Ep. 553 The Ultimate Bone Health Masterclass Series Part 1 | Menopause & Bone Health

Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives. This is a special bone health mashup series with physicians Dr. Joy Ceylin Whitstein, Dr. Jessica Shepherd, personal trainer Deborah Atkinson, and lastly, PhD researcher Dr. Darren Kandao. We dove into the impact of contraceptive use on bone health, especially in young women, the role of underfueling and relative energy deficiency and how this can contribute to a great deal of bone health issues at a young age, how thyroid health and bone health are interconnected, how often we need to strength train both volume and intensity for our bones, why vibration plates might be helpful long term for bone health, why screening guidelines for osteoporosis are way too late. We should be screening women's bones at a younger age. And last but not least, the role of creatine monohydrate and its impact on bone health with really encouraging recent and relevant research. Again, this is a first in a series on bone health with multiple experts. I hope you will enjoy this conversation or these conversations as much as I did recording them. Yeah, I think that's a wonderful benefit. Let's talk a little bit about bones. I think that bones are oftentimes forgotten about until there's a fracture, there's a problem, there's pain involvement, there's an injury. I think that many individuals probably don't realize that we hate peak bone and muscle mass in our 20s and up to maybe age 30. And so when you're talking to younger patients, people that might be on oral contraceptives or depoprovera, really looking at the research about how that can impact bone development over time, what are some of the things that you're looking for that might be red flags, not just in younger patients, but in your other patient populations of someone that probably never laid down good quality bone. Right. So yes, that's true. We really do peak in our bone density by age 30. And so I want to be clear that doesn't mean that after the age of 30, you can't work on your bone density. And it's not like doomsday. If you didn't figure out, you need to strain and do impact training until you were 50. It's just that you do have this unique opportunity before the age of 30 to build that bone bank and really increase your peak bone density. And a lot of things like that can happen before the age of 30 that might reduce your ability to do so. One of them is overtraining and underfueling, which was traditionally referred to as the female athlete triad and women with disordered eating. But you can have someone that's not like truly anorexic, for instance, but they're just chronically underfueled because they're overtraining. And men can also have energy deficiency. So we now call this, you know, relative energy deficiency in sport. And so girls who started menstruating and then lose their cycle or have a really, really delayed onset because of the overtraining and underfueling. And for instance, we see this sometimes in endurance athletes as a common phenomenon. And they may, like during college, have some stress fractures and they recover and they keep training. And these people that are at risk for entering the age 30 and beyond with a lower peak and therefore if you decline from there, say at 1% per year or at menopause 2% per year, they're going to be really high risk for osteopenia, osteoporosis early on. I mean, you could have low bow density at the age of 21 if you had really severe energy deficiency. And then you mentioned depropovera. That is one of the contraceptives that does reduce bone density while you're on it. And there are studies that show that the bone density does rebound and return over time, you know, it could take a couple of years perhaps, but or maybe not for everyone. That drug concerns me when someone is taking it and then they have an injury in their reduced bone density state. I can't undo their injury in that state and that's a real problem. So that's probably my least and again, I'm an orthopedist, probably my least favorite contraceptive to see a teen or 20 year old woman on in general. Obviously, I didn't make that decision with that person. There may be a reason why that was chosen, but it does affect bone density, at least while they're on it. Yeah, it's really interesting. I just finished writing a book talking about the microbiome changes that occur in perimenopause and menopause. And when I was doing a ton of research about oral contraceptives, deproprovera, it certainly was clear to me that in the literature, teens and young adults are the ones that are most susceptible to the impact of not being able to lay down the same quality of bone. And I think I'm the first person to say, if you need good contraception, you do good contraception period. With that being said, I think that there's a lot of maybe missed opportunities to help patients understand, just so you know long term, if you're taking these drugs for a period of time, it can impact the quality of your bone. And when I was in my teen years, I wasn't worried about bone. I wasn't even thinking about bone. And I think that's how many teenagers and young adults are thinking. They're going about their busy lives. And they're like, you know, menopause is a thousand years away. And I'm not even thinking about that. Although my teenage daughter just said to me, oh, my number one concern right now is menopause. It sounds awful. Because I think she hears me talking about my pain sense. I'm like, it shouldn't be your number. She's like, the thing I most fear is menopause. Oh, how funny. But you know what? I don't even think, but it's incredible though, like our generation is having those conversations. I think that maybe I can only speak for my mother, but like my mother's sibling. I mean, no one talked about menopause. And so I think that it's wonderful that maybe teenagers even understand what that conflict is. My teenage son, we go work out every week together at the gym. And he said, mom, do you think your estrogen patch is making your joints feel better? Because I started to do that. Wow, amazing. And carry menopause. And I'm like, yeah, actually, I think it is. But it's kind of funny. He brought it up as a conversation. That's amazing. That's amazing. I mean, and I think it just goes to show I have all boys, all teen boys, and having conversations with them just to help them understand, your dad will go through andropause. I mean, he's in it and I'm in menopause. And it's kind of like women get, and I tell them it's kind of like women get shoved off a cliff. That's how dramatically the hormones fall. Whereas men, it's a little more gradual and kinder. With that being said, I think that it speaks volumes of this generation is having those conversations with their parents, even if you're fearful of what that is to come. So when we're talking about red, so this relative energy deficiency syndrome, I think that is certainly really important. And that kind of focuses in on this disordered eating, irregular menstrual cycles, and then also bone loss. But there are other things that can set us up for being at risk for osteoporosis. And I think this is worth mentioning because some of these things we have control over, and some of them we do not. Yeah. Thyroid conditions are one that can impact bone turnover and the way bone is formed. Yeah. Medications, if you have a seizure disorder and you have to take a seizure medication for a long period of time, those can contribute to decreased bone density. If you have really bad reflux disease or get gastric ulcers and you need to be on proton pump inhibitors kind of chronically, that can lead to lower bone density. So yeah, there are some things, and that's how I like to describe them too, some things that are under your control and some of them aren't. And it's just good to know if you have some of those risk factors. Like if you arrive at honestly even like 40 and you had any history of that sort of energy deficiency picture, now you're on a thyroid medication or maybe you've been on a proton pump inhibitor from your GERD, you're someone that should be screened with the DEX scan much earlier than someone that doesn't have any of those conditions. This being said, I think the recommendation of waiting until 65 to be screened osteoporosis is way too late because I think women need the information about where they're at with their bone density around the time that they're making a decision about using hormone therapy or not because I really think if women had that data would inform their decision more about do they want to use hormone therapy for prevention of osteoporosis? Like what if they found out they're osteopenic or near that? I really think that would help. I think information helps people with decision making. I'm not saying every single person or woman needs to use hormone therapy, but it would be nice to know where you're at because if you take that DEXA scan test at the age of 65, you're not going to get started on hormone therapy that far beyond menopause. You'd like to do that within 10 years. So the test is like mistimed with the decision making for something that is preventative. I agree. And I think that it's both inexpensive and important because if it's run in a particular way, you can look at the not just the quality of your bone, but you can also look at the fat-free mass. I mean, it gives you some degree of your body composition, which I think is so important. You can get information about the density within your lumbar spine versus your hip. And we know that like impact exercises, it's more likely to help you gain bone density in your hip and strength training is more likely to help in the lumbar spine. I mean, these are both good things to do, but it would be nice to know the reason behind why you're doing things and what you really need to work on. Well, and I think it makes it easier for patient buy-in. You're absolutely correct that information allows us to make decisions that are fully informed to your point about if we're screening at 40 or 45, at least then women can be properly counseled. These are the things that you need to be doing to help protect your bones. And I think for a lot of people, and I speak from, you know, I have a lot of older female relatives and how many of them have fallen and fractured hips and they're all sharp as tax and, you know, still going even, you know, years past their original hip fracture. But I think for a lot of people, understanding that, you know, estrogen therapy can have huge therapeutic benefit for the prevention and improvement of bone quality. And I think one of the statistics in your book, you talk about 75% of women will experience a fracture. That's quite significant. Well, and when you look at hip fractures, you know, three out of four of them occur in women. And, you know, we know why. And I just think so many women don't understand that hormone therapy, that one of the actual approved indications for it is for prevention of osteoporosis. Correct. You would much rather prevent it than treat it. Because treating it, you know, these medications, like the bisphosphonate glass of medications, it doesn't, it helps you maintain and gain a little bit of bone density. You know, if you're on those meds for a few years, you'll gain about 6% bone density. But it's a different kind of bone. It's not necessarily organized in exactly the same way that bone would be formed if you were disforming it from activity and with maintaining your estrogen levels. And there are some side effects of those medications, like some that are really concerning and rare, like, you know, jaw osteonecrosis and heartburn and some atypical fractures, like the hip fractures that happen below the level of the hip joint, those can be associated with those medications. But the point is you'd like to not get to the point that you need them at all by maintaining your bone density. There are definitely major reductions in the risk for hip fractures and vertebral compression fractures, all the locations that people get, you know, osteoporosis and fractures. So it's just, I just think that most women don't think of hormone therapy as something that's preventative of osteoporosis and fractures. They think about it for hot flashes and night sweats and things that will theoretically pass, not the long term, you know, consequences that exist. So. Well, and it's so interesting in my past life as a nurse in the ER of inner city Baltimore, I can't tell you how many compression fractures I saw on women, how many hips had to be reduced sometimes in the ED itself, or they went off for surgical intervention and understanding that there's this whole generation of women that really for the most part lost the opportunity to be on HRT post WHI. And so I'm so grateful that things are kind of sweet. The pendulum is starting to shift back a little bit where we're having conversations to help educate women so that they can then go to their physician, their nurse practitioner, their PA and have a conversation about the appropriateness of therapy. And the thing that I find so interesting is there are lots of things we can do about bone health that are not per se those drugs that have the side effects. Like I tell you how many of my patients were on this phosphate and they would say to me, oh, my dentist is now fearful to do dental surgery on me because because I'm on this drug. That's that rare complications. Now I do want to be clear. If you have osteoporosis, those medications will reduce risk of fracture. And there may be a time if you're diagnosed so far into the process that you're you know, more than negative 2.5 on your Texas scan, like those are important medications to have, for instance. And so it's not that they're a never thing. It's just, yes, there are many things you can do to not end up in that place where where you need them. But they are very important medications when we need them. And the whole concept of sarcopenia and helping your patients understand that muscle loss begets frailty, frailty begets falls. Do you find that most of your patients are open to the concept of strength training? I think many people viscerally, if they haven't been strength training, and they're 67 years old, they're like, no way I can't do it. Or do you find like, people are more open and receptive to discussions around that type of exercise therapy? I think women as a whole seem to be very open to doing cardiovascular exercise, and less likely to be interested in strength training. I think that's shifting and changing. I do think it's changing. And I talked to patients about that a lot. Again, like the common scenarios, someone coming in with nuanced knee pain, and they can't run like they used to want to run. And that was their main form of activity was cardiovascular exercise and running. And also to be clear, cardiovascular exercise is not bad. Like it's very good for our heart and our lungs. 150 minutes of cardiovascular exercise per week has been shown to help, you know, one of the things that prevents dementia. So these are good things. But strength training is definitely beneficial when we can't necessarily guess what I should say is people get to this point where they do kind of naturally kind of shift away from some of the higher impact cardiovascular exercise. And I am telling them like, you know, strength training would help you have less joint pain. But I take that opportunity to also tell them there are major metabolic benefits for you to strength training, like you're going to have better glucose control, you're going to be less likely to fall the pushing and pulling and tugging on your bones from the strength training stimulates greater bone density. So strength training, you know, programs and women who have decreased bone density will improve bone density a little bit a few percent over the course of six to eight months has been shown. And, you know, I always take that opportunity. I always tell women who are having, you know, struggling to do their usual cardio, like this is a good time to think about the benefits of strength training. And I always tell them the other benefits relate to, you know, their metabolic health and their bone density. So it's just, I think it is something that people are open to adding on and taking on if you give them a little education about the benefits of it, like long term and give them a little instruction. If you're in perimenopause or menopause and are feeling more fatigued, dizzy, lightheaded, struggling with headaches or noticing your workouts feel harder than they used to, electrolytes may be part of the missing piece. As estrogen declines, we lose some of the fluid regulating and vascular protective effects that hormones once provided. 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What is the research showing in terms of strength training and impact on our bones? We know that we lose 10% of our bone in the first five years of menopause, and that's when we're at greatest risk for osteoporosis. I think for many women, they understand the interrelationship of strength training and walking and stimulating bone because actually those hormone changes, especially estrogen and progesterone changes, actually they increase, they upregulate bone breakdown as opposed to bone building. Those are the things I think about. What is the research show about how much strength training and how often to support our bone health? Yeah. I'm so glad you asked. It's so exciting actually to be a woman post-menopause now because we are going to create the results, the data for again for our daughters to come through. Think of this in 1995 when I first personally started lecturing on osteoporosis and osteopenia. I had to define it. People didn't know what it was. I had to draw pictures and look at this is modeling. This is remodeling. You're like a pancake cooking and here's what's happening, but you're getting too many holes and they're not filling in. Now it's household words, but back then we thought that once you got diagnosed, I mean it was like bubble wrap. We got to, you know, don't do this, don't do that, don't do this, contraindicated. And it was really, people were nervous. They felt like, I remember having clients come to me and they were in tears about to retire thinking they were going to retire to their dream home in Fraser, Colorado. If you're listening, you know who you are and ski, spend their life skiing. And all of a sudden, you're a petite size two, told you have osteoporosis and you're at high risk. No doctor wants them downhill skiing like a bat out of hell, which is probably what she was. But now that's not what would happen. We know if you were already doing it, you should probably keep doing it. We got to have the joy factor in there as well. And we got our strength training and doing the right things. And today, since about 2015, the research since then has been coming out on women post menopause, because for a very long time, researchers were afraid to impose and do no harm, you know, comes out in research and they say, you know, it's not ethical to take a limited population and apply terrible stress to them. Well, finally, they were like, we've got all these women who've had osteoporosis for 20 years, they're not fracturing in exercise, they're fracturing in unique things in life. You know, so isn't it about time we start studying this? So amen to that, whoever said that argument. But we're doing high impact and high intensity exercise, like some of the protocols we've described, five sets, five repetitions, or maybe five to seven. So there's what Dr. Belinda Beck out of Australia calls two in reserve. So you might do five or six reps and say, I know I could do two more, but you're actually not going to force yourself to do them just to conservatively not risk injury of the connective tissue in the ligaments and joints. So we're seeing from the results of those kinds of studies and high impact. So they were having women like, hold on to a bar or jump up to it and then jump down to box jumps. So that's, you know, loading it not just with a jump in place, but a jump from a box down to the ground. So really increasing the gravitational ground force, no injuries. And they loved it. The high intensity exercise, they also had that feeling of mastery and achievement accomplishment that no other researcher has ever documented. You know, researchers who'd participated in research prior to this said, you know, with this we've never seen before, you know, like they kept coming back, the dropout level was low adherence high. That's always a factor too. But the injuries based on exercise with nil. So that makes it exciting. These studies are really longitudinal. So they're long, they're over time, which matters partially because you have to start safely. We do start with lower weight, higher reps and progress over time. And that's one thing that we all have to remember, right? That, you know, no matter what bone density may be your key or metabolism, in which case, both points you want heavier weights for your advantage, but we have to start later. And it takes a series of weeks and actually months, two to three months to get to a point where you're lifting heavy enough. And or you find the point where I can't go heavier because I feel vulnerable, some things going on, but you then do it slowly enough where you stop yourself before an actual injury occurs, which is good news. Yeah, that bodily awareness, I would imagine, is very important. And working with women, some of whom probably aren't yet on HRT, some who are on HRT, how do you see the recovery? And I know this is a small sample size, but over time, how has HRT impacted your clients in terms of being able to build and maintain muscle, build and maintain bone? Because I'm starting to see, like I always say, my N of several hundred, if not a couple thousand, you know, the sleep piece is where I see the most benefits, you know, in terms of like consistently, if women come to me with HRT, they're sleeping through the night. Yes, anecdotally, what I can say is that both for muscle and bone density wise, I would say there are fewer to compare. And the reason is it's obviously it's a longer period of time before we're going to see results. Somebody first gets diagnosed and is then aware this is my key priority. It's another year, at least until they're going to do a scan in most cases. I mean, some women are more proactive, but definitely the women who are on HRT are seemingly getting better results. I say that saying probably easier results. They don't have to fight for it quite so much. They're getting that little boost from the estrogen is my guess. I feel like I owe you an answer to how much I'm not sure I really answered that coming back to the bone density. So two to three times a week for bone density. And this is where, you know, I have a little incongruent, you know, we really like two times a week of flipping 50 because so many women suffer from that adrenal fatigue, not recovering and or time is everybody's number one obstacle to exercise. And when we talk about muscle, we know that the benefits are there and there are insignificant difference between two or three times a week with bone stimulus. It could be different. But again, I think we have to come back to our overall endocrine system. How are we doing there? How do we feel and say, okay, maybe I should do other things with ground forces with high impact or as high impact as anyone listening can do safely five to seven days a week is the recommendation. But listen to this because you can do it in two or three minutes. So don't get overwhelmed here. This is 10 to 20 impacts and about four sets of it. That's two minutes or less of exercise. And you can do one now, you can do one at lunch, do one in the afternoon and one tonight and imagine 10 little hops in place. That's it. And you've done one. If you like to jump rope, you probably do this naturally and easily. But it goes anywhere from walking, dancing, hopping, little jumping, jumping to a box, jumping off of a box doing squat jumps, going lowest to highest ground force. And each of us again, will have a line where I can do everything below this and these are okay for me. And that's your playground. So know that. And for those who can do high impact, you still wouldn't necessarily want to do super high impact every single day. And we want to do some side to side because that stress laterally is different than stress just down, down, down or forward and back jumping. That's an important distinction. So I'm curious, you alluded to a power plate or a vibration plate. Where does that fit into all these other pieces in terms of our flexibility and our bone and our recovery? How does that fit into that? Oh my gosh. Well, so first of all, let me just say this, I was the biggest skeptic. So I should apologize to somebody in the whole body vibration world because 15 years ago, I remember I was approached as the personal training director for a club and we wanted you to have this inner club. And I was like, no, that's, they need to be doing other things. They need to be doing functional work. And now I see it for what it is. I have one in my kitchen. So I'm using it every day. And I can lift heavy. But for me, it's like icing on the cake. It's like, I'm going to be 60, not very long. And it's like, I'm going to take this seriously. Like, I'm going to pull out all the big guns. Like, but what else can I do? And so I use it when I'm doing a quick strength training work at home, I will actually do my squats on it. I will lie my back on it and do my chest press and I will stand on it and do bent over rows on it. So I can do the full workout, what I call a real quick one, the basics on that. Otherwise, I'm using it for core on a daily basis, hands on it and planks, side planks. I'm, you know, doing a dead bug on it, balance, agility. I have a foot that thinks it wants to have plantar fasciitis, but I'm not going to have it. So I'm standing on that every day. Y'all heard that here. I said it here. Ask me about how that's going later when you see me. But, you know, the vibration is also helpful in recovering from injuries. When I spent six and a half years in Boulder, I worked at the clubs side by side, world-class triathletes. I mean, these are the ones who were in Kona doing the thing and finishing long before I was, you know, at dark at midnight. There, we were using it for injuries, you know, a hamstring pull. You sit on it. You've got something wrong with your elbow, your wrist, you're maybe going to plank on it or just sit on it and lie on the floor and put your calf up on it if you've got a calf tear. So the stimulation is lymphatic movement through the body, stimulating the vibration, the frequency, all beneficial. So for muscle recruitment, doing less, but still getting more, those of you who can't lift as heavy, that recruitment of muscle is about 138% more than if you're not doing the weight training on it. So that's pretty good. That means the same muscle is stimulated more. Other fibers are also recruited and all of that is good for metabolism, obviously, in circulation. Absolutely. When you're talking to your patients about bone health, I think this is a big topic. We know one in four women will fall after the age of 65. If they have osteoporosis, which is, you know, bone that is is poor structurally, the wrists are even greater. I have a family member who broke her, her hip two years ago, fell and broke her femur on the same side. She has not been able to walk since May. And it is devastating for her. She's someone who's cognitively sharp, but her body is really failing. Let's talk about what is happening to our bone as we are navigating this menopausal transition, because this is super significant. Everyone who's listening needs to be aware of bone health risks and what we can do to offset this transitional time. Yeah. So osteoporosis and osteopenia, which I'll just share my my gripe before I start, is that the fact that we do dexa scans to check for it at 65 and noise the hell out of me. But nonetheless, when we think of bone health, you know, our bone is really organ of vitality in the sense of when we get older, that really is our stability, right, in addition to muscle. So when estrogen starts to decline, again, that relationship of estrogen receptors on the bone being able to make sure that we're increasing our osteoblasts, which is going to build our bone up, we start to see a shift again in that relationship between the cells that build bone up and that breaks it down. And you'll start to see more of the cells that break it down have a priority. And that's what we start to see over the course now of what 20 years, when we get into our 60s and 70s, our bone kind of foundation and structure has de mineralized to such a degree that even in the smallest kind of fall, it like blows, it's like powdered just like blows the bone apart. And so the studies clearly show that estrogen is directly correlated to bone strength. And so without women having this one knowledge base and fundamentally knowing that, well, if it's going to protect my bone and help my bone strength, why wouldn't I take it, but also taking away the kind of scare tactic that was used for 20 years estrogen causes breast cancer. And everything comes with risk. But now that we can identify what that risk is, which really is not a significant risk to once say breast cancer, but it creates such a huge benefit to bone strength. That's where I like to drive the conversation is because everyone at the end of the day has a choice and what they would like to take partake in how much they would like to do. And when you're able to present everything to the forefront, that's when I think that we're able to give better ideation around making decisions and patients having agency versus giving it in only certain sub segments of information, which can either be for or against. And it should be brought together so the patient can therefore decide, what do I want my life to look like? What are my risks when I get older? And what am I willing to take a risk on for me individually? I think it's so important. I think about the fact that certainly my generation, we're started on oral contraceptives at a young age, late 20s, early 20s, late teens, wherever that fell and missed out on peak bone and muscle mass building. So I think my generation, there's a lot of women who started out perimenopause osteopenic and we recognize this is not technically a diagnosis, but when they're comparing 50 year old bone to 25 year old bone, you know that you're at a disadvantage already. But when I think about as you stated appropriately, women not getting dexes until they're 65, it's like a shot in the dark. You don't know, it's like a ticking time bomb. If you know at 40 or 50 that you have work you need to do, it can help you with the, as you mentioned, agency being able to make decisions with your clinician, but be able to say, maybe I really need to think about hormone replacement therapy because I'm already osteopenic. I missed out on those benefits in my 20s and 30s. And now I recognize how important it is to have healthy bone. What types of exercise do you like to counsel patients on for bone building specifically? Yeah, for bone building and also for improvement in muscle as well in bulk of muscle, meaning strength. So one, building up your bone for improving quality of bone, but also building your muscle for strength is going to be your weight training. So any type of resistance training. And so the goal is to get one, get you there safely and with heavy. So please don't go squat like 100 and what 100 and like 60 pounds tomorrow in the gym. But the other part of that is resistance training can be just with your body, right? So whether that's pushups, whether that's lunges, but also with things like Pilates and water aerobics are also helpful as well. Because I think the other thing that I've seen start to happen here is as we're new in this, this kind of wave of information and understanding really what perimenopause and menopause is an estrogen is that we are trying to get the message out in a big way. And so sometimes we only focus on one part of something. And so the message might sound like right now, only eat protein and just lift heavy weights. When really the message is understanding the importance of it, but not taking away from some of the other features that also need to be included. And that's why when we hear like lift heavy and I say it all the time, lift heavy shit. But I think also Pilates is okay to do. And I think that other resistance training exercises are easy or okay to do as well as cardiovascular. And so weight training to me is one of the easiest ways as far as results, one of the easiest ways that you can improve bone and also maximize on increasing your lean muscle mass. Yeah. And I think for a lot of women, it's still that kind of prevailing philosophy of, oh, I need to, you know, just go run five or 10 miles. That's what I need to do to maintain body composition. And it's not to suggest we're telling patients that we want you to be couch potatoes, but understanding that we start having this acceleration of muscle loss after the age of 40 that's called sarcopenia. It's not a question of if, but when it will happen. And what goes along with muscle loss over time is this risk for frailty. And frailty is something we all want to avoid. We probably all have loved ones that are older, that we see them and they either don't move very efficiently. I've been in multiple airports over the past few days. And I'm oftentimes stunned and humbled by some of the people I see walk in and off the plane. And I'm like, gosh, all they would need is to like lose their balance and they look like they would just fall over and break. We want to avoid that at all costs. So at all costs. If you're a woman in midlife or beyond, you'll probably notice those changes in energy, strength, and recovery just don't feel like they used to. And what's frustrating is that for many women, this happens even when you're eating well, lifting weights, prioritizing protein and doing all the right things. You're not lazy, you're not unmotivated, and you're not doing anything wrong. A big part of what's changing actually starts inside your cells. As we age or mitochondria, the energy producing structures inside our cells become less efficient. And when mitochondrial function declines, it can show up as lower energy, slower recovery, reduced muscle strength, and feeling less resilient overall. 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It'll take you to multiple options for where you can order the menopause gut in pre-sale. And specific to my listeners, most of whom are middle-aged women that are in perimenopause and menopause, what is some of the new kind of relevant research about bone health in particular? Because I think there are so many women that are not appropriate candidates for hormone replacement therapy, maybe they're breast cancer survivors. And understanding that there can be a conferred improvement in bone health and bone quality with the utilization of creatine. Yeah, I think you hit the nail on the head. I think that would probably be the number one hidden area that a lot of people didn't expect, especially for female health. I think most people that are familiar with creatine would think of it for athletes getting bigger, stronger, faster. And there's been a lot of emerging research probably in the last two to three decades at most. So it's not that new, but it is emerging showing that females across the entire lifespan, so to speak, can get substantial benefits. And as you pointed out, the hidden factor or results were kind of around bone health. Creatine was kind of designed for muscle health, as we all know. And if we can put on muscle mass, we get bigger, stronger, faster, and improve a lot of aspects of our life. But lo and behold, under the muscle, there's a really precious tissue that we often don't think of, because we can't really see it in the mirror. And that's bone health and bone strength. And as you alluded to, premenopause, the menopausal transition, and then we get into the really critical stage of postmenopause, the cessation of the last menstrual cycle up until basically the day you die. And that's really important because the cessation of estrogen, we decrease that anabolic capability of estrogen. So we kind of have to come up with lifestyle interventions to replace it. And there's only been a few studies that have actually looked at creatine directly on measures of bone health. The vast majority are focused on postmenopausal females. And that's probably because they're more susceptible to bone related diseases such as osteopenia or osteoporosis, and then God forbid, frailty and fracture later on. And we've done a series of studies and some colleagues in Brazil have done a series of studies as well. And it's very clear with the minimal amount of research, I should preface that creatine without exercise probably won't have any beneficial effects on the skeleton. The skeleton really seems to respond just like muscle to mechanical stimuli such as weightlifting or plyometrics or even running. But it seems to have some beneficial effects primarily in postmenopausal females when combined with exercise. The primary stimulus will be weight training, but we did perform a long term study with walking. And overall, collectively creatine seems to preserve some aspects of bone mineral or bone strength around the hip region. It seems to improve lower limb below the knee bone area. And those two factors could have huge implications for off-steadying the risk of fracture later on in life, or withstanding a fall. Most people are living in climates where winter is coming with icy roads. And if you were to fall, most young individuals can bounce back up. They might be embarrassed, but they didn't fracture a bone. Unfortunately, some older individuals suffer hip fracture or ankle fractures, which are very susceptible for osteoporosis. And of course, if you fracture, you are not performing activities of daily living or physical activity. And that could lead to a lot of chronic diseases. And so we can talk about some smaller research or the long term study, which we did in a large cohort of postmenopausal females. But overall, it seems to have some extra benefit in addition to exercise. And I think that's really encouraging because you're bringing up a very important distinction. We know that the lack of physical activity is a prognostic indicator, if you will, for metabolic health. And that's certainly a topic that we speak about with great frequency on this podcast. So understanding that it isn't just enough to take the creatine, you have to take the creatine and move your body. And I think that larger two-year study that I was reading about was speaking about just the process of walking, like ambulation and how important that can be in getting some of these conferred benefits. And so let's start there. And then we can talk about some of these other kind of smaller studies, because I'm sure there are people listening that are thinking, oh, this is a great example. I can just take the creatine and I don't have to do the exercise. And that's not what we're saying. The creatine plus exercise is where you get the conferred benefit. Yeah, it's so crucial. So I think a lot of people are always trying to look at a magical pill or powder to sort of save everything about them. And at the end of the day, nothing will replace exercise. I think we can all agree with that. So exercise is foundational. And then a nutritional supplement such as creatine in this case can provide some small but beneficial effects. So in summary, the study that you're talking about, it took, we put postmenopausal females and all these were postmenopausal for 24 months. We wanted to totally make sure that they were really completely in their postmenopausal stage. The average age was 59 years of age, and they were healthy enough to participate in exercise. And we were really fortunate to finally publish a paper that was adequately sample size. But we were very fortunate. We got funding from the federal government here in Canada to look at the effects of two years of exercise. Now the exercise protocol was three days of supervised weight training, a whole body routine, and then six days of walking. And the reason we did that is here in Canada, and I believe the same in the United States, we're trying to promote physical activity specifically. So here in Canada, we're advising 150 minutes of physical activity from an aerobic type of standpoint per day, and then at least two days of resistance training. So we sort of adhere to those recommendations with the study. And then we wanted to look at creatine supplementation over time. Now the dose we gave was a little bit different than what's typically recommended. We've done some preliminary data showing that creatine had some potential and some small favorable effects in postmenopausal females at a higher dose than what's typically given with muscle. But the theory here is that as we get older and we're having natural bone loss, maybe we might need more to overcome or sort of compensate for the natural age-related reduction in an bone. So typically with muscle, most people hear about three to five grams a day, and I have no issues with that from a muscle perspective. But when you look at the totality of bone research, the lowest dose that seems to be effective for postmenopausal females is at least eight grams. So we started to see some trends and we thought why not give a bit more? And again, creatine is extremely safe. So giving a bit more shouldn't cause any adverse effects. So we gave on average 11 grams a day, and this is important creatine monohydrate, 11 grams a day for two straight years. So it was the longest trial in the world to combine creatine and exercise. And when we did a whole gamut of assessments, we saw that the females on creatine, they had a preservation of bone strength around the area of the hip, and they actually had some indication that the strength of the bone was stronger compared to the females that were on placebo. Now this is an interesting fact. Even two years of weight training wasn't enough in this large cohort of postmenopausal females, and we actually assessed about 174 to offset the negative effects of exercise. So some people might say, why didn't you use a group that did nothing? Well, ethically and morally, I would hate to just say, hey, volunteer for the study, and we're not going to really do or give you any beneficial effects. So exercise was beneficial from performing some activities of daily living, but it wasn't enough or in relation to creatine have the same effect. So at the end of the day, we concluded that two years of creatine and resistant training provided small, but yet very beneficial effects to the integrity of the skeleton primarily around the hip region, and that might have huge implications for offsetting fracture later on in life. And just as important, we measured kidney and liver function to measure side effects. And for two years at a really high dose, there was no greater effects than placebo. And most people might be surprised by that. But realistically, when you look at all the evidence based research, creatine essentially is a nitrogen containing compound is very similar to protein. We naturally produce it in the liver and the brain. And when you consume it in food such as red meat and seafood, it gets processed very easily. So it kind of makes sense the body would recognize it. And if there was any excess amounts, it would simply be excreted or converted to a byproduct in the urine. So that's probably why we don't see hardly any side effects whatsoever from a liver kidney aspect, even at high dosages. So it was a foundational study leading into the thought, now what do we do with premenopausal females, females going through the transitional phase? And what about young females? Can we increase or strengthen the bone at the younger age? And maybe that will offset off your process later on in life. So it's sort of opened the door for a lot of potential research. It's really exciting because I think for a lot of listeners, I was certainly part of the generation that was prescribed oral contraceptives to fix every menstrual irregularity. So at the time of my peak bone and muscle mass building years, I was kept in a low estrogen state. And not surprisingly, I'm osteopenic. I'm also within Caucasian female with a family history. But it makes me think about like my nieces and younger women. And, you know, could this be something people could be incorporating at a younger age to help, you know, kind of bolster their bone mass? So the first question was, for the menopausal women, were they on HRT? I don't know. Here in the United States, they're starting to become, you know, we're getting the second wave of, you know, coming off the Women's Health Initiative where there was a whole generation of clinicians and patients, frankly, who was terrified about hormones, now starting to get this resurgence and understanding that HRT can be very beneficial. Were any of these study participants also on estrogen or progesterone or testosterone therapy? No, they weren't. And that's one of the reasons we went 24 months postmenopausal. And then they weren't allowed to be on any anti-catabolic steroids like glucocorticoids or estrogen selective receptor medication or anything that could adversely affect bone biology. So we were very specific there. We did include females who did start it with low bone mass, but they were randomized equally across groups. So no, they had to be very specific because we couldn't conclude maybe it was the HRT that was influencing the bone. So we had to be very specific with the selection and inclusion criteria. Yeah. And that certainly makes sense. And then the other question I had was, when you were looking at bone strength, were you looking at DEXA scans? Was that the standard that you were using? Yeah, we did DEXA for segments of the whole body. And then we had some hip structural analysis we got from John Hopkins University to focus on the bone and actually measure the strength. And something I forgot to mention, we didn't measure the rate of falls and fractures over the entire study, including one year after. And yes, both groups did experience falls, but there was no difference between conditions. That's really exciting. And for anyone who's not listening, it's something that I certainly saw clinically in medicine that you would sometimes get 50, 60-year-old women. We kind of think of it as our grandmothers, like women in their 70s, 80s, and 90s. But understanding that if you fall and break a hip at a young age, I mean, it has a tremendous amount of prognostic indication in terms of looking at future fall risks, mobility, et cetera. So definitely things that we want to be conscientious about. I know you had mentioned that there was some other smaller bits of research that had been done in Brazil. What were some of their findings with regard to the utilization of creatine and bone health as well? Yeah, my colleagues in Brazil, who I think are probably the best overall group of creatine researchers, they did some really exceptional studies. And they looked at a very low dose of creatine. So this was quite different. They looked at one gram a day, and then they moved it up to three grams a day all the way up to two years. So the same duration of a study, but they did not include structured exercise. And what they found was basically nothing. One gram and three grams without structured physical activity had no beneficial effect. Of course, it had no detrimental effect, but had no beneficial effect compared to placebo. So in other words, taking creatine, kind of like a vitamin pill you would do in the morning and going about your activities a day to live in will probably not cause any significant effects. We conclude that exercise has to be there. It has to be foundational. And for the young females that are watching that are hesitant to perform resistance training, please understand that huge benefits you get from weight training, it sort of does everything that cardio will do. And then you get the extra benefits from strength and functionality. So again, exercise has to be there and creatine may cause a small beneficial effect. But please just don't take creatine and expect bone benefits. We don't see any evidence to suggest that whatsoever. I think that's a really important point. And one other thing that I want to tie up in terms of looking at bone and muscle health is, you know, we talk a lot about sarcopenia, how this kind of accelerates after the age of 40. And I believe I caught in one of your other interviews, you were talking about what is the progression of sarcopenia? Like, do we start with sarcopenia first? What happens first? And I think this is really interesting for people to understand because I know that when I was in the latter stages of perimenopause, the first thing I noticed wasn't the loss of muscle mass, it was the loss of strength. All of a sudden I'd be on an airplane with my typically overpacked bag trying to put it in the overhead. And I would say, oh my gosh, like it's the first time in my life I've noticed this hesitancy about picking that heavy bag up and putting it over my head. So let's talk about the progression because I do find this interesting. It may not start with, oh, I can't seem to build muscle. It could actually, it actually starts with that strength loss piece. Yeah. So the evolution of sarcopenia has actually changed quite recently. Understanding we used to define sarcopenia as the age-related reduction in muscle mass, strength, and functionality. But the problem with that was when we said muscle mass, most research studies would measure lean mass, and that includes water and fibrotic tissue and a little bit of lean tissue mass, the estimation is about 50%. So recent sort of research groups around the world, leading research groups, have now sort of repurposed the definition of sarcopenia to talk about first the age-related reduction in strength, as you mentioned, then and or muscle mass and functionality. And the theory here is that the reduction in strengths highly correlates with a lot of chronic diseases and functionality. And there's some new data suggesting that the lack of strength is one of the main reasons you're placing long-term care facilities because you can't live freely independently later on in life. So by improving muscle strength, that is crucial. That's called dyna-penia. And one of the best ways to improve strength is obviously performing weight training or resistance-style training. So the reduction in strength and or muscle mass can occur in the fourth decade. And that might surprise a lot of people, but around then the biological process of aging starts to occur. And then as we get into the ages of 50, 60, and later on, the reduction in muscle mass seems to occur, but not as fast as the reduction in muscle strength. So it's really critical to improve muscle mass and strength and functionality in the early years. And hopefully that'll offset the rate of decline later on. But this is really important. You can have centerians a hundred years of age and older. It's never too late to start. You will get fast improvements in strength immediately, and then eventually muscle mass and functionality. But again, exercise, it's never too late to start. And I would argue it's never too early to start. You try to do this on a semi-regular basis throughout your whole life. And so again, sarcopenia or you'll hear dyna-penia, which is the focus primarily on the lack of muscle strength, they're hugely important. And there is high association from sarcopenia and osteoporosis. So for example, if you have poor muscle strength and muscle mass, you'll have less muscle mass pulling on the bone, you're probably going to be doing reduction in activities of daily living. And therefore the bone is not going to be stimulated. So there is high association between sarcopenia and osteoporosis. And it's formed a new definition called osteocircopenia. So that's something that your viewers may have heard of or be aware of. And that unfortunately, the third factor with that is obesity. And then you get into something called sarcopenic osteo obesity. And it's sort of a triad of three things that go together. Yeah, it's really interesting. And it's something that sarcopenia is something we speak about with great frequency on the podcast and really trying to bring greater awareness to the process that by the time it's started, you probably aren't even aware of it. It's happening very subtly. And then all of a sudden, especially for middle-aged women in particular, they're like, I'm weight loss resistant. I'm doing all the right things. I'm overdoing orange theory fitness or crossfit. I'm not doing enough strength training. And so it becomes this kind of dual edge sort of understanding that zone two training and the strength training really become critically important. And I think it's interesting that we've never looked at the effects of creatine in diagnosed sarcopenic older adults. That is planned, but individuals who have a specific criteria. But the key factor, and I think most of your viewers will be well aware of this, is high protein intake is going to be absolutely essential. So unfortunately, the RDA is so outdated, it's almost embarrassing, but 0.8 grams per kilogram. If you're 70 kilograms, that's only 56 grams of protein a day. And exceptional researchers around the world, including Stu Phillips here in Canada, is clearly shown empirically, Don Lehman in the United States and Luke Van Luna in Europe and Lee Breen. But there's many researchers clearly showing time after time that about 1.1 to 1.2 grams per kilogram seems to be the minimum. And they can even push that up to a maximal range of around 2.2. But a nice range seems to be about 1.2 to maybe 1.6, even for older adults. And that's been shown to hopefully offset the negative effects of sarcopenia. So resistance training and exercise walking is very beneficial. Please make sure that protein is going to be higher than what the RDA is suggesting. And then maybe creatine can be sort of that little icing on the cake to give you a small extra benefit.