The Healthy Ageing Doctor: Doing This For 30s Will Burn More Fat Than A Long Run! Dr Vonda Wright

Do you only have to do that for 30 seconds? That will burn 40% more fat than even high-intensity interval training. Really? So, it begins with Dr. Vonda Wright is a renowned orthopedic surgeon and a pioneering researcher in mobility and aging. Through simple methods, she enables people to maintain their strength all the way through till their later life. We have no excuse until our mid-70s for slowing down. These are MRI slices of a 40-year-old athlete. We have beautiful muscle architecture, but if we sit around for 35 years and have a desk job and we don't go move our muscles, this is what happens. Jesus. My god. But, this is a 74-year-old who had just invested in their mobility four to five times a week. So, if you're an 80-year-old consistently lifting weights, you are functionally as strong as a 60-year-old person who doesn't. But, I worry about joint pain. Is joint pain inevitable? It is not, but one reason people have pain is because of how much we weigh. Small changes in our total body weight can have profound effects on the joint pain we feel. Let's say this rock is 1 lb. If you gain 1 lb, you would think that this is all the amount of pressure you're going to feel, but because of the mechanics, what you actually feel is the weight of these bricks. So, you think gaining 10 lb doesn't mean much, but imagine gaining 100 lb of pressure. So, how should you be investing in your mobility every day? There are four components that we should try to find time for. Number one is Quick one before we get back to this episode. Just give me 30 seconds of your time. Two things I wanted to say. The first thing is a huge thank you for listening and tuning into the show week after week. Means the world to all of us, and this really is a dream that we absolutely never had and couldn't have imagined getting to this place. But, secondly, it's a dream where we feel like we're only just getting started. And if you enjoy what we do here, please join the 24% of people who watch this channel regularly and have hit the subscribe button. Means more than I can say. And if you hit that subscribe button, here's a promise I'm going to make to you. I'm going to do everything in my power to make this show as good as I can now and into the future. We're going to deliver the guests that you want me to speak to, and we're going to continue to keep doing all of the things you love about this show. Thank you. Thank you so much. Back to the episode. Dr. Vonda Wright, you've been treating patients, learning about medicine, taking care of people, and working in the industry you've worked in for almost 35 years now. To do that, Yes. you must have a great deal of passion. You must be on a bit of a mission. So, my my first question to you is as you sit here today, what is what is occupying your your focus, your mind, your passion? What is that when you wake up in the morning and you think about the work you're doing and why you're doing it? What is the answer to that? The answer to the question of why I wake up every day and and rush into my work, whether it's into the surgery or whether it's into taking care of individuals or writing, is because I have been working under the mantra of um I'm going to change the way we age in this country or in this world. Because when I started, there was this steadfast belief. Doesn't The national zeitgeist has changed now, but when I started, there was this belief that aging was an inevitable decline from the vitality of youth down a slippery slope to frailty where we would spend 20 years of our lives dying, going to the doctor's office every 3 years. And I never ever believed that. I never believed it. And maybe it was because when I was a child, I lived at in the '70s where you could just take your kid with you to a race, and my dad would do that. I mean, he'd take me to a 5K and say, "Wait here. I'll be back in 20 minutes." And I would see people in their 50s and 60s racing and they would be celebrated or or maybe it's because I started as a cancer nurse and I saw people fighting every day for their lives and I believed that that was not the destiny that we were that we were doomed to. So, as I progressed through my career and I started doing the research myself, I realized that this myth we had in our country that or all over the world that aging had to be this inevitable decline was based on population studies. And what does that mean? Well, population studies just look at a cohort of people and see what happens over time. There's a huge study uh funded by the NIH in the United States called the Health ABC for instance and they looked at a population of 70-year-olds and just followed them over time. Well, what do we know about populations of people? Well, what we know is that up to 70% of them do not do one extra step of mobility a day. So, what we know about aging has been what we know about sedentary living. And so, I did not believe that we truly understood how the trajectory of our aging could be for people who remained active across the course of their lives. So, my team and I did that original research and we proved that you can be healthy, vital, active, joyful long into the foreseeable future much more than we gave ourselves credit for. And it drives me because even over all these years, 35 years, 20 years of it as an orthopedic surgeon, it is only now that people are beginning to pick up the mantle of prevention and not only disease care. And so, sometimes I sit back and I think, "Oh my god, you know, I've been preparing for this time in the history of people my whole career." So, I am made for such a time as now. So interesting cuz it's only in recent times, I think from doing this podcast, that I started to question the idea, the sort of mind virus that even I had, that once I get to a certain age, I just have to kind of concede to the inevitable decline. And it's only recently that I thought, "Actually, there's a been a couple of people that have came here and told me about how to have that that that's not the case. And actually, it is a bit of a mind virus. Mhm. Like the virus of that belief, the impact of that belief, is what causes you to give up. Yes. uh become frail and to stop moving and those kinds of things. Well, because with that, our brain tells us, we know this, I've been you've had many discussions about the connection between our brain and our body. Our brain will believe whatever we tell it. And if our brain thinks that, oh, sometime 63, a light bulb goes off and we go from youthful vigor to aging and decline, well, then we start believing that about ourselves. And you know, there's a concept now that I work with all the time that really examines the difference between life expectancy. In the UK, life expectancy right now is 81. Unfortunately, in the United States, it's 77.6. From the from birth, babies born now have a life expectancy of that much. Our health expectancy, our health span, the amount of healthiness we have, is only about 63. So, that gives us a huge runway to change the trajectory. And it also tells us that we're not dying at 63. We're dying on average at 81. So, we can do everything we possibly can in those 20 years. And we also know that 70 to 80 to 90%, depending on who you believe, of our health and aging is predetermined by our lifestyle choices, not the genes we inherit. So, my mother is very thankful that I stopped blaming her for all the health things that go on, but but each and every person has the ability to live outside of their genetic predisposition. And that is a very hopeful message that can pivot your mindset virus. I I took the top sort of illnesses and diseases, things like heart disease, lung cancer, um I can't even pronounce this one, chronic obstructive pulmonary disease. Yeah, COPD. Strokes, lower lower respiratory infections, Alzheimer's disease, type 2 diabetes. I can't pronounce this one either, colorectal cancers. Colorectal cancers. I nailed that. Breast cancer and prostate cancer. And I got the average ages that typical people typically get them. Then I weighted it by the amount of people that die um from each of those diseases with heart disease being the most popular. Yeah, it did actually come up. I used ChatGPT. I'm pretending I did this math for myself. Uh it came up that 62.94 years old chk is the exact age where on average I'm going to get one of these and I'm going to potentially die from one of these. Those are when they manifest. You may have them before then. to Maybe you never knew it because I have people who say to me when I ask them their health history, "What medical problems do you have?" And they're like, "I don't have any." Only because they've never been to a doctor. Mhm. Or maybe they've been diagnosed, but they haven't gotten so bad that they're not spending 3 days a week in the doctor's office. Or maybe they are they are sick. Those three categories, right? But your ChatGPT data is correct that that is when it shows up. And what does that correspond to? That corresponds to when the average person retires. So, just when you start thinking you have time to live the life that you envision, you're saddled with health problems that you have not taken care of. But but think about it this way. Talking about this mind virus and how we need to change it, um we can talk about this, but I think that 40 is the most remarkable decade of a person's life and it's also the time to adult or get your proverbial expletive together. It's time to get it together from a health perspective. Well, between 40 if you're just noticing your health at that time because maybe you've been working so hard and you never noticed it before you're raising other people or whatever the circumstances are. Between 40 and 63, you have time to course correct. But if you decide at 63 to pay attention, it is much much much harder. And so, you know, part of my mission, you asked me why I wake up every morning to change the way we age in this country, is to not only take care of people in my demographic, my middle-aged demographic, but to really get to my millennial children and my millennial nieces and nephews to say, you have such control of your health if you just look up and pay attention. What's your academic education? Can you run me through your sort of qualifications and how that pivoted and turned uh throughout your career? Sure. I have a degree in biology uh from Wheaton College and then immediately after that uh there was such a shortage of nurses that they the Rush University said, "If you have a good bachelor's degree, come. We'll give We'll train you in another bachelor's degree in nursing and a master's degree in 3 years." So, I did. And with that, I went and took care of people with cancer and ran the Rush Cancer Institute with the physician that was there at the time. And then at 28, I decided to that through a series of decisions, we can talk about that um I wanted to do great research, but I still needed to take care of people because it is in my heart and soul to do that. And so I went back to medical school at the University of Chicago at 28 only to choose the longest possible road, which is orthopedic surgery, which is an additional 11 years because it's 4 years of medical school, 6 years of residency, a year of fellowship and then I finally emerged. What is orthopedic surgery? Oh. Explain like I'm a 10-year-old. so orthopedic surgery is the lifetime care of the musculoskeletal system. So, what that includes is bones tendons, ligaments muscle, adipose tissue. It's the joints the from the spine to the shoulders, hips, the knees. It's everything from cancer care of those organs through each one of those has a subspecialty, hand, uh foot. Sports. I'm a sports surgeon, so I'm trained in shoulder, hip, and knee arthroscopy. Meaning I do very big surgery through very small apertures uh for athletes and active people. Um but this fun orthopedic sports career I've had of taking care of active people and athletes of all ages and skill levels extends outside of the operating suite, right? I have I take care of the whole person, which is unusual for an orthopedic surgeon. Usually orthopedic surgeons are very procedurally driven, but I am whole person driven. And I think that stems from at 23 years old taking care of people's in the fight of their lives knowing that their whole lives are worth taking care of not just pushing chemo in the middle of the night. When you say you focus on the whole person, can you help me understand that? Cuz I think on one end of that spectrum is doing the surgery Yes. which you do. Mhm. And then is the other end of that spectrum thinking about their I guess their psychology, their emotions, their how they're feeling, what's give you a few examples. So, if you're a uh you think of a sports surgeon taking care of young athletes. So, if I have a young athlete come in who I have I'll give you an example of a real person. He's 19. He has been an athlete his entire life and just and been great at it, right? But never been hurt. Had the great fortune of never being hurt until he stepped wrong. He got slide tackled on the football field and he blew out his knee. And his family was moving, so he didn't get immediate care like he could have had he been in his own town. So, weeks later he shows up to me with a knee that's completely non-functioning. This child, who's a 19-year-old man, is panicking in his brain. He doesn't know why he's in so much pain, why his knee won't work. Um psychosocially, his family is in transition. They don't have any of the support system and he no longer has his own team. So, that young man is dealing not only with the physical pain of injury. He's dealing with the psychological anxiety of oh my god, oh my god, oh my god, what just happened to my knee? Will I ever play again? And they're dealing with the social aspects of here's a family without social support. So, as a whole person doctor, realize severely in this family not no not only is there sports surgeon, you have an ACL tear, your meniscus torn. Here's how I'm going to fix it. Here's what we need to do before then. Here's the technical aspects of the surgery, but how much protein are you eating because I need your body in tip-top shape to heal. So, I talk to my patients about their nutrition as well as their surgical. But then from the perspective of I too am a mother with a lot of children thinking of myself, how am I going to meet the needs of my child? Thinking of the mother, she has no resources in this town. She just moved here, right? Trying to set them up with the the other people they will need to be surrounded with care. And that approach to this individual family is exactly the surrounding them with care approach we take with professional athletes. There is not one thing that is left unturned for a professional athlete. We take care of them from the minute they wake up to the minute they go to bed and their family needs. So, this whole person care extends all the way across all types of people. For a woman, for instance, who comes with a which is so typical for midlife women to come in with an inflamed shoulder, a frozen shoulder, she'll come in because her shoulder no longer moves. But, knowing what I know about the life cycle of a woman and what happens in midlife, before I even address the shoulder, because sometimes they come in saying to me without any prompting, "I think I'm falling apart and sometimes I think I'm going crazy cuz I didn't do anything to my shoulder, right?" When they say that to me, we immediately start talking about, "Well, how are you sleeping? Are you having any hot flashes, night sweats?" So so that I address them as a midlife woman who's lost her estrogen, not just as a shoulder that doesn't work because for me that's pretty cut and dry. It's the rest of it that truly is taking care of the whole person. So, that's what it means to me. Mhm. It's um it's personal to you, isn't it? I I feel like you have a great deal of empathy. I can feel it on your on the surface of you. I can see it in your face. Yeah. Where does that come from? Mhm. You know, I think I think that I'm a much better Listen, you make people cry on this podcast and I think you're going to make me cry and I don't mean to, but that kind of question, I think that this unrelenting need to take care of the whole person has to have come from my time as a cancer nurse. Because I was only I was only 22 22 to 28. I was a cancer nurse and imagine what it's like to be so impressionable, right? You I got all this education but in the middle so my job was giving chemotherapy to people who were in the struggle of their life and I'm 23 years old. And chemo is pushed in the middle of the night. And at the time in the 90s we did something called primary nursing which means every time that person came in if you would have come in I would have been your nurse every time you're in the hospital every month for 6 months. So the kind of therapeutic relationship you develop is meaningful. And so I was 23 years old 23 to 28 the formative times of how I built my perspective on the world and I'll never forget. This is the one story there's so many stories like this but this is the one story that answers that question I think why is this is personal to me. So I'm taking care of this woman and you know many many of the people I took care of won their battles. You know they I was with them for 6 months every night so some nights because people just want to feel normal I'm giving them their chemo they're watching TV and buying stuff online on the TV and I'm like why are you doing all this because they just want to feel like themselves, right? And many many people successfully walked out and forgot forgot our names, right? But not everybody did and so this one family she had been with us for 6 months and I don't know if you've ever been around people who are losing their battle with an illness or are are are living the last days of their lives but you can tell it's coming just by the way they breathe. It is true people rally right before they die and so I knew this woman's time was coming, but she had the most faithful family, Steven. Her family came every single day and she had a big family and we knew they were coming, they were kind of loud and and we loved having them here, but the night that answers this question, I knew it was going to be her last night. You can always tell and it was just she and I and the the light in a hospital room, there's a light over the bed and then the bed, so there's this light behind her and she's breathing in an agonal way, but I can tell that she's waiting. She knows her family's going to come the next morning. So we make it through the night. It's just she and I and and in the morning in this hospital in Chicago, there's a a window at the end of the hallway that faces Lake Michigan and the light starts coming in. The floor lights up again and that's starting to happen. It's about 7:00 and I hear the elevator bing and it was her family coming, so I step out into the hallway and this one was different. They always came together every day, but this time her sister was dressed in her wedding gown and the whole family with it was in their tuxedos cuz her sister was going to get married that day and they wanted her to be part of that, even though there was no way she was ever going to be part of that. So I I'm 23 years old. I'm standing in the doorway. My patient is over here. Her family is coming towards me and that indelibly seared in me the the balance between life and death, the woman who is not going to continue her journey and her sister who's beginning her journey and I don't know how at 23 years old for that not to impact what I care about in life. Steven, if you come to my house, I don't give a rat's ass about my curtains or buying the shoes with the red soles, even though I can, but at 23, that kind of life and death made me decide that people were worth working for and worth saving. And so, she had waited for them to come to her that day so she could share in the last family time they were going to have together. And I don't think you come out of a situation like that without your whole life perspective being different. And so, even though, you know, I'm a I'm a sports doctor now, how is that remotely as hard as being a cancer nurse? I'm a much better doctor now than I would have ever been had I gone straight into medicine. What is the the perspective it's given you, specifically that then translates to being an even better sports doctor? How does it change how you view death? that I can't view the procedure as just putting screws in the ACL. Or what? I tried out a new ACL procedure last week. It was fascinating. But, sometimes that is the beginning and the end. That's not the beginning and the end for me. How this kid, it was this 19-year-old kid, how this kid is going to recover in 6 to 9 months and go back to living the life he envisions, how he's not going to feel abandoned by the sport that he loved, or how am I going to help him find a new team because sport is not only an individual thing, it's an entire environment. It's the It's the the society the kid lives in. So, for me, it's not just the cool new technique I did on Wednesday in the OR. It's taking care of that whole person through the whole journey for the next 9 months. The lady that you were taking care of when you were 23 years old, has that impacted what how you view death? Yeah. It has. I view death. We're all going to die, Steven. How rapidly we get there can change. How we arrive there can change. How we feel about our life can change. But we're all going to get there. So, I don't I don't view it as something to run away from at all. In fact, in some circumstances, in some of my patients' circumstances, or even as an orthopedic surgeon in some of the traumas I've been involved in, I think death can be kindness. And death can be done with extreme dignity. I don't think it's always the enemy. Mhm. One of the things that I think is is also um really sort of front of mind in that image of the lady in the in the bed when her sister arrives in the wedding dress is that she had friends and family there. Oh my goodness. And a lot of people, you know, Right. there's so much beauty in that moment regardless of the the um the reality of what's going on there, that she's losing her life, but she's losing it surrounded by Yeah. a group of people that love her, and I think for many of us, I think I actually had a conversation with a good friend the other day, and their their biggest fear in life is that they'll actually end up aging and dying alone because they don't have children yet, and they don't have children at all. They made the decision not to have children. Um they don't have siblings, so you know, if I'm not scared of death. I'd like to extend my health span, but um when I do die, I'd like to have people around me that uh love me, and that's one of the things that I think she she clearly had. Yeah, she she did. It's funny you mention that. I think about that. What happens if we live so long in our quest for longevity that everybody we love or raised has already gone before us, and I don't know. What do I do? Do I hire the girl next door to sit with me, take me to my doctor's appointments? Yeah, I don't know what to do. probably pay a few people to bit of planning. It takes a little bit of planning. So, if we if we talk then about this health span issue and your central mission that you described at the start, usually when I have these conversations, I try and hazard a guess where I should begin, but actually I want you to tell me where we should be beginning. If we're talking about extending our health span, where where does that begin? Where do we need to start this conversation? That begins when your parents are raising you and they have the choice of teaching you how to eat, teaching you I'm old enough that literally I got a cell phone at 38. So this is not a problem with me growing up, but there's a problem now where we don't send kids out due to safety and digital to just go play and don't come in until dinner. That was a real thing when I was growing up. And so what we know is children's mitochondrial load, meaning how many of our powerhouse mitochondria metabolic kingpins are really predetermined by how active we are as a child. So it's really a concern for those of us interested in metabolic health is what are we doing when we raise our children to sit around for the first 10 years of our of their lives when they're really made to run around, right? So it begins with what we teach our children and I think I hear parents a lot of times saying, oh my kid won't eat this or that or I can't get them to do anything and I'm not scolding them when I respond in the way I'm about to respond to you. I get it. I'm the mother of a blended family of six children and you can't always make your children do things, but here's what I know. Children learn from what they see. My children were foam rolling with us. They learned to eat vegetables or they didn't get up from the table or they learn what we teach them. So the time to begin is when our children are little. Some would say the time to begin is in utero, which is frightening cuz I might have done things differently during my pregnancy, but when they're little. But as they're being raised, I certainly think the time to really begin is no later than your mid 30s. I call between mid 30s to mid 40s with 40 being the center of that the critical decade. Literally, we're not children anymore. We've at 30 the literature says we've probably maxed our bone out. We've probably maxed our muscle out. do you mean? I'm 30 with I know. I'm thinking about you right now. What do you think I've maxed my muscle out and my bone out? that some some scientists, muscle scientists, believe that at 30 we've got our peak muscle mass. And unless we really invest in growing more muscle the rest of our lives, like if you choose to be sedentary the rest of your lives, you peaked at 30 and you're using it the rest of your life, right? And so same with bone. Bone maxes out at about 30 unless we continue to invest in it. Well, what do we know? 70% of our population is is sedentary and don't reinvest. So, between 30 5 and 45, I call it the critical decade. If you've never thought about your health before, now's the time to hone in. We need baseline labs. We need your first physical. We need some of your first screening exams. I think men, this is not policy anywhere, but I think as I'm trying to replace testosterone in men in the future, I don't know what I'm raising them up to. I know I'm putting them with within a within a healthy range, but I would want to return you to what your testosterone was when you were a young man like you are now and not just guess. I think we need first labs, first physicals, um to be more of a quantified self just like you we were talking earlier, you saw a human brain for the first time, to notice our bodies so that we can take better care of them early so that we can then do the exercise prescription that I'm sure we'll talk about um going forward because it becomes very very hard with every decade. But I think for men 40 to 50 is a an amazing decade for you for a lot of reasons. For women, I think between 35 and 45 is critically the time to get our stuff together before our hormones start walking out the door. So, it it's much earlier than you would suspect. If you If you suspected maybe 50 is the age, maybe 60, no. Too late. Not too late. Much harder, right? Mhm. Yeah. You know what I There's this image that I saw online the other day and I saved it as a bookmark. I I actually wasn't connected to me speaking cheap, but I just found it to be fascinating cuz it's part of this emerging picture in my mind about the importance of muscle. And one of the things you said there is you think we'd reach our peak muscle by Around 30. According to some sort of muscle scientists. Is Does that kind of correlate to what I'm seeing here? I'll put this on the screen for anyone that can't see and I'll link it in the description below. But on this graph, which we'll call figure number one, graph number one, are you saying to me that the peak point there is Around 30. Yeah. And then from it's sort of downhill from there. So, you know, on this graph, the peak, if we call it 30, this is a precipitous decline. It looks very hopeless. But what I believe and what our research shows is that you can extend this green line into a more flat curve so that you die quickly. Maybe in your sleep. Yeah, like this. Zoop, done. Okay. Instead of this steady decline over time. But if we do not reinvest in our health and mobility every day, our muscle wastes, our VO2 max, or our cardiovascular health declines 10% per decade. So, it's like what happens if you have a Formula 1 car and you get it all maximized, it takes one big race, and then you never reinvest in it. I mean our bodies are not unlike a machine. When you talk about lean muscle mass, what does What is lean muscle mass? I know what muscles are, but what's lean muscle Yeah, you know what? I say lean muscle mass and people are like, "What do you mean? Lean versus fatty muscle mass?" What I'm talking about is your skeletal muscle mass. We have three kinds of muscle. We have smooth muscle, which is what our guts are. It's the peristalsis that's happening in our intestines. Our cardiac muscle, the muscle that will that is our heart. That's the cardiac muscle. Um and it beats onto itself. It has its own electrical rhythm. The rest of the muscle in our body is striated skeletal muscle. So every time you do this it's with a type of muscle called skeletal muscle. We have 650 skeletal muscles. It is the reason you move. Uh it is Muscle is not only important for locomotion, but it's very metabolically active. It sends off hormones that help control other processes in your body. It's where most of your mitochondria, which are the powerhouses of your body, take glucose from your blood and turn it into energy. So it has a lot of roles. Most of us just think about it as what you see in the mirror at the gym getting bigger and bigger, but it serves a function of locomotion and metabolism. You did a a study. Yes, I did. Um and I think that's the picture I have here which talks about So what I'll put this on the screen again. This is picture number two for anybody that's listening on audio and wants to see the photos. Um this is a pretty startling image. It is. Um and it scares me. Please can you explain what it is? It shouldn't scare you because you are healthy You are going to be mobile every day when you leave me here, but So remember that study I introduced the Health ABC, which was an NIH-funded study of a group of 70-year-olds. They just took a cohort of 70-year-olds and watched what happened over a decade. Yeah. Well, they did a similar study as this uh using cat scans. I used MRIs. And what they found is that uh that what they described as the inevitable decline of muscle, the inevitable infiltration of your muscle with fat, like marbling. And I said, "That cannot be true. That is what happens if you are sedentary and sit around for the trajectory of your life." So, because I'm a sports doctor, I am surrounded by masters athletes. So, I did a study of masters athletes from 40 to 85. What this picture is is MRI slices in their mid thighs. So, MRIs take pictures of us using a magnet and creates these beautiful pictures. So, the top picture is the MRI slice of a 40-year-old and my athletes were usually runners or triathletes of the thigh of a 40-year-old. So, I'll describe this for you. It's gorgeous. Yeah, it's beautiful. Yes, we have beautiful muscle architecture of the quadriceps on the top, the hamstrings on the bottom. The bone has a nice cortex. There's very little peripheral fat. And when I looked inside the muscle uh with a microscope and special software, there was not infiltration of fat or marbling. So, if you want to say it colloquially, this is a flank steak Yeah. with no marbling. This is lean muscle. If we sit around for 35 years and have a desk job and we and we sit at the desk uh 10 hours a day and we don't go move our muscles, we're not purposeful, this is what happens. We lose our muscle architecture. These muscles are are almost you can't even tell what they are. Uh they are of that person? This is a 74-year-old. Now, I had a large group. This is one representative person in each of the groups. This is the control group. But, the center one, the muscle I'll tell you is grossly fatty infiltrated. It is well marbled. It is like a Kobe beef. And then there's a thick rind of peripheral fat. This is a picture of what we called sarcobesity. Meaning we have loss of muscle, sarcopenia, and we have obesity. Excess adipose tissue. Oh, so the white area is the fat and the middle part is the muscle. Yes. And so, you know, you'll see people walking around with these big old thighs. Well, the truth is um sometimes a lot of that is fatty rind. But look what happens if we invest every day in our mobility. My athletes in this study were not professional athletes. They were recreational people like you and me who just invested in their mobility four to five times a week. This is the picture the third picture is a 70-year-old triathlete. Really? If you didn't know better, you would say that I just took another slice of the 40-year-old and put it down here. Very little peripheral fat, very little fatty infiltration, and amazing muscle architecture. And when we looked at the strength of this person compared to this person, there was virtually no difference. There's a small difference, but we know from other people's studies that um lifting weights consistently infers a 20-year advantage such that if you're an 80-year-old consistently lifting weights, you are functionally as strong as a 60-year-old person who doesn't. And so not only does this study show us that by investing every day in our mobility that we can retain our muscle mass that has implications for frailty. That has implications for activity. And what's interesting about that picture, Steven once I published it, it has taken on a life of its own. It is like everywhere on the internet because the reaction is so startling with people thinking, "Oh my god, I am in control of my health and aging." And I couldn't be more pleased about that. No, it is it is unforgettable Yeah. in every sense of the word. I can't believe that. The thing that really obviously shocks me is the 40-year-old's um calf muscles or the calf or thigh thigh thigh muscle Yeah. is arguably And that's a triathlete is arguably not as good as the 70-year-old triathlete's. Oh, well, actually say that they're two different people, so the 70-year-old wins. And that is that is startling because I I thought that aging muscle decline, the sort of senescence, I think it's called, of the of the body and the muscles is inevitable. And this is unequivocal evidence that it's not. That if I make good decisions now, I become a triathlete, I can have the flank steak thighs when I'm 70. What it tells you is that there is no age or time in your life when your body will not respond to the positive stress you put upon it. And it takes daily investment. It's not like you can store it all up and then ride on it. Mhm. It Yeah, it's so it's so important. That's one of the things that's been a real revelation for me is this idea that muscle is so critical as I get older. Yeah. Um I often think about different exercises that I should be doing as I age and you know, sometimes I think about um running, but I but it's quite I don't know, I worry about joint pains and stuff. Yeah. So, I'm a bit of an upper body workout freak. I just focus on my upper body. Um What do you think of my exercise regime? What should I be adding to it to make sure that I can have the flank steak thighs, but also just a longer health span? You know, what's critical for long-term function is being able to stay upright. So, it's all great that you've making big arms and have upper body strength and do pull-ups and lift your suitcase above the in the airplane. Thanks. But what you really want to do when you're 97 is walk anywhere you want to, go up and down the stairs, do, you know, drive any car you want to, and that takes lower body strength. So all your biggest muscles in your body are below your belly button. So if I were you and had all this trajectory of time, I would work equally as hard on my my glutes, my quads, my hamstrings, my calves, every muscle below your body. But not only would I work on my strength to get bigger, but I would focus on power, and those are different lifting techniques, right? The hypertrophy aspect of growing big muscles cuz they look really great. Uh you do Now, and I am not a I am not a uh trainer, but I've done this quite a while, so trainers, you're welcome to add in, but uh you do more reps of lighter weights because that will stimulate hypertrophy. Okay. Hypertrophy. a growth of muscle, bigger biceps. If we're truly interested in power and longevity, which is why I lift, I lift for longevity and power because I am not going to be that little old lady frail in a bed unless I can help it, right? I mean, I'm going to help it. I'm so determined. Um I want to be able to lift heavy. So that is fewer reps, but much heavier weight. So number one, you got to lift with your legs. Number two, people become frail for a number of reasons, but another reason people lose their independence is they lose their ability to balance, and they're falling all the time. And when you fall, no matter how good your bones are, you're liable to break something. And so I always train my people not only in muscle building or carrying a load, as I like to call it. But in equilibrium and foot speed. So in the in the place I put my office, it's a performance center. It's surrounded with all the bells and whistles of the best performance stuff. And we have a speed and agility coach who usually works with elite division one track athletes. Well, I had her design foot speed and agility drills for midlife people because I do this all the time. I put my my red work bag too close to my desk. I get up quickly. My bag's in the way and I trip. But because I've got the foot speed, I can hop over it. But if I hadn't retrained that, I might have tripped over it and landed on my hip and broken something. So, it's important as we're going forward, yes, I want you to increase your muscle lifting in your lower body, but I want you to work on speed and agility drills so you stay nimble, stay able to balance and don't fall down. If you fall down, if you trip over your bag, what's the not kind of effective that cuz you just heal, right? I just heal. Yeah. Yeah, I just I ran a Spartan race recently and fell off an 8-ft ring and didn't break. So, I am working towards being unbreakable in my own life. That's what I want to happen for you. But if you're if you're not unbreakable, what happens when you trip over your bag and fall is you could break your hip. And then what happens? Yeah. Well, if you're of any age, but particularly older, when you fall and break your hip, 50% of the time, you do not return to pre-fall function, which means you cannot live in the home you raised your children. You cannot drive your car. It bones are bones in adults take about 3 months to heal. Imagine being down for that amount of time. And unfortunately, in men greater than women, 30% of people die in the first year from the complications of being that sick with a hip fracture. So, you know, as your orthopedic surgeon, I am desperate to prevent frailty. I'm desperate to prevent you from falling and succumbing to that sequela. So, we got to lift weights with our rear end and our legs. We got to work on our speed and agility. It was you that used this term, the sitting epidemic. Mhm. What is the sitting epidemic? The sitting at epidemic is what we're doing in our country uh when we in every aspect of our lives, whether we're working or working, but we're sitting at a table. We're uh playing, we're sitting and we're playing on our phone or watching something. It is the epidemic where we're spending I don't know, 10, 14 hours a day sitting in this position. In fact, I was thinking about it, if it was logist- logistically possible for a 3-hour interview, we should go for a walk. Not so much. But, but it's the epidemic of sitting around. What does sitting around do? Well, it sends us towards a pathway of something called sedentary death syndrome. I wish I had made that up, but I didn't. A professor out of Columbia University in Missouri made up this term that I had been using my whole career to describe what happens to us when we sit our entire lives. Sedentary death syndrome are the 33 chronic diseases that we die of, including the top five, cardiovascular disease, stroke, cancer, um even even things like fracture that are completely impacted in a positive way by mobility. So, if we could eliminate sedentary living from our lives we could probably live better. And that was the whole supposition of all these studies I did in the beginning of my career at the University of Pittsburgh was to prove that if we took sedentary living out of our vocabulary, that we could save our bones. We proved that with two studies. Our muscles, we proved it with the one that you just saw. We could save our brains. We were one of the first to do brain studies looking at the effect of mobility on the brain. And it's a very hopeful picture. It's super interesting this subject. I this week had a friend of mine diagnosed with I think he'd slipped like two discs in his back or something. I think like I think disc five and six or something and he sent a x-ray of his back into the group chat. I thought oh, this is so interesting cuz I've had lots of conversations with people on my podcast about sitting and all of these things. I spoke to one particular guy called David Raichlen who went and studied the Hadza tribe in Africa I believe, which is a hunter-gatherer tribe. And what he found is they do sit for about nine or 10 hours a day, but they They squat. I knew that. Yes. So we sit in the chairs. sitting. They're squatting. He told me that I think it was him and Daniel Lieberman told me that. They'd brought brought a chair over there. Yeah. And like these Hadza tribe had like never seen a chair before. So when they like walked off to go to the toilet, the Hadza were all sitting in the chair. No, but they would they would take the chair and be like, "Oh my god." So like all the chairs were taken cuz they just loved the chairs. Cuz they'd like never had chairs before. So that the researchers like couldn't find a chair cuz all the Hadza were like chilling in the chairs. But typically when they they sit for 10 hours a day, they're doing this little sit mini squat thing, which means their muscles are still activated. But also I think the the posture in which they they squat is Their backs are straight. Yes. And it got sent me down this rabbit hole this weekend, literally this weekend, looking at why sort of 80% of Americans will complain about back problems, but the Hadza tribe, back problems aren't even like a thing there. He told me it like almost doesn't exist, the idea of having a back problem. But 80% of us are going to have back problems. It's endemic. Well, think about it. If we weren't trying If I weren't trying to be on my best behavior, I'd be sitting in this chair like this, right? Like a C-shaped back. Slouched over. My front core is completely relaxed. My back core is relaxed and stretched out. And so, over time, they just get weak and atrophy. It's like laying in bed. There's no stimulus for them. Plus, my shoulders get all hunched over and my posture becomes like this. And so, that's why we just sit in chairs and atrophy. When you're squatting, and I posted recently challenging people to see if they could do a squat like that or get up from a squat like that. And the response I got was overwhelmingly, "Oh my god, I can't do that. I'll work on it." Because we're so used to sitting in chairs. do like a single squat, these people are saying. To get down, getting down people can do. Sometimes it's falling over. Getting up is the problem. What would you recommend Yeah. in order to avoid the back pains, the sort of sedentary death syndrome, or whatever it was called. What do I do? Because I I I I feel I run a business. I work in an office at a desk. Yes. Well, you know what? Even simple things. Uh for instance, I bought my assistant a standing desk because when I'm in clinical all day, uh for 10 hours, the choice for him was sitting at a desk or standing at his standing desk. And so, that can go a long way. Number one. Number two, taking mini blasts of mobility, right? Getting up, running out the stairs, be a fidgety person, go to the copier, get steps in, just be moving all the time. The other thing, honestly, nobody knows when you're on a phone call what you're doing. You could be wall squatting. In fact, I have challenged whole groups of people in their next board meeting to wall squat the whole time. No I don't know how much thinking would go on, but just adding little things like add that in, you don't have to sit to take a phone call. Um even in a Zoom meeting. I mean, people have seen worse than you doing a wall squat, you know, in the time of COVID. I I was wondering this morning um on my way here cuz I was in the bathroom and I dropped something on the floor. I can't remember what it was. Might have been the toothpaste or something. And I went down to pick it up and my my back is just like so tight. Is it? Like my whole I feel like my whole body I'm so unflexible. I like went down to pick it up and the way that I go down to pick it up is you'd think I was you know, I was going to say an age then, but that's kind of after seeing that flying knee I'm like this guy's got better flexibility than me. But I just feel like You're stiff. I'm stiff as hell. Uh-huh. And I don't know what to do about it. Cuz I I think there's like a I don't know. Is it a joint pain joint pains that I have or is it just I don't I don't have strong core? It could be all those things. So, when I talk to people about to get to tie into the other question, how should you be working out? How should you be investing in your mobility every day? Uh there are four components that that we should try to find time for. Number one is flexibility and dynamic stretching. What so that means is is warming up every single joint in your body every day. And that can be as as simple as seriously a set of jumping jacks, doing uh there's something called an inchworm where it's like a push-up position and you walk your feet up and that'll warm up your ankles, your knees, your hips, your shoulders. But going through a dynamic warm-up every day to warm up the joint, putting them through demanding they go through a full range of motion. And then not forgetting after you work out to static stretch. We don't static stretch before we work out, we static stretch after. It's done. Uh static stretch is what we were taught in in elementary school with, you know, you stand against a wall, you hold the stretch for 30 seconds. That happens in every body part after you work out before you dynamically warm up. And so that's when things like yoga and Pilates and whether it's reformer Pilates or uh floor Pilates or can be great for people. To me that is the the salt and pepper of your workout regimen. It's not just what you do. It's what you sprinkle over it. So that's number one, flexibility. A, oh, because the acronym I use is face. Just so people remember. F, flexibility. A is aerobic, right? We can talk about that. C is this weight lifting we talked about. C, carry a load. E is equilibrium and balance. So when you were reaching over and thinking you were so stiff, you could still do it because you're in your 30s. You still have the youthful pliability to do it. Imagine you're 60 now and you haven't done anything about it and nothing's moving and you reach over and you don't have the foot speed to catch yourself. You fall over. It happens all the time from a standing position. So the way I teach people to retrain their balance literally is to stand on one foot while you're brushing your teeth every morning because the perturbation of moving your whole body requires core strength, it requires proprioception and that's how you'll retrain that particular motion. So I really need to introduce something like Pilates or yoga to my Or just daily stretching. Okay. For how long? Um well, if you stretch every you dynamically warm up before you do anything including your weight lifting and then um the static stretching afterwards of every major muscle group whether it's your triceps or whether it's your hamstrings which are critical for low back pain or your calves. You hold the stretch without bouncing for 30 seconds. And what you'll feel is at the end of the 30 seconds, you'll kind of relax into it and you'll get more of a stretch and you only do four reps. You are going to get most of the benefit of that stretching after four reps. But I don't want to only do that. I find many people asking me, "I do Pilates and yoga. Is that enough for me?" And I say, "That's great, but it's never going to be enough." One of the other things which is related to this that people see as being inevitable is this idea of joint pain. We think we kind of just get joint pain as we age. Is joint pain inevitable? You've actually brought a big bone with you today which absolutely nobody asked you to bring, but I guess this is what you carry around with you. Steven, this is a femur. A femur? A femur. Yeah. This is a human femur. Um and I guess a femur is the It's the bone that connects your pelvis Yeah. to your knee. Oh, okay. So, it's that big bone in your leg. bone. It's the longest bone in your body. This bone you brought with you. Um a lot of people talk about joint pain. Yes. Is joint pain inevitable? I'll give it to you because you probably know more about this stuff than I do. So, what is a joint? A joint is the is the space that is occupied by two bones. So, the femur, the top of it, that's in your hip, is a ball and it sits in a cup in your in your pelvis. So, two different bones, the pelvis is connected to the femur through the hip joint. It goes like this, right? So, and then on this end, this end of the femur is connected to your tibia and it makes your knee. Okay. Yeah. So, uh is joint pain inevitable? It is not. Do we get it with aging? Often, so that you would think it's inevitable, but it is not inevitable. Why do we get joint pain? Well, every bone at the end is covered in an end cap of a structure called cartilage. Cartilage is a smoother than ice matrix that cushions the bone so that you don't feel your joints. One reason people have pain is because they've traumatically disrupted that cartilage and there's potholes in it. Like if you're a football player and you get hit hard and a piece it impacts so hard it pops off. That's a traumatic cartilage injury. You will have joint pain from that. Another reason we can have joint pain is not traumatic cartilage loss but because you've just done so many reps over a lifetime that you've worn it down. That's called osteoarthritis. And so it's not a pothole per se, it's like the whole surface has been worn down with sandpaper for instance and there's just not enough of it. Well, the reason we get osteoarthritis, some of it's genetic but much of it is how much we weigh. Sometimes it's related especially in women to whether or not we have estrogen. Um we only get one set of cartilage for a lifetime unless I reconstruct your cartilage cuz you've been injured or something. Uh we get one set. So we get joint pain because the cartilage has started to wear down. We can get joint pain because we've worked really hard in a workout and we've just seen a lot of impact and it inflames your joint but that's usually temporary. The permanent The permanent is usually due to osteoarthritis. So so how do I if I want to work out and I want to make sure that I protect my joints so that I don't have this um permanent sort of naturally irreversible joint pain? Yeah. Is there certain workouts that I should be avoiding? Are there certain workouts that are more likely to give me to erode my cartilage and give me joint pain? Well, I think principles that should be used are the principles of weight lifting with progressive overload. So if you started out cold and decided you know, I'm young, I'm healthy, I'm just going to uh lift to my maximum all the time, you're probably going to inflame your joint. Your joint is not used to seeing that kinds of load. Joints bear five to 10 times body weight. So, if you've gone from zero to 500 lb squat, that is 5,000 lb. Yeah. That's a lot. Versus, if you start from zero and progressively up, your body will get used to the load, your bones will build, your uh your cartilage won't grow, but it will become more used to the pressure. So, the principle is um to not have aching joints is progressively go up and not just let your ego take over. So, you're saying that muscle helps to kind of as a suspension mechanism for the cartilage? Well, what things project protect the joints? Uh being of a healthy body composition, which includes weight and muscle mass, right? So, the way muscle helps protect the joints is exactly as you said, instead of pounding together like this, Yeah. muscle acts as a shock absorber. So, the the bones come together more softly. Ah, okay. So, where for people with osteoarthritis, one of the remedies for that is building muscle. Um I've got um you mentioned a second ago that staying at a decent weight also helps to stave off joint pains and that's sort of erosion of cartilage. Mhm. And I was I was reading in your work about this pretty shocking um Grab my my brick and my rock. This pretty shocking stat. Yeah. That God, this is heavy. You can take that. Okay, I'm going to put it down for you. Yeah. Um in your work you describe how putting on even a small amount of weight increases the pressure on our joints by a huge amount. So, can you explain that using this? Yeah. So, when we think about pressure across our joint, we're we're thinking about whether we gain weight or lose weight. The joint, which in this bone is the femur, the femur, the end of the femur is sitting against the tibia, and that's what makes your knee joint. When you go up and down the stairs and have pain in your knee, what's happening there? Well, if you gain 1 lb, this rock is 1 lb, you would think that this is all the amount of pressure you're going to feel, but because of the mechanics, the physics of the long bones, the pressure of gravity pushing up on you, what you actually feel is the weight of these bricks, which is 9 lb. So, gaining 1 lb in weight 1 lb in weight exerts nine times the pressure on your joint. So, you think gaining 10 lb doesn't mean much, but imagine gaining 100 lb of pressure. Or the reverse of that is even small changes in our total body weight, 1 lb, 10 lb, can have profound effects on the joint pain we feel. So, if I lose 1 lb, I'm taking 9 lb this away. Mhm. Uh what some research shows that if you lose 10% of your body weight, you can make a profound difference in uh the pressure your joint experiences and decrease your pain. So, when I prescribe treatment for arthritis, here's the whole person, whole person approach. If I just wanted to say, "Okay, you've got arthritis, I'm going to give you an injection and sign you up for surgery." That might be a typical surgical approach, but my approach is we look at your nutrition, we talk about anti-inflammatory nutrition, enough protein, uh not eating sugar. Sugar is a huge inflammatory, which increases your arthritis pain. We talk about building muscle so that we have more shock absorption. We talk about losing absolute amount of body weight so that we unload the joint in another way. Even before we get to any medical type treatment, it's the lifestyle approaches that you can use. I would have thought that if I put on 1 lb of weight, I would put 1 lb of pressure on my joints, but what you're saying is if I put on 1 lb of weight, I'm actually putting 9 lb of pressure on my joints. Yes. You know, it has to do with the across the joint, the physics of the lever arms of our bones. So, for instance, in our shoulder, if you put 1 lb in your hand, the pressure felt in your arm because of this long lever arm to lift it is is 10 times. So, I always tell my patients who are recovering, "Don't feel discouraged when you lift up 2 lb weight, it's 20 lb on your shoulder." It has to do with the the physics of pulling the weight up in the axial load. It has to do with the gravity and the impact of bones one on another. You talk about these three major mindset changes that we need to kind of um experience in order to make sure that we can be fit and healthy in our late years. Things like not focusing on weight loss, but instead focusing on building muscle. Mhm. That for me is again, it's a bit of a a narrative violation because um I think as we age, one of the things that we see as being an inevitable is that we are going to gain weight. So, most people go to war with just trying to lose specifically abdominal fat. Mhm. a lot of men are really quite obsessed with their abdominal fat. Why why do we need to make that mindset shift? You know what? And I'll take that shift even further, and it's I like to frame it as we don't want to lose weight. We want to uh recompose. What are we made of, right? We want to be made of healthy muscle. We We want to care about how much body What percentage of our body is fat? We need fat. Fat has a purpose in our body, or we wouldn't have it. But what percentage are muscles? So, what happens when we just focus on losing weight and our primary method is calorie restriction? What we know, it is clear from from many papers that if we just calorie restrict with nothing else, we will lose 25 to 50% of our weight as muscle. And then that makes us metabolically less healthy because muscle is a glucose sink. Mhm. You know, when we feed ourselves and there's sugar circulating, it is taken up by our muscle. With if we lose 25 to 50% as we lose weight, we have less metabolic availability to get rid of all that. And then when we come off our crazy calorie restricted diet, the weight we gain back is 80% fat. So if we are if we're troubled with yo-yo diets, which so many people struggle with that, they'll lose weight, they'll gain weight, they'll lose weight, it becomes this circle as we're continuously losing more muscle. So when I frame it for men and women, I want them to to think of recomposing. How as I'm losing fat percentage can I gain muscle? And so that puts it in a different perspective. I don't care what you weigh. You know, I'm a muscular woman. I weigh more probably than people would think I would because I have lower body fat. I have higher muscle content. And that's what we care about. And for people I always chuckle when I say this that are really interested in the way clothes fit, which I am. I'm as vain as they come. Well, muscle is nature's Spanx. You may weigh more, but you're tighter and everything fits and looks better. So it's not weight, it's composition. Can we be as in shape as we were when we were 25 when we're 45? We can be different. Different, okay. There are lots and lots of examples all over of uh either people staying healthy. I mean, look at Tom Brady. He's a great example, right? Cristiano Ronaldo is a great example of a classical athlete. I just saw him the other day uh playing actually in this Europe tournament. I just saw him playing. Um there are lots of examples of that from pro sports now, but even in mere mortal athletes, they're posting all over the internet how they have maintained or many people a light bulb turns off and they say I'm a I'm sitting on my rear end. I'm as strong today as I've ever going to be unless I do something. And we have pictures of people investing in weightlifting and high protein meals and and getting in better shape than they ever were. I was in the best shape of my life when I was 40. And then I went through perimenopause and thought I was going to die. And now I'm 57. I'm in some of the best shape of my life. I am in not I'm not 19% body fat like I was when I was 40, but as a whole person, this is the best it's ever been. It's really interesting as a football fan, a soccer fan. Um No, it is called football. As a football fan seeing how two different players at the same age. I'm thinking about I won't name names cuz it's makes it personal, but someone like Cristiano Ronaldo and I compare him to another player from my club Manchester United who Cristiano played there at one point who is also 41 years old or whatever Cristiano is now. And they look 15 to 20 years apart. Really? And Cristiano Ronaldo carried on playing. He By all accounts from things that I hear at Manchester United has the most discipline with his routine, his nutrition. And then another player who at the time when they both played together in their 30s, they kind of looked the same physically. Yes. But just because for some reason they let go, it almost appears that they let go. They got on the alcohol a little bit. Their diet shifted. They now look like they're 15 years older than Cristiano. But at 35 they kind of look the same. They both had abs. And it's so crazy how just a couple of years of just kind of forgetting about these simple disciplines can send your perceived trajectory of your health so widely apart. Mhm. Whereas Cristiano, he literally looks like I saw him. He did a He did a penalty kick. Yeah, I'll put a photo of of him the physique he he's in up on the screen cuz Whoop, who are a sponsor of mine my sponsor of this podcast, they went out there recently to Saudi Arabia, I believe, where he's playing, and they did a topless poolside interview with him, and I was like, "Jesus my god." Look at that. And I compare him to the his colleagues and I contend to you though that that colleague Yeah. because he's still in his 40s if they put the time back in Yeah. could become ripped again. Um the the basic stats that I need to think about in order to be a Cristiano Ronaldo as opposed to another one of his colleagues that didn't manage to stay in shape. What are those fundamentals that you think Cristiano is hitting? Or from your work with athletes? Yeah. I think that um I think we harness the power of our age, the wisdom of our age. So, he probably works out now differently than he did when he was 25. He He probably, and I don't know his routine, but people like Dara Torres or Michael Phelps, they spend more time on recovery, more time on muscle work. They're very systematic about their workouts. They do max-min. They they get the maximum workout in their skill set their skill workouts. They're not out on the field for 4 hours anymore. They get an hour and a half in. They work on the skills they need to do. So, they're smarter, right? Number two, nutrition is monitored from literally When uh one of my jobs at the University of Pittsburgh was as the medical director of the UPMC Lemieux Sports Complex. We housed the Penguins, the Pittsburgh Penguins, which is the professional hockey team. They had a full-time chef from the minute they woke up. They came in for breakfast. Lunch was cooked. All snacks were provided. Even the food on the airplanes was provided so that they had this very regimented diet full of the nutrition they needed not only to fuel them, but to recover them. So, that's nutrition. Nothing is a mistake. Uh number three, they are their workouts are not only the skilled workouts, but the conditioning workouts are completely monitored. I mean, you're sponsored by Whoop. Whoop takes care of a lot of athletes. We know their recovery state. We know how well they slept the night before. We know their response to the heavy lifting. So, I think that athletes at that level are able to maintain the way they are because it's a science. Also, frankly, they're genetically specimens. They got this great cytoplasm they were born with. Sugar. You don't speak very fondly of it. You I've read it quite where you say it will destroy your body on so many levels. It does. So, you know what? I love sugar. I'll you know, I love sugar. I would rather eat cookies for breakfast, but I don't. And and the first time I sugar detoxed, after the first 3 days it was rough because, you know, sugar is addictive. There's an addictive center in our brain, you know. And so, after 3 days you can gut it out and use your willpower discipline. But after 3 days, the fourth day you're going to your cupboard and you're standing there and you're like, "I don't know why I'm here." Well, it's your brain looking for a dopamine hit of sugar. So, what does sugar do? I am not opposed to carbs. Our body needs carbs. It doesn't need as much as we get, but we need fiber-filled carbs. Fiber is critical in our bodies. What we don't need is beet and sugarcane and honey and agave, all the simple sugars that have a a steep glycemic index, meaning you eat it. It's easily digested, rapidly digested, goes immediately to your blood, your blood sugar will spike. Give you some examples. And then what happens is our pancreas will release insulin, which will frantically try to carry it into our muscles to be used. Well, that happens at a finite rate. And when you have too much sugar circulating, that overcomes the rate that it can be removed, our body stores it in fat, right? With a high blood glucose, our body goes through a circumstance called uh glycosylation, which is essentially caramelizing proteins in your body. It's like you have a steak and you leave it on the grill extra long and it gets that caramelized. Well, that state of our proteins in our body is highly inflammatory. Well, we know high inflammation is something that contributes to chronic disease. It This excess of blood sugar contributes to insulin insensitivity, meaning our poor pancreas is trying to pop out enough insulin to get rid of the sugar that it pops out so much that it we become insensitive to it. There's just an overabundance. So, all of those reasons are why I am not opposed to com- complex carbs and fiber. I am opposed to the highly processed, sugar-filled diet that is produced for us by our current food system and by the choices we make. I don't blame society. I don't blame our food system. I blame them and the choices we make. Um So, I That's one of the first things I recommend to my patients. Do you know it's the hardest thing for them to give up? And they'll do everything else. They'll get to a gym. They'll they'll do aerobics the way I want them to. But then when I say, "And we need to eliminate simple sugar." That's when the excuses come out. It's interesting cuz yeah, I mean it's difficult. There's obviously a physiological sort of chemical hold that sugar has over over us. But on this point of psychology and willpower or whatever we want to call it, everything that we've discussed so far today is kind of contingent on you making a decision. Yes. Now, how when you talk about the whole human, how can you influence someone who might have got this far in the conversation today and they they understand everything you said? They go, "Yeah, I know some of that stuff. I know this thing here and you know, I've heard that over in this book or this podcast before, but for some reason I just can't Can't do it. Can't do it. Can't get myself to do it. Maybe I'll do it for 1 day, but then the yo-yo goes back to the bottom and There's this concept in banking called temporal disconnect. It's a banking term. I came upon it as I was writing these books initially and the concept is that bankers, financial people, want us to put a little bit away every day. Not for today. There's no satisfaction in that for today. In fact, it's deprivation for today. But it's for the future. The concept of temporal disconnect is that you don't know who you're going to be in 30 years. You're or 40 years, a 70-year-old Steven. You don't know that guy. You don't care about that guy. You don't even know what he's like, what he's going to become. So, but you do know today's Steven and so you're going to take care of this guy, not that guy. And so, that's why bankers can't get us to invest our money in the general population, right? Most people don't have much savings, right? The same is true when we apply it to our health. What do we want now? What's going to make me feel good now? What, you know, can I bargain with myself that I'll do it tomorrow or this little bite's not going to hurt me, right? Because the temporal disconnect of at 63 if I don't do something now, I'm going to have chronic disease rear its ugly head. That is a hard argument. Some people are disciplined enough to think like that. That's a hard one. So, some of the ways to help people now is to help them identify how amazing they're going to feel now. In- instead of feeling sluggish, sitting in a chair all day with back pain, if we invest every day in walking, in sprint intervals, which is going to make us lose fat, or lifting heavy, which is going to put on the muscle of spanks and make us look good. And plus, when you get done lifting heavy, you feel like a badass, right? If you can make that the reward, that is an easier thing to do. Because you are right. We know what to do. We just don't do it. And we know what to do, and we don't do it because the battle is in the 5 and 1/2 inches between our ears. It's not actually picking up the barbell. Right? And so, it's identifying how this is going to make me feel today, not for 20 years. And here's the other thing. I honestly think sometimes it comes down to self-worth. Do I believe that I am worth the daily investment in my health? Or do I believe that everything else is more important than me? And that's hard. And I have come to understand that until you believe that you are worth the daily investment in your health, nothing else matters. Yeah, it's so interesting and I think one of the things again that has been um cured, that used to be a mind virus of mine, was I think part of me did think when I get to 50, when I get to 60, I'll address it then. Yeah. I if I've got um certain um health issues when I'm 60, well, I'll just go to the gym then, and I'll just uh Yeah. I'll just fix it then. I'll just start becoming uh active when I'm 50 or 60. But I But that's not how any part of my life works. That's not how my business or my investing works. Everything is compounding now. Yeah. So the decisions I make at 20 or 25 or 40 or your daughter's upstairs. She's what she's young 16 16. The choices I start making then Yeah. are sowing seeds that will flourish for better or for worse when I'm 60, 70. And you know what's easier than doing a little bit every day? That's easy. You know, my daughter upstairs, she poor thing can't get away from knowing what the right choices are. It doesn't mean that she does always does them, but if she maintains this healthy lifestyle she has because she lives in our house, it'll be easy every day. It's a lifestyle, right? It's not a monumental pivot. It's just the way she lives. And you know, the same if if you do all the things that you know to do now, it will become just the way you live. It's not a high energy expenditure versus waiting until you're 50 when you're 50 lb overweight when you have to totally rebuild all your lean muscle mass, you know, you're feeling like a whatever you're going to feel like. That's a big pivot versus I'm just living another day Mhm. doing the things I've always done. This is who I am. I am Yeah, that's one of the things that's been really helped me I think from doing this podcast is obviously I'm inundated with lots of information about health. Mhm. So that the the framework I use to decide what to take in and what to implement is just I I hear some things that my guest say and they might say, "Oh by the way Stephen, um apple juice or orange juice is full of sugar." Mhm. And in my head I was going, "Oh my god, I thought that was healthy." And then and I don't really I could take it or leave it anyway. So these small sort of modifications, taking these sort of very sugary drinks out of my life is something that happened. Um being consistent with my workouts, focusing on muscle gain thinking a lot about how I sit, but also making sure I'm as active as I can be. Mhm. Um and then the other thing actually has been supplements. Yes. Because I sit in this Diary of a CEO studio a lot and I sit in Dragon's Den's little dungeon a lot. Mhm. I spend a lot of time sat at my desk inside without any sort of natural light. So, I've started taking vitamin D supplements frequently because actually I went to the doctors, did my my tests and it How low was it? How low was it? It was very low. They said everything's fine, Steve. You've all good here, here, and here. I did like the full body. I did my testicles to my toes to everything, my blood, everything, my moles, whatever it might be. And the the one thing he did say to me is your vitamin D levels are low. Mhm. So, I've started supplementing. Is is how crucial is vitamin D for healthy? I mean, You know what? It's a it's a hormone that affects so many organ systems. It's important for your bones. It's important for your immune system. It's important for your brain. So, it's something that everyone should supplement. They should get their level checked. We're all low. And then we should supplement up and then have it rechecked so that you can have a maintenance low dose. You usually take it with potassium to help absorption. Magnesium is a is another key player with vitamin D. What if I want really strong bones? What should I be taking? Uh, vitamin D, potassium, magnesium. Yeah. You should be eating uh 1 g of protein for every lean for every ideal body pound you have. So, you build muscle to um to help your bones. You know, there's some remote data on boron and zinc, but I'd rather you have the three that we know work. To build strong bones, you not only need muscle, you need proper nutrition, you need to I should find another term, but you need to bash your bones. You need to impact your bones. The mechanical stress of impacting bones, whether it's jumping up and down, running, going up and down the stairs. For people with poor bone density, you can use a reformer, which is a which is a a trampoline. Um, is all important for sending the biomechanical signals to your bone that you're doing work, you need stronger bones. That is transformed into a biochemical signal that makes your bones uh, that your bone cells lay down new bone. That's how you keep healthy bones across a lifespan. Can you grow new bone? Um, you can Yes, you can actually. You can can increase your T-score. It's a multifactorial. T-score is a score that we measure using a test called a DEXA scan. Uh, a DEXA scan will tell us uh, not only our absolute bone density, but it but compare us to healthy people. And this DEXA scans are usually used for women or older men who have fallen and fractured. But a T-score tells us what our bone density is compared to a healthy 30-year-old, right? Assuming a 30-year-old has laid down optimal amounts of bone. And we can talk about how that's becoming not true. But so once we know our T-score it tells us the health of our bones. Um just to give us a gauge of can we rebuild? So yes, all the things we can lift weights, we can impact our bones, we can have proper nutrition. If we are a woman and uh, have lost our estrogen, which starts in our 40s, not our 50s. It starts in our 40s. We can make our estrogen decision, as I know you've talked about before. Uh because estrogen and testosterone are critical in bone health. And then if you show up with a T-score that shows that you have frank osteoporosis even 2 million men in the United States have osteoporosis. It's it's huge. Osteoporosis is uh, critical bone density weakness, meaning a T-score of minus 2.5. So, if you This is how it goes. So, remember in the in the tests in lower school where they would grade you on this bell curve? Mhm. Straight up the middle is bone density at 30 in a healthy woman, for instance, zero. Any positive number for your T-score, your bone density is more than zero, perfect. You're all good. Bone density one standard deviation or minus one below a 30-year-old healthy woman is called osteopenia, meaning your bone density is getting low, we really got to step up our efforts. A bone density number, a T-score minus 2.5 is the definition of frank osteoporosis, which is bones dangerously brittle. That score, plus there's this index called a FRAX index of FRAX index, which which takes all your lifestyle risk, meaning is your mother shrinking? Do you have a family history of osteoporosis? Did you already fracture? Fracture is the number one predictor of future fracture. Did you smoke your whole life? Did you have an illness where you had to take a lot of steroids that predisposes that break down bones? Are you of genetic makeup where you're predisposed to bone density? The FRAX index takes all those and calculates your risk for having a fracture in the next 10 years. So, a T-score of minus 2.5 and a FRAX index of 3.6 or three, meaning I have a 3% chance of a fracture in the next 10 years, those are indications for employing some of the pharmacological drugs to either maintain bones or to build bones. And there's a few categories of those that I usually send people to an endocrinologist to weed out. It's kind of a complex decision. If I was If I was getting to that stage, what kind of things would you tell me that I needed to do? So, if I was getting to the stage where I was minus two on that scale. If you were already a minus 2.5, we would have a long, hard discussion about all the lifestyle interventions, nutrition, lifting. You can still lift. Uh how we're going to add mobility, uh impact. How we're going to get some impact in without breaking a bone. But, we're also going to have a conversation about our hormone status. Um and we're also going to if you're already that low, have a conversation about whether we use a pharmacologic augment like bisphosphonate or Forteo or some of the drugs that are available to support bone density. And each person, man or woman, has to have their individual risks assessed to know which road to go down. But, what we cannot do is we cannot ignore it and hope that it goes away. You've You've done um so many studies, and I find studies really fascinating cuz they're they're first first party in that regard. So, it's really finding things out for the first time. What is your What are some of those studies that we haven't discussed that relate to our conversation today that you find most interesting? Yeah. So, let's talk about We'll start with bone because we're just talking about in masters athletes, we did two studies looking at could we preserve bone density across a lifespan if we took the variable of sedentary living out of the equation. So, in the first studies that we my group did, uh I we formed a group called PRIMA, the Performance and Research Initiative for Masters Athletes. We looked at 3,000 masters athletes. You had be 50 years old uh and uh they were competing in the National Senior Games, which is uh like Olympics for people over 50. And these weren't just these weren't just everybody that could go. These were the people who had qualified in their state games to go to the national games. So we looked at 3,000 of them. We did two bone studies. We found the first question asked, could we maintain bone density across upper age limits because we were active? And what we found was that yes, a very high percentage of people up even up into 85 had normal T scores. But then we did a second study that we wanted to ask, okay, so of all the activities you could do, what would make the biggest response from your bone? And not surprisingly, we found that impact exercise, the running sports, the volleyball, the the basketball sports, versus the swimming, the biking, the bowling, for instance, there's bowling in senior Olympics. Um those with sports where you impacted your bone, that impact exercise was as predictive of bone density as things you can't control, like your age, your sex, your genetics. And so it just shows how important putting mechanical stimulus against your bone is. So that was really important. So even bones can be preserved. We've already talked about the muscle preservation study, which was fascinating. The very first question I asked was to answer the question, this is this virus in your brain. When do we really slow down? When can we say, oh, I'm just getting old. I'm going to slow down. I based on the athletes I saw, I knew that it wasn't 50. So I studied 3,000 of these athletes again. I looked at all the track and field athletes. I looked at athletes in the 100 m all the way up to the 10,000 m. So, all distances, sprints versus long distance. I looked at finish times of the top eight finishers in every age category, and here's what I found. To answer the question, when do we significantly slow down? It's not 50, it's not 60, it is not until our mid-70s when we significantly slow down if we use athletic performance as a biomarker of aging. So, what does that mean? The example is this. If you put a bunch of men in a 1-mile race, the 50-year-old man in the year I did the study finished that 1-mile race in 5 minutes and 34 seconds. To put that in perspective, the boy that won the Pennsylvania State High School Games won his mile in 5:17. Oh, wow. I know. 20 seconds in in in 30, 40 years, right? How old was he? 17. Let's say he was 17. Uh but, the 50-year-old winner did it in 4:34. The 70-year-old winner of that mile race did it in 7 minutes. So, nobody was getting lapped. Right? So, I used those times to see how much we slow down. Before age 70, we slow down less than 1.2% a year timing-wise. So, after 70, there is a rapid decline in times, or you get slower and slower and slower. And I call that biology taking over. Either you don't have the mindset to work that hard anymore, or you've got enough injuries that you can't work that hard anymore, or you've lost enough enough lean muscle mass or or bone flexibility. But, what it tells us is that we have no excuse until our mid-70s for slowing down if we invest every day in our mobility. So, it really set the stage. That was my first study. Really set the stage for wanting to find out, okay, what's our muscle doing? What is our bone doing? The third study we did, which took us 5 years because we matched for everything. And now it's common knowledge, but at the time it wasn't, we asked the question, well, if we take sedentary living away from our brain, what happens? And so we had the athlete group, and we had a control group that was matched for every variable except their activity level. And what we found was that people who were chronically active maintained their mental agility and their speed of decision-making, and their physical aspects of something called the SF-12, which is your perception of your physical prowess, were all higher if you invested in your mobility every day. So, even our brains are responsive. And And we know that now. There's lots of studies. It's a It's something that's talked about a lot. The final interesting group of studies that we did before I left University of Pittsburgh was to start asking the questions of why. What's going on here? Why? Well, there's this protein called Klotho. Klotho was uh one of the Greek gods who spun the thread of life. So, this protein, when it was discovered, was thought to play a role in longevity. Every organ has receptors for Klotho. We know that mice that are genetically engineered to not be able to make Klotho die old very young. They're chronologically very, very young mice, but they're physiologically very old because they lack this protein. So, I decided to measure Klotho in my athletes and compare them to sedentary people. So, we drew their blood, we ran the ELISA study, and and not surprisingly, youngish 35 to 50-year-old masters athletes had the highest level of circulating Klotho longevity protein. The second highest level of Klotho in our study were people over 75 who were still athletes. Do you know the who the lowest Klotho level was? Sedentary 30-year-olds. So, if Klotho is the longevity protein, and exercising people have the highest levels, the next question was, "Okay, so what's going on? How does exercise give us more longevity protein?" Well, one of my one of my colleagues, Dr. Fabrizio Ambrosio, did the study that showed that contraction of skeletal muscle stimulates the transcription or the making of the Klotho protein. So, it's our body's response to the stimulus of activity that makes us make more longevity protein cuz our bodies believe that we are reinvesting in ourselves and not just sitting in a chair waiting to die. Mhm. But, that's fascinating, right? Right. Interesting. You I read I read about study you did as well with rats and stem cells, which is seems somewhat linked to this idea of muscular Yes, I'm glad you brought it up. So, it's the So, remember that picture we talked about that at a tissue level that we can maintain our muscle mass. So, that's at a tissue level, the whole flank steak we can maintain. We wanted to see, well, what's happening at a cellular level? What's happening at a stem cell level? And so, we we had a bunch of old lady mice. They were mice. Mice, when you're old, you're 2 years old. That is a long lifespan for a mouse. These little old lady mice were sitting back in the back of their cages, just hanging out, waiting for their next food. And we sampled a little bit of their muscle. Because the lab that I was a part of looked at a kind of muscle derived stem cell. Meaning all of our tissues have stem cells in them, including muscle. And And we now know those cells as satellite cells. At the time, in the in the early 2000s, we called them muscle derived stem cells. Well, we took them, and what did we find? These little old stem cells Healthy stem cells are round. These stem cells had started to become all spindly, like tree branches. They were no longer pumping out growth factor, meaning they were not reproductively healthy. They were not doing what they were supposed to do. And do these stem cells make muscle? These are stem cells that are found in muscle, and when stimulated, produce muscle. Okay. And so, they were not dividing because they were all spindly. They were not producing growth factor, and death in cells is an active process. They had turned on the genes that were leading to cell death. So, we took those little old lady mice, and believe it or not, you can buy treadmills for mice. Do you know how much a mouse treadmill costs? No. $30,000. I'm not. It was like a big part of my whole grant. So, we bought this treadmill. We put the little old lady mice on. Here's what we found. In 2 weeks, twice a day, many workouts, their stem cells were fat and replicating again. They were churning out growth factor, and they had turned off the pro programming for program cell death. So, what that told us is that even at the stem cell level, that we can rejuvenate stem cells by something as simple as skeletal muscle contraction. And so, to me, that is a fountain of youth type intervention. Mhm. At the cellular level. Someone said to me on this podcast one day, I'm I'm probably going to butcher it, but they said aging is the rapid pursuit of comfort. And I And as you were saying that, I was thinking, oh, that's now that kind of fits. That much of our aging is just to do with our increased pursuit of comfort for whatever reason. Mhm. Um I was thinking about that this morning when we're thinking about I was thinking about, you know, what is the what is the minimum amount of time we have to work out to What is the min-max? And I thought, well, honestly, you can probably accomplish what min-max is in about 45 minutes a day. So, what are we doing with our other more than 90% of the time? And it goes kind of goes to this. What are we doing? Are we pursuing pleasure all day? Or we're working, but once we're not working, what's the rest of that? We're just sitting around being pleasurable all day? And so, that's an interesting question, but another way to motivate people uh is to start associating taking care of ourselves as pleasure. And not or comfort, and not just in the senses I'm going to get a massage or a facial, which is what often we think of self-care, but that's temporary, right? It just lasts an hour until you get I often think that. I get off a massage bed, I'm like, okay, that was good, but do I have to do this every day? Mhm. Yeah. So, you stop thinking of taking care of yourself as pleasure. Putting yourself in discomfort. Temporary discomfort, because I'm not really kidding you, and you're probably the same. When you churn out an upper body workout, and your muscles are full of blood, and you're looking in the mirror, cuz I know you do, we all do, and you're like, that is a good result today." That's pleasurable. And if we if we stop for a moment and notice how good we feel afterwards, uh it's a motivation for how much we don't want to get there, cuz I don't want to get there as much as the next person doesn't want to get there. To the gym. If you are a B2B marketer, then you want to stick around for the next 30 seconds or so. As a business-to-business marketer, you'll know how tough it is to explain what you do. I've been there, too. But there's a platform that gets us, and that's LinkedIn, where I'm happy to say sponsor this podcast. Imagine a place where you can connect with professionals who truly understand your world. That is LinkedIn Ads. LinkedIn Ads helps you to build a meaningful relationships and drive results in a respectful environment. 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What what do women that are and men that are have a partner or a friend or a a mother or whatever it might be need to know about how menopause impacts our musculoskeletal functioning? Yes. So, I think um it is very common for people to know about hot flashes, brain fog, night sweats. What is less commonly known is that 80% of all women going through perimenopause will experience what the term we've coined the musculoskeletal syndrome of menopause. We coined that after the genitourinary syndrome of menopause, which is five or six different things put into one category so we can talk about it more easily. So, in the musculoskeletal syndrome of menopause, we know that 80% of women will experience it. 25% of women will be devastated by it, and 40% of the time when you go to the doctor and they do due diligence and they work up, they send you for imaging, nothing will be found structurally. So, that's why women sometimes think, "Oh my god, I'm just old. I'm falling apart, and am I going crazy because my doctor's telling me there's nothing structurally wrong." But, that's why we created this nomenclature so that women would realize that ubiquitous on every musculoskeletal tissue are receptors for estrogen, just like in the brain, just like in, you know, every other body part, the musculoskeletal system, muscle, tendon, bone, adipose, the inflammatory aspects are responsive to estrogen sitting these receptors. So, what are the things in the musculoskeletal syndrome of menopause? Well, number one is inflammation. In estrogen is a huge anti-inflammatory. It prevents the release of a cytokine, a inflammatory cytokine called tumor necrosis factor. And menopause, just to be clear, is the part part part of the symptoms is the loss of estrogen? So, if we if we just clarify the timelines, so uh a woman's hormones are unlike men's. Men, once you're through puberty, your testosterone will stay pretty steady. Women, every month, as we go through a menstrual cycle, cycle, estrogen goes up and down. When we in around These are average times. Around 45, it can start early like 35, but around 45, we have used up enough eggs from our week our monthly cycle that we start to become low in our estrogen and our body is trying to adjust to that. Our brain without estrogen gets brain fog. It has a lot of receptors and nothing to go in them, right? Once we have used up all of our eggs and we are 1 year from our last menstrual cycle, 366 days, that is the one day definition of menopause. And we live the rest of our 40 40 more years we live post menopause without estrogen unless we supplement. So, in perimenopause in our 40s, that's why I say at 47 I thought I was going to die. As estrogen is going away, all these receptors that used to be filled with estrogen, which would then cause all these marvelous downstream effects, all the muscle protein synthesis, the bone laying down, the inflammation would be kept at bay, suddenly have have no stimulus. So, when we're talking about inflammation, estrogen is an anti-inflammatory effect. It prevents the release of tumor necrosis factor, which is a inflammatory cytokine. I think of it like a fire or, you know, nuclear war or something that chemicals in our body. Um so that gets out of control and then uh estrogen is also really important interacting with a part of our immune system called the inflammasome. So, without estrogen controlling inflammation, we can get something called arthralgia, which is your total body hurts for no reason. And this was one of my primary symptoms when I was 47. I went from being an athlete, active all the time, surgeon, I do hauling people's bodies around to I could barely get out of bed. It took me a lot to like crank out and get out of bed. My whole body hurt. There's nothing structurally wrong. It's due the inflame inflammation of loss of estrogen. Another very very very common inflammatory symptom of the musculoskeletal syndrome of menopause is frozen shoulder. It's all over social media right now. It's where it is an inflammatory state. Men can get it, usually diabetic men. It just means that you're you're inflamed. So you'll present to my office with the story of Doc, I did nothing. I didn't have an accident. I didn't hit my shoulder on the closet in the middle of the night when it was dark, but I woke up and my shoulder is killing me and I can't move it. It's It's It's literally like this. And that's because for some reason the shoulder is very sensitive, the capsule, the inside skin of the shoulder, very sensitive to inflammation. And so people show up like that. Frozen shoulder can take 2 years to get rid of. It's miserable. So that's inflammation. Is that the the whole hook your bra test? Yes. Yes. I made this thing up. You can't hook your bra, right? Most women do this. Yeah. The first motion you lose in frozen shoulder is internal rotation, which is what this is. Hooking your bra on. Hooking your bra. You can't. Cuz what happens is the first thing that goes, you can't do this. Your arms kind of stuck at your side. And then you can't lift it up. And you can't do your hair. So you're trying you know, you're doing all this trying Imagine not being able to move your arm and when you did move your arm, it's excruciating. Oh, it's painful as well. Excruciating pain. Like women say to me, I'd rather give birth again than have this shoulder. So What's going on there? Like what's going on in the shoulder? Yeah, there's there was a study done by Jo Hannafin, who was a mentor of mine at at Hospital for Special Surgery, who looked at the stages of a frozen shoulder. And first, it's just big inflammation. All the inflammatory cytokines go and inhibit the I keep doing this. The shoulder has an inside skin that surrounds the bones called the capsule. It's like a a thin sheet of paper, like cellophane. That gets inflamed, hot and red. That's painful. Over time, the inflammatory cells of the immune system that crawl into the capsule, the pain will go away, but it will cause a a capsular shrinkage like this. The It will actually contract. So, your pain your shoulder might not be as painful, but it still won't move. So, that's why it's really critical that people come to doctors like me and we get it moving quickly. We do not want it to become stuck in cuz it literally can take 2 years to defrost. All due to this inflammatory into We don't know why the capsule is so sensitive, but we know it is. So, that's the inflammatory aspect of this. We know that without estrogen, uh we can lose uh 2 to 3% of our um muscle mass. And rapidly during this period, we have estrogen is an anabolic steroid. It It's made for muscle building through the mTOR system. And so, without that, and we build less muscle and our muscle stem cells or satellite cells become decreased by 30 to 60%. It's profound in a very short amount of time. We know our bone about bone density. We talked about that. Estrogen's role in the bone is to control one of the cells called the osteoclast. If we talk about bone biology briefly, if we have that femur, imagine on one side of the cell, when uh you impact your bone, the biomechanical stimulus is converted to biomechan- biochemical stimulus and it says, "Hey, uh we need to build more bone." So, the osteoclast crawls up the cell and starts digging out minerals to release to the body to do its function. What happens when you have estrogen is the osteoblast comes back up behind it and fills in that hole and builds bone. Estrogen helps control osteoclasts. The more I learn about bone biology after all these years, it seems to me that the osteoclast is a little bit of a rogue entity. It's going to go uncontrolled. It needs a lot of a lot of control with estrogen, testosterone. Without those controls, what happens in osteoporosis is you you can still lay down bone. Your osteoblasts are still working, but it's out of control. You're breaking down more bone than you're building. Okay. Yep. So, you know, inflammation, then you have muscle, you have bone. Here's one. We talked about arthritis earlier. There are estrogen receptors on the cartilage. Cartilage estrogen sitting on the cartilage helps maintain this spongy mate- spongy matrix of cartilage that then protects your bones. Without estrogen, the cartilage matrix breaks down. So, before 50, men have more traumatic arthritis than women. After 50, women can have a rapid progression of their arthritis. Pile on top of that the weight gain that happens to many women with the load we talked about and it's a disaster. And so many women rapidly progress and need total joints, which as an orthopedic surgeon is not the end-all, but we'd like to avoid it, right? So, that's due to estrogen being missing from the cartilage. And And finally, On that point, you talked about weight gain there in menopause. I read that you you gained weight when you went through menopause. I gained 30 lb. 30 lb. So, that's equivalent to four roughly four of these bricks if each brick weighs um 7 and 1/2 lb. Which is a lot of weight to suddenly gain. And when we think about the impact that that will have on your joints based on what you said earlier. Yeah. My pain was more an arthralgic pain meaning total body pain. Although when I had that weight on I had um knee I had pain underneath my kneecaps going up and down stairs because of the extra pressure of the my kneecaps on my femurs. So does that make sense? Yes, it does. Yeah. That's That's uh yeah, something that we don't I don't think I'd never really considered. I never considered how the impact on our joints of weight gain period, but then also when you go through menopause weight gain is something that I've heard about over and over and over and over again because of the loss of estrogen and how that will then have a skeletal impact on a variety of different areas of your body. But then imagine this perfect storm, right? You you don't feel like yourself. You're tired. You your joints hurt. Maybe your whole body hurts. You're losing your muscle. So, that causes more impact. There's no shock absorption. You're losing your bone and without even realizing what's happening cuz it creeps up on you, right? And you're so busy I mean all the excuses are so busy. Women very rapidly find themselves at 60 and they have you know, there's a syndrome called OSO osteoporotic meaning bad bones. We talked about that. Sarco bicity loss of bone, loss of muscle, gain of fat. You've got all three things. And the morbidity and mortality of being osteosarcobesity is three times what it would be if you had one alone. So, it creeps up on you and you can see how none of these tissues are separate from each other. It just becomes this horrible storm and women are like, "What happened to me?" What's the What's the remedy for that? What's the remedy for that? Well, the remedy is understanding that you can feel like yourself again and here are the steps I ask every woman going through this to do. Number one, you must make your estrogen replacement decision. I believe that that decision to replace your estrogen must be based on science and not the fear or the myths that are circulating. Though, and I know you've had these conversations, but the Women's Health Initiative study has been largely overturned. Um And so, every woman is a sentient being with agency, ability to make their own decision and they should make that decision and not just go on hearsay. So, that's number one. Let's make our decision. If you make your decision to do that, which I have done, I replaced my estrogen not for my hot flashes, night sweats, and brain fog. Those go away, frankly. I do it to preserve my bone, my muscle, my brain, and my heart. That's decision number one. Number two, you are never ever going to feel better until you decide to invest every day in your mobility. And so, what is mobility? It is lifting heavy. Women have to put down the manby pamby pink weights that we do 20 sets of because we don't want to bulk up. You're never going to bulk up unless you do it purposefully. We must lift as heavy as our bones will let us. So, for my people, I've simplified it into once you have started enough that you feel comfortable moving your body, we must lift four rep or sets of our major muscle groups in compound motions. So, push pull with your upper body, bench press, pull, some kind of pull down. And then for the lower body, it's squats and deadlifts. Four reps, four sets in a progressive manner. You can start with 2 lb, but I want you to progress up. And then for the accessory lifts that support the big compound lifts, like for instance, for my for my bench press, I support that with biceps, triceps, lats, delts, eight reps, four sets. Okay, that is the basis of lifting heavy. The other thing we need to do is uh do a do our cardiovascular training with 80% base training, which is lower heart rate. I mean, everybody's talking about zone two. I happen to in in the place where my office is, we have a metabolic lab um that was built by Iñigo San Martín San Martino, who's the guru of zone two. And so, we use his protocol, and that means that I need that I need people to do uh 60% effort 3 hours a week, but that's not all. Twice a week, we're going to sprint as hard as we can, and that freaks people out cuz we're in the Olympic trial. We're in the Olympics right now, and everybody thinks it's supposed to look like that, like the like track and field trials. What sprinting means is you just work at maximum heart your maximum 100% effort for short bursts. So, 30 seconds, short burst, hard as you can go, and then you recover for 2 to 3 minutes. So, I'll give you a concrete example. In my life, my base training heart rate, because I have the luxury of measuring it with a lactate threshold, is 130 beats per minute. I achieve that with an incline of 4 to 5 and a speed of about 4.2 and it's a brisk walk. It's almost on the verge of having to jog. For 45 minutes. When I'm done with that, cuz that's good for my cardiovascular base, I punch it up to 11 and I go as hard as I can cuz I'm not very tall and I don't want to fly off the back of the treadmill. But my heart rate goes up to about 186 and I keep it there for 30 seconds. What that does, that will burn 40% more fat than just uh even high-intensity interval training, which is done at about 80%. That amount of effort burns 40% more fat. It is stressful enough, it offsets our normal homeostasis enough that it um helps stimulate the formation of more muscle stem cells. The the muscle perceives that effort. And so, that is the the working out portion of what we need to do and then the smart anti-inflammatory nutrition, we need to get rid of simple sugar. We need 1 g of protein per ideal pound. High-quality protein, what does that mean? We need a very high concentration of one of the branch-chain amino acids called leucine. Leucine is the most powerful amino acid stimulus of the mTOR muscle-building pathway. Leucine is found in highest percentages in whey protein. So, you can get it from plant protein, but just in much lower percentages. Whey has about 10% leucine. And we know that's important to nature because mother's milk is mostly whey. Which means it has the highest amount of leucine as we're trying to grow muscle in our babies, right? So, leucine is high in whey protein, about 10% in animal protein, any kind of meat is is about 8%, and then beans and legumes and plants are about 6.5. So, can you get enough protein from plants? Sure, you can. You just got to eat a lot of it like a bull does. What about fiber? People are going crazy for fiber at the moment, it seems. 30 g of fiber. So, that just means complex carbs. Your microbiome needs fiber. It it it is a slower digestion so that we're not causing carb spikes. I'm not wearing it today. It's the first time in about a year I haven't. I I'm not diabetic, but I have worn a continuous glucose monitor because I am just a data geek. I love my data. I know exactly at this point what foods will spike my glucose and how to keep my glucose steady all day. What's been the most surprising cuz I I literally have just taken my continuous glucose monitor off. I wore it for the last 2 weeks while I was filming a TV show called Dragon's Den. And I gave one to all of the dragons with me and we've been talking about it every day. What was the most surprising food for you that caused a glucose spike? The surprising food, um well, it wasn't surprising. I mean, I am to the degree my glucose spikes shot up is I am so sensitive to simple carbs. I can't even look at a simple carb and it goes up to 165, which our body is meant to respond to spikes. I'm not saying that you have to live like this because I have also found that when I only ate protein or most very low low low carbs, that I was so low energy, I would be slogging through my clinics and I just need I could feel I needed energy. So now I've added sourdough to my breakfast knowing that I'll get a small spike. So that was very interesting to me how extremely sensitive It's a simple carb. A simple carb is a sugar, ice cream, white bread, white potatoes, white pasta. All the good stuff, annoyingly. What is the What's the most important thing that we haven't discussed in your work or the most important idea that I don't know has changed your life, maybe people don't understand or think about it enough that's foundational to having a great health span, living long, being healthy, all of those things that maybe we haven't discussed. Yeah. I want to address that question in a couple ways. Number one, um you have to We talked about temporal disconnect. And doing the things today that feel good today, but for the future. And so the way I have really changed since I've been through this is I have thought ahead about what I want to be when I'm 97. And how did I choose 97? Well, I'm 57 now. My daughter, my youngest daughter was born when I was 40. If I want to be around to bug the heck out of her until she is my age, I need to live till 97. What do I need to do to do what I want, when I want, when I want it? Like you can imagine, I don't want to be told what to do. I'm a surgeon, I'm usually in control of my environment. And I think people just want to be in control. I want to do what I want. Well, what's it going to take? If I just wait until 63 when when my health span is over to pay attention, I'm never going to get there. So that has really pivoted my mindset that I have to do it every day now. I don't love doing it. I mean, I'm not going to lie to you. I don't love going and working out most days. but with this perspective I will. But the other the other tenant that I think is so important, we talked about lifting heavy, we talked about zone two and sprinting, something I've layered on this year uh is the concept of our VO2 max and the fragility line. Fragility means you get older, slower, weaker. Uh you lose your functional capacity. 25% of all people are frail and unable to live independently by the time they're 85. Not on my watch. And so um the frailty line is the cardiovascular health that you need the cardiovascular capacity that you need to be independent in your own home. You may not be running marathons. So for men it's 18 ml of oxygen per kilogram per minute. For women it's 16. So how do we figure this out? I would go have my Have you had your VO2 max tested? Uh I haven't. It's torture but you should do it. I think well I had a cardiovascular examination and they made me sprint on a treadmill. Yeah. Um and they were look but they were looking at my how well my heart coped. I don't know if they're measuring my VO2 max. They didn't. Yeah. You should do it while you're young so you know your base. I didn't have a mask on, you know. Yeah. So what it tells is your cardiovascular capacity for for exchanging oxygen from your blood to your lungs. Elite athletes like the Tour de France have have VO2 maxes in the above 75, sometimes 200. They're just genetic specimens. Um the 50th percentile for a man your age is 55. The 50th percentile for a woman my age is 31. That's the average, right? That's the average, 50th percentile. When I was 50 I'm going to give you an example. Every decade we lose 10% of our VO2 max if we don't do anything about it. That's just the way we age. 10% I can get it back though, right? You can work at it. People who are out of shape can make bigger deltas getting it back. People are in extreme shape and the delta smaller cuz they start out well. So for me, I'm going to give you an example so people see how this works. At 50, when I was 50, I did it. My VO2 max at that time was 45. So at 60, if I lose 10%, let's just do big numbers, I'll be down to 40 VO2 max. At 70, I'll be down to 35. At 80, I'll be down to 25. I'm still above the frailty line. At 90, I'll be 20. Still above the frailty line. Not what I was at 50, but not frail. I can still live on my own. So what I've done now, since the things that I've talked to you about are a lifestyle, they don't take much energy cuz it's just how I live. I've layered on VO2 max training, which is a different way to do cardio training. It's 4 minutes as hard as you can go. Torture. And then you recover for 4 minutes. Only 4 minutes. And then 4 minutes as hard as you can go. The good news is you only have to do that three times or so once a week. And it will work you hard enough to maintain or improve your frail your VO2 max frailty line. That's something special that you can add on once you've optimized your health, once you've done the peak performance things we've talked about, then you can add those things on. Okay, well I better get I better get on with it then. Don't feel guilty. I need to go to the gym today, but it's certainly changed my perspective on what I'll be doing in the gym and and also why I'll be doing it. I think. I think the why piece is so critical. I think a lot about discipline and incentives and why certain behaviors occur. And I wrote in my my book that um I was trying to sort of sort of simplify why some habits in my life have stuck and others haven't. And then why some habits where I was a bit of a yo-yo suddenly stuck and I held them for 5 years and still to this day and and others haven't and um I kind of simplified it down to this idea that the discipline equation starts with the strength of your why. Like this So you've given yourself a really strong why by having this sort of 97-year-old uh goal, like who I'm I'm going to be when I'm 97 and then linking that to your daughter, which is a pretty strong why. Yeah. Plus the the enjoyment I get from the pursuit of the goal. Mhm. And then minus the friction or the like lack of engagement from Yeah, the hard like if the gym is really far away, if it takes too long, if it if it's embarrassing is friction. So if I'm going to a gym and I'm a guy and there's lots of beautiful people there and I'm overweight, it's Yeah, all of that all of that's friction. So how do you like influence that equation to increase your why, make it more enjoyable or psychologically reinforcing the act of the discipline, and then kill all the friction I possibly can. And for me, that's where the habits we're talking about today have really stuck. Yeah. Interestingly, I've said share this before, but I'll share it again. I was a um a yo-yo gym goer. My gym routine and my health strength routines were all very inconsistent until the pandemic. And it was for me just seeing that health is the foundation of all of our lives, seeing that on a screen in lockdown, that the real sort of variance between outcomes for people that got COVID came down to your sort of pre-existing health. Yeah. And so at that point I thought, "Oh my god, like it's not my business, it's not my dog, it's not my girlfriend, it's not my my family that matter the most. Actually, number one, the foundation in which all those things sit is my health." So that became my first foundation, my non-negotiable. Um and hopefully, as you say, that'll mean that my kids, when they arrive, whenever whenever I become a father, um will have a dad until I'm 170. So that's the goal. That's the goal. We have a closing tradition on this podcast where the last guest leaves a question for the next, not knowing who they're leaving it for. And the question left for you is what was the last time you took an uncomfortable risk? The last time I took an uncomfortable risk and what happened when I did was uh I am an academic orthopedic surgeon. Which means I create big business and care and practice within big hospital systems. So, there's a big safety net in that. But, I have always been what I've called an intrapreneur. Meaning I'm using somebody else's money, somebody else's time, and but I'm building them a big business. Three years ago, I left that comfort. In a late stage of my career, I left that comfort and decided I know what I'm doing. I believe in myself. I'm going to spend my own money and I'm going to go out on my own in private practice. And I'm going to uh build these side businesses, my keynote speaking, my precision longevity practices, which are purely entrepreneurial ventures. And and at 57, to go out and create my own business when all I have ever known is a W-2 tax form, is a huge risk for me and my family. But, but I love that um I am confident enough in my own capacity, Steven, and my own work ethic that even if I had to go work at Starbucks to bridge the gap, that I'm going to make this work. And it's a it's a very freeing and and beautiful mindset to to take what I've learned this whole career and do it for myself. Well, it certainly is working. I think you'd agree, right? It's great. It is great. I mean, you've galvanized a community online of many millions of people. You've written some absolutely incredible books, all of which I'll link below. And you're still doing um incredibly important work through uh YouTube and through Instagram and through all of your channels, which I'll link below as well. And it's very necessary work, because you are you're confronting a mind virus that I think can hold us back from living long, happy, healthy lives. And sometimes it's just an idea, right? Sometimes it's just an idea that can change your life. And it's also, conversely, sometimes just an idea that can ruin your life. And I think the work you're doing is replacing those potentially inhibiting ideas with much more constructive, healthy, positive, optimistic, hopeful ones. And for that, I thank you. Thank you.