The Ageing Doctor: These Are They Early Signs Of Arthritis! If You Run & Don't Do This, Start Now!

Runners who only run are hurt a lot, and it's usually due to emotion imbalance. So I always do this test to show them whether your butt muscles are strong enough to keep your pelvis straight and whether you're strong enough to keep your knee from falling into this position. I look like I'm drunk or something. How are you doing this with your heels on?

Dr. Vonder Wright is a leading orthopedic surgeon and Longevity expert, leveraging her expertise with Elite athletes to revolutionize the way we move, eat, and train to live longer, stronger, and better. I'm on a rampage to make bones sexy again because in the United States, at least 50% of women will get osteoporosis, along with 2 million men. Now, osteoporosis is low bone density, and studies show that people with low bone density have higher cognitive decline. It increases your risk of fracture. If you break your hip, 50% of the time, whether you're a man or a woman, you will not return to pre-fall function, and 30% of the time you will die. And there's a lot that causes bone fragility, such as aging, not building enough bone in our youth, it's our sedentary lifestyles, the myth that women have to be teeny tiny, and it's even things like a woman breastfeeding will lose 20% of her bone density in the first 6 months. But it's not inevitable, and I will lay out a lifestyle that I call unbreakable. It's about muscle, bone, nutrition, but the most important part is mindset.

I'm very, very excited. Uh, just to pause, is there a link between menopause and brain density? Yes, and it's because of the plummeting of estrogen, which is critical for muscle, bone, tendon, ligament, fat, and without it, it can have dire effects. So you need to know the following: this has always blown my mind a little bit—53% of you that listen to the show regularly haven't yet subscribed to the show. So could I ask you for a favor before we start? If you like the show and you like what we do here and you want to support us, the free, simple way that you can do just that is by hitting the Subscribe button. And my commitment to you is if you do that, then I'll do everything in my power, me and my team, to make sure that this show is better for you every single week. We'll listen to your feedback, we'll find the guest that you want me to speak to, and we'll continue to do what we do. Thank you so much. [Music]

Dr. Vonder Wright, yes, for anyone that's unaware of what you do and who you do it for, what do you do and who do you do it for? So you know, in as a sports doctor, over the years we've learned how to take really high-performing athletes, you know, those who are winning all the time, who need to continually get better and better and better at their craft. And over the 30 years of my career, we've gone from really focusing on how they train, the periodization of their training, to the last time I uh was at the University of Pittsburgh. I was the medical director of the UPMC Lemieux sports complex, which is where the Pittsburgh Penguins are housed, and it had gotten so uh scientific, they had a full-time Chef, every meal from breakfast, lunch, dinner, every meal on the planes were prepared because when it comes down to split-second agility, top of brain thinking, every little bit counts. And so in the 30 years of my of my medical career, it's gone from just learning more about performance science of how to train to how to feed people to how to recover people. So instead of doing, for instance, I think Dara Torres was talking about her uh Olympic runs in her 40s, right? She trained much differently when she was 24 and in her 40s after she had had a child. It was much more about recovery, not as much hours in a pool. So I take all those things that we've learned over this course of my career and now apply them not only to athletes but to people like you and me who were in high-performance jobs. I need to be tip-top in every sphere of my life as you do, and how do we eat better, recover better, take the principles of performance that we've learned from athletes into high performers and even mere mortal athletes like me.

I love that my work involves like cognitive performance, making sure my brain is sharp when it needs to be.

Yes, how much of your work crosses over into the cognitive realm? You know, I am not a brain scientist myself, but I am fortunate to be surrounded by people who are expert in that. So from my own perspective, I've come to appreciate at a much deeper level personally, um, as well as professionally, the role of sleep. In fact, we've talked about my previous books from the early 2000s before, and when I wrote those books, Mobility was King. I wrote only about mobility, and then as I progressed in my career, I got deeper, deeper, deeper into nutrition, and then I would say, okay, nutrition is number one, and Mobility is second, but at this phase of evolution of sleep science and knowing how restoring the brain and providing adequate time and nutrients, I put sleep first, sleep and Recovery first because you can't do any of these other things without a well-recovered brain. In fact, somebody asked me the other day about timing of working out and is it always necessary to do it in the morning, like that's the Mantra, get up, go do your workout, and my answer to that was you have to know how your brain works. For instance, my brain is best between 5:00 a.m. and 2:00 p.m. That is when I'm going to get all my deep work done. I'm going to be creative, I'm going to think. After 2:00 p.m., I could build you a house, I can continue operating, but if I'm going to write a book, it's going to be early. So I do not work out in the morning because I'm not going to waste that brain energy on physical activity when I need it for this deep work. So that's the way I apply brain science, but I I'm so lucky to be surrounded in in the place I am now with people who put EEGs on your head and map your brain and tell you which brain Pathways you're too stressful on and and which brain Pathways we can train. And you can train the physical brain like a muscle. You can train the physical brain like a muscle.

Yeah, so there's this company called Nestery that I just happen to have access to, and they put EEG helmets on my Precision longevity clients, and we map their brains and look at, for instance, here's an example, things that are habitual take very little brain energy, uh, even if we need a lot of brain energy, they become so habitual, our brain turns away uh energy from them versus things we're learning or things we're stressed about. We devote so much energy to that. So once they this company Maps our brains, then they have this training program where it's almost like getting your your cognitive brain out of the way and let your subconscious brain reapply energy to the pathways that you actually need, that you you've begun to to ignore, and it makes you more efficient, and I'm being inadequate in explaining it, but brain scientists believe that you can retrain the brain like a muscle and devote energy to neuropathways. So I know we do this to athletes to try to squeeze performance out of them. When you use that term Precision longevity, what does that mean?

So you know, after the understanding of human DNA, knowing what we're truly made of, it pushed us out of a time in medicine where we've been for the last 150 years, which is Observe and one size fits nobody. Now that we've sequenced the human genome, we can develop Health Plans, your health plan, my health plan, it's not generic. Here's an example: when I have people who want to talk to me about living healthier longer, and we and we draw a set of biomarkers, it's not 6,000 biomarkers, it's just a set of about 23 that are Beyond regular labs, and I see that for instance, maybe Stephen, you have a high load of senescent cells. Well, I'm going to specifically design your Gap nutrition according to what you need. You might not need anything for inflammation because maybe your inflammation labs are good, but historically what we would have done is say, okay, let's just give everybody the same formula, but now we are able to devise what your body needs at your time. I do the same thing with exercise. I never say let's have you do 150 minutes of moderate exercise because I have access to lactate threshold testing where you're walking on a treadmill, running on a treadmill or on a bike, every four minutes we're pricking your finger, and I can tell exactly what when your mitochondria, the little energy storehouses in your cells, go from burning fat to burning carbohydrates, and that place is called the fat Max, and that is when your mitochondria, your energy organelle, are most efficient, and that's where we want to work out 80% of the time. So that's just an example of how I'm going to tell you what heart rate you need to work out in. I'm going to tell you how to get fill the gaps in your nutrition instead of just doing broad guidelines because that's the state-of-the-art right now. When you think about personalization, I was thinking also not just about the individual but different phases of life and how maybe in my my 20s there's a certain set of things I need to be thinking about more so than in my 30s, my 40s, and my 50s and my 60s. Is that a useful way to think about it? Are there different things we need to be thinking about in different seasons of our life or is it the same things in every season?

Well, I love that question, and the one one-word answer is yes. Every season of our life is different. Let's take bones for instance. We build, build, build, build bones yeah until in women we're about 28 and uh men 30, we reach Peak bone mass. We then reach a plateau where we keep our bone density, and then in women it begins to plummet due to hormonal influences. For men, men usually maintain their bone density until their 70s when they plummet unless they have a metabolic problem, an autoimmune disease, or having had the need to take a lot of steroids, and then you see a big difference at 50. So in Bones, that's a good example how every few decades our bones are reacting differently. Muscle is the same way. We know that we can gain muscle at any time in our lives, but we do it most easily until we're about 30, right? We also know of uh changes in the way our gut functions as we age, having to do with absorption and the uh the ability of the microvilli in our gut to absorb nutrients and different kinds of nutrients. Women in midlife, for instance, need vitamins that are something called methylated, which means broken down a little more because our gut function is less efficient. So every phase of our aging were different.

Well, on that point of bones, that that sounded like you were saying men's bones maintain their density longer and women don't. Why, why is that, and is that linked to menopause?

Well, men uh because of the influence of testosterone and the genetics of having um XY chromosomes build more bone initially, thicker cortices, more more absolute poundage of Bones, and so um and then because of the plummeting of estrogen, which is critical for bone health, women lose bone faster than men such that after about age of 40 when we get to that Plateau, women start to lose bone density about 20% by the time they get to their menopause, and um that can have dire effects for women, but that is all due to the role of estrogen on controlling bone density.

So is this inevitable? Is the loss of bone density inevitable for women?

It is not. In um in 2004, we studied a very large group of Masters athletes, meaning athletes uh 40 and older in the National senior games, which is Olympics for uh people of that age demographic, and the National games you have to have won your State Games to qualify. So these were pretty high-level recreational athletes. So we did a study looking at their bone density across time, and the first thing the first study we found was that with chronic exercise such as these people did, you can maintain your bone density at a very high proportion into your 80s. The second question we asked was, okay, if we know we can do that, what exercise is really important for that? And so we divided Sports up into uh bounding Sports where the bones were being impacted like like basketball, running, um volleyball, anything when you come down hard on your bones versus swimming, bowling, the less biking, and we found that bashing your bones, impact was as important in maintaining bone density as things you can't control like your age, whether you're born with XX chromosomes or XY chromosomes, family history. So impacting bones, causing them to build up over time, is critically important for maintaining bone density. So to answer your question, is loss of bone density inevitable? Loss of estrogen is inevitable. Loss of bone density doesn't have to result in osteoporosis, fracture, and Frailty. So I want to get into why that's happening, but just to pause there because a lot of people don't think bones are that important. Oh, like I think a lot of people see our bones as just some thing that yeah, we can't influence. You don't think of them like muscles. Muscles, I go to the gym, I can expand my muscles, I can get strong, but with bones it feels like they're static, you know. So how how would you refute that so that I start caring about my bones, and what is the cost if I don't care about my bones?

Well, you know what I'm on a rampage for this year, that to bring to make bones sexy again. CU here from a very superficial level is why we should care, and then I'll tell you from a more scientific level. You know, we only think of our bones usually in a couple of times like you look in the mirror, and somebody tells you, oh, your bone structure is magnificent, look at this model's bones, and or uh and we're all touching our cheekbones, or we think about them when we hear about a great archaeologist who's just discovered a new people group, and we can tell from our bones how they lived, how they died, how healthy they were. In fact, in that setting, bone is the last remnant of your whole life. It endures the longest. I mean, the hisory the history you talk about in your bones outlives anything. Muscle goes away, skin goes away, everything except your bones, which remain. That's fascinating, right? But the other reason we even think about our bones is when they break, right? When they bones, people think bones are silent, like a strong silent type, just hanging back until they break, and then they're screaming at you, right? And and causing Frailty. And here's some bone stats because the real answer to the question is coming. One in two women will have an osteoporotic fracture in her lifetime. So it's either me or your partner or me or your assistant, right? One in two will have an osteoporotic fracture. Women have 70% of all hip fractures. Hip fractures are one of the main contributors to ending up in a nursing home because you can no longer walk and take care of yourself, right? 70% are women. If you break your hip, 50% of the time, whether you're a man or a woman, you will not return to pre-fall function. You cannot go live in that house where you raised your children. You may not be able to drive and go be totally independent, right? And 30% of the time, it's a huge number, 30% of the time you will die, either from the complications of the fracture, from the bed rest, from the infections you get, the bladder infections, just the sequelae of being that sedentary. So those are those are not meant to scare people. That is the reality that I see every day as an orthopedic surgeon on call, but there are other reasons to care about the bones because fracture is a big one. Bones, and it makes sense. Nature is so conservative. Bones are in our body from the top of our head to our pinky toe, right? Bones are master communicators. We think of muscle, which we're all talking about now, and Bone and adapost and everything as as siloed organs that don't have much to do with each other except they live next to each other. The fact of the matter is, for instance, when we're talking about the musculoskeletal system, bone, tendon, ligament, muscle, fat, cartilage, muscle stem cells, there are all all derived from the same stem cell, the mesenchymal stem cell. So they're not distant neighbors, they're cousins, and they all speak in the same language. They may have different dialects. I was thinking about an example of of this, you know how in the UK English is the language, but depending on what parish you live in or which country within the UK English sounds very different, but it's the same language. So within musculoskeletal tissue, issue muscle and bone are not separate, they are one ecosystem such that when muscle releases a protein called irisin, it talks to the Bone. When bone releases a protein called osteocalcin, it talks to the muscle. But in the case of bone osteocal, if we just stick with that protein, it talks to the whole body. When your osteoblasts, the bone-building cells in your bones, released osteocalcin, it goes to your brain and has a neuroprotective effect by decreasing inflammation. It goes to your brain and causes the synthesis of neurons in the hippocampus. It goes to the pancreas and helps with insulin insensitivity. It goes to the muscle and helps the muscles scoop up glucose out of the blood, right? If you're a man, osteocal can travel to the testes, and that organ, the litig cells, under stimulation of osteocalcin will produce testosterone. So it's like a miracle and a wonder that we just think of Bones as the strong silent type that hold up our muscle because actually bone and and the proteins that it produces are Master communicators, and it makes so much sense because we have bone everywhere in our bodies. Why wouldn't our body bodies use it like that? I thought it was just a frame.

Well, and it is a frame, right? What's Muscle without bone? Just a heap a metabolic tissue, right? It makes us gives us our statue, but it's a master Communicator. The framework is almost a secondary job in my opinion. The bone is releasing stuff. I got this um this little analogy. I'm going to put on the table in one of the one of the tubs. I've got some mineral some, and then this is the body. Yeah, so could you explain to me how the the bone is releasing something into the body? So we've talked about the bone being structural, right? It holds you up, it gives you your stature. We've talked about bone being a master Communicator. Another job of the bone is as your body's Storehouse to really, really important. Maybe if we just talk about one of them, calcium. Calcium is is a critical mineral in our body. We need it for muscle contraction, for pushing um molecules across cell membranes, but we've got to store it somewhere. So when we eat food, our body pull our intestines pull it out of the food we eat and stores it in our bones. And so our body is always sensing how much calcium, how much phosphorus do we have? What do we need? When our body senses that we need more, it goes to the Bone, it tickles the osteoclastic and say osteoclast, we need some more calcium. The osteoclast breaks down some bone, releases calcium, and it goes into the body for use. And then the body has enough to use, the body does not just keep piling it in because hypercalcemia causes heart arrythmia. It's bad, right? The body is perfectly in homeostasis, in Balance. So when the bone has released enough, it sits back and keeps storing it, right? The calcium your body doesn't need, if the bone is full, it's excreted through the kidneys. And this is a really fine balance between building bone, releasing the storehouse of minerals into the bloodstream, or saying, oh, we've got enough, let's send it out in our urine. The body is such a miracle like that.

So if I don't have enough calcium or some of these other minerals, does that mean that my bones are going to become fragile?

So you know, there are lots of things that go into bone fragility or osteopenia, and one of them is not laying down enough bone in our youth. If we T you asked me earlier about changes across a lifespan when it comes to Bone, what's interesting is that I get very, very young women in my clinic for 25, 28, whom for various reasons I do a bone density test on, and they are already have brittle bone. I know it's it's it's shocking. Well, I think that happens for a number of reasons. Number one, we didn't build enough bone. There is still a myth in this country that women have to be teeny tiny, that we have to starve ourselves, and when that happens, many women do not have consistent menstrual cycles and estrogen, which then helps us lay down bone. So that's number one. We don't. Estrogen plays a role in laying down, but yes, it does a critical role. So we're not laying down enough, or maybe we're athletes. We're in we Title 9, which is the law that um equalize sport for women in college, is 53 years old. So maybe young women are not laying down enough bone because they're expending so much energy, 10,000 calories a day, and then they're not refeeding in the way. So they're always living in a state of energy deficit and not laying down enough bone, or maybe young women are coming to my office with not enough bone because we are raising an entire generation of sedentary children who are sitting around in their basements on playing games, building brains but not building bodies. That is borne out by looking out of the University of Wisconsin Orthopedic researchers. There studied which women's sports build the best bone, and it's gymnastics. It is the pounding and the feeding of those athletes that builds the best best bone. So we have trouble with not enough brittle bones in adolescence because we're not building it. The second place in the lifespan that we may become low in bone density, and hear me people, I am not saying not to breastfeed. I mean, I in my children, I my child, I breastfed for a year. It's really great for babies, but a woman breastfeeding will lose 20% of her bone density in the first 6 months of breastfeeding, and if she's not really careful to get 500 milligrams of calcium a day in her food or through supplementation, she will not build it back. And then if you have children in ear in succession because many women are waiting until 30s to have their first child and then have less time, we may never build backbone. So that's another key point that people don't realize could be dangerous to the bones. And then finally, yes, is this period about around per menopause, starting around 45 when estrogen levels become very chaotic and then ultimately zero, that can cause the rapid decline in bone density and Bone weakness that you're actually asking me about. And that's because estrogen is critical for controlling the absorption, this part, the absorption of bone, and without estrogen controlling the absorption, it just keeps breaking down bone faster than the osteoblast, the building cells, can build it. So there's an an unbalance, a disregulation. So I want to go into all of that, starting with the point you made about um having doing Impact Sports when we're younger, yeah, because like people often say if you do Impact Sports when you're younger, especially some of them, there's other consequences like injury or hitting your head. So you're saying that we should be running or jumping when we're younger to build our our bone strength?

Absolutely, to build everything. Oh, it's you know, we we uh make mitochondria, most the energy of ourselves, we make a lot of mitochondria in our youth. If we're not active in our youth, we don't have the anabolic stimulus as much to make as much mitochondria. If we are sedentary children, we will make bone, but we will not build bone to the extent we do if we're bashing it every day. And I and I think the data out of Wisconsin is a good illustration of that, and is in all seasons of life. If I'm 60 years old, should I still be bashing that bone, playing basketball? Abs, and that's what my study from the national senior game shows that by impacting your bones across your lifespan, you can change your bone density.

So on that point of pregnancy, which was your second point there, during my pregnancy, after my pregnancy, what do I need to be doing? Is it drinking milk?

Yeah, so if, and this is the data I gave you was specifically for breastfeeding, okay? So for breastfeeding mothers, uh, you will lose about 500 milligrams of calcium a day as you're making milk for your child. You must replace that. I like people to replace their calcium with whole food, right? With prunes and dates and and high calcium um Dairy, if you will. If you simply cannot do that, okay, take a supplement, but if you forget to do that, I mean, I get it, I was a young mother, I was exhausted. I wasn't a young mother, I was a 40-year-old mother, exhausted. You have to be so mindful as your the baby's latching on to eat some calcium, eat your yogurt, eat your calcium chew from Whole Foods if you will, so that you rebuild your bone, which you're completely capable of doing. Studies show you will rebuild your bone, but not if you're not aware, not if you're in the I've got to lose the baby fat starving phase. Let's not do that.

You talked to about how bone has an impact on various parts of the body, and I've had you talk about this phrase, the bone brain axis. Yeah, what is the bone brain AIS?

Well, if we just talk about um just choose one of the the proteins that bone makes, osteocalcin. So as that's released into the bloodstream, one of the places it goes is into it through into the brain, and it can cause it can Aid in the neuroprotective effects. So what is that mean? Under normal metabolism, we um develop free radical through du due to normal metabolism cell work um we develop oxidative stress, and osteocalcin works to decrease that oxidative damage to repair cells in the brain. So that's number one. Number two, it stimulates the release of something called brain-derived neurotropic protein, BDNF factor, which stimulates the growth of neurons in a part of the brain called the hippocampus, which is involved in memory. And here's here's the opposite side of it. We know in people that have low bone density, they also have higher brain cognitive dysfunction with age, and vice versa. There's an association in the literature with osteoporosis and cognitive decline and vice versa.

I heard you in the The Business Insider interview describe there being a critical decade, yes, for bone health.

Mhm. What is the critical decade?

I think the critical decade for most of our health, Stephen, is no later than 35 to 45 for men and women. That's because um we know for women that's when estrogen starts to decline or become chaotic. So when we're in our 30s to 40s, that is the time to get all of our health habits together. It's time to get a physical to see what your Baseline labs are. I think it would be critical for men and women, particularly men, to get a baseline testosterone so that in the future when we're thinking about supplementing testosterone, we're supplementing back to your particular level because in the future, let's say when you're 50, a man's testosterone could be 600, which Falls within the normal range, but if he's still feeling low energy, not himself, a lot of tendon and ligament injuries, well, his young testosterone might have been 800 or a 1000. So I like people to get baseline labs if they've never been to the doctor before uh around 35, all things so that we know what we're returning you to. Number one, number two, if you have been so busy with your career and stepped away from any semblance of mobility and resistance training, now is the time because had I known then what I know now when I was 40, I was training for triathlons, I was an aerobic athlete, right? I ran, I biked, but what I would have done then if with what I know now is I would have been lifting a lot of weight to build maximum muscle while I still had the most hormones to start at a better place because you can build muscle, but it's better to start from a higher average. So get some Labs, make a relationship with the doctor, get all your preventive screening, do not uh blow that off, um develop the habits that are going to carry you through a lifetime, whether it's smart anti-inflammatory nutrition, whether it's getting into a resistance training program, building up your cardiac machine. I saw that you were running a lot now, and we want the highest possible V2 Max that we can as we enter into midlife because we never want as we age to cross something called the fragility line. So V2 Max is the measure of it's the ultimate measure of fit, how much oxygen you are capable of pulling out of the air and diffusing across your lungs into your blood. World-class athletes, I was just at the US uh Olympic Center in Park City, Utah, those athletes have a V2 Max of 75, 80, sometimes 90, right? Mere mortals are considered excellent when they have a V2 Max uh of around 50 for women, around 50. So you can build V2 to Max and should in the critical decade because once we hit midlife, we will decline 10% a decade if we don't consistently build it up.

So what does that look like? So if I started at 50, 50 years old, my last V2 Max was when I was at when I was 50, and it was 50. It was pretty good because I was an endurance person, right? Just in whole numbers, by the time I turn 60, it's going to be 45, 70, 40, 80, 35. I never ever ever want to hit 18 if I'm a man or 16 if I'm a woman because that is the level of V2 Max when we can't get up from a chair by ourselves, we when we can't walk across the room because that takes cardiac function. And so the higher we get our V2 Max in our youth, the more Runway we have, even if we don't continue to build it up.

Yeah, I've got a family member that can't walk upstairs without being out of breath, and it's so debilitating because when you have grandkids and the grandkids start running around and you want to play with them, it's so sad watching this particular family member see the grandkids come, the grandkids say let's play, the grandkids run off, and this person can't go after them. So they just have to watch. They literally watch the the grandkids playing in the garden because they can't play with them, and I think it's such a sad thing. It's one of my big motivators to try try and stay healthy is just to be able to extend my health span.

That's right, so that I can be healthier hopefully until the day that I die. That'd be great. But would I want to talk about running? I want to talk about V2 Max to close off on the subject of Bones. There's two terms that I that I want to hear. One is this term osteoporosis. Yes. Now I have no idea what osteoporosis is. I've heard it a couple of times in my life, but I don't know if it's something I should be thinking about, worried about, um, or what it means.

Yes, osteoporosis is the word we use to describe low bone density. Okay, so so the way we measure osteoporosis is uh using an x-ray called a DEXA scan, a dual X-ray, and it just measures it. Compares your bone density to that of a 30-year-old healthy person, and it gives us something called a t-score. So it's it's like when you're in school and you're graded on a bell curve, and the center of the curve is average, and that's the average for a 30-year-old. When you get a DEXA scan score and it's positive, fan fantastic, you have bones of a 30-year-old. If you get a t-score on a DEXA scan that's from 0 to minus 1, it's okay. Minus 1 is the definition of osteopenia, meaning watch out, your bones are getting weak. The definition of osteoporosis is minus a t-score of minus 2.5, increases your risk of fracture by 40% or more. All the bad statistics that I talked to you about come with osteoporosis. And how many people have osteopenia, osteoporosis in over the age of 50 in America? Well, 2 million men have osteoporosis. Interestingly, isn't that interesting? You don't think about it as a men's disease, and uh one in two women will have an osteoporotic fracture. So at least 50% of women, but it's not inevitable. That's why I'm so interested in in Catching people early in the critical decade. It's not inevitable, but it will be inevitable if we don't catch it. But here's the thing that's bothersome in the United States and in many other countries uh with people I deal with, you cannot get a DEXA scan paid for until you're 65. By 65, the damage is done. Why are we waiting? Even with people who have had a fracture, there's a gap in followup such that they should all have a DEXA scan because the number one thing that predicts future fracture is past fracture. So Public Service Announcement, if you've had a fracture, get a DEXA scan, even if it was a traumatic one like you had a car accident, but definitely if you have fallen, if your dog pulled you down, if it was a low-trauma fracture, get a DEXA scan because then at least you'll know where you are and can then plan a course for building your bone.

Are there any early warning signs that I might be suffering from osteoporosis or on my way to osteoporosis?

You know, I think you can get Clues from your own family. Okay, if your mother shrank, if you if you used to be able to look your mother in the eye like me, my mother looked me in the eye at 54, and now she's way down here. We lose height in both men and women due to uh compression of her spine vertebrae. We lose height. So if your dad shrank, if your mother shrank, that's a good indication that you have a family history where osteoporosis can exist, or if your mother had a hip fracture or or if for some reason maybe asthma, you've had to be on uh high-dose steroids your whole life or an autoimmune. That's very bad for bones. So from a medical standpoint, from a family history standpoint, from a personal standpoint, usually fracture.

What about if I'm a smoker? Does that have an impact on my bone health and chances?

Yeah, I'm really glad you asked that. Smoking is a poison to Bone healing, whether it is fracture will heal more slowly. In fact, we have a very a much higher rate of non-union, which is where we fix a fracture and it still doesn't heal in smokers. We know that uh there is a big body of data within the orthopedic literature for people who have spine surgery who are smokers; they are not only less healing, but they're more infected. So the the noxious chemicals in smoking are very bad for bone.

Good thing I don't smoke. Is that smoking, vaping, or is it?

It's all. Vaping might be more dangerous; we just

Your pancreas is no longer functioning, and the bad sequella that can come with that. What people are not aware of as much, at least as a people who come to my clinic, is pre-diabetes.

If you don't mind me diverging a little bit because it's so important to discuss the question you just asked me: Can we prevent it? And if we got to choose, what would we choose? But I have people coming into my office all the time, and I look at their labs and they have a fasting glucose—they've had their labs drawn, they've done what we've said, get in front of your critical decade—they've had their fasting glucose drawn, and it's 110, which is—I'm going to tell you—and their hemoglobin A1c is nearing six.

So fasting glucose is the glucose that remains in your blood after you haven't eaten for 12 hours. In a normally functioning pancreas metabolic system, we want our fasting glucose to be around 85. Right? That's normal. Means we eat something, insulin comes out of our pancreas, the sugar is put into our muscle, and then the blood sugar is around 85. If it's staying up 110 consistently, we know from the literature that you have a 70 to 100% chance of developing full-blown diabetes within 10 years.

But what I see in people coming into my office is I'll say, "Did anybody ever tell you you were pre-diabetic?" And either the answer is no, or the answer is, "Oh yeah, somebody told me; they said just make a few, you know, focus more on your exercise." And what I think the reaction to pre-the diagnosis of pre-diabetes should be is running and screaming to get healthy. Because if we know that with a consistent blood sugar in the pre-diabetic range and we're casually told by our healthcare provider, "Oh, just go try to exercise more, you know, just casually approach this; don't eat so many carbs," that is not serious enough. Because we know from a preventative standpoint, from a Precision longevity standpoint, which is all about prevention, we can prevent you from getting to diabetes in the next 10 years if we're really, really serious about lifting weights, about cardio health, about anti-inflammatory nutrition following. So I don't view pre-diabetes as a casual thing at all, because if in 10 years you're going to get diabetes, and in 10 more years you're going to have Alzheimer's disease, and I could have prevented that by paying attention when I was 40, it's almost inexcusable that we're not paying more attention to it.

96 million people in the United States have pre-diabetes. 96 million. 96 million, according to the American Diabetes Association. I just gave a talk at their annual convention. 96 million have a preventable characteristic that we can prevent them from becoming diabetic and getting Alzheimer's disease, and yet it is too casually spoken of. That's like almost one in three; that means that there's three of us in this room. So Jack's got pre-pre-diabetes, perhaps potentially. You're an—an—an endurance athlete, wouldn't you say?

I was an endurance athlete, and I'm—I've been—I don't have it today; it ran out—but I'm a little obsessed with continuous glucose monitoring, so I've been wearing it for about 18 months, and uh, it's so interesting. I told you that, you know, I just finished this book, and I've gotten a little bit off my regular intensity, and it changes my blood sugar. So I run a little—I because I haven't been lifting four times a week, only twice a week because I haven't been sprinting twice a week like I norm—my normal regimen is I lift heavy four times a week; on the other days I do about four days of Bas training Zone two; two of those days I sprint. I always eat a lot of protein; that is my lifestyle, and my blood sugar is 85 when I do that, and I'm a midlife woman, and you know the metabolic things that happen to midlife women, even backing off a little bit starts to creep up my blood sugar. So this is a constant daily habitual lifestyle that we all need to lead.

And so when I see that and someone as healthy as me, when my patients show up and they've casually been told that they have something that's going to kill them, I don't think that's enough attention. That's what I've been thinking a lot about recently: what diet is going to lead me to better cognitive performance? To someone that spends a lot of my time talking, yes, but then also I'm on stage, I'm in boardrooms and in meetings and in negotiations; I'm reading emails and writing books, etc. So I'm always thinking, if I can just get a 5% edge, well, I can tell you for instance, the dietitians and chefs that make the food for the pro athletes that I've taken care of across my life, they're not only eating meat; they have a very well-balanced diet that includes lots of vegetables, lots of high protein; they take amino acid supplements if they need to fill in the gaps, right, if they're not getting enough leucine or something, but they just don't go down one—one pathway. I haven't seen that in the pros that I take care of.

He, too, has given me a very sharp mind; has it—an extremely sharp mind. It's so interesting as a podcast when you sit here and you have all these conversations, because some days you show up, and sometimes these conversations last for four hours, and your brain and mouth just don't feel like they're connected. Yeah, and then on other days I come here like boom boom, and it's automatic. Yeah, it's like I don't have to think, and it's just flowing off—off my mouth. The variance—the big—I said so the causal factors are obviously sleep is one of them; the other one is how many carbohydrates I've had in recent—yes—hours. So if I've had a lot of carbohydrates—something, you know, like if I've had bread—my mouth and my brain have no connection. If I've had lots of sugar, my mouth and my brain are completely done.

Agreed. Agreed. You know, because of this CGM thing, I found that if I only eat protein for breakfast—which uh, egg white omelette or, you know, whatever, just protein—that I needed a little complex carbs in order for about 10:00 in the morning to be able to function at a high level with my patients. So now I've added 50 gr of carbs in the morning, but that's not a lot of carbs; not very much. I just needed that little complex. But uh, interesting, right? And what do you eat?

I eat 130 grams of protein a day. There's no upper limit on how much protein you can eat in a single setting. I try to get at least 30 because there is a lower threshold for 30, and so if I do that uh, it takes three meals and a couple snacks a day. I—that's a lot of volume of food, so I try to eat really dense. So uh, a cup of Greek yogurt is like 18 grams, and a really pure beef stick is another 16. So at this time—at this point—I've memorized the most dense foods that I can to get that much protein. It's a lot of protein; it's a gram per pound; it's a gram per pound, and that's what I need to build muscle. Studies have shown that uh, eating high protein—also—without lifting as much as I want myself and others to do will help maintain muscle. And then I eat a lot of vegetables. I don't—now I hope people are not going to throw them at me—but I don't eat fruit except blueberries. Fruit is Nature's dessert, so if we're going to eat fruit, eat it as dessert. I eat—I eat blueberries with my yogurt, but um, and then carbs—I only eat complex carbs if I eat them at all.

Quick one: I want to talk about something we all need to take seriously, which is cybersecurity. Whether you're a first-time founder facing your very first audit or a seasoned professional who's been through it all, staying compliant is getting more critical than ever and more complicated, I have to say. And that is where Vant comes in, who is a sponsor of this podcast. Vant takes the pain out of security compliance, automating the tedious but essential process of proving your business is secure across over 35 frameworks like SOC 2, ISO 27001. Centralize your workflows, answer security questions up to 5 times faster, and protect your business without losing focus on growth. And this is really a critical part of this. A new IDC white paper found that companies using Vant save over $535,000 a year, and it pays for itself in just 3 months. For a limited time, my community gets $1,000 off Vant at vant.com. That's vant.com for $1,000 off.

You're um a very big advocate of muscle. You know, when we talk about longevity, something that you continually come back to as the most important thing for people's longevity, I think I would put muscle and bone near the same category, because you can have all the muscle you want, but if you break your hip, you still have the downstream effects. Now you're much—less—likely to break your hip if you're strong, but I think muscle or bone are really important. What if you're 65 years old, 70 years old, and you haven't got much strong muscles right now? Now your muscles have um declined, let's say, over the last couple of decades. Is it too late?

Never. It's never too late. It is never too late. Your body will always rise to the strategic stress you place on it. So there are a lot of—and growing number of—what used to be anomalies all over the internet of people in their 60s, 70s, 80s and beyond in a gym powerlifting, becoming uh competitive bodybuilders. So even if you're starting not being able to get up out of a chair, over a very short amount of time—6 months, a year—you can reverse the trajectory of your frailty, but it takes consistency, right? I do wonder—that I think about—think about my father, and he's approaching his 70s now, and I don't think he's done weight training for the last 15—15 years. Yeah, and there is a part of me that did wonder, is it too late now to to start doing weight training? Because it's almost like a a two-sided problem in the fact that you haven't done it, yes, so you find it harder, so you don't do it, so you find it harder, and then you sort of spiral down to this sedentary state.

Well, and you know what you do for that is nobody expects you to start with powerlifting squats, deadlifts. Nobody expects that. Moving our body through a range of motion, doing body weight, progressing to free weights, progressing to like kettlebells, progressing to bands. When once you see that your body is capable of adapting and progressing, you will get there pretty rapidly. I used to do this program called a start where I would take people fresh off the couch, and over three months we would get them to a 5K race, because 5K is a meaningful distance for people who are sedentary. And over that course of 3 months, we did a series of um body weight and kettlebell type exercises in a circuit followed by walking. And people started with 51% body fat, not being able to get through the warmup, not be able to hold himself up in a plank, and in three months they could plank for 2 minutes, they could walk for three miles, they could keep going for the entire 10-minute circuit without having to stop. So there is never an age or skill level when our body will not respond to the strategic stress you put on it. So uh, get a trainer for your dad if he'd accept it—if he would accept it. I'll call him after this.

If I am trying to build muscle, are there a certain amount of days of the week or repetitions I need to do to build the muscle? I think about this a lot when I'm out here in LA. I'm—I'm—I'm trying to make sure that I don't lose my muscle, but I spend a lot of time sat down in here recording podcasts. So is there a certain amount of times I need to work out that muscle before I lose it? You know, I was just reading this morning actually that um, even with a 10-week hiatus from—let's say you're lifting consistently—even with a 10-week hiatus, uh, you will retain muscle memory so that you don't make serious declines, which is little relief to me because it's been a little while with this book. So you retain muscle memory, and you can quickly, once you get started again, get back up to the place you were. Um, so all is not lost if you take a few days off. But the minimum, if we're really working at it, is a couple days a week progressively lifting harder. For men in midlife, it's about eight reps, four sets; for women, once we've trained to the place we can lifting heavy, four reps, four sets. And when I say that out loud, I get a lot of comments about somebody's going to get hurt. Well, it's true, but you have to work your way up to that, like any sport; you have to work your way towards that level. Because what we're trying to do by lifting heavier, especially for women, is replace the anabolic stimulus that estrogen was—you must work hard enough. Estrogen creates growth; we must signal our body by the intensity of our work to build muscle, and lifting heavy does that. So if you're starting on the couch, uh, start with bands, start with light weights, start with the Mambi Pami pink weights that I rail against, but don't stay there. Continue to work your way up in a progressive way to heavy lifting, total body at least twice a week to maintain.

Do I need to increase the weight load to build muscle? Because I wonder when I go to the gym sometimes, you know, I might be using smaller dumbbells, but I'm doing more repetitions. Yeah, is that still going to build muscle? Well, it depends what you want. So so lighter weights, higher reps is uh will—will—uh function for hypertrophy, for big—bigger—total muscle, but not necessarily power and strength. In—in midlife and beyond, I am lifting for longevity—and power—so I'm not as interested as I once was in the bigness of my muscle; I'm interested in can it move powerfully over time? Can I get up off the floor? Can I lift my suitcase above my head? So lifting for power is lower reps, higher weights. So it just depends what our goal is. You may be focused on hypertrophy right now, which is fine because you've not reached the critical decade.

So if I'm looking for hypertrophy, yeah, higher reps, lower weights; so 12—12—15 reps, low weight. And then if I was looking for power, then maybe 6—8—6—8. That's right. How many do you do?

I do four.

You do four. Mhm. So big weight, four big weights, four reps, four sets. Interesting. I didn't know that. M—interesting. And just to give some sort of foundational knowledge as to why muscle is so important, because some people still might not um be aware of the link between longevity and muscle, a lot of this is to do with—from what I understand—glucose. So it has to do with muscle as the sink for glucose. Uh, it is a key factor in preventing insulin resistance, not to mention strength, staying upright, not falling down, causing a fracture, right? So muscle is a metabolic endocrine organ; it releases—when it releases—um, you know, one of the things that releases is skeletal muscle contraction—by curls—causes the transcription of a protein called Klotho, which is the longevity protein. About 30 years ago, it was described in Nature; it is the protein when muscle contracts that's transcribed; it works on every organ. We know that it's critical for the longevity and repair of organs because mice who are born without the ability to make Klotho die old—very young chronologically; they're very young mice, but they die very old mice because they have not enjoyed this protein Klotho. We make Klotho by the contraction of skeletal muscle. Here's a study I did uh years ago that showed that I measured Klotho level circulating in the blood of older Masters athletes—people 60, 70, 80—younger Masters athletes—40—and sedentary people. And what I found that the highest levels of circulating Klotho—the longevity pro protein—were in young athletes—not surprising—the second highest level of longevity protein Klotho were in Old Masters athletes—70, 80—the lowest level of longevity protein were in young sedentary people. So even old athletes had more circulating Klotho than young sedentary people. So just the contraction of skeletal muscle can add to your longevity through this protein. Another protein that's released with skeletal muscle contraction called Ginin; it is transcribed, goes to the brain, works at a place called the nucleus accumbens, which is critical for resilience; it makes you more resilient; it helps you able to problem-solve. And then, you know, a very popular uh protein that is transcribed with skeletal muscle contraction is called irisin; it's the exercise protein, which you know, it works on bone; it works on fat—to brown fat from white fat to brown fat—which is has higher thermogenesis; it has higher mitochondrial load. It—so muscle, just in doing its thing, not just looking pretty in a gym mirror, does all these metabolic functions, and so that's why we think it has such a key role in longevity.

So if I'm trying to protect my muscle as I age, are there any supplements that I should be taking? I mean, do they sell Klotho supplements?

They don't. You have to make it—oh—contract your own muscles. Well, uh, you need to feed your muscles. I always quote people one gram per ideal pound, because listen, I—I—I'm an actual practicing person doctor, and here's what I know: people need really specific instructions, and they can't be confusing. So is there a range of protein people need? Yes, there is, but people can remember one gram per ideal pound. So you got to feed your muscle with protein—high-quality protein. The highest-quality protein has the greatest percentage of an—an—essential amino acid called leucine. Leucine is not made by the body; it has to be taken in from the outside; it's a branch-chain amino acid, and you get it from whey protein—the best source in the universe of leucine. And whey protein is mother's milk, but most of us don't drink that as adults, so we get it from dairy products. You can get it from plants for everybody that is a plant lover; you just have a much lower percentage; you have to eat a lot more of it. So high-quality protein, number one. Number two, there's a lot of research uh for uh creatine supplementation for both men and women. When I first started being aware of creatine in 1992, it was during the Olympics; I was working with a bunch of wrestlers at that time. Um, we would give very, very high doses; we would cycle the creatine; we would come on and off. Now steadily five uh grams a day will help build muscle; it will help build brain. It's really interesting. A couple of uh months ago, I asked the people in my office if they used creatine, yeah, and a couple of the guys put their hands up; none of the women put their hands up. Huh? And I asked them why; I said, "Why didn't you use creatine?" They said that they thought it was for bodybuilders. Well, it started out for bodybuilders, but it's for everyone, actually. It's very well studied. So I actually had this um debate with my girlfriend last year at Christmas time um because I was taking creatine and asked if she wanted some, and she made the same comment to me that it was for bodybuilders, and I—she put on weight if she had it—and then I said, "No, that's not true." So she Googled it, and she saw that it's good for like cognitive performance, skin, hair, muscle, bone, etc., etc., and now she takes it every day.

Perfect. I think there's a big um re-education piece to be done there because we—us—we almost used to think of it like uh a steroid or something, and it's not at all. You know what, despite podcasts like this and despite me screaming from every mountaintop, I find that there still is an incredible knowledge deficit in the general public about the principles of how to be the healthiest we can be, and an even bigger gap in the ability to take action for ourselves. I mean, and it's not a judgment; it's simply an observation that we know what to do, but we don't do it, and we know what to do, and we don't do it, even if we see in our family someone who's going through the throws of diabetes or even on the Alzheimer's; it's still not enough motivation. And I think that's the real problem to solve: motivation.

How'd you solve that? Sometimes—sometimes we solve it by scare, right? You know, someone has a tremendous health problem, but sometimes that's not even enough. I have found that it is never going to be motivating enough to try to say, "Okay, if you do this today, in 20 years you're going to be much better." There's this temporal disconnect; people just don't get it—what they're going to be like at 70. I think we have to make you feel good every single day. It's like when we were talking about your brain, when you're doing heavy work and cognitive work, if you can feel better every single day, you'll continue the behavior—not for a promise. So I think that is the—that is the way to talk to anybody—way I talk to my patients—"Can I make you feel better tomorrow? Can I make you feel like a badass 'cause you lifted heavy weights today?" Um, it's hard though with things like bone. You're telling someone that they need to be getting—I don't know—their calcium and stuff like that; they think, "Well, I can't see my bones, and osteoporosis is so far away that—"

Yeah, it's hard until you see someone fracture or you fracture yourself.

I agree with you. Vitamin D as well as crucial, isn't it, for bone health? I was reading that there—it is—it is. Magnesium, vitamin D, magnesium, uh, lesser-known things: strontium, zinc, boron, and micronutrients, but big thing: vitamin D, magnesium, sleep. Sleep, talked about that a little bit as well, how important that was. Um, you mentioned that I'm running now.

Yes, you are. Thank you for noticing. You'd never mention it, and a million others are supposed to join you.

I noticed. Yes, we're going to try and get a million people running.

That's great. You're going to save a lot of lives.

Oh, thank you. Um, but much of it because of the work that people like you do and that come on my show and inspire me to think about things like my V02 max. And I'd definitely been just weight training for the last couple of years, not really thinking about my bones or my V02 max, so this has been quite a big shift for me. Yeah, but when I think about running, I definitely hated it. I still hate it a little bit, but I—I hate and love it now, which is progress. What are the things I should be thinking about? 'Cause people talk to me about runner's knees and stuff like that, and I don't want to get injured, right? But I'm running quite a lot. So I hear uh from a lot of runners that, "Oh, okay, I'm going to lift with my arms because I'm running, so that means my legs are going to get stronger." Well, what I know from 30 years in practice is that runners who only run are hurt a lot, and here's why: running builds a big cardiovascular engine, but it does not build muscle mass below your belly generally, unless you're running uphill all the time and you're building glutes. But so what happens—running is a single-leg sport. If you—if you look at a gate analysis, you're on one leg at a time; you're never on two legs. And walking, you're on two legs; on running, you're on one leg. So if this is—if my hands are on someone's pelvis when we're running, we can't be going like this every single stride—sort of oscillating—oscillating like we're walking on a catwalk in Fashion Week. We want to be running like this—straight. Well, that takes tremendous glute strength—butt strength—because it's the glutes that balance the pelvis. If we were in my office and you came in with pain as a runner, I would stand you on one leg to see even if in a controlled—POS—uh environment you could do a single-leg squat and keep your pelvis stable without your knee falling in. And if you can't, it just tells me that we have a lot of butt, core, and hip strength to do, and my lower back.

Something I think about because when I train, especially I'm training for a football match at the moment, oh—um—in the UK, and I always seem to get a glute injury, so I—and it's all—it's almost like 100% predictable that if I don't stretch properly—even—even if I stretch a little bit but don't stretch fully—yeah—when I run on that football pitch within five minutes I feel like a little—it's almost like a little tear in my glute.

Yeah—almost.

What am I doing? What do you think is happening?

It might be useful to you as you're training to have a motion analysis, to have someone stand you on one leg and look at the way that that one motion pattern is different from the other, because if it's predictable like that, M, there's an imbalance in you, and so it can likely be trained. I mean, I can give you an example in my life if you want to see how that works. So when I run and when I increase my—my speed and distances, I predictably—predictably—get left Achilles tendinitis, and I get right hip flexor sharp stabbing pain—predictably. That is because my left big toe, from wearing high heels all my life, has arthritis. So when I run, I don't run through the center of my foot; I run through the side of my foot where your pinky is—where my pinky is. So instead of running through like this, I run through like this—puts extra stress on my Achilles tendon—changes my gate enough that it's tight all up through the left side of my body, and my right um hip flexor is taking the brunt of that. That is a motion pattern deficit that I know I have. So if you were predictably getting the same injury all the single time, it's probably due to something's too tight on one side, something's too weak on the other side, and if you get it evaluated, you could probably train it out of you.

You have athletes and people that come—you stand on one leg to test something. Yeah, what is that? Do you want to see it?

Yes, yeah. Let's do it. So to test whether we have muscle imbalances that could cause injuries when we run, because I had said runners are very hurt athletes that I take care of, this is called the Trendelenburg sign, and it tells us whether your glute—your butt muscles—are strong enough to keep your pelvis straight and whether you're strong enough to keep your knee from falling into this position, okay, which is called valgus. Okay, collect yourself; we're going to stand all stacked up on our left knee—my left knee—yeah—oh gosh—yep—and then we're going to do some single-leg squats without falling over. So what happens is people drop their hip, and their knee falls like this; it goes blop. Yeah, a thousand steps a mile, so you can imagine if your knee's like this a thousand steps a mile, your little kneecaps getting pulled off, and we can't balance; we're getting our balance a thousand steps a mile. So we can train this. Let's do the other leg—engage—sit—single-leg squat. You look like I'm drunk or something. Yep. There you go. Now you're compensating, but the goal in the mirror is not to have the hip drop and not to have the knee fall in. I feel like this one's way stronger, and that's why it was easier. It—it looks that way. So that means this glute—this rear-end glute—is stronger than that one. That's the one that always gets injured—my left one—yep—because it's not functioning as well, and it leaves this side unprotected. So what have I got to do? So uh, double-leg squats are good, but single-leg step-ups, single-leg lunges, as in like—so if we had a step, we would be holding a—we could start with no weights like this, and you're tall, you could start low, you could go up here. I usually—usually—use an 18, and then when you feel comfortable and your hips not bouncing up and down, take your—your—weight—your barbell—and step up and step down. Okay. Yep. Y—right, 'cause it's single leg, so I'd have my weight, and I'd be going like this—MH—and then I step down—step down with the same foot. And what am I—what am I doing here? I'm—I—I'm just—you're strengthening one side at a time, okay, because if you step up—if it—and you're wobbly, M, then that's what's happening when you're running. Okay. And so you can do step-downs, too. I mean, you can come this way and then come like this. Okay. Yeah. And then we do—there are lots of things like this—a good physio—but if we're up here, we can do things like um hip hitches where you put your leg down. I am in heels today, but we go down like this without going down like this. Yep. Okay. Thank you so much.

Let's get the table back. In your gut—and my gut is the home of our digestion, and it's also a gateway to better health, but it can be hard to know what's going on in there. Zoe, who sponsors this podcast, has one of the largest microbiome databases on the planet and one of the world's most advanced at-home gut health tests. Their blood sugar sensor, which I have in this box in front of me, goes on your arm so you can see how different foods impact your blood sugar. Then there's the at-home blood sample, which is really easy and analyzes your body's blood fat, and of course the famous blue Zoe cookie, which tests your metabolism. Oh, and I can't forget there's also a poo sample, which is a critical step in understanding the health of your microbiome, and you post it to Zoe, and you get your results back, which will help you to understand your body's response to different foods. Using your results, Zoe's app will also create a personalized nutrition plan for you. And this is exactly why I invested in the business. So my question to you is, how healthy is your gut? Head to zoe.com to order your kit and find out. And because you're one of our listeners, use code Steven10 for 10% off your membership. Head to zoe.com now. I've invested more than a million pounds into this company.

Perfect Ted, and they're also a sponsor of this podcast. I switch over to using matcha as my dominant energy source, and that's where Perfect Ted comes in. They have the matcha powders, they have the matcha drinks, they have the pods, and all of this keeps me focused throughout a very, very long recording day, no matter what's going on. And their team is obsessed with quality, which is why they source their ceremonial-grade matcha from Japan. So when people say to me that they don't like the taste of matcha, I'm guessing that they haven't tried Perfect Ted. Unlike low-quality matcha that has a bitter, grassy taste, Perfect Ted is smooth and naturally sweet. And without knowing it, you—you're probably a Perfect Ted customer already if you're getting your matcha at places like Blank Street or Joe and the Juice, but now you can make it yourself at home. So give it a try, and we'll see if you still don't like matcha. So here's what I'm going to do: I'm going to give you 40% off our matcha if you try it today. Head to perfectted.com and use code steven4. Or if you're in a supermarket, you can get it at Tesco's or Holland & Barrett, or in the Netherlands at Albert Heijn, and those of you in the US, you can get it on Amazon.

On the subject of obesity and weight, we talked last time—really fascinating thing that you said to me which stayed with me is that the more weight we're carrying, the more harm it's doing to our bones in a really disproportionate way. Could you clarify that again, but also talk to me about—give me the case for keeping my body fat down as I age?

So what we were talking about is uh joint health, yeah, and the fact that every bone—if in your knee, for instance—if your fe—if this is your femur—the end of every bone has a bumper of cartilage. Cartilage is a matrix of collagen fibers that has cells in it, and its entire job is to shock absorb so the bones don't do so much of this. Bones are pretty fragile, but they glide. Cartilage has a—in physics—a coefficient of friction that is less than ice, so it's smoother than ice; it glides, right? If it's perfect. Cartilage is very subject to the forces of weight such that in our laboratories when we were doing cartilage research and wanted to damage cartilage, all we had to do is drop a marble on it. So it doesn't take much. So if we're carrying around a lot of heavy extra weight, and we don't have the muscles to support that—instead of muscles actually like a shock absorber and protecting our cartilage—we're banging more. Now remember, banging is good for bones; it's not good for cartilage. So we want to make sure that we have a healthy weight so that we're not exerting so much load, because it's 7 to N—we talked about last time—7 to N times uh body weight pressure across the joints. And so that's why we want to compose our body and have a body composition—not a weight—a body composition of of more muscle than adipose tissue. Yeah. This kind of goes back to what we were saying earlier, because you can say these things, but still—changes—still far away from many, many people. And I was just wondering, in the people that you've seen make radical changes that you've worked with, are there key things that happen? We talked a little bit about someone hits rock bottom; they get a bad diagnosis; they're forced, but is there—is there anything else that one can do to will themselves to change?

To keep a journal, some kind of exercise—I think it's really helpful to know as much about yourself as possible. So if I'm intaking someone into a program we're going to build—I don't—I weigh them, but what's most important is

Can make your decision very early. What I want people to do, uh, is educate themselves. I call it menopause literacy because we have a very low level of menopause literacy in this country. I want them to make their hormone replacement decision—meaning, am I going to go on them? Where am I going to get them? Can I find a clinician to help me?

Number three, I would like them to, as we talked about earlier, build their unbreakable lifestyle. Develop the habits early—not when they're in the throws of menopause and feeling desperate, but early—of lifting weights, of cardio that includes base training and sprint intervals, anti-inflammatory nutrition early, so that it's just the way you live. So that when you're feeling so bad, you're not trying to learn all these things at once. And there is a significant link between menopause and bone density because you lose some of those critical hormones like testosterone, like estrogen and testosterone. So estrogen on bones acts to control the cell that breaks down bones. We talked about in bone health there's a cell that breaks down bones called the osteoclast, with a c, and a cell that builds bones called an osteoblast. Estrogen helps control the osteoclast, so even in menopause when there is no estrogen, we're still building bone, but breaking down bone outstrips building bone. So replacing hormones helps rebalance bone breakdown and bone rebuilding. And if we lose our estrogen around the time of this perimenopause, menopause, we can lose 15% of our bone density. And if we don't catch it because insurance only pays for DEXA scans when we're 65, which is far too late in my opinion, we're behind the eight-ball. So I encourage everyone, once they start going through perimenopause, to get a DEXA scan, whether they have to pay for it at their gym, save up their coffee money—it's worth knowing your bone status.

What are some of the most, um, obvious but pertinent musculoskeletal syndromes of menopause? I'm glad you asked that. In July, my group and I created a nomenclature called the musculoskeletal syndrome of menopause because women were showing up in my office saying things without prompting, because I, I'm a doctor who listens. I sit down on a stool; we have a conversation. I do not chart in front of you, so people talk to me. And out of nowhere, women would say to me, "Doc, I feel like I'm falling apart, and I don't know what's going on, but I feel like I'm going crazy because I've been told nothing's wrong with me." And I started noticing that more and more as women started coming in with their shoulders not moving, which is an entity called frozen shoulder. And so as I started looking at this pattern and reading the very few studies that were done, we've known for 30 years that the incidence of arthritis, inflammatory arthritis in women after 50 is much higher than inflammatory arthritis in men. We've known it for 30 years. And as I started researching—remember how I said earlier that every musculoskeletal tissue is derived out of the same type of stem cell, the mesenchymal stem cell—all of those tissues, muscle, bone, tendon, ligament, fat, muscle drive stem cells are all sensitive to estrogen. And without it, several things happen. There's something called arthralgia, which is total body pain—meaning your body hurts so much that you can't even get out of bed. That was one of the biggest things I had. I'm an athlete, and I could barely get out of bed because I was so inflamed due to the lack of estrogen. Estrogen is a huge anti-inflammatory agent, so I was totally inflamed; my body hurt. That's called arthralgia. Women come in, and I'm not kidding, they come in; they say, "My arm won't move; literally, it won't move," or, "I can't hook my bra." That is due to the inflammation of losing estrogen. In Asian cultures, it's called the 50-year-old woman's shoulder because it happens to 50-year-old women. It is a sign of the inflammation of losing estrogen. We know about sarcopenia, the loss of lean muscle mass, about 20%, when you lose your estrogen. We've talked about loss of bone density. We have increased incidence of tendon and ligament problems—Achilles tendon, tennis elbow, patellar tendon—because the collagen fibers of tendon and ligament have estrogen receptors on them. And so everything starts to work less well without the presence of estrogen. So I saw all of those things, and we gathered the world's data, which isn't a lot—a lot more research needs to be done—and we gave it a nomenclature; we called it and published it as the musculoskeletal syndrome of menopause. Because I tell you for sure, Stephen, if someone goes into their doctor's office—which in this country is so restricted in the time that we can spend—and says, "I have this and this and this and this and this," six things in 15 minutes, it is difficult to get through that. But if someone comes with a nomenclature of, "I think I have the musculoskeletal syndrome of menopause; my arm doesn't move," blah, blah, blah, immediately you don't have to go through a differential diagnosis of 600 things; you're like, "Oh." As a doctor, this paper on the musculoskeletal syndrome of menopause has currently been downloaded almost 300,000 times. And to put that in context, some of the biggest journals in the world, medical journals in the world, documented they did a, a survey of how many times their best articles had been downloaded; the best scientific journals, their articles are downloaded about 10,000 times. This musculoskeletal syndrome of menopause has been downloaded nearly 300,000, and it's not because, yes, it's a good paper; the need is so great, Stephen, to communicate what the heck is going on with people that I made it open access, meaning you don't have to pay to get this article. And I encourage people to Google it; it'll come up number one, to print it, to read it, to give it to your doctors so that they can understand that you're highly inflamed; that's why your total body hurts, that your shoulder doesn't move because you're inflamed, that your knee hurts because you have the arthritis of menopause, and just to build the understanding of what is actually going on with people.

Fascinating. I didn't mean 300,000 downloads. I know it's amazing. It's like a New York Times bestseller—bestseller research paper—30,000 p over, or something crazy, crazy.

Yeah, congratulations.

Well, you know what, research is a team effort, and and we all work together, but thank you. It's needed. You used a word there, arthritis, which we've not talked about yet, but but used it to describe your big toe as well.

Yes, I did. What is causing arthritis? I don't want to get arthritis. Oh, who does? There are, there are two kinds of arthritis. There's an autoimmune, meaning your body is identifying yourself as not yourself, and that's called rheumatoid arthritis. That is very different than the way I used it today, which is osteoarthritis, which is wear-and-tear arthritis. Okay, so wear-and-tear arthritis can happen through thousands and thousands of repetition, uh, on a joint. Uh, we were talking earlier about running; it's a thousand steps a mile. It can happen due to trauma. I have a lot of—I used to take care of the University of Pittsburgh football team, and I had a lot of 20-year-olds with knee arthritis because the impact was so great as linemen hit each other that they would wear out their cartilage. So wear-and-tear arthritis, osteoarthritis, is loss of the cartilage layer on the end of bone. It causes aching pain; it causes swelling; it causes stiffness, uh, and then to the degree that you have it, we can treat you conservatively through a variety of ways, or at the end of the road, we can replace your joints.

I want to just circle back on—we were talking there about the collection of symptoms that are associated with menopause, and you were talking about how arthritis is a, is a factor. Are you telling me that to avoid the musculoskeletal symptoms of menopause, I should be taking hormone replacement therapy?

Here's what I'm telling you. I'm telling you that every musculoskeletal tissue has alpha and beta estrogen receptors. We know that when those sit empty, you will manifest some of the musculoskeletal syndrome of menopause. 80% of us do. What I'm telling you is that estrogen sitting in those receptors can prevent bone loss, can prevent muscle loss, can decrease the inflammation of arthralgia and frozen shoulder. So everyone gets to make their own decision. People are thinking beings; they have agency; they get to make that decision to get out of pain and to prevent the musculoskeletal syndrome of menopause based on science and not fear.

One of the, um, one of the things I'm a little bit concerned about these days is back pain. Yeah, lower back pain in particular. Um, I read that lower back pain is the single leading cause of disability globally, significantly affecting individual's quality of life and productivity, which was published on the World Health Organization, yeah, article in 2020. Lower back pain affected 69 million people globally, and its prevalence is increasing due to a number of different factors, one being aging, but also I just think generally how we're living, more sedentary lives and sitting on these chairs and stuff like that.

Mhm. Back pain. Yeah, common thing. Only seems to exist in the Western world. I had someone come here from the—who studied the Hadza tribe in Africa, and they don't have back pain there.

Yeah. How do they live? Not like this, right? They squat. Yes. They don't have chairs. Yes. Well, back pain is endemic in our population due to our lifestyle. We're sitting here for several hours. I'm probably sitting like this, all hunched over at some points. Our, our cores are relaxed; we're not—our front cores are relaxed, relaxed; our lower back is relaxed. There's no stimulus to keep our core strong, sitting in a chair, and we do this 10 hours a day at least, right? That's number one. Number two, then 70% of people do no meaningful exercise any time of the week, so we never rebuild it. So we get low back pain due to muscle weakness. And another reason we get low back pain, particularly in women or very elderly men, is compression of our vertebrae, compression fractures of our spine that can be very painful. It presents as low back pain. I want to differentiate for people listening the difference between low back pain and and nerve impingement that needs surgery. Low back pain is that aching in your low back, the stiffness. When you go to a doctor with low back pain, they should be telling you how to get stronger, sending you for physical therapy, to stop smoking if you're smoking. CO2 that poisons bones, right? All the lifestyle things. If you have pain starting in your back but shooting down your leg like electricity down the back of your leg—like literally think about how lightning would feel—that is because a nerve is being impinged as it comes out of your spinal cord. That is something that needs to be examined and looked at, but I just want to differentiate that because a lot of people, um, mistake the two. And a lot—I think it was 80% of Westerners—will experience lower back pain. And it got me thinking about standing desks and things like that. Do you advise people to use standing desks?

I do, and walking treadmills, um, because there's so much work that we do during the days that isn't deep work. We're emptying out our email; we're returning some phone calls; we're doing the less heavy brain-heavy parts of our job; all can be done standing. Or I've encouraged, uh, groups of people that I work with to hold their meetings doing wall squats. Just don't sit at the board table; pull up a wall; everybody's squat. Better be a pretty quick meeting because that, that takes a lot of strength. But to build in that kind of mobility, the only time we really need to sit is when we're solving world peace. Yeah, the rest of it we can stand. And in fact, studies have shown that if we're trying to learn something, it's better to be moving as we learn because the kinetic energy of learning is better for our brain. For instance, I used an example, uh, yesterday actually, when I, I was teaching people how to time manage, and I said, "When I'm listening to long-form podcasts like this, I can't sit for three hours, but I can walk and listen, and I retain more," for instance. So that, that's been proven that if we're in exercise, we retain more in terms of studying.

Oh, okay. You've done a lot of studies; they're so fascinating. Have you got a favorite?

The very first one we did on master's athletes, answering the question, "At what age do we really slow down?" Because if you believe Hallmark and all the, uh, rest in peace balloons that go around on your 40th or 50th birthday, slowing down is an inevitable part of aging. But the fact of the matter is, and our study showed that when I looked at track and field athletes in every race from 100m to 10,000m, and I looked at the top eight finishes in every age group in every race, that we do not significantly slow down until we're past 70. So between 50 and 70, the guy who won the one-mile race finished it in four minutes and 34 seconds. The same year of the study, the kid that won the high school mile race did it in four minutes and 17 seconds. The 70, 70-year-old who won the one-mile race did it in a little less than seven minutes. It just shows you that if we're slowing down dramatically before our 70s, we've either decided not to train so hard, we're just not trying anymore, we've been terribly injured, right, and we can't. But it's not because of biology, because of psychology.

Exactly. No light bulb goes off. We think, though—we think that when we experience that first twinge, that first pain, we start to get a little bit tied. We think it's natural, so we kind of relent to it; we just give in. And then that's that slow spiral downwards into a lifestyle which becomes self-fulfilling. I guess we stop trying hard; we stop playing hard because we stop trying hard because we think it's inevitable. We think, "No, aging is inevitable." How we age is, is up to us.

You're working on a book, aren't you? You've just handed in the manuscript for—we're very, very excited about this book, *Unbreakable*.

*Unbreakable*: Go strong, live long, age with power. And it really picks up the conversation of aging and longevity that I've been talking about for a long time, but really focuses on the longevity of women. So the book is framed around the pillars of aging, which I call time bombs—the time bomb of metabolic dysfunction, uh, the time bomb that we think means our DNA as our destiny, which it is not; we can modify ourselves—and several others—and really explain the science of what's going on, and that aging is not an inevitable decline from vitality to frailty unless we cop to that attitude, right? And then the second part of the book lays out a lifestyle that I call unbreakable. It's about muscle; it's about bone; it's about nutrition. But the most, a very important part is what you just said; it's about attitude and mindset. And so I help people set standards and goals for, for what they want based on their values. If I didn't value independence, if I didn't value having my brain till the very end and all the other things that I value, then my goals would be uninformed. I could say, "Oh, I want to run a marathon at 80," but that's not enough unless it's connected to my values. And then further along, we talk about building resilience because brain resilience can be built in the same way that skeletal resilience can, and I believe it takes both, both of those things to progress and to age with power. And then the final sections of this book really take us to the next level: "How do we, now that we've optimized our health and decided that we are not the victims of time"—I don't believe that; I believe we can shape our future—"how, what do we do for peak performance? How do we continue to squeeze performance out? And what are the cool techniques, technologies that can help us?" I'm very, very excited.

Yay! Can we pre-order it yet?

Uh, not yet, but you can get on my waitlist on my website.

Okay, I'll link that below for anyone that's keen to get that book. I, I'll be on that list as well. I'll give you one—is there anything else that we should have talked about that we haven't?

Dr. Vonda, last week I was, uh, speaking at the American Diabetes Association and talking about midlife and menopause, which you and I have talked about, and all the metabolic changes that go on when estrogen walks out the door. And we've already talked today about prediabetes and how we need to put on a big alarm because of all the metabolic changes that will lead to diabetes and Alzheimer's. But when I look at those two things separately—perimenopause and all the metabolic changes and the lipid changes and the fat distribution and the insulin insensitivity and prediabetes—they are nearly identical. And what we know is that this is another alarm to sound. If we have not paid attention in the critical decade of our lives and become prediabetic and then are a woman and lose our estrogen, it compounds the normal metabolic changes that happen with insulin resistance to the loss of estrogen. And after menopause, women have more diabetes and therefore more Alzheimer's. And so if I can back all this up and start people thinking about it when we're 35, that is work worth doing.

That's exactly what you're doing. It's exactly what you're doing. I think, you know, the reason I'm so compelled by menopause as well, a secondary reason, is because I have so many wonderful women in my life, including my partner, who yeah, might not be as fortunate to be exposed to all the information that I get exposed to by doing this. So many of the questions I'm asking you almost pre-preparing me to be a supporting act in her, in her life. She's what, 32 now? So you know, critical, critical years.

You know what, Stephen, if I could get more men to take the attitude that you've just expressed, to have the curiosity, to learn about the changes in midlife women, and not only bodily changes but but attitudinal and the sexuality changes, I think we could save a lot of marriages. But I find that there is—for the lack of knowledge, there is amongst the women; there is even less knowledge among the men. But if it's a partnership—so I think your attitude and curiosity is, is laudable because I think we could save a lot of relationships if everyone felt that way.

Yeah, because for me it has created a ton of empathy, and with empathy you approach challenges differently, with a different perspective. Yeah, and there's less blame and there's more, yeah, I think, supporting, um, encouragement. So that's really why I think it's important as well for men to understand these things because when you start noticing differences, maybe in someone, in a way she, she's feeling, or your mother or, yeah, grandmother or even your daughters, you might not be some of those, you know, naive doctors who think someone's losing their mind or that they're just being different or it's their personality, and you might understand that there's something deeper going on, um, and also something that's at least in part you can do something about.

Absolutely. Which I think is the most important conclusive point. We have a closing tradition on this podcast where the last guest leaves a question for the next guest, without knowing who they're leaving it for. And the question left for you is, "How do you know when is enough?"

I think how you know when it's enough, when it becomes—if it pertains to work or striving for something—or is when you don't love it anymore. When it becomes a grind and you don't love it, that's when it's enough because it's not feeding you.

Amen, Dr. Vonda. Thank you so much for the work that you do, um, you're such a star, and I think everybody should go follow you on Instagram because you built an incredible community over on Instagram where you give away so much of this knowledge absolutely free of charge. But I also think everybody should go to your website.

Thank you. They should buy this book. I know this book is—maybe they should just get on the waitlist for the upcoming book as well, *Unbreakable*.

*Unbreakable*. Um, and they can get on that waitlist on your website right now.

Yes, they can. Join your Instagram community, which I think is phenomenal. It's so wonderful to see. Yeah, um, how—because you know, usually people have a following, but I really feel like you have a community.

Yes, I see it in the comment sections; I see that people are really, really engaged, and there—as you saw from the amount of people that downloaded that paper that you published—there's a real thirst and hunger for this information. And I get so many messages when—from the last conversation we had, yeah, but from these conversations generally about—from women, from their husbands who are so thankful for you. Oh, like, so thankful. It's, you know, because I have lots of conversations about lots of things, but this particular conversation provokes a certain type of energy that is very atypical.

Oh, you know what I mean? You understand it because you feel it every day, but I really feel it as well. So thank you for doing the work that you do and for turning the lights on for so many people that are living in the darkness as it relates to information. And that information is no doubt undoubtedly saving many millions of people's lives.

I hope so. And that's work worth doing. So thank you so much, Dr. Vonda.

Thank you. This has always blown my mind a little bit: 53% of you that listen to the show regularly haven't yet subscribed to the show. So could I ask you for a favor? If you like the show and you like what we do here and you want to support us, the free, simple way that you can do just that is by hitting the Subscribe button. And my commitment to you is if you do that, then I'll do everything in my power, me and my team, to make sure that this show is better for you every single week. We'll listen to your feedback; we'll find the guests that you want me to speak to, and we'll continue to do what we do. Thank you so much. Some of the most successful, fascinating, and insightful people in the world have sat across from me at this table. And at the end of every conversation, I asked them to leave a question behind in the famous Diary of a CEO. And it's a question designed to spark the kind of conversations that matter most, the kind of conversations that can change your life. We then take those questions and we put them on these cards. On every single card, you can see the person who left the question, the question they asked, and on the other side, if you scan that barcode, you can see who answered it next—something I know a lot of you have wanted to know. And the only way to find out is by getting yourself some conversation cards, which you can play at home with friends and family, at work with colleagues, and also with total strangers on holiday. I'll put a link to the conversation cards in the description below, and you can get yours at thediary.com. [Music]