itself.

52:23Momentus went the other way. Signature-spec creatine is made in a pharmaceutical facility using reverse osmosis water purification, verified through a six-stage testing process with four independent agencies, 10 times fewer impurities, heavy metal limits 2-5 times tighter, screening for PFAS and microplastics. It's also ultra fine so it actually dissolves. No grit, no clumping at the bottom of the glass. If we're taking something every day for our health, I think it's worth it being the best version possible. If you want to try Momentus Signature Spec Creatine, head to livemomentus.com and use the code THEPROOF for up to 35 % off your entire first order.

53:07That's livemomentous.com, promo code THEPROOF for up to 35 % off. livemomentous.com, promo code THEPROOF. I'm often asked for advice on building a podcast or a business. One thing that I've learned is that the people I've watched build well aren't necessarily doing more than everyone else. They're delegating better. There's a point in anything that you're growing where the constraint stops being effort and starts being expertise. You need someone who is very good at the thing you're not and you often need them for six weeks, not forever. I've been using Upwork since 2015, legitimately, when I built a customer service team out of the Philippines.

53:54They were so good I ended up flying over to the Philippines to run retreats with them in person, but that's a story for another time. Upwork is a platform to find, hire, and pay expert freelancers across more than 125 categories from software development to marketing and operations. You can browse profiles, look at past work, and get help scoping the role before you commit. With Business Plus, you get the top 1 % of talent and AI shortlisting comes back in under six hours. quicker than most of us, answer an email. Visit upwork.com right now and post your job for free. That is upwork.com to connect with top talent ready to help your business grow.

54:38That's upwork.com. Upwork.com.

54:48if someone is really focused on building stronger bones so let's say that they are someone with a family history of osteopenia or osteoporosis or maybe they have osteopenia themselves is there anything in that current framework that we've walked through that you would want to tweak or add or modify for that person? I think everything we covered really touches on it. The only thing is, kind of going back to what I talked about earlier, like strength is the really, really big rock there with all of those things. But we do have some trials in menopausal women looking at like jump landing training or small jump training or hop training or some sort of acute polymetrics or whatever that looks like training in conjunction with the strength training for improving bone density and bone outcomes.

55:42And I know a lot of women get hesitant for that because maybe they have pelvic floor issues or knee issues or things like that. That's why I really emphasize that like the strength training is going to be the bigger rock in that component there. But that is something that can complement that, add that. I like that. Or, you know, we never really circled back to people who are doing things that are like from home with maybe inadequate weights or just body weights or just bands. And some of these trials, I mean, they're like a year long, but they have women doing like a few sets of 10 to 12 like pogo hops a few times across the week and they do see some improvements in you know bone density so if you're not able to access those and you can gradually progress to something like that like it could be something that you mix in that can support that kind of thing um so i like that as i can i kind of bucket like power and jumping and strength into like it can be kind of combined into one big cohort of things that you could do for strength power muscle support in my head.

56:37But that is something that we do have some data and trials on that you can do in conjunction with the strength training to complement it. But again, I like really hate the podcast and make people think that things are like very absolute and scary. You have to do one thing. And I really want to emphasize that like if you're just doing the strength training, like that is really sufficient. You're going to get a lot of progress if you're loading it as we loaded it and things like that. I personally like that in conjunction. If you're able to do it, you can tolerate, you want to do it, whatever that looks like.

57:07But again, really easing into something like that, not just like literally jumping into it kind of thing, especially if you don't have a training background, a training history. I don't want to say there's like minimums you have to meet for that. But you just want to be careful about doing too much too fast too soon with any exercise program in general.

57:25Dr. Lauren Colenso-Semple: I alluded to this earlier, but we care about bone density as a measure because it's a marker for fracture risk. And so when we think about what we can do to prevent fracture risk, it's also about fall prevention. And so I would love incorporating some sort of balance training into our resistance training. And we could do that with something like a walking lunge, for example. So it doesn't have to, you might think of balance exercise as some other type of exercise, but it really could just be the way that you can orient your body doing a single leg movement or a single arm movement, or can we do step-ups with a controlled eccentric, something that is really allowing us to move through a full range of motion in a way that if we were in a position to kind of lose our balance or stumble, that we would be able to catch ourselves because our strength training program includes exercises that are encompassing all those planes of motion.

58:41Yeah, that really emphasizes the importance of exercise selection because back to your earlier program that you were describing um that could look very different if you're choosing you know all you know lower body exercises where you're using both legs together kind of bilateral versus unilateral or like split leg squats for example things like that it could but i would say if we're going back to basics or if we're just starting out then we want to choose exercises that are

59:17Dr. Lauren Colenso-Semple: easy to learn. We don't want something that's too complex because we're still developing that kind of kinesthetic awareness. Where is my body in space? That's why deadlifts are so challenging. It's just a hinge movement pattern. It's really challenging to teach people that movement pattern because it just doesn't feel that natural. And so I would start, I think machines like the machine circuit, I'm a big fan of that for a beginner because we're hitting the basics of targeting all the major muscle groups and learning what failure is and getting comfortable with some of these movement patterns.

59:51Dr. Lauren Colenso-Semple: And so once we've done that, then we can start to graduate towards the dumbbell or barbell movements or the single leg movements. And I think we can end up with a nice mix. But I would still, if we're day one, then I don't want to overcomplicate it. I was going to say, the only thing I would add to that is that I think, tying back to our conversation earlier about like thinking embedding things into your active life like I'm thinking about our avatar of like the woman playing pickleball like keep doing those things because you're being reactive you're moving laterally you're moving forward you're moving a multiple planes of motion you're and it doesn't have to be pickleball it can be you know maybe you hike on like really rocky trails or you're having to react to the terrain or maybe you play with your dog or your kids or your grandkids like don't also ignore like how other activities can fit into this whole picture here.

1:00:40It's not just like go to the gym and become lifting robots and that all. Movement should also be variable and fun and add to your life. And I just want to hone in on that because I think a lot of times midlife women think they're not doing enough or they have to give up activities they love. No, those absolutely contribute and complement to all of these things that we're talking about here. So our 52-year-old pickleball player that's adding and lifting, well, I'm going to tell her to keep playing pickleball. Like, I'm never gonna tell her to stop playing pickleball. I'm gonna say, keep playing pickleball until, like...

1:01:08Right. Because that's the specific stimulus at the end of the day, which her body is adapting to. Yeah, and it's a great... Like, I think a lot of adults in general stop playing, or, like, in general, whether that's for fun or, like, a sport. Like, and moving in different ways, like, that's good for you. So it's not like you only have to do the one thing, like, keep doing the things you love, and then just find ways to complement them with the stuff that, like, is the stressor that moves things forward, kind of thing.

1:01:33Dr. Lauren Colenso-Semple: My parents are 70, and I was saying to them the other day, because they live in a place where they've had so much snow this winter. And I said, why don't you just pay someone to shovel for you? Pay a kid to come and shovel. And my dad said no, because it's forced physical activity. So we are always going to cut the grass, we're always going to shovel the snow. And so it's another thing. It's not just the thing you enjoy, but maybe the thing you don't enjoy that still has to be done around the house that keeps you physically active. And I think that ties into a conversation that you didn't ask in a question, but I know we talked about wanting to mention here, is that there's this perception of like, this lack of perception of like, maybe activity decreases as we age, we slow down, we're not as active, maybe with menopause, potentially being influenced by that, where like, you think that you're being active, but you're not.

1:02:21and like that building in a life around, I think we all build our lives around resisting effort now, like everything's automated and forcing yourself. Like I mentioned earlier, the stairs, the walking further, but like the shoveling, like that's, that's amazing, right? Like my dad's 65 and if it's too cold outside, he'll walk up and down his steps for 30 minutes a day in the house. People don't do that, but that's amazing. And that's so like silly and accessible, you know what I mean? But that little bit of like stuff that we kind of don't do or opt out of or kind of start to forget that we don't do and we're indirectly moving less, which at the end of the day, I think people underestimate how much like daily activity can contribute to like weight creep across time for everyone.

1:03:03But especially as we age, we just, we move less, we play less, we do less things, we sit more, we have jobs, kids, you know, we're stressed, commutes, things like that. I'm not shaming anyone for those things, but, you know, being aware of like where you can bake in those little bits of that across your life can be really, really potent. Yeah, there's really kind of two different things here. We're talking about exercise, which is this more prescriptive stuff that we're going through, but then there's generally just movement. And exercise can't replace movement through the rest of your day. And if you look at the centenarian populations, they're not necessarily doing the formal exercise that we're talking about, and maybe that would give them even better health outcomes.

1:03:46But one thing that they are doing is shoveling the snow and walking down the street to get their groceries and farming, and they're doing that into their 70s, 80s, and 90s. Yeah, I think there's a lot to be said about continuing. Everyone's obsessed about the exercise routine that they should do, and that's important and amazing. And I think it comes because of the stressors of life, but building that life around activity is probably going to be the easiest way to feel like you're able to sustain health and fitness without always feeling like you're never doing enough. Makes me a little bit worried about the at-home robots that will be doing the dishes and the laundry soon.

1:04:24Use it to make more time to train, I guess.

1:04:27Dr. Lauren Colenso-Semple: Yeah, I think it's important to acknowledge the people who hate structured exercise. Yeah. I mean, how many people are actually meeting those physical activity guidelines that we discussed? No. And I bet a lot of women listening to this podcast. I mean, I see it all the time. I just hate lifting. I just hate it, or I don't want to do it. And I'm like, well, then do what you're going to do. Like, just be, be, I think the biggest thing with all this stuff towards women right now is like, it's okay to say, I'm know the benefits or the risk factors of not doing this or why I should do this, but I'm going to just not do it anyway.

1:04:57Cause I don't care. I prefer this and this is what I'm willing to do. And that's okay. Like, that's okay to say that, but that doesn't make like what we're saying to be like, not true. But you can say like, I just don't like that. Is that the best thing for muscle and bone and health? No. But if you're going to go be active in other ways, it's still amazing and positive and beneficial. And I think that is tricky because like, I think a lot of women are, you know, sold the weightlifting thing and a lot of them are drinking that Kool-Aid, but there's still so many that don't, I can't get my own mother.

1:05:25She's going to listen to this podcast. I'm sorry, mom. I can't get my own mother to weight train and my grandmother died three months after hip fracture. And like that just is the outcome that you see with those things. And but that's a choice, right? Like we all have the choices that we make, but staying movement in the way that you can incorporating balance or whatever that looks like to you. And or I know we just talked about like this idolized way of resistance training, but if you're only able to do body weight training at home or resistance band training or some other form of whatever that looks like to you, like that's okay.

1:05:59And it is better than nothing. We see compounding benefits across the spectrum. So even if it's not optimal, that doesn't make it worthless. Right. I've been using WHOOP for over six years, and I can confidently say it keeps me on track when it comes to my sleep and exercise routines. The next generation of WHOOP isn't just tracking your workouts. It's monitoring your sleep quality, your recovery state, and even giving you insights into your biological age. No screen, no distractions, just continuous data on what your body actually needs. And here's what matters. Daily WHOOP wear is linked to increased physical activity, to better sleep and improved heart rate variability.

1:06:44I have no doubt that my WHOOP is helping me train smarter, recover faster and make decisions that support my long-term health. Head to join.whoop.com forward slash Simon That's join.whoop.com forward slash Simon to get one month off your first subscription. I was actually going to ask you about maybe the person who's doing yoga and Pilates or one of and feels pretty strong, has pretty good balance and is wondering, do I really need to lift weights? Go ahead.

1:07:27Dr. Lauren Colenso-Semple: It's not a substitute for resistance training because it isn't challenging all the major muscle groups the way that we discussed. It isn't typically progressive in nature the way that we discussed. And if that person would do those two 20-minute resistance training sessions, I would be really happy with that. But it is important to acknowledge that personal preference when it comes to physical activity is huge. Because if someone is going to take anything from what we discussed today and then follow that guideline for a month and then just fall off, that's not doing much for their long-term health.

1:08:13Dr. Lauren Colenso-Semple: And so if we can find something that includes even some of this, but we're able to do it for months and years to come, then we're getting the real benefit. And I will say on that too, it's not Pilates and yoga, but I think a lot of women freak out because they get a lot of like fear messages around group fitness programs and how they're not adequate enough or they're bad for them and things like that. But women are more likely to do something in a social setting. So they're more likely to do something in community with each other. And that's an important thing we have to think about here too. And so my advice to that is that if you love like your Orange Theory or your F45, your Burns Bootcamp, or I don't know what all of them are out there, like do those, but take the advice and guidance that we gave you about the weight training.

1:08:57And when you're in like the weight training section of that class, load it heavier at your F45 or whatever it is. And even like Orange Theory now has like more weight focused days. Like go to two of those classes a week and take the same principles we gave you here today to pick the heavier weight or go closer to fatigue or failure in the exercise that like you're willing to do. But if you like variety, and I know we haven't gotten into cardio, but you like other things like the group fitness classes, the Pilates, the yoga. I really love the framework for all people of like get two days of the resistance training in a week and then have everything else you do be the variety, the fun, the different, the interesting, the whatever it is, have that be your like structured sound anchor.

1:09:36And then unless you have some specific goal for like endurance training or cardiovascular training or mobility flexibility training, like a lot of that can be kind of changed a little bit more often week to week unless you have some like specific progressive goal within it and allow that to be where you have like the interest or the variability or whatever that looks like. And if you can tolerate that two structural days per week or apply those principles to what you are doing, you can kind of like make do with whatever else that you prefer to do in your training plan. There you have it, friends.

1:10:07I 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. Finally, 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.

1:10:30Thank you.