322 - Bone health for life: building strong bones, preventing age-related loss, osteoporosis, & more

1. 0:00 – 0:59

   Intro

   1. BBBelinda Beck0:00

      So it was all about just systematically training them in the technique and, uh, and then gradually increasing the load. And a lot of people think of older people, and particularly older women, and particularly postmenopausal women who, you know, the assumption is they go completely loopy through menopause, which is not true. Um, they think about old people as completely incapable, incapable of doing stuff and incapable of learning. But old people are you and me who just kept living longer. It's we ... You know, we have the capacity to learn, and, and older people are perfectly capable of learning how to do a deadlift and a squat. You know, it might be pretty ugly to start with, but they get better. And as they get stronger, they get even better.

   2. PAPeter Attia0:48

      [upbeat music] Hey, everyone. Welcome to "The Drive" podcast. I'm your host, Peter Attia.

2. 0:59 – 7:12

   Belinda’s journey into bone health research and training

   1. PAPeter Attia0:59

      Hey, Belinda. Thank you so much for getting up so early, uh, in Australia to sit down with me. Would, uh, would love to be doing this in person, but it's a bit of a hike for you, so, um, this will more than suffice. Um, [clears throat] you know, I've referenced, uh, your work many times before in, in talking with patients and, you know, talking on social media, talking on other podcasts. And, uh, so I've wanted to speak with you for some time because, you know, it's one thing to hear me talk about something, but it's, I think, far better to hear the expert talk about it and, and as opposed to me just sort of paraphrasing. Um, but maybe we'll just spend a second giving folks a little bit of your background. Uh, I'll have obviously introduced you already. Um, but, but tell folks a little bit about how you kinda came to, to find your, your interest in this. Um, y- you know, your, your, your PhD and postdoc were both done here in the US, correct?

   2. BBBelinda Beck1:56

      Yeah, that's right. Uh, and my master's as well, actually. I think we can safely say a lot of people end up in research because of some personal interest, and that's exactly the case for me. I was a runner and a field hockey player, and I constantly suffered from sore shins, and nobody could help me. They couldn't even tell me why I was getting them, much less how to prevent them or, or make them better. This was back in the day, mind you. Uh, and so even when I was in high school, I knew that I wanted to find out what was going on, and that's actually where my research started in my master's. I was looking at, um, tibial stress injuries. It became clear very, very early that this is a bone injury. This is not what everybody was saying, Tibialis posterior pulling on the border of the ... That was all bunkum. That was somebody making a supposition. And that set me down the pa- path of trying to figure out what are the mechanical signals that stimulate bone to adapt-

   3. PAPeter Attia2:56

      Mm

   4. BBBelinda Beck2:56

      ... to, to mechanical loading. You know, pursuit of Wolff's law. Why does a change in mechanical loading, uh, cause the bone to change shape in this amazing way? And of course, as soon as I discovered bone did that, I was hooked 'cause it is just an incredible tissue. So then, um, when I'm ... I did an animal study for p- my PhD and quickly realized that that was not something I wanted to do for the rest of my life 'cause it involved killing animals, uh, constantly. So I went, I went to Stanford and did a postdoc, and that's where I learned about clinical trials and sort of, um, then realized, of course, that osteoporosis is, is the greatest burden when it comes to bone problems. And so, uh, being an exercise head, that's something that I wanted to, to figure out exactly what was the ideal exercise program to, to assist people living with osteoporosis.

   5. PAPeter Attia3:50

      Yeah. And before we started the podcast, we quickly figured out that we overlapped together at Stanford for the entire three years of your postdoc. I was in medical school, um, which of course I, I just get a kick out of knowing the fact that there was probably a day when we were literally in the same cafeteria at the VA or something. And of course, uh, who would've predicted, you know, whatever, more than 25 years later we're sitting here. But that's, that's ... I love those coincidences. Um-

   6. BBBelinda Beck4:17

      Me too.

   7. PAPeter Attia4:17

      So, um, l- let's also talk a little bit about what you're doing today. So you're, you're obviously back home. Um, t- talk about the, the, the clinical practice that you have now and what type of patients you, you, you work with and, and what type of research you're still focused on.

   8. BBBelinda Beck4:36

      Yeah. Okay. So I should clarify I'm not a clinician. I'm an exercise physiologist, and, uh, I've never had a personal clinical load. Uh, although exercise physiology is one of the allied health, um, uh, professions in Australia. Uh, I came back to Australia to an academic position and was ... I've been teaching anatomy my whole professional career but continued my, my bone research. So I'm, I'm a professor at Griffith University on the Gold Coast in Queensland, and that's where, um, we sort of ... My career sort of, I guess, triangulated onto this question of there must be a way to load people who have osteoporosis in such a way that they can grow bone because everybody had been saying we couldn't do that because their bones were so fragile.

   9. PAPeter Attia5:32

      Mm.

   10. BBBelinda Beck5:33

       Now, when we did, and I'm sure we'll come back to the actual trials we did that showed that, um, after I showed that, I did realize that the exercise, the nature of the exercise was not Um, really safe for just anybody, and it needed to be applied in a certain way and very specifically, and it needed to be a- applied by somebody who really knew what they were doing because this is not a program that should be done unsupervised if you're at high risk of fracture. And the only way to do that was to implement it in a clinic. Now, it's hard enough to convince doctors who've been telling patients f- osteoporotic patients for years that they should not lift anything heavy, but, but to tell somebody in a clinic to start doing this exercise in... I just knew that was never gonna happen. So that's what The Bone Clinic is. I set up a clinical facility. It's a translational research facility where we actually implemented the program. But every patient that comes in, uh, is a research participant, and they agree to share their data. Um, we do the same testing as we did in the LIFTMOR trial. It's a two-and-a-half-hour appointment at baseline, and then every year thereafter we test them again with the same thing so that we can see if the exercise program works in, in the real world. And of course, um, I added in other things that are really important, like diet and, um, and we take care of them. This is not a clinical trial. This is... We don't have a control group.

   11. PAPeter Attia7:05

       Mm-hmm.

   12. BBBelinda Beck7:06

       Now, of course, I've got an enormous amount of data and, uh, [laughs] am needing to, uh, wade

3. 7:12 – 13:51

   The physiology of bone and how bones adapt to mechanical loading

   1. BBBelinda Beck7:12

      through all of that.

   2. PAPeter Attia7:13

      Well, let's, let's start the discussion with, um, a little bit of the physiology of the bone, right? It's, um... I think for many people, myself included, right, people who, you know, went to medical school, we don't-- I don't really recall getting much of an education in this. I probably did, but it's, it... You know, once you choose your specialty, y- you know, you, you, if it, unless it happens to deal with bones, um, as in orthopedic surgery or rheumatology perhaps, um, or maybe sports medicine, you know, most of us end, end up kind of getting far and far away from it. But, um, given the ubiquity of osteopenia and osteoporosis, um, it, it really comes back to be in the fore, uh, uh, f- for, for many physicians, even if they aren't trained in it. So, so I, I think it'll be helpful for everyone, myself included, to go over a little bit of bone physiology. Um, so handle it any way you see fit, um, but, but I think, you know, we, we can, we can talk about this in as much depth as, as, as you like because, uh, we have a, we have a pretty sophisticated audience.

   3. BBBelinda Beck8:20

      Okay. So I suppose there's a couple of different ways to look at types of bone. The very basic way to, to describe them according to their shape, uh, which is completely related to their function, uh, the whole basis of Wolff's law, I guess. Um, so you have long bones like the long bones in the levers in your limbs, um, and your, and your, your feet and hands. Uh, you have short bones like the little, uh, lumpy bones in your ankles and wrist. You have irregular bones like your vertebrae and your, um, scapula and so on. Um, all of them are comprised of two basic kinds of bone. One is cortical bone, and one is trabecular bone. And there are different way, different words for those, cortical or compact bone, trabecular, spongy, or, um, uh, cancellous bone. Now, cortical bone is typically, uh, the shell of a bone. Every bone has cortical bone on the outside. It might be very thin in the case of vertebral bone, or it might be extremely thick as in the shaft of, you know, the diaphysis of a femur. Um, most bones have some degree of trabeculae or trabecular bone in them. If it's a long bone, it's in the ends. Uh, and if it's a short bone, it fills the whole thing. If, like a vertebrae, irregular bone, it also fills the whole body of an irregular bone. If it's in the skull, it's called diploe, and it's sandwiched in between two layers of cortical bone. Um, you know, ribs ev- even have diploe. They're a flat bone as well. So, um, the very cool thing about the bone tissue itself is the microstructure. So in cortical bone, you have an, a lamellar structure, so layers and layers of bone, and that occurs because of the way osteoblasts lay down bone. But the really cool thing is the fact that in each adjacent layer, the, the collagen is laid down almost, not perfectly, perpendicular to each other so that this, these, this, um, the lamellae combine to create a, a, a tissue that is beautifully resistant to torsion as well as the normal loading of compression and, um, and tension. Now, in trabecular bone, there are also some lamellae because of the way osteoblasts produce bone. But the really cool thing about trabecular bone, and this is I think probably what Wolff in 1882 spent most of his time trying to describe mathematically, is the arrangement of the trabeculae. So each individual strut is best aligned to the na- to the forces that are put on bone. If you look at a cross-section through the proximal femur, you'll see that these are, they're those wonderful arches that go away from the head, through the neck, and down past the greater trochanter. And then from the greater trochanter, there are trabeculae that come from the surface of the trochanter and arch down, uh, to the other side and over towards the lesser trochanter. So you get this interconnection of bone that is beautifully arranged to best withstand the bending load that you will get from the opposition of the weight of the body on the head of the bone and the ground reaction force coming up the diaphysis. So, and that repeats itself throughout the body. If you look at any part of the body where trabeculae are, they are just Aligned, uh, in response to the forces. And of course, that's one of the things that will change if you change the nature of the loading

   4. PAPeter Attia12:08

      You've mentioned Wolff's law a couple of times. Uh, probably worth stating it and, uh, explaining its relevance to, to bone

   5. BBBelinda Beck12:15

      So it has been paraphrased over the years, and I don't think there's any harm in that, to mean that bone will adapt to the nature of loading to which it is chronically exposed, and the purpose being that it's best adapted to withstand forces to prevent fracture. In actual fact, um, I couldn't recount what his actual law is because he was a mathematician, and he was trying to describe this mathematically. We've taken that notion and just encapsulated it into that, uh, that law of bone adaptation in response to loading

   6. PAPeter Attia12:55

      Now, is there a built-in assumption to Wolff's law that, that that adaptation can only happen in the setting of certain physiologic parameters being met? So, um, for example, like sufficient calcium, um, you know, healthy osteoblasts, like, you know, absence of certain disease pathology, or is this truly a universal law that is indeed axiomatic?

   7. BBBelinda Beck13:23

      I don't think anybody knows the answer to that for sure, but I would be willing to stake my firstborn on, don't tell her, uh, that this is-- this just occurs. This is something that happens as, as sand running out of your fingers falls to the ground to, to wa- because of gravity.

   8. PAPeter Attia13:43

      Mm-hmm.

   9. BBBelinda Beck13:43

      This is how bone reacts to loading. It's a physical, uh, phenomenon

   10. PAPeter Attia13:50

       Okay.

4. 13:51 – 29:05

   Bone development from birth to adulthood, why early life is a crucial period, the functions of osteoblasts and osteoclasts, and gender differences in BMD

   1. PAPeter Attia13:51

      You've also alluded to osteoblasts, so maybe talk a little bit about the difference between an osteoblast and an osteoclast, how this mineral makes its way to the bone. W-what does this look like as a child is, is born? Like, maybe even start at birth and talk about what, what the bones are like in that fetus and how they develop over the, the ensuing, uh, you know, two decades

   2. BBBelinda Beck14:16

      Yeah, okay. So well going right back, we, we start, um, as a little cartilaginous, uh, model of a skeleton, and even by eight weeks, um, we have that model in that tiny little being. Uh, and that is, um, progressively mineralized, uh, as the, as the skele- as it becomes skeleton. Uh, there is, there, there are two different ways really is-- of ossification, but the primary one is, uh, endochondral. Um, once a baby is born, they have, um, ossified the long bones and, uh, quite a portion of their skull bones and most of the other bones that are around organs that need-

   3. PAPeter Attia15:02

      And, and just for folks listening, ossified is this process of putting mineral into the cartilage and turning it from sort of soft into hard, right?

   4. BBBelinda Beck15:10

      That's right. I think, uh, when we talk about ossification, when bone cells invade the cartilage, once there's a bone cell in there, it's, it's considered to be ossified-

   5. PAPeter Attia15:20

      Mm-hmm

   6. BBBelinda Beck15:20

      ... uh, because they start to excrete osteoid, which then becomes mineralized. So yeah, that's right. Um, there is a... Yeah, there's a whole process of endochondral ossification. Um, so yeah, babies are not born obviously fully ossified. They have still little cartilaginous hands and feet, and they have lots of cartilage just to different degrees in their, in their skull bones, and those continue to ossify throughout life. And I think, in fact, some of our, um, our growth plates don't even fuse until, particularly in men, till they're about twenty-five years old. Um, but largely, you know, most of your bones are fully formed and, and have bone in them by the time you're, you're two, um, and that's coinciding with when you're really starting to run around and load the skeleton. Um, the skeleton then continues to grow throughout li- throughout the, uh, first two decades, with the vast majority of growth happening when you're very little, little toddlers and, but primarily during puberty, and that's what we all know as the growth spurt. And that's happening because your bones are growing like crazy. That begins to slow, um, but that, that growth spurt happens earlier in, in girls, probably about twelve, um, probably about thirteen, fourteen in boys. And it slows, probably is ending round about eighteen in girls, can be as late as twenty-five in boys. Um, and once you have reached your peak bone, uh, growth there, your, your epiphyses have joined to your diaphyses, so the growth plates have fused. You're not gonna grow anymore, and you almost certainly have all the bone that you're ever going to have. So there's definitely a making hay while the sun shines, uh, mantra of those of us who work in the world of osteoporosis because childhood is, uh, so incredibly important. People often call osteoporosis a childhood disease. The goal is to get as much bone as you possibly can. That's limited by your genetics, and we can come back and talk about that if you want. But you do have a blueprint that, that you will achieve, but you want to optimize that, get as much of that genetic capacity as you have

   7. PAPeter Attia17:49

      Sorry, I just want to r-repeat that point, Melinda, 'cause it's actually quite profound, um, and I want to make sure nobody missed it. You said osteoporosis is a childhood disease Now, what you meant by that, of course, is based on what you said just prior to that, which is you will reach your maximum bone potential by the time your growth plates fuse, which again, for most people is probably late teens, maybe in the case of, uh, men, early 20s.

   8. BBBelinda Beck18:21

      Mm.

   9. PAPeter Attia18:21

      And, you know, in that sense, it's sort of like a glider, right? It's sort of like saying this glider will reach its maximum altitude 20 years into your 80 or 90-year life, and you better get it really, really high because the best we can do is reduce the rate at which it declines, but we're not going to get it higher than it was at that point. Um, now we're, we're going to get into a whole bunch of nuance, I'm sure, later on because I think what you're going to tell us is that actually we can maybe even change the elevation of the glider later on in these patients with osteoporosis. But I think there's no denying this idea that anybody listening to this who's thinking about osteoporosis for themselves should also be thinking about it for their kids and asking the question, "What are my 10-year-olds, 12-year-olds, 15-year-olds doing today to reach their genetic potential?"

   10. BBBelinda Beck19:26

       Yeah. There's-- It's one of the strongest messages that I, I speak mainly to older people and I say, "You know this, the horse may have bolted for you, but you have children and grandchildren and this should be your mantra. Get them outside and active every single day and doing, you know, XYZ bone-friendly activities." I should say, you know, we talk about peak bone mass being achieved, and we, we use the word, um, end of the second decade because that's the average between men and women. But it, it can creep up a little bit, but most... I, I don't-- Nobody is growing any more bone after age 30, and most people are well and truly done by then. Um, so yes, I, what I'm, I'm probably giving a somewhat old-fashioned view of this because, as you say, I do believe that there is capacity to, uh, get the glider higher later in life. But, um, I guess the concept is you're not going to grow bone anymore. You're not going to grow the length of bone anymore, so it becomes a lot more difficult. And the other message that is extremely important is that genes determine, you know, it's been sort of 70% to 80% of the bone that you're going to have. So to a certain extent, you're working within some reasonably tight bounds. You only have to look at your, um, your parents and grandparents to get an idea of what your risk is like. If they are very osteoporotic, then your risk is also very high.

   11. PAPeter Attia21:05

       So I think you said 60% to 70%, or did you say 70% to 80%? I know it was a high, high range you gave there.

   12. BBBelinda Beck21:11

       Well, it does depend on who you read, but, um, I sort of have settled on the 70% to 80%-

   13. PAPeter Attia21:17

       Okay

   14. BBBelinda Beck21:17

       ... because, uh, I, I think that there is certainly evidence to say that's the case, that there are twin studies and, and so on.

   15. PAPeter Attia21:25

       And, and sorry, that's bone density as well. Obviously, bone length is highly heritable, right? Just as height is very heritable and it's determined by bone length. But you, you're also referring to bone density by referencing osteoporosis, correct?

   16. BBBelinda Beck21:39

       Yeah, I suppose. I mean, I'd probably prefer to use the word bone mass. The trouble is we measure it by bone density using-

   17. PAPeter Attia21:47

       Mm-hmm

   18. BBBelinda Beck21:47

       ... a bone densitometer. Um, that is our proxy for bone mass because the only way to measure bone mass is to, to actually, you know, ash the bone, and you can't do that in a living person. So, um, yeah. Again, bone has been variously measured throughout the, the decades. Um, BMD is the most common way to do it. And if you look at BMD plots, you'll see there's very obvious, I'll do this in reverse, uh, growth in, in, um, childhood and then a flattening, so pretty much a plateauing and then a gradual loss.

   19. PAPeter Attia22:22

       Mm-hmm.

   20. BBBelinda Beck22:22

       And that flattening or plat- a plateauing or, uh, timing of loss, that is also, uh, I believe, genetic and individual, but that's the thing that is most amenable to exercise intervention. So somebody might have genes that, um, allows them to get a peak bone mass of a certain amount, uh, that is the same as their neighbor. But because the rate of loss is different and their level of activity is different, they may lose more quickly. And then you throw in menopause, uh, you know, average age about, uh, 52 to 54 or something. Uh, and for women, you'll see that loss rapidly accelerate, uh, for probably five to eight years. Uh, this is because, um, circulating estrogen almost vanishes from your blood, and estrogen is an incredibly important hormone for bone because, um... I don't think I came back to talking about bone cells. I should probably do that. Uh, because of its effect on osteoclasts, it, it largely inhibits osteoclasts. So it keeps, keeps a, uh, check on them and prevents them from over-reabsorbing. So while I'm on those cells, yes, there are a number of different cells in bone. The two primary... Well, the main one is an osteocyte. That's your standard bone cell that sits in bone tissue in its little cave, and it is responsible for maintaining the tissue around it and also for sensing what's going on in the, in the tissue environment. We can talk about that a bit more later. But, uh, osteoblasts are osteocyte precursors, and they are the ones that when they attach to a bone surface, they exude osteoid, which is the new bone tissue, which then becomes mineralized. So they're the bone-forming cells. Osteoclasts are these big, multinucleated cells that, um- Also attach to bone surfaces and resorb bone in packets. And, um, this is really important. This is not a bad thing. You know, bone remodeling is one of the most important ways that we maintain our skeleton, uh, get rid of microdamage, and also adapt to mechanical loading. So resorption formation is happening throughout our life, is, um, the way that we release calcium into the blood for when we need it for all those other things we need calcium for. So it's, uh, it's extremely important. The trouble is, uh, estrogen does help to contain those osteoclasts. When it disappears from the blood, osteoclasts have a little bit of a party for a few years and resorb bone like crazy. And so that explains why, uh, in women at menopause, we have the, experience this, uh, dramatic loss of bone, uh, for, for a period of years. Then it levels out again and sort of matches men. But you can see why more men than women are fracturing with osteoporosis because firstly, we don't gain as much peak bone mass. We're smaller-

   21. PAPeter Attia25:23

       Meaning, meaning more women fracture than men.

   22. BBBelinda Beck25:26

       That's right.

   23. PAPeter Attia25:26

       Yep.

   24. BBBelinda Beck25:27

       Yeah. Um, but in sort of in our 20s, we don't have as much bone as men, and then we lose more throughout life. So by the end of life, there's this greater disparity. And, and then add on to that, women fall more than men in later life. And so you've got this perfect storm of this is why more women than men are affected by osteoporosis and fracture.

   25. PAPeter Attia25:50

       And do we believe that women fall more because of a greater prevalence of sarcopenia?

   26. BBBelinda Beck25:56

       It's a hard question. Uh, I would say p- probably yes. Um, I think there's some ev- well, there's a reasonable amount of evidence to show that women are less active, um, throughout their life and as when they're older. Uh, not that older men are particularly active these days either, but I suppose because men genetically have more bone to, uh, bone and muscle to begin with, uh, they've started from a higher place. So, uh, yes, a very frail old woman has, um, not just not very much muscle, but not strong muscle, not, not very functional muscle. So, uh, their balance, the whole sort of neuromuscular package, if you like, has deteriorated to the extent that their, if they are, if their balance is perturbed, they will struggle to regain their balance before they fall.

   27. PAPeter Attia26:49

       So again, there's a lot there, so we'll, we'll just sort of summarize it quickly. But basically, oversimplifying a little bit, we have osteoblasts and osteoclasts that live in... Early in life, the balance probably favors the osteoblast. You're adding more bone than you're subtracting. We get into an equilibrium where there's a remodeling that's constantly occurring, um, and the bone acts as, in this sense, as a reservoir also for something like calcium. And so you're having rebuilding and remodeling. You know, if there's damage to a bone, obviously, you know, you, you, if you get shin splints, there has to be some healing that goes on. All of these things take place. Um, obviously, if there's a need for calcium, more of it comes out of the bone, et cetera. Um, and then we get into this state of decline where maybe the osteoclasts start winning. And in women, this is really amplified in the five to eight years following menopause when the, the s- most important hormone for bone preservation, estrogen, is taken away. And estrogen being the thing that keeps osteoclasts in check is now gone. And to your description, the osteoclasts kind of have a party now. Now they really get to run amok, and women experience a disproportionate loss of bone mass compared to men, who are also in a state of decline. Because by the way, men's estrogen levels are also declining 'cause they're tethered to their testosterone levels. So as testosterone goes down, so does aromatized estrogen, and it goes down with it. Um, and then they both sort of end up on the same parallel path again, but the women are considerably lower because they've had that accelerated loss.

   28. BBBelinda Beck28:37

       There's one thing I would just add, um, in... I feel like I have to say this because I drum it into my students' heads when I'm teaching bone growth, is that the skeleton actually grows via cartilaginous proliferation, and it's replaced by bone. So the osteoblasts aren't causing the growth of bone. They're just-

   29. PAPeter Attia28:57

       They're just solidifying it.

   30. BBBelinda Beck28:59

       That's right. They're re- replacing the cartilaginous tissue with bone tissue.
5. 29:05 – 50:25

   How parents can optimize their children’s bone health through diet (calcium and vitamin D), sunlight exposure, and physical activity

   1. PAPeter Attia29:06

      okay. So let's talk a little bit about the preventive medicine side of this. So before we even get into kind of the, the work that you're mainly focusing on, which is on, um, taking people who are at risk for osteoporosis and maybe holding them back from that or taking people who are in osteoporosis, l- let's, let's first address the question for the parents who are listening, 'cause, um, contrary to popular belief, we do not have a huge teenage audience to this podcast.

   2. BBBelinda Beck29:37

      [laughs]

   3. PAPeter Attia29:37

      Um, uh, for reasons I don't understand. I, I, I j- my daughter-

   4. BBBelinda Beck29:41

      I imagine why. [laughs]

   5. PAPeter Attia29:41

      My, my daughter just, she just hasn't found this podcast interesting in her little 16-year-old self. Um, so what, what, what can I be doing to ensure that my 7-year-old, 10-year-old, and 16-year-old are set up for the best life possible when it comes to bone health, uh, given that I've already given them something pretty good? Fortunately, knock on wood, my wife and I both have pretty high bone density, at least as measured by a DEXA scan. We could-- I'd like to talk about how valid or how we could be misled by that if, if the case. So, so from a genetic standpoint, they're not set up on the back foot. But I want to make sure that we're going above and beyond What, what, what needs to be considered for us from a nutrition perspective, from an exercise perspective, from any other lifestyle perspective to allow our kids to reach their genetic potential?

   6. BBBelinda Beck30:39

      Well, let's start with the low-hanging fruit, which is diet. Um, I don't think there's... Anybody could argue that a balanced diet is important for everything, for every [laughs] ... To be healthy, you need all the nutrients that, that we've known about for years, and the same can be said for bone. That means, um, particularly, and there, there are some minutiae, but, uh, the most important one obviously is calcium. Uh, f- that the amount that you need throughout your life does vary, but by the time you're a teenager, you probably need about 1,000 milligrams a day of calcium. Um, and you need the vitamin D to go with that, otherwise you can't absorb it from your gut. So, um, making sure... Dairy is by far the most, um, has the, it's the most abundant source of calcium. It's most bioavailable, meaning it's most readily absorbed. Um, it's packed with calcium. You can get most of what you need, um, each day from, well, let's say a, a regular glass of milk, so 300 mils.

   7. PAPeter Attia31:49

      Mm-hmm.

   8. BBBelinda Beck31:49

      Is, uh, or 250 mils. That has 300 milligrams of calcium. So if you had three of those, you'd basically be getting what you needed. No- not too many people are drinking that amount of milk, although I suppose the number of bowls of cereal my son eats, uh, could possibly be approaching that number.

   9. PAPeter Attia32:05

      [laughs]

   10. BBBelinda Beck32:07

       Um, so, um, but there are sources, you know, cheese and yogurt and, and then there's the discretionary foods. If you eat a lot of ice cream and cream, that sort of thing, you can get from there as well. But we would say yogurt and cheese and milk are the, the best sources.

   11. PAPeter Attia32:20

       But that, but that, but, but that's, that's... I mean, 750 ML of milk or milk equivalent is, is probably less than most kids are consuming.

   12. BBBelinda Beck32:32

       Yeah, I, I would say so, particularly as, uh, as they move into their teenage years and probably getting more conscious about, uh, weight and are thinking that they might be drinking diet soda instead of a, a milk drink.

   13. PAPeter Attia32:46

       And, and, and it doesn't matter what the fat content of the milk is, I assume?

   14. BBBelinda Beck32:50

       Well, actually, curiously, low-fat-

   15. PAPeter Attia32:52

       I mean, for the vitamin D it probably does, but does it matter for the calcium?

   16. BBBelinda Beck32:56

       Well, low-fat milk actually does have more calcium in it just by virtue of the fact if you take the fat out, you can fit more calcium in.

   17. PAPeter Attia33:03

       You have more volume. Okay. Got it. Got it.

   18. BBBelinda Beck33:04

       So yeah, it is, it, it is actually, um, uh... And plus you can buy fortified milk. We have Physical in Australia, uh, which has more calcium in it, and I'm certain you guys fortify a lot of your foods. Uh, and I believe you do put vitamin D in your milk, I think. Um, so it's, it's nice to get, to get both. But by far the easiest way to get vitamin D is the sun-

   19. PAPeter Attia33:28

       Yep

   20. BBBelinda Beck33:28

       ... and converting it in the skin. We in particular, Australia is, uh, you know, we are white people live- living in a Black people's country. We have a very high rate of skin cancer here. Uh, our sun is extremely strong, so we're quite scared of the sun. We cover up. We slather ourself in sunscreen, hats, sunglasses, the whole bit, and to the extent that we've actually set ourselves up to have vitamin D deficiency. And particularly in Tasmania, very south, they, you know, the, there's a high prevalence of vitamin D deficiency. So the, it's important to, um, figure out when is a safe time to be in the sun and ensure that you get a little bit of sun, because it is by far the most efficient way to get your vitamin D. Never go even close to getting sunburn, but you don't have to get sunburn. In Australia, we should be able to get our, our vitamin D requirement before 10:00 AM and, and after 2:00, possibly a little later if you're in a really hot area. Um, in, in Hobart, in Tasmania, in the middle of winter, you would need to stand shirtless for an hour in the sun to get what you needed. So, you know, then you've got to start thinking possibly about supplementation.

   21. PAPeter Attia34:40

       What, what level matters, Belinda? Do you... I know in kids it's... I mean, I don't think any of my kids have ever had a vitamin D level checked, although in an adult we do this all the time. Um, is there a level beneath which you, you would say, "We've got to be supplementing you if you can't do better than this with sunlight"?

   22. BBBelinda Beck35:01

       The problem with vitamin D [laughs] is that nobody can agree. There are two schools of thought. There are two levels that have been published, and people will die in a ditch over those. Um, if you've got pe- smart people feeling that strongly about two different levels, it tells me that nobody really knows.

   23. PAPeter Attia35:21

       What are the two levels that people are dying over?

   24. BBBelinda Beck35:25

       Uh, I think, um-

   25. PAPeter Attia35:25

       30 is probably one of them, right?

   26. BBBelinda Beck35:27

       Well-

   27. PAPeter Attia35:27

       30 seems to be one of the cutoffs

   28. BBBelinda Beck35:29

       ... 30 is, is the, um, I believe is the deficiency cutoff. 30, yeah-

   29. PAPeter Attia35:35

       Mm-hmm

   30. BBBelinda Beck35:36

       ... in nanograms per milliliter. And w- and 50 is considered sufficient.
6. 50:25 – 53:00

   The best sports and activities for promoting bone health, weight training for kids, and advice for parents

   1. BBBelinda Beck50:25

      um, or you mentioned what are the benefits or, and how early should we get kids doing weight training. And for years there were, uh, you know, people were very scared of that and think, "Oh, no, you'll stunt their growth."

   2. PAPeter Attia50:39

      You'll stunt their growth. Yeah, yeah.

   3. BBBelinda Beck50:40

      And, you know, there is no evidence of that, and I don't know where that even came from. I mean, people talk about, "Oh, you'll, you'll compress their growth plates." Why? That doesn't make any sense. [laughs] It just takes a lot to do that. Uh, I'm, I'm not necessarily saying that you should be loading kids up with enormous weights. There's no need for that. But there is certainly nothing to suggest that you shouldn't do resistance training when you're a kid. I, I would say the only reason that you wouldn't do it is if they didn't like it because the thing you don't want to do is, um, discourage a, a child from being active throughout their life. So the best thing you can possibly do is whatever that child loves to do, and then if that happens to be something that doesn't include particularly bone loading, then just try and add that stuff in. Don't, don't force it down their throat. Otherwise you'll... [laughs] It's very counterproductive, as those of us with children know.

   4. PAPeter Attia51:37

      Yeah. I'm really, I'm really glad you brought that up. I've-- I, I, I was gonna ask you, and I, I got a little distracted, but, um, I think this is one of those myths that just drives me bananas. Um, and we, we've looked. I mean, we have tried and tried and tried to find the evidence that suggests that kids can't lift weights, and we're, we're coming up empty. We're just coming up empty.

   5. BBBelinda Beck52:02

      Yeah.

   6. PAPeter Attia52:02

      Um, and, and so hopefully folks listening to this are, are also realizing... A- and I think as a parent, the easiest thing you can do, especially if you have some equipment at home that you can use to exercise, is just have your kids come in the gym with you when you're lifting weights. And, and that's what we do. And, and never once have I said to my kids, "I want you to lift weights." It's just, "Hey, we're gonna go in the gym, and I'm gonna lift weights, and you can do whatever you want." And look-

   7. BBBelinda Beck52:29

      Mm-hmm

   8. PAPeter Attia52:30

      ... there's not much else to do in the gym. [laughs]

   9. BBBelinda Beck52:32

      [laughs]

   10. PAPeter Attia52:32

       They're gonna start picking stuff up. They're gonna start-

   11. BBBelinda Beck52:34

       Yeah

   12. PAPeter Attia52:34

       ... copying you. So-

   13. BBBelinda Beck52:36

       Yeah

   14. PAPeter Attia52:36

       ... um, so anyway, I think-

   15. BBBelinda Beck52:38

       And-

   16. PAPeter Attia52:38

       ... I think that's, that's helpful.

   17. BBBelinda Beck52:40

       It's a great opportunity to teach them technique 'cause that's what's gonna mess people up, not just kids, if they're not doing it right. You know, you don't want a kid just going over and trying to do a deadlift and not doing it right. So there's your opportunity. Teach them from a young age, do a beautiful deadlift. There's a... There is one of the most useful exercises they can do their entire life.

7. 53:00 – 57:15

   The impact of corticosteroid use on bone health in children and strategies to minimize negative effects

   1. PAPeter Attia53:01

      Yeah. I'm glad to hear you say that because my little boys are so competitive with doing kettlebell deadlifts now. Um-

   2. BBBelinda Beck53:08

      Mm

   3. PAPeter Attia53:08

      ... I have to hold them back because, as you know, once they start to try to go really heavy, their technique actually kinda breaks down a little bit, so. Um, I want to talk about another kind of sensitive area with kids that I'm sure you get asked about a lot, which is invariably some kids will have asthma, or they'll have other conditions that require the use of corticosteroids, either inhaled or systemic. And I know that we, we see this in our practice when, when adults come in, and we're surprised to see in an otherwise healthy person astonishingly low bone density. And of course, through our history we realize, oh, you know, you, you were on st- you know, you took prednisone for this many years of your life. So, um, I know that nobody out there, no physician out there, no parent out there is-- takes it lightly. But is there any guidance you can provide as far as the minimum effective dose, or maybe is there some comfort you can provide to a parent that says, "Hey, you know, an inhaler for asthma used at this frequency is not going to impact the long-term bone health of a child"?

   4. BBBelinda Beck54:15

      There's no evidence 'cause we haven't got long-term data as far as I'm aware, and again, not, not really my area. Um, all I can say is [laughs] corticosteroids should be minimized as much as possible throughout the whole life. Um, if a, if anybody, child or adult, is able to, uh, manage their asthma just with Ventolin, which doesn't seem to have any negative effect on, on bone, uh, that is what I would be recommending. Try to stay off steroid inhalers if you possibly can. If you're on high doses, try to, try to titrate them down. Um, see if you can manage in other ways. Uh, I mean, I don't, I don't wanna terrify people, but really there's-- it is ve- abundantly clear that corticosteroids are the enemy of bone, and, uh, the longer you're on them, the more damage they do. Um, beyond the-- if, you know, many people, they're life-saving for some people.

   5. PAPeter Attia55:18

      Yeah, yeah.

   6. BBBelinda Beck55:19

      So, so you have to go on them, and then just get off them as quickly as you can once, once your respiratory condition has calmed down. Um, and of course, if, uh, if you are in a situation where you must take them and at high doses, then you absolutely would probably need to... Absolutely, probably. [laughs] You would really need to consider, um, some bone medication to counteract that. That's what I would be recommending for adults.

   7. PAPeter Attia55:47

      Yeah. A-and maybe the, the lesson here for, for parents, again, is if your child requires being on corticosteroids, well, presumably they really require them. I don't think any doctor takes that decision lightly. But it might just mean that's all the more reason to double down on the other things we talked about, right? Which is if, if your child is on corticosteroids for a medical need, then let's make sure that that's the kid that's getting seven hundred and fifty ml or twenty-four ounces of milk a day, and they're out in the sun every day, and they're lifting weights, and they're doing diverse sports.

   8. BBBelinda Beck56:23

      Yeah.

   9. PAPeter Attia56:23

      Because again, like, let's take everything else and stack it in their favor so that when they come to see their doctor in their forties, the, the doctor will, on the one hand, realize, "Oh, you were on steroids as a kid, but hey, lo and behold, your bone density is actually okay. You haven't been as impacted by it as possible." Are, are children more susceptible to corticosteroids because they're in a developmental phase? Or are adults equally susceptible in terms of... In other words, does it affect kids more because it's affecting them on the way up, or does it affect adults equally because it has just as much of a down impact on them in the maintenance phase?

   10. BBBelinda Beck57:03

       Yeah, I-- that, that would be very much stepping out of my lane to answer-

   11. PAPeter Attia57:07

       Okay

   12. BBBelinda Beck57:07

       ... that one. I don't know the answer to it. Um, all I know is they're bad at any age.

   13. PAPeter Attia57:14

       So I think

8. 57:15 – 1:06:08

   Advice for people in middle age to preserve bone density: physical activity and bone-loading exercises

   1. PAPeter Attia57:15

      we've got a pretty good primer on what, what parents need to be thinking about with, with kids. So now let's turn it back over to the adults. So, um, we're, we're talking about men and women in their thirties and forties. Um, so for most women, they're still on the, on the, on the positive side of, of estrogen balance. Um, beyond what we just said for kids, is there anything you would add to that as importance-- important tools as a person enters middle life?

   2. BBBelinda Beck57:48

      It's actually exactly the same. You've just-- you've got to maintain, uh, your diet and levels of exercise, um, because your bones need th-that-- those two, uh, elements to ma- to maintain. And so in the old days, we, we-- I'm sure you can picture in your head the, uh, trajectory of bone growth, plateauing, and loss. Uh, and the mantra was, "This is inevitable. This is what, you know, that's what bone aging looks like." Um, for years, I've been saying that's what sedentary behavior looks like. That's what the sedentary effect on a skeleton is. I believe that if you maintain your, your levels or increased your levels, uh, from-- of physical activity, friendly bone loading, from the time you were twenty until the time you died, I would be willing to bet that you could go a long way towards maintaining that plateau. And the masters athletes-

   3. PAPeter Attia58:51

      Hmm

   4. BBBelinda Beck58:51

      ... data seems to support that. So if you look at those data, you'll see that b- BMD is maintained in, in masters athletes as long as they're maintaining their activity. There may be a slight loss, yes, but that's probably because the loads that they're able to produce in their, in their physical performance also, um, reduce. But it-- this is a, this is an atrophy effect. This is not a genetically programmed aging effect. And I know that there are many people around the world who would argue with me because I, I don't have much data aside from, um, that sort of... the, the masters athletes long-term data. But, you know, it's im- it's almost impossible to collect those data 'cause that-- those are lifelong studies, and I would, I would be dead before the study would be finished if I started it now. [laughs] So-

   5. PAPeter Attia59:44

      Well, this is, this is a very provocative idea, but I'll, I'll, I'll give you an example of where I think there are, there are two arguments I would offer that suggest you, you could be right. The, the first is, um, when you look at spontaneous activity and movement of people as they age, you see a very similar, um, pattern, which is a relative plateau preservation of not just activity, but lean mass, um, th- followed by a deterioration, suggesting that as lean mass goes down, movement goes down, activity goes down, and th- then it feeds back on itself. It becomes a vicious cycle, and away you go. So again, as you said, it could be that the-- what we see as a, quote-unquote, "physiologic decline of bone loss" is not that. It's rather a proxy for muscle loss and reduced activity. The second point I would argue, again, in favor of this hypothesis, is something that, um, that Luke Van Loon, uh, I don't know if you know Luke, but he's a, a protein, uh, s-scientist, and I had him on the podcast recently, and he, he, he shared something that I thought was fascinating, which is we-- I've always taken it as a given that anabolic resistance occurs due to aging. Because of course We see it clearly with aging. But he, he discussed some exercises, uh, pardon me, some studies that demonstrated that anabolic resistance was most exacerbated by inactivity, and this was done on the cast study. So you take a given individual, you cast one leg, not the other leg. You know, before you do that, you run the amino acid isotopes through them. You do this exercise for two weeks. You take the cast off, so you have an atrophied leg and a normal leg. You do the same amino acid, uh, isotopes, and lo and behold, there's like 40% or 50% anabolic resistance on the leg that was in the cast.

   6. BBBelinda Beck1:01:44

      Mm-hmm.

   7. PAPeter Attia1:01:45

      This is not because they got older in two weeks. It's because they were inactive and, and they lost muscle activity. Well, if that's true, it really suggests that we shouldn't accept anabolic resistance as an inevitability of aging. And, and I'm, I'm quite inclined to, to think your hypothesis could be correct here, which is if you just don't stop the movement, if you just don't stop the exercise, this decline of, of BMD might be far better than what the actuarial data predict based on sedentary behavior.

   8. BBBelinda Beck1:02:20

      I 100% agree with you. Sounds like a Village People s- song, "Don't Stop the" [laughs] "the Movement." And, uh, you know, you only have to look at those beautiful studies that have shown MRIs of, um, [lip smacks] masters athletes' calves compared with an age-matched person who's not active. This is, uh, uh, also compared with a young, um, person's calf. The young and the masters look identical. You know, the muscle volume and quality. There's no fatty infiltration-

   9. PAPeter Attia1:02:53

      Mm-hmm

   10. BBBelinda Beck1:02:53

       ... and the subQ fat is, is virtually nonexistent. Whereas you look at somebody the same age as the masters athlete who's not active, and you've got this shrunken down little sarcopenic muscle belly, that fatty infiltration, and a big wad of subQ fat. And obviously that's, you know, you could, you could select anybody from the population and, and you could make the data look like what it, what you want it to by comparison of those age groups. But, uh, all those the same age. But the, the appearance of that masters athlete muscle essentially, uh, you know, it confirms what you and I are both saying. This is a, this is a sedentary, um, problem. This is not an age problem. And, and of course, this comes back to the problem with the, the-- A lot of people will say, "Well, who cares? I know that, um, 60% of the population will not do enough physical activity to maintain that, so we need to invent, um, drugs that'll do the same thing." As far as I can tell, I, I, I never say never, but I think we will struggle to ever find a drug that will be able to replicate, uh, the action of exercise, physical loading on muscle and bone, because you can't replicate the stimulus. And, you know, any drug that is found to work probably will still need exercise for it to manifest its benefits.

   11. PAPeter Attia1:04:15

       Yeah. And there's another kind of deeper issue there because, uh, as you know, and maybe the listeners as well, um, there is an enormous interest from a pharmaceutical standpoint in anti-sarcopenic drugs. Um, you know, as it stands today, obviously we have anabolic steroids, and they're very efficacious, but they require the training stimulus, as you pointed out. You know, you can give a person all of the testosterone in the world, but if they don't do-- if they don't train, they have zero benefit, uh, or virtually zero benefit, you know, slight benefit. Um, and of course, the holy grail is can we give, you know, agents that can cause muscle growth even absent the, the, uh, the, the, um, the profound training stimulus that, that is needed in other regards. And I always say, well, the answer is maybe, but will it be functional muscle?

   12. BBBelinda Beck1:05:12

       Yeah.

   13. PAPeter Attia1:05:12

       Um, and, and to that extent, will it be functional bone? So even if, you know, a drug like BEMA or an IGF-1, uh, agonist or, um, some of these other drugs or molecules that are being touted potentially increase muscle size, it's not clear that they're gonna increase strength, function, um, and, and, and, and bony composition. So, um-

   14. BBBelinda Beck1:05:39

       I think, yeah-

   15. PAPeter Attia1:05:39

       Yeah, I guess it's just, it's just the nature, I think, of our species. We really love shortcuts.

   16. BBBelinda Beck1:05:44

       We do. Take-- If we can take a pill, why would you expend any effort? And, and that's unfortunately the gene which is gonna be our undoing in terms of, of healthy aging. Um, but, you know-

   17. PAPeter Attia1:05:56

       Right. That, that actually got us very far when resources were scarce.

   18. BBBelinda Beck1:05:59

       [laughs] It did. It did.

   19. PAPeter Attia1:05:59

       That was a very, very helpful, uh, gene in an abundant-

   20. BBBelinda Beck1:06:03

       Yeah

   21. PAPeter Attia1:06:03

       ... in a resource, uh, scarce environment. Um-

   22. BBBelinda Beck1:06:06

       Yeah

   23. PAPeter Attia1:06:07

       ... l- let's,

9. 1:06:08 – 1:10:20

   Bone loss during the menopause transition for women: hormone replacement therapy and other strategies to mitigate BMD losses

   1. PAPeter Attia1:06:08

      let's talk a little bit now about this menopausal transition. Um, again, it's, it's, it's right up there with death and taxes in terms of inevitability. Um-

   2. BBBelinda Beck1:06:16

      Mm-hmm

   3. PAPeter Attia1:06:18

      ... it's an area that I have become intensely interested in, um, because I view it as y- you know, one of the great tragedies of the past 25 years i- is, you know, this very popular study done, the Women's Health Initiative, which was done, uh, p- published in the early part of the, uh, of the century and, and really came to, in my view, a very erroneous conclusion, which basically scared an entire generation of physicians and women away from HRT. Um, and, and as a result of that, not only has there been an unnecessary abundance of symptoms associated with menopause, but I, but I think the real hidden tragedy has been the larger epidemic of, of osteopenia and osteoporosis in a, in a group of women who may have otherwise received estrogen as they, as they went through menopause. Um, so I know that your area of interest is not, or area of expertise is not, you know, in the hormone side as abundantly as it is on the training side. But is there, is there anything on the hormone side that, that you want to talk about beyond what we've already discussed, which is the important physiology, the important role estrogen plays specifically in managing the role of osteoclasts in bone remodeling? And, and, and you know, I assume that most of the women and men, presumably the women of course for the purpose of this discussion, that are coming into this clinic, are they mostly post-menopausal?

   4. BBBelinda Beck1:07:49

      Yeah. The majority would be post. But we got... You know, we, we have thousands of people on the books. Uh, and so that, that number, y- you know, is... of people who are not post-menopausal is, is still substantial. Um, so I think th- the, the years, uh, that we've been open, and we've been open almost exactly nine years now-

   5. PAPeter Attia1:08:13

      Hmm

   6. BBBelinda Beck1:08:13

      ... um, the... an awareness has grown in the, in the community about us. Uh, people who are not post-menopausal but are aware that either they have low bone mass already or that mom or dad or, or granny or grandpa had low bone mass, they want to prevent it. So it... this... one of the happiest things that has happened that people are realizing that premenopause is the time to start, uh, taking care of this issue. So we do have a proportion, but of course most people don't have any idea what their bone health is like until they either have a first fracture or they go through menopause and they have a savvy enough GP who says, "We need to get your baseline DEXA. Let's get you started." And all of a sudden, "Yikes, I have either osteopenia or osteoporosis." Away you go to the bone clinic.

   7. PAPeter Attia1:09:06

      And, and you, you said something very important there, which you and I take for granted. It's v- I think it's very important to reiterate for the, for the listeners, for the female listeners in particular, um, which is you don't want to wait until you're into menopause to replace estrogen. You have to do it during the pre- and perimenopausal stage to get the maximum effect. And again, this is something that I think, um, not enough women are being educated on. And as such, even if they know, "Oh yeah, I've kind of heard that estrogen matters, and this might be a reason for me to consider HRT as part of my decision matrix," you know, they might think, "Well, let me go through these two miserable years of perimenopause, wait till I'm completely amenorrheic, my estradiol levels are unmeasurable, and my FSH is through the roof, and now we should start doing it." No, it turns out that there are data that suggest that they've actually lost quite a bit of bone up until that point. Um, which again, to me is... It's, it's so preventable. Um, so I just... I hope that women listening to this are, are, are sitting with doctors who, who can, can help them through that transition. I'm sure

10. 1:10:20 – 1:18:30

    Interpreting the bone mineral density results from a DEXA scan: T-score, Z-score, and more

    1. PAPeter Attia1:10:20

       many people listening to us have had a DEXA scan. So when you get a DEXA scan, um, sometimes it... So let's put aside the body composition part of it where you see body fat and, and lean mass. Um, sometimes when you get a DEXA scan, it shows you total bone density, and it says your total bone density Z-score is this and your T-score is that, but it doesn't give any segmental information. It doesn't tell you about the lumbar spine or the hips or the femurs or anything like that. Um, and if you look closely, it might even give you a number in grams per centimeter squared, uh, as an actual number. Do you want to just help people make sense of what all those numbers mean? Uh, why, for example, is it grams per centimeter squared, not grams per centimeter cubed as a density? Um, and, um, maybe explain to people the difference between their Z-scores and their T-scores and if anything can be, uh, understood from the total body Z-score and T-score, or if we must be looking at segmental. I know there's a lot in there, but have at it.

    2. BBBelinda Beck1:11:31

       Okay. So, uh, dual-energy X-ray absorptiometry is a low-dose radiation tool, much lower dose than a, than a X-ray of your chest, uh, where... The, the name describes what it's doing. It's sort of sending two d- two energies through the body in a, in a way to determine the density of the tissue it's going through. Now, it is a misnomer. It is an areal density, you know, which is a contradiction. Because it is a planar, uh, view. The X-ray source is underneath the bed. You lie on the bed, and the detector is in the arm above. And it is... It's a projected image of this sort of two-dimensional density. They call it areal bone mineral density, um, because the, the... Without going into too much detail, and I'm, I may screw it up not being a medical physicist, uh, the, the method of measuring is looking at the, at the... what is detected according to the density of the material. So it's not volumetric at all. If you want a volumetric density, you have to look at, um, a three-dimensional, um, method of measuring. Uh, so you can also get bone mineral content and area from the same scan, and they're derived from this density measure Uh, so they talk about it in grams per centimeter squared because it's an areal measure. So the answer to the question, uh, about total BMD, bone mineral density, that is the, the amount of bone that you're observing from a whole body scan. And normally, if your doctor wants to know if you have osteopenia or osteoporosis, they will send you to the radiology clinic, and they will do a standard spine and hip scan. They're the normal ones from which you would diagnose, um, those conditions, not a whole body scan. The only reason you would do a whole body scan is if, like us, we want to look at body composition 'cause we're interested in lean mass. I wouldn't use the value, the BMD value that I get from the total scan as a marker or as any index for osteopenia or osteoporosis because the WHO definition was actually based at the hip. Um, in fact, it, it was based on femoral neck. We've moved away from looking at femoral neck as the standard, and we look at total hip now because there's... it can be quite a bit of variation of femoral neck, um, because of the way that you analyze it. So osteoporosis should be really diagnosed from hip, uh, BMD. According to the definition of the World Health Organization was that a T-score of minus 2.5 is definitive of osteoporosis, but a T-score between 1 and minus t- minus 1 and minus 2.5 is osteopenia or low bone mass. Now, they are-- that's essentially... A T-score is a standard deviation. So what is that compared to? Your value is compared to a reference database, and the T-score is actually comparing your score to what they call a young normal. Uh, it depends on the site, but, um, and, and that does vary, but let's just say it is roughly a 20-year-old, between 20 and 30, uh, of the same race and sex. So a 52-year-old woman is going-- Uh, let's say a 50-year-old white woman i- her value, her BMD value is going to be compared to the average BMD value of a white woman age 20. That's the T-score. The Z-score is ca- comparing your value to someone the same age and sex, so compared to the average BMD of a 52-year-old white woman. Uh, so that is... If you're looking at the plot, and you have the average score goes up, uh, like today we were talking about in, um, uh... Actually, it doesn't go up because we start at age 20. It's pretty much plateauing, and then it begins to go down. So your score will be plotted on there age 52. If you went straight up to the average value, that is what your, uh, BMD Z-score is being compared to, so it's a standard deviation from there. The T-score is being compared to right at the start of that plot to the... And this is-- The reason why they give us these two values is because it's thought that at any stage of your life, if you are two and a half standard deviations away from, uh, the amount of bone that you probably started with, then you are at increased risk of fracture. And obviously, the problem with that is the fact that you could have started higher or lower than that average, and most of us did. S- Very few of us are actually average. Um, but the Z-score gives us information about where you lie in re- relation to your peers and how, how normal that is. And so the, the Z-score is normally not as scary as the T-score, uh, because you will have lost some bone.

    3. PAPeter Attia1:17:08

       Yeah. The way I try to help my patients understand it is that, um, you know, as you said, like I always give them an example, right? Like if your, if your, if your Z-score is zero, you're at the 50th percentile of the population. Um, if your Z-score is one, you're a full standard deviation above the mean, so what's that? You're in the 85th percentile if I'm doing the math correctly. Um, so, and, and obviously, as you said, the T-score is always going to be lower because we're comparing you to a perfect standard. We're comparing you to that super healthy, you know, 20 to 30-year-old. So what we say to patients is, "Look, we want your T-score to..." Like if you show up with a decent T-score, your T-score is zero, and your Z-score is plus, you know, .8, we say the win is keeping that T-score where it is and letting-- and watching the Z-score go up. Because over time, we want you being better and better and better than your age-matched peers because they're going down, and we're going to hold you plateau, and that means we can't improve you relative to the T-score, although I'd love to hear in your experience if you're-- what you're finding there, but we can improve you relative to your peers.

    4. BBBelinda Beck1:18:26

       Yeah. It's a good example. And, and yes, you're right. We

11. 1:18:30 – 1:29:05

    The LIFTMOR study: testing the effects of heavy weightlifting on bone health in postmenopausal women with low bone density

    1. BBBelinda Beck1:18:30

       can incru- improve the T-score.

    2. PAPeter Attia1:18:32

       Well, let's, let's get right to it because this is, this is... You know, going back to the outset of this discussion, Belinda, I, I learned about you l- I don't, I don't even know how. I think I was, like, literally just watching stuff on YouTube and somehow saw a clip, it's probably many years old, from local news in Australia highlighting you talking about the LIFTMOR study. And I-- There's just some-- Like if you look at the things that I can get sucked into on YouTube, uh, it's car videos, uh, F1 videos. Like there's, there's like the, there's this world that just sucks me in, but I'll tell you another one of the things that sucks me in, videos of elderly people lifting weights. I can go down that rabbit hole like it's my I mean, it's ridiculous. You show me a 90-year-old woman deadlifting and, like, that... I could watch that for days. So the... It must be that the algorithm knows that, and it was, it served you up to me. So, um, so let's, let's talk about the LIFTMOR study.

    3. BBBelinda Beck1:19:38

       So I suppose at round about 2013, I, I just g- I got to a point i- in my research career where I, I looked around and thought, "Okay, the, the guidelines for osteo- the exercise guidelines for osteoporosis are get your kids jumping and running and, and playing as much sport as possible. Keep doing that for as long as you can, but then when you get osteoporosis, stop doing all that and just prevent falls-

    4. PAPeter Attia1:20:11

       Mm

    5. BBBelinda Beck1:20:11

       ... so you don't break." And I just... I said, "Are we done? Is this the best we can do? This, th- this, you know, this is lame." I, all my animal research experience had told me that even with very low bone mass animals, if you load them, they, they can grow bone.

    6. PAPeter Attia1:20:29

       Mm.

    7. BBBelinda Beck1:20:29

       The only reason we hadn't been doing that in research is because we were terrified of hurting someone. And so it seemed to me like we hadn't really tried, and at the risk of hurting somebody, we decided to do it. So we had three physiotherapists on that trial, including the PhD student who, who ran it, Steve Watson. Uh, we decided to do a brief, because bone doesn't need a lot of loading. You don't need to run a mar- marathon. You just need to do one sprint to get those bone cells stimulated. So we had twice a week, 30 minutes, four exercises, and we wanted them lifting heavy, so it was 85% 1RM. Uh, we used compound movements because we wanted them, you know, this needed to be an efficient, um, sort of, uh, project. We wanted to involve as much muscle as possible. It needed to be weight-bearing, and we wanted something that would transfer to really useful daily activities. So clearly a squat and a deadlift was gonna be fundamental. These are fabulous, uh, compound movements that they tick all those boxes. And these are not on machines. This is with free weights because you want to engage as much, um, of those other systems and capacities as possible. We're trying to improve balance 'cause we're trying to stop people falling. So away we went. It needed to be... Ideally, we wanted it to be 12 months because you do need a fair amount of time to be able to detect change on DEXA because DEXA ionizing radiation picks up mineral. So you can't just measure new bone, which would be the osteoid unmineralized. You need a full, um, period of time to allow for a full remodeling cycle and mineralized bone. Because it was a PhD project, we couldn't afford a full year for each, uh, every person, so we just made it an eight-month intervention, which I was confident would be enough to detect a change. We did really comprehensive, uh, bone and functional measures at baseline. We recruited about 100 people, randomly allocated them to this high-intensity resistance and impact training, and a... Because in research you, you have to... Exercise research is really hard to blind to your participants, and, and blinding is so important in clinical trials. So we had to not tell our participants which was the intervention that we thought was gonna be effective. We just said, "If you got randomized to this low-intensity home program, we were trying to see whether that worked too." Of course, we knew that that was not gonna work because we've got years of experience to know that that is not gonna improve bone. But we gave them things like walking, stretching, some body weight lunges and toe raises, and things that would potentially improve their balance. So we weren't completely ripping them off. So then we had eight months of this intervention. It was supervised by-

    8. PAPeter Attia1:23:29

       And sorry, o- once again, Belinda, you said the, the, the treatment group was 20 minutes three times a week?

    9. BBBelinda Beck1:23:35

       No, 30 minutes two times a week.

    10. PAPeter Attia1:23:37

        Got it.

    11. BBBelinda Beck1:23:39

        Yeah. Uh, maximum group size was eight, and we recruited post-menopausal women. So we were looking for people. We, we advertised for over 60, but I think we did recruit one person who was 58 because she had been through menopause when she was young. Um, and they just needed to be well clear of menopause. We didn't want to be fighting that withdrawal of estrogen phase. Uh, and they needed to have low bone mass, so they needed to be at least a T-score of minus one, uh, at either the, the spine or the hip. So away we went, and I have to say we were looking through our fingers for a little bit, and we were so incredibly conservative to begin with and just being very careful that we weren't hurting anybody. It became abundantly clear very quickly that we weren't hurting anybody. In fact, we were making people feel a lot better.

    12. PAPeter Attia1:24:37

        Just let me just ask you about that because a- again, I, um... The video, which we'll link to in the show notes, was, even though it was just a local news segment, was just really inspiring. Um, I think there were women there that were at some point basically able to pick up their body weight. I mean, is that... Am I remembering that correctly? Like, literally these women were deadlifting their body weight. Um-

    13. BBBelinda Beck1:24:59

        Yeah, yeah

    14. PAPeter Attia1:25:00

        ... how did you even train them to do this? So you re- these, these, these, these women show up to this study and, you know, they're probably told it's an exercise study, so they think, "Great, I'll be doing, you know, pool jogging or something." And then you drag them into a weight room with Olympic bars. Um, how did y- how did you even go about getting them to do this safely? How did you... How much, how much resistance was there on their part to, to the fear of weightlifting? Uh, I assume prior weightlifting experience was not an inclusion criteria?

    15. BBBelinda Beck1:25:34

        No, they could have had it, but they couldn't have been doing anything in the past 12 months because you know bone is a lose it or use it, use it or lose it tissue. So, um, you know, they, they needed to not be already doing this. Um, we described it as, you know, we told them what the basic exercises were, so these had to be people who were willing to do this. Um, we never throw somebody straight into lifting something extremely heavy, and certainly nobody would have expected that we're gonna-- we would end up with people lifting their body weight, certainly least of all us. Um, we just did it very systematically. We... You know, you start with a broomstick, and you make sure that people's technique is good. And I have to tell you, we had people with fractures, so they had existing kyphosis. And you know what a kyphotic curvature looks like in a deadlift position. This is not a pretty thing. But-

    16. PAPeter Attia1:26:33

        [chuckles]

    17. BBBelinda Beck1:26:34

        ... as long as they had an extensor moment, uh, it was okay. We don't want people flexing and lifting weight because then we're putting them at risk of fracture. But it's all in the coaching, and it's, this is the reason why it's so important that the person who is coaching somebody with osteoporosis knows what they're doing. They don't just... They can't just be a strength and conditioning coach, although that really helps. They have to have an understanding of... They have to have some clinical training. So because people come to you in a clinic with not just osteoporosis but, you know, pelvic floor dysfunction, frozen shoulder, spondylolysis, vertigo, just every... Neo-A, you've got to be able to manage that. Uh, many of those conditions were actually screened out of the LIFTMOR study because it was the first time we were doing it, and we didn't want to have to manage all of that. But I just put it out there because it's something I d- I, I want to remember to talk about. Um, so it was all about just systematically training them in the technique and, uh, and then gradually increasing the load. And a lot of people think of older people, and particularly older women and particularly post-menopausal women who, you know, the assumption is they go completely loopy through menopause, which is not true. Um, they think about old people as completely incapable, incapable of doing stuff and incapable of learning. But old people are you and me who just kept living longer. It's we, you know, we have the capacity to learn, and, and older people are perfectly capable of learning how to do a deadlift and a squat. You know, it might be pretty ugly to start with, but they get better. And as they get stronger, they get even better. So-

    18. PAPeter Attia1:28:22

        I, I just, I just love it so much. I cannot... You know, for, for people listening and not watching right now, just the, the grin on my face listening to you talk about this, it just warms my, my heart. Um, and, and again, it's, um, it's-- I, I, I just agree with all of that. I think that, um, uh, uh, one of the saddest sort of, I think, misconceptions people have is that once they get to a certain age, it's too late. Um, and they sort of accept their fate. And, oh, I have this kyphotic spine, and, oh, my bones are too brittle, and I guess I'm just gonna spend the next decade of my life doing nothing. Um, and, and studies like this demonstrate that that's, that's not the case.

12. 1:29:05 – 1:40:48

    Profound benefits of weight training outside of BMD improvements: exploring the broader impacts on patients in the LIFTMOR study

    1. PAPeter Attia1:29:05

       And, and so, um, uh, uh, I- I'm looking for some of the other kind of soft stuff as you think about the, the evolution of this study. I mean, what, what else did you notice in the subjects? What did they tell you? What was their-- How did this translate into the rest of their lives? Because obviously-

    2. BBBelinda Beck1:29:20

       Hmm

    3. PAPeter Attia1:29:20

       ... you as an investigator are, are, are looking for something very specific, right? You want to probably understand how much muscle mass they put on, what their bone density did, how much their T-scores changed. But were there other things that you learned about these, these women as the study went on that, that spoke to their quality of life?

    4. BBBelinda Beck1:29:39

       Oh, yeah, undoubtedly. And, and for them, that was the most important thing, and that's what makes... That is what made me want to open the clinic. This is a quality of life issue. This is-- It turns out this is not a bone, [chuckles] a bone issue. I'm a bonehead. I care about what their BMD scores did. But the reality is comments like, "Oh my God, Belinda, I can see my shoulders in the mirror again," you know, because their posture changed. The fact that we have... You know, when you do a clinical trial, you measure height and weight as the standard baseline how to describe your population. Who knew that we would actually be citing height as an outcome? Because the control group shrank, whereas the, uh, the intervention group grew a little. Of course, they didn't grow, but their posture improved to the extent that they were taller at the end of the, the study, and the difference between groups was significant. It was only half a centimeter, but hey, wouldn't you prefer to maintain-

    5. PAPeter Attia1:30:39

       That's in eight months. I mean-

    6. BBBelinda Beck1:30:41

       Yeah.

    7. PAPeter Attia1:30:42

       Yeah.

    8. BBBelinda Beck1:30:42

       And so those, if you like, soft outcomes, you know, people saying, "My husband is hiking the Kokoda Trail, and I, and I just thought I was gonna be cheerleading. I can go with him now. I've got this, this incredible strength. I've basically got my life back. I can, I can get into the garden, and I can, I can push the wheelbarrow full of potting mix around now, and I'm, I don't feel like I'm gonna break." And-

    9. PAPeter Attia1:31:10

       Hmm

    10. BBBelinda Beck1:31:10

        ... you know, "I can lift my grandchild again. Um, I can get my own shopping out of the car." You know, so it's, it's all about independence, um, yeah, quality of life. We measure quality of life as well, and, and, uh, at the, at the clinic, it's, it's pretty obvious that that is something that is improving.

    11. PAPeter Attia1:31:34

        So what did you find after eight months with respect to, to muscle mass, bone density, and the other sort of clinical metrics?

    12. BBBelinda Beck1:31:42

        Yeah. So, um, we ended up with a net benefit of a bit over 4% at the spine. That, that equated to about 3% improvement at the spine in BMD and about one and a half or one and a bit loss in controls. The-- I would say that this program definitely has the biggest effect at the spine, which is, you know, uh, that is a good thing because it's one of the places that, that fractures most frequently. At the hip, it was a real head-scratcher. When we-- when I first looked at the results, we had something like a 0.6, uh, percent improvement at the femoral neck, and I'm thinking, "These women deadlifting and, and squatting 70 kilos, how can that be?" We ended up with a significant difference because the controls lost two and a half percent, so there, you know, there was a net benefit. But I couldn't figure it out. Luckily, I have some 3D hip software which allows me to reanalyze my 2D BMD data from DEXA and look at the geo- changes in geometry. From that, you could see, uh, things like, um, cross-sectional area of the femoral neck, cortical thickness, and so on. When you look at cortical thickness of the total hip-- uh, sorry, total femoral neck, there was a 13% net benefit, uh, in the intervention group. And if you looked specifically at the lateral femoral neck cortex, there was a 27% improvement. So it turns out that if, if, if you were just looking at BMD from DEXA, it would look like, you know, this kind of lifting only has a maintenance effect at the hip. But actually, what's happening is it's changing the geometry. It's making it stronger by making the cortex, that cortical bone, thicker and more resistant to, uh, to bending. So that was a, you know, another of those fantastic moments where I had only just got this, uh, software and, and it was just in time to show this really novel outcome.

    13. PAPeter Attia1:33:55

        Uh, I think that's such an important point, by the way. And, and given that most of us clinicians don't have access to that, um, can we, in your opinion, rely on the stabilization of the Z-score, uh, or the improvement of the Z-score, the stabilization of the T-score as a win if we're in that situation? So we have that patient who comes in at a minus two. You get them on a strength training program. They're putting on muscle mass. The, the Z-score gets better, but the T-score does not. You still say, "Look, you're probably winning," even though you don't have the, the radiographic tool to document the cortical bone thickening?

    14. BBBelinda Beck1:34:33

        Yeah. If you can maintain bone mass [chuckles] at the hip, uh, uh, or bone mineral density, yes, that is absolutely a win. And, you know, don't get me wrong, there were some people who probably the, the largest gain we had at the hip in the LIFTMOR study was about 6%. So there were some people who improved BMD. But, um, yeah, on average, it's, it's something that you don't always see and-

    15. PAPeter Attia1:34:56

        The important thing I think for people to understand here is even if going on this type of a training program at best maintained you, let's assume even the cortical thickening was maintained, there's two important points to consider. The controls are having the floor dropped from underneath them.

    16. BBBelinda Beck1:35:18

        Yeah.

    17. PAPeter Attia1:35:18

        So that gap between what you would be doing and what you're doing is widening even if you're not getting better. So a- the fact that you're even getting better slightly is mind-boggling. But even if you don't, the, the gap between where you are and where you would be is enormous.

    18. BBBelinda Beck1:35:36

        Yeah.

    19. PAPeter Attia1:35:36

        The second point is your fall risk is going down dramatically because you're putting on muscle mass, and to the very important point you made, you're using these free weights, and you're getting-- you're improving your balance. So you have more muscle, more balance, more motor control. You're-- The, the likelihood of falling to get in the position that you're gonna break a bone is going down so much. So when you add to the fact that, oh, and by the way, cortical bone is increasing by 13%, like this is just a win, win, win, win, win across the board.

    20. BBBelinda Beck1:36:11

        I know. Show me a bone drug that does that. [chuckles] So it's a, uh... If you look at our functional outcomes, we had back extensor strength, leg extensor strength, and then we had tandem walk, timed up and go, sit to stand, vertical jump, and we also, um, measured kyphosis. All of those things improved, but especially, uh, lower extremity strength and back extensor strength. Now, people think, "Oh, well, back extensor strength, yes, it's just making them stand up straighter." But it's, it's not a-- there's no just about it. If somebody has kyphosis and their posture is such that their vision is angled downwards, they've lost that peripheral vision for, say, when they're walking to their car at the shopping center, which is not their, their comfortable environment. S- um, perhaps a little kid runs out in front of them, and they haven't seen them coming, and that's when a fall can happen on a hard supermarket floor. Um, you know, walking outside their own home and the neighbor's dog runs out, you know, they don't see it coming, they get a fright, and they'll fall. So posture is actually really, really important to fall risk and risk of, of fracture 'cause we know pretty much half the time you fall, you're gonna fracture.

    21. PAPeter Attia1:37:30

        Uh, I would add something even more to that, which is, um, you know, uh, we, we, we, we have, um, a couple of folks in our practice who are really, um, forward-thinking in their understanding of the role of vision in brain health. And, and we know this is true with auditory stimuli as well, right? So we, we know that, you know, hearing loss is a risk for dementia because it's reducing sensory input to the brain. And, um- You know, w- we would argue that you see the same thing with the reduction of visual input. So a, a reduction of visual input is a reduction of cortical stimulation, cortical meaning brain cortical, um, and that's also increasing problems. So in addition to everything you said, which is this increased risk of falling as vision is getting narrower, uh, you're also reducing kind of brain input and, and I think you run the risk of also exacerbated or accelerated, uh, degeneration of the brain. So yeah, I, I, I, I agree with you completely. It's not that you just reversed kyphosis. That's a really big deal to get somebody looking up and forward. Um, yeah, it's just... I, I mean, the other things that I'm sure you saw were improvement in grip strength, so there's another benefit because you can't deadlift without grip strength. So if a, if a woman's picking 70 kilos off the ground, think of how strong her hands are and think of the implication of that on mitigating fall risk. You think about that person walking down a flight of stairs, now imagine the grip they have on the handrail as they confidently walk down the steps. And you, you know, you think of the devastating injuries that, that people can have of any age, but certainly older people, um, when they can't hold onto a handrail and then they don't have the leg strength to stop themselves going down the stairs. Uh, I mean, a- again, I, I... J- just to reiterate this point that we can't make enough, which is, yes, there are some really interesting and exciting drugs on the horizon for the management of this. Yes, pharmacology and endocrinology play a very important role in managing these things. I would argue estrogen more than any other drug out there. But none of these things compare or should ever be thought of as a substitute for what you're describing.

    22. BBBelinda Beck1:39:45

        No, that's right. Um, you know, I, I sort of briefly mentioned the tandem walk and sit to stand and timed up and go and vertical jump, and all of those things are risk factors, uh, or predictive of your risk of falling. So yeah, we do know that improving those things reduce your risk of falling. Um, you're, you're quite right about grip strength. I, I do as much of this lifting as I can, but I'm frequently... You know, I've just been to Europe for a month. I've been to the US for a month, and, and my lifting falls away. So I come back to the, to the gym and go to lift again, and whereas my muscles m- my, my major lifting muscles may be okay, but I end up on my last set, I am just holding onto that bar with my fingertips 'cause my grip strength goes. So it is absolutely part and parcel. This is why these Olympic lifts are so incredibly helpful, because they are compound movements using virtually every muscle in your body, including if you're frowning [laughs] while you're doing it.

    23. PAPeter Attia1:40:47

        So

13. 1:40:48 – 1:48:47

    Guidance for people wanting to use exercise designed to improve their bone health

    1. PAPeter Attia1:40:48

       Belinda, there's, there's no chance that anybody listening to us at this point would call into question the value of, of, of this type of intervention. So now the question is, for virtually everybody listening to us, they don't have access to you, and they don't have access to your clinic. Um, so what, what would, what would be the advice for the men and women who are coming, coming to this discussion or who wanna send this... You know, people listening to this who wanna send it to their parents or, or, or loved ones who, who really are showing up and are in the same state that the women were in at the beginning of your study. How can we take that person and provide them with the safest environment to go forth and conquer? Because again, if you're saying all you gotta do is 30 minutes twice a week of this very, very specific type of lifting protocol, which is, again, very straightforward, um, in, in concept. Uh, obviously in technique it requires execution. How can they go about doing that? Who, who would you recommend they see? What type of individual to coach them?

    2. BBBelinda Beck1:42:00

       So, um, there's, there's levels, uh, uh, to that answer, and without being a... You know, turning this into an advertisement for, for Oneiro, which is what the program is called that we deliver through the, through the, uh, The Bone Clinic. Um, you know, this is... We-- Because we get that question all the time. The minute I opened The Bone Clinic, everybody wanted the program, and the problem is I didn't want to initiate a, a, an avalanche of fractures for people doing the program and hurting themselves. So we decided to license it and provide that program to physiotherapists, what you call, you guys call physical therapists, and accredited exercise physiologists or their equivalent. And we have licensed... There's probably about 60 in Australia at the moment and a growing number overseas now. It's just starting to take on in the US, but it, it's... You know, I'm a, I'm an academic, so I'm not a salesperson. I don't sell this. People come to me, and I'll, and I'll... You know, that's how they get it. Um, the be- very best way that... Th- this, the training for that is a very comprehensive six hours online. You must have these qualifications to do it, and then you're ready to deliver it to your patients in your clinic, uh, as long as you have the gear. And, and they've always got access to me and a lot of supportive information to do that safely. And the reason I want physios and EPs to deliver it is 'cause they have that background information that I was telling you about, that clinical training that allows them to look after the millions of different con- comorbidities that are gonna come into their clinic.

    3. PAPeter Attia1:43:44

       So tell us again, Belinda, just to make sure everyone's hearing this, and we'll link to it in the show notes, but the... What's the name of the program? Where can somebody go as a, as a, as a exercise physiologist or a physio to become accredited in this program?

    4. BBBelinda Beck1:43:59

       Yeah, so that's a, it's a, Ownero is the name of the, of the program, and they just need to Google Ownero, Ownero Academy, or they will-

    5. PAPeter Attia1:44:06

       O-N-E-R-O?

    6. BBBelinda Beck1:44:09

       That's right.

    7. PAPeter Attia1:44:09

       Okay.

    8. BBBelinda Beck1:44:09

       Yeah. Um, and the... Yeah, I can give you the Ownero Academy-

    9. PAPeter Attia1:44:14

       Yep

    10. BBBelinda Beck1:44:14

        ... um, website.

    11. PAPeter Attia1:44:14

        Okay. We'll link to it. Yep.

    12. BBBelinda Beck1:44:16

        And they can read about it.

    13. PAPeter Attia1:44:16

        Okay, so, so, so it's a, this is not something that the patients go to. This is something that the trainers go to to become accredited. So if, if a person is listening to this and they want to be trained, can they go to that site and find out where the accredited people are?

    14. BBBelinda Beck1:44:35

        Yeah. Or well, go to The Bone Clinic site, and we host a map, and if you zoom in on your area on that map, you'll see a little, little red tag.

    15. PAPeter Attia1:44:44

        Okay.

    16. BBBelinda Beck1:44:44

        If you click on the tag, the contact details of that Ownero provider will pop up. Now, as I say, at least in the US, not a huge number of them at the moment, but a, the demand is so incredibly high in the US, really, um, the best thing that you could do if you were in that situation and you wanted to go to an Ownero provider is go to your local, um, PT or, um, or kinesiologist, exercise physiologist, some equivalent, and say, "Okay, you need this program. Here's the website. Contact Belinda," and I can get them licensed, and they can, away they go. It's, for me, it's research. They, there is a, a way for them to contribute to our research program. I give them access to our database. I'm really interested in making sure that this works, not just in our hands.

    17. PAPeter Attia1:45:34

        Mm.

    18. BBBelinda Beck1:45:34

        And so that's part of my research. But for them, of course, it's a revenue stream, so it, it is a win-win for them. For the patients who cannot convince anybody to do Ownero, then the, the next best thing would still be to contact The Bone Clinic. We can do a telehealth, uh, appointment with them and give them our very best advice for a program that they can do either at home or at a gym. If they're not, if they don't want to do that, then the next best thing they can do is just go to the gym and get some gym program. Just anything is better than nothing, and start lifting weights, and try to get some supervision because if you've got a T-score of minus four, I'm not comfortable with you training by yourself. So even if you're not doing Ownero, get somebody to look after you.

    19. PAPeter Attia1:46:24

        Mm-hmm.

    20. BBBelinda Beck1:46:25

        Um, so those are the sort of three levels. If you can find an Ownero-

    21. PAPeter Attia1:46:28

        Yeah

    22. BBBelinda Beck1:46:28

        ... provider, do supervised Ownero. If you can't, call, uh, email The Bone Clinic, and we'll, we'll do a telehealth appointment and get you a program that you can do, uh, which would be the, the very best that we can come up with that you could do unsupervised. And then the next level down, just get yourself to the gym with someone supervising you and do some weights of some kind.

    23. PAPeter Attia1:46:53

        I guess I'm gonna add a fourth one, which is I've been to the Gold Coast many times. It's absolutely spectacular.

    24. BBBelinda Beck1:46:59

        [laughs]

    25. PAPeter Attia1:47:00

        I think a trip to Australia is never a bad thing. Maybe, maybe scrap the telemedicine visit and just take a two-week vacation to the Gold Coast and, uh, get some time at the clinic maybe.

    26. BBBelinda Beck1:47:11

        We'd love to see you. Actually, the clinic's in Brisbane. I live on the Gold Coast 'cause that's-

    27. PAPeter Attia1:47:15

        Got it

    28. BBBelinda Beck1:47:15

        ... where Griffith University is.

    29. PAPeter Attia1:47:17

        Yeah, yeah.

    30. BBBelinda Beck1:47:17

        But the clinic's just up the road. [laughs]

Episode duration: 1:48:47