The Peter Attia Drive - #214 - AMA #37： Bone health—everything you need to know

00:00:00.000 Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the drive podcast.

00:00:16.500 I'm your host, Peter Atiyah. At the end of this short episode, I'll explain how you can

00:00:20.460 access the AMA episodes in full, along with a ton of other membership benefits we've created,

00:00:25.440 or you can learn more now by going to peteratiyahmd.com forward slash subscribe.

00:00:31.140 So without further delay, here's today's sneak peek of the ask me anything episode.

00:00:39.180 Welcome to ask me anything AMA episode 37. I'm once again joined by Nick Stenson. In today's

00:00:47.040 episode, we dive really deep into one subject, bone health. This is a topic we get a lot of

00:00:53.520 questions about, but we decided to save our AMA for a time when we had accumulated enough

00:01:00.080 questions that we could cover this comprehensively, which as you've gathered by now is sort of how we

00:01:04.000 like to do things because it allows us to go much deeper. So in this AMA, we're going to cover the

00:01:08.300 following. We look at why everyone should care about bone health. In other words, why is this

00:01:12.340 such a priority, not just for yourselves, but also for your children? We break down what bone mineral

00:01:17.780 density is, how it's measured, and how much variability exists between people, between sexes,

00:01:23.280 and how it changes over the course of your life. We also talk about what influences it both early

00:01:28.560 in life and later in life. We look at differences between men and women when it comes to this health

00:01:32.920 and why menopause has such a disproportionate effect on the bone mineral density of women. 0.97

00:01:37.460 We then get into ways that you can improve bone health from exercise to nutrition, supplements,

00:01:42.740 and of course, drugs. We end the discussion around what happens when we're forced to be sedentary

00:01:47.760 and how you can work to minimize the damage during these periods. As a reminder, if you are a subscriber

00:01:52.260 and you want to watch the full video of this podcast, you can find it on the show notes page.

00:01:56.320 If you're not a subscriber, you can watch a sneak peek of this video on the YouTube page. So without

00:02:00.740 further delay, I hope you enjoy AMA number 37. All right, Peter, welcome to another AMA. How are you

00:02:11.940 doing? Doing well, man. The final seven episodes of Ozark dropped tonight. We're recording this April 29th.

00:02:20.540 Interesting date for two reasons, by the way. The other thing that occurred to me this morning

00:02:24.180 is that the days and dates in this year, 2022, were the same as they were in 1994. So I was like,

00:02:31.900 oh my God, today is Friday, April 29th, which is the same as it was in 94. So on Friday, April 29th in

00:02:40.260 1994 was the practice day at Imola. And that's when Rubens Barricella had that horrible, horrible

00:02:46.980 accident. We can link to the accident where he basically hit the chicane and launched into a

00:02:53.060 barrier and amazingly only escaped with a concussion and a broken nose. The following day, which is the

00:02:59.400 same day as tomorrow will be, which was Saturday, April 30th, was when Roland Ratzenberger was killed,

00:03:06.860 which made it the first fatality in Formula One in 12 years. The last one being Gilles Villeneuve

00:03:12.940 in 1982. And then of course, Sunday, May 1st, which will be the same this year, was when Senna died.

00:03:19.400 All in 1994.

00:03:20.900 Yeah, it was at the same race. You had these three horrible accidents resulting in two fatalities in 1.00

00:03:26.080 one weekend. But again, to think it's the exact same days this year as it was 28 years ago. I

00:03:32.380 didn't notice that until today.

00:03:34.080 This is really off topic, but do you still have the skill that you had back in the day where you can

00:03:39.600 remember what day, like day of the week, a date was?

00:03:44.060 Only if I can peg it to something, but not as profound as it used to be.

00:03:47.980 I remember in meetings, we used to just throw out random dates and then we would fact check it.

00:03:52.000 I feel like we wasted a lot of time doing that.

00:03:54.360 Someone would tell me their birthday and I would tell them what day of the week they were born on.

00:03:57.980 On the complete opposite end of that, what we're going to talk about today

00:04:01.200 is the topic that we get asked about a lot. And we've gotten a lot of questions that have come in,

00:04:06.060 but we've never really dove really deep into it, which is what we're going to do today.

00:04:10.520 And it's kind of all things, bone health, bone mineral density, osteopenia, osteoporosis,

00:04:16.800 things of that nature. And I know this is something that you work a lot with in your

00:04:21.300 patients. And I know it's something that's of really big interest for people. And so

00:04:24.980 our hope is that we can go through this episode and focus on why is this important? So why should

00:04:32.140 people care about this? People listening right now, there'll be a subsection of them that are

00:04:36.860 going to be super interested. And there'll be probably another subsection who are maybe younger.

00:04:41.480 They've never really thought about their bone health and they might not think it really applies

00:04:45.040 to them. But our hope is in the beginning, at least, we'll walk through why they should care

00:04:48.560 about this and why they should focus on it early on in life. And then from there, we'll talk about

00:04:53.960 how bone health changes as people age, the differences between sexes with men and women.

00:04:58.540 And then we'll also focus on things on how people can improve or help their bone health become

00:05:04.780 better from physical activity to nutrition, supplements, drugs, and more. And then if all

00:05:10.480 that goes well, and we still have time, which is always 50-50 on how these AMAs go, we'll also

00:05:15.180 focus a little bit on people dealing with acute injuries and how they need to think about this,

00:05:21.100 which I know is something that you're interested in given your recent shoulder surgery. And now

00:05:25.940 you're not as active in one side of your upper body as you used to be. All that said, I think

00:05:31.760 before we start going through those questions, it's going to be helpful to set the stage a little

00:05:36.060 bit just so everyone is on the same page and the definitions and what we're talking about. So

00:05:40.600 why don't we start with what are some of the types of bones we'll be referring to? Because

00:05:45.700 at least for myself coming into this, I just kind of think a bone is a bone and I don't really think

00:05:51.320 much more beyond that. So why don't you dive into that a little bit?

00:05:55.280 Bone is, it's a living tissue. Okay, that's obvious, but I think it's also easy for a person

00:06:00.780 to forget that and think of bone as somewhat inert. But in fact, bone is heavily vascularized.

00:06:07.260 Bone is an organ that plays a very important role in a lot of things. I'm actually not going to go

00:06:12.060 super deep into the anatomy and physiology of bones. I'll point out just a couple of things,

00:06:16.680 right? So first of all, think of a couple types of sections of bones. So we think about the cortical

00:06:21.560 or compact bone, and that's what forms like the shaft and the exterior of long bones. So if you

00:06:25.840 think of your femur, your humerus, things like that, they have the long shaft and then the nubbins at

00:06:31.340 the end. So the shaft of that is the cortical or compact bone. And then at the end, you have the

00:06:37.200 trabecular bone, sometimes called the spongy bone. Those are kind of at the end of the bone. And there are

00:06:42.040 some differences amongst those in terms of their vascularization and things like that. But again,

00:06:47.380 I think for the purpose of this discussion, whenever I talk about compact or cortical bone,

00:06:51.600 I'm talking about the shaft. And whenever I speak about the spongy or trabecular part,

00:06:55.200 I'm talking about the end. Again, I think marrow, people probably intuitively understand that marrow

00:07:00.800 is important, but again, it's very important, right? Marrow is what's producing our white cells and

00:07:05.980 our red blood cells. So in this era where we were thinking about a post-COVID world,

00:07:11.180 it's important to understand that the memory B cells and memory T cells that are going to provide

00:07:17.300 lasting immunity against this virus and other viruses reside in the bone marrow. The whole

00:07:22.460 purpose of being infected and then having a subsequent infection that's less devastating,

00:07:27.860 purpose of being vaccinated for the same reason, is to have memory B cells and T cells that are sitting

00:07:33.460 there in the bone marrow that can respond immediately and quickly upon reintroduction of the same antigen.

00:07:38.580 When you mentioned nubbins, it made me think about your banana nubbins. And you recently posted on

00:07:44.640 Twitter, you might be looking for a new profession. Do you want to let people know what your new

00:07:49.340 interest is in the world of longevity? I've been very interested in human longevity for a little

00:07:55.760 over 10 years, and I'm sure I will remain so. But I've at least considered moving into banana longevity

00:08:01.760 because I think the opportunity for impact is huge. It's one thing if you can figure out how to take

00:08:07.340 the average person from being 80 to 90, that'll have a huge impact on the world. But if you could

00:08:12.400 take the average banana and go from like two days before it turns mushy and brown to 10 days,

00:08:19.320 I think it's revolutionary. I just noticed I was on the USDA's most wanted list because of how many

00:08:24.220 bananas I waste. So I got to do something about this.

00:08:27.140 If you solve the banana crisis and you move to avocados, they'll probably give you a Nobel Peace 1.00

00:08:31.860 Prize as well. The upside is very high in this new world. Avocados last so much longer. I could buy

00:08:38.820 like seven avocados and eat them in a week. I can't buy seven bananas and eat them in a week at one a

00:08:44.060 day. It just doesn't work. I think that entire fruit space is just a racket. I think bananas are a

00:08:49.260 pyramid scheme. The whole thing is just total scam. Maybe one of our upcoming AMAs will just do a

00:08:55.300 conspiracies with Peter Atiyah and we'll just go into the world of bananas. So Peter, you mentioned

00:09:00.920 earlier ago, B cells and T cells. Can you walk people through what cells make bones?

00:09:06.980 This can be made as complicated or as simple as you want. Just think about osteoblasts and

00:09:12.460 osteoclasts. And I kind of remember from medical school, the way I used to remember this. So

00:09:16.520 osteoblasts B are responsible for building bone by producing collagen bone matrix and mineralizing it.

00:09:24.980 Osteoclasts remove bone by reabsorbing calcified bone and the matrix. So osteoblasts contribute to

00:09:34.540 increasing bone mineral density. Osteoclasts, the opposite. It's also important to understand

00:09:39.840 this exists in an equilibrium. So we're constantly remodeling bone, adding to and subtracting

00:09:47.180 from this and basically turning over calcium. So bone is like 50 to 70% mineral. And obviously

00:09:56.480 what's the predominant mineral? It's calcium. We'll talk about that in a second. It's about 20 to 40%

00:10:01.560 organic matrix. So again, what is organic mean? Organic is carbon, hydrogen, oxygen, sulfur,

00:10:06.820 etc. And then the rest of it is a bit of water and lipid. And again, you'll see that primarily in

00:10:11.360 marrow. In an adult, like the entire human skeletal system can be remodeled in a really long cycle.

00:10:18.220 It might take 10 years to turn over all of the mineral and organic content within the bone over

00:10:25.140 and over again. But at the micro level, calcium balance is happening quite frequently. I don't

00:10:30.980 remember the exact number. I want to say it's like 99%, but virtually all of the body's calcium

00:10:36.560 is contained within bone. And therefore bone plays a very important role in calcium homeostasis.

00:10:43.620 And if anybody's taking a physiology class, they probably remember how important calcium signaling

00:10:48.640 is to everything within a cell. Again, we think of these bones as structural entities, which of course,

00:10:55.740 first and foremost, they are. But remember, they're also a very important reservoir for calcium,

00:11:00.180 which is another very important ion in the activity of every cell.

00:11:04.220 You talked a lot about calcium. What about vitamin D? What role does vitamin D play in the bones?

00:11:11.420 They're both very important. And again, there's two forms of vitamin D, vitamin D2 and D3. But really,

00:11:18.120 when I talk about vitamin D, I'm going to mostly talk about D3, which is the active form. So what's

00:11:23.880 the problem with being deficient in vitamin D? Well, again, people might recall a disease called

00:11:28.760 rickets. And you see this often in developing parts of the world where people are really

00:11:32.980 malnourished and they have really, really soft sort of spongy bones. Actually, just yesterday,

00:11:38.560 I had a friend over who does a bunch of mission work in Rwanda. And she was showing me a child at

00:11:46.180 their camp whose legs, the child was like probably five years old. He was sitting down and they were

00:11:51.340 doing something with his legs that you would think would be impossible to do with a human being.

00:11:56.340 Basically, while he was sitting on the ground, they were able to move his foot back and forth,

00:12:01.380 back and forth. And he was in no pain, but it's because he didn't have bones that were anything

00:12:05.680 other than basically rubber bands. So he couldn't stand. And within, I want to say six months of

00:12:12.260 correcting his nutrition, totally normal. Amazing opportunity when you think about what happens in

00:12:16.940 that part of the world and how you can fix that. But what is it about vitamin D? Well, vitamin D

00:12:21.160 increases the gut's absorption of calcium. So if you're woefully deficient in vitamin D,

00:12:27.000 you're going to have trouble absorbing calcium through the gut. And we're going to talk in this

00:12:31.120 podcast later about the importance of dietary calcium and or supplementary calcium. And so you

00:12:36.900 can see why that becomes part of the issue. The other thing to kind of keep in mind here is the role

00:12:41.420 of another hormone. And again, I'm trying to only introduce concepts now that are going to become

00:12:45.840 relevant later, either through treatments or nutrition or supplementation. So I'm being

00:12:50.700 a little bit simplistic. But the other thing that you can't avoid here is understanding the role of

00:12:55.860 calcium and parathyroid hormone. I think most people are probably familiar with their thyroid

00:12:59.460 gland sits here in the neck. It's kind of got this shape to it where it's got like two main lobes

00:13:06.580 and then each lobe has two poles. Well, at each of those poles is a little tiny gland called the

00:13:11.680 parathyroid gland. So you have four of those. And the parathyroid gland is really the master gland

00:13:18.040 for regulating calcium levels. So low levels of calcium in the blood stimulate parathyroid hormone

00:13:24.540 secretion. As parathyroid hormone level goes up, it simulates the release of calcium from the bone

00:13:31.920 into the blood. Now, it also induces enzymes in the kidney, which then convert vitamin D into its

00:13:37.600 active form to then aid and speed up in the process of reabsorbing more calcium from the diet.

00:13:44.040 So all of this stuff, parathyroid hormone, calcium, vitamin D, very important to maintaining bone

00:13:50.780 health. And anytime you have things that disrupt that system, you're going to see disruptions

00:13:55.660 potentially in the bones. I think that was a good quick overview of what will be important for what

00:14:00.660 we cover next. And I think the natural follow-up to it is what is the consequence of poor bone health?

00:14:07.140 What is the consequence of low bone density? Some people who will be listening to this will have

00:14:12.480 already known issues of bone density. And some people have never thought about this before in

00:14:18.340 their life. What would you say to those people on why they should care about this and why they should

00:14:22.500 think about it? Thank you for listening to today's sneak peek AMA episode of The Drive. If you're

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The Peter Attia Drive - July 18, 2022

#214 - AMA #37： Bone health—everything you need to know

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