Ep 382 - The Science of Building Bone (ft. Dr.Lora Giangregorio)

What's up everybody? Welcome back to Iron Culture presented by Mass. It is me and a good doctor Helms joined by an esteemed guest tonight. Very excited about this episode. Helms, I'm going to get the simple stuff out of the way. Do what you're supposed to do. If you're listening like, rate, subscribe, review, check out massresearchreview.com, support our friends at EliteFTS.com, use the discount code MRR10, stands for mass research review, 10, get a 10% discount off your order if you want some gym gear and a peril. Helms, that is all the business out of the way. And now it is pure science. And I am going to pass it over to you, because you are steering the ship for this episode. I'm going to be here to make wise cracks to try to derail the conversation at strategic points. But other than that, I'm along for the ride here. So Helms, take it away. No, thank you very much. I appreciate you teeing up the episode. It has been probably too long since we've had a guest episode with more than just the two Eric's blabbering at each other about the things we like. And we have decided to bring on a guest, at least just to give us a little bit of a break at blabbing. No, but in all seriousness, we brought on an esteemed guest because we have some really cool questions that have come as of late related to bone adaptation to resistance training, the crosstalk. I think we checked. Am I wrong that we literally just did a Q&A episode and we had a person asking about the transition from powerlifting to bodybuilding and how to maintain those high load adaptations related to tendon and bone. Am I remiss remembering? You are correct and you specifically use the word crosstalk. So your memory has not failed you yet? No, it's just a matter of time, literally. But well, at least now I will bask in my functioning cognitive abilities. So first off, I want to welcome Dr. and you're going to have to tell me if I missed pronounce this because we just went over this and now I'm on the spot and I'm getting nervous and I'm only going to get it wrong. Dr. Jean Gregorio, is that accurate? It's good. Yeah, it's fine. No. How about you introduce your own last name and I will listen. Yeah, it's all good. So yeah, we can go with Dr. G is usually what my students call me because they don't want to try to pronounce it. So yeah, Laura is also fine. Awesome. Dr. G, I like that. I do pride myself on trying very hard and failing to get people's names right. It's just it makes me look incompetent but also respectful, which I think is probably an accurate representation of me. So yeah, no, I really appreciate you joining us. We specifically reached out to you because you are someone who has a very specific expertise in bone and adaptations to exercise in bone and I thought it would be great to have a, you know, the conversation, but what do we really know? What is speculative and how does this apply not only to kind of the hard core lifting crowd, which is a lot of iron culture, but also given so many of the hard core lifting crowd happens to train other people. How we can apply this to our aging population, clinical scenarios, our friends and family, recreational lifters, and also people who are just maybe getting into lifting for the first time. And maybe because even their doctor told them, hey, this is a good idea and that bone mineral density is looking a little low and I'm concerned about frailty fall risks or propenial osteopenia. And I know there's a perception among a lot of people my age who have not been lifting their whole life like I have of is it so late that it doesn't even matter how much can I shift the needle or I'm a menopausal woman. Can I even, you know, build bond at this point or is it just stemming the loss? And I think there's some nihilism, hopelessness or at least a face of grief when people get that information for the first time. So who better to talk to than you? So without further ado, I would really appreciate it if you could maybe introduce yourself to our audience a little bit on your background, who you are and what do you do? That would be really appreciate it. Sure, I think, first of all, thanks for having me. I was really excited to tell my son who lifts that I was going to be talking to a bunch of seasoned lifters tonight. He was really excited. So he will probably also listen to your podcast. But yes, I'm a professor in Kinesiology and Health Sciences at the University of Waterloo. So I do research related to osteoporosis, exercise is a good activity. A lot of my work is on the, if you think about sort of, like cells and animals and then human research and then kind of clinical trials and guidelines and then moving it into practice, I'm kind of on this end of this spectrum. So most of my work is kind of clinical trials, guidelines and moving research to practice. So that's the space that I do researching. And I also teach in the Kinesiology department. Beautiful. Now, that's perfect here, because you know, when we all get together, the mass crew and someone says, oh, you're through your bench researcher. I know they're either talking to me because I literally do research on the bench press or potentially talking to Lauren because she's literally done the like the cell culture work on a bench. And it means two very different things, two different levels of expertise. But all very important, especially the translational work you do. So I guess my first question is, is what led you down this path to where this became your area of expertise? And you've been now a seasoned professor studying this for a long time. What sparked your interest and where did this all begin for you? It's a really good question. When I was in undergrad, I was very interested, I did it at my undergrad in Kinesiology and I was really interested in rehab. And I'd actually worked in cardiac rehab. And so I went to work with, you know, Courtney, who was in one of the Canadian leaders in cardiac rehab at the time to do my masters. And he got a grant to do this project in bone and muscle responses to rehab and spinal cord injury. And he's like, wanting you to transfer the PhD program and work on this project. And so I'm like, sure. So I switched my area, but he wasn't a bone researcher. So I actually had to seek out people to kind of be mentors in that space. And I was introduced to, that worked with two wonderful clinicians, Dr. Peppier and Dr. Adachi, who do osteoporosis research. And I was introduced to that area. And I was always really interested in clinical research and research that kind of, I could see the impact of. And so I started doing a little bit more training related to clinical trials and more in osteoporosis. And so I started learning that. And that's kind of where I, and I saw these spaces, these gaps in research in osteoporosis, especially in people that are higher risk, right? So not your 50 year old or healthy 60 year old, but the people who, you know, or have vertebral fractures or have really low bone mass, because those are the people whose clinicians are telling them, don't bend, don't lift, don't do anything. And, you know, that's actually perpetuating muscle and bone mass, which we don't want. So I saw this niche of we need to do better in this space. And that's kind of where I went. Awesome. Not that that that's great. And it makes a ton of sense as far as like most researchers, I talk to they identify something where there is a need and they have a, they have a connection to and a motivated by it. And then, you know, that that's the fuel they, they ride for at least an initial portion of their career, but if they don't, you know, act like Dr. Trexel over here and decide that he's interested in, you know, guerrilla urine after he's done the whole metabolism and natural bodybuilding thing. But for, yeah, single-minded people like myself, I definitely relate. So I think the question that I really want to ask you and probably the overarching theme is, and it might be why there is somewhat of a gap in the exercise science literature on bone adaptations is, man, muscle adapts relatively quick compared to to bone. You know, if we were to look at our four, six, eight week trials, especially on untrained individuals being given a robust resistance training stimulus, and sometimes not even robust resistance training stimulus, we can measure changes in muscle thickness, cross-sectional area, and sometimes even lean, but lean body mass and more macro, you know, two compartment models, pretty quick. But to my understanding, it takes a lot longer for bone changes to occur. And there's less of that than skeletal muscle on our body, and it's harder to image. And that's something we've only had with more recent imaging techniques. So do you think just the simple time course of adaptation and bone, and the logistical limitations that we have, especially in actually comparative trial studies, is a large component to why we haven't done as much robust research in this area? Do you think it has to do with other factors? I definitely think that is a factor. So one bone remodeling cycle takes four to six months, depending on what area of bone you're measuring. And that's a very, very small packet of bone. So one bone remodeling cycle is like one less than one millimeter cubed bone replaced, right? So those are, that's happening in little packets all over your body. So if you think about sort of bone cells like osteoblasts coming along, or osteoclasts coming along, breaking down bone, and then you can replace by osteoblasts, that's like one unit, that one kind of less than one millimeter unit takes four to six months. And so then that's happening all over to remodel, but you can see how if it's one millimeter, less than one millimeter cubed at a time, and you're trying to measure this, like it's hard to see changes, right? So I think that that's part of it. And so we have to do trials for like eight months, 12 months longer to actually see a change. And that's even to see very, very small changes in bone. Because you, because you would have to have that stimulus be there for a long time to be able to then have the bone adapt over at least to bone remodeling cycles to then see that one 2% change, right? In drug trials they see changes larger changes than they do in exercise trials most of the time, but yeah it is a long process. So most of you see studies that are showing bone density changes after four to six months, you might want to be a bit skeptical unless they're doing some sort of drug intervention that really has a huge effect on bone remodeling. I'm always very skeptical and this is where like again a lot of the studies that are published like sometimes maybe your reviewer might not catch that, but the study is only like you know three months long and they're reporting a 5% change in bone density like that doesn't match, right? So you need to be skeptical and even ones that use like bone turnover markers. So there's markers of bone resorption, bone formation that you can measure in blood, but you're measuring one snapshot in time, right? And so you don't know what's happening over the course of that for months. So the bone resorption phase is much shorter than the bone formation phase. So if you take the blood where are you? What are you? What phase are you measuring unless you do multiple measures? And so there's a lot of you know over and like the sports nutrition side of things. Most people are doing trials typically eight, 12 weeks, right? Because it fits the semester calendar basically. And so every now and then you will see you know some of these short studies that do report typically using DEXA you know significant changes in bone density significantly significant increases. So do you tend to find a lot of times that in these studies DEXA is just throwing basically false positives due to measurement error? Like when you say being skeptical is it a measurement error thing? Like what do you think is going on? Yeah like I don't I would not believe a study that said that they saw bone changes in eight weeks 100% would not leave. Because it because like again a bone remodeling cycle takes four to six months. So how are you possibly seeing significant changes in that short a period of time? Yeah. So like for us like we study a lot of like muscle hypertrophy and be like if somebody's like yeah it looks like people put on you know a pound or two of muscle over that 72 hour intervention and we're like wait a minute you're you you're doing looking at swelling, carb loading, hydration shifts, measurement error but you're not looking at hypertrophy right? Yeah yeah exactly. So I mean certainly you can have you know like if certainly like if you're kind of shutting down bone remodeling or if you're you know really like like there's some medications that can maybe have effects that are maybe larger than you see with exercise or in shorter terms but for the most part um the kind for me the rule of thumb is like I wouldn't I I want to see an intervention be at least eight to 12 months to have especially an exercise intervention because they don't have large changes in bones so I would want to see it be that long to be confident that it's real because because there are lots of things that can cause variability indexes can. So huge like positioning errors, technologist errors, you can have changes in body composition can actually change bone because it's you know it because the body composition affects how with the dense tomater sets it's like basically if you it's looking at attenuation right? So and it's looking at attenuation profiles and if you have a shift because you've a change in body composition that might change where the edge is detected and you know what you mean? So there's a bunch of things that can it can affect it. The other thing is that if you have arthritis or you know aorticousification or other things that create artifact and those artifacts are slain in different places when you do this game because of positioning that can affect how the bone density is measured. So there's lots of things that can affect bone density so you have to think about what is the error, the precision around the measurement and then one of my actually observing and does it make physiologic sense right? So those are all the things I would consider and so I'm just very skeptical when you start seeing these really short-term studies reporting changes in bone density. For first you which happens all the time in exercise research where they say we did this type of training compared to this trip of training we saw no significant difference therefore they're the same which is a huge problem but they didn't actually design the study to actually be long enough to or large enough sample to detect the changes in the first thing. Yeah you see a lot of that where it's like I can imagine for bone it's like we're going to claim that these two training strategies are the same for bone but neither of them were measured over an adequate time scale in an adequate sample size to actually detect a real difference and then statistically they didn't actually test for similarity they test for difference so even the statistical interpretation is different right so yeah and this is something they don't talk about so when you want to look when you want to make a claim that two things are the same you have to do a non-inferiority design right or an equivalence design depending on your hypothesis right so you can't you can say we didn't detect a difference but you can't say that they're the same right it's a different different type of study design if you're trying to make those claims all right Helen I butted it and did enough side side tracking and I'm again passing the baton back over to you well I know that means nothing on this podcast so you will do it again and that's fine you're welcome you're welcome too is what I should say and as you know my brain will tangent with you so we're still on stats folks you heard it you want to learn about should I power lift your body build but no I'm going to start talking about systematic versus uh equally distributed measurement error because I think this is something we we've talked about on on other podcasts um there's a big issue we have in our field where kind of like your stock standard typical exercise assumption I would say it really is outdated but is persisting is these a priori power calculations which assume an effect which we know to be at least more than one and a half times the the overall effect of lifting weights at all in a like a 10 or 12 week period and lifters and go sweet so if I see significance it's real and that basically requires that if the study got published and found significance that it magnifies the observed effect right so I think when we're talking about muscle it's kind of okay because or it eventually will be okay because you can look across all these studies and go okay well that's some combination of sampling variants and measurement error biological variation and some high responders being allocated to one condition or group or something going on environmentally during that crossover arm but if we see a whole bunch of knolls and some positives but no negatives going the other way there's probably something real there if and when that does become properly metanalyzed but I think what we're talking about here with Dexa where there could be not just a randomly distributed error so sampling variants but a systematic error to where if someone is gaining you know more muscle mass or having some change in their overall fluid composition or if there is a technician who doesn't know the Nadine to manually exclude someone's like pin that's in their knee if they're dealing with athletic population or or a hyperplacement which takes additional effort and training to know how to do on the back end then you can get systematic errors that are actually driving a persistent signal and you can test for that but that's often not something people are looking at and when you see that then you should be skeptical right but I think that's what I'm hearing because if we did observe in sufficient sample sizes in equal distribution of error and repeatedly we did see bone growing faster than the question would be not be is that real but why is that happening and different what we expected and it might be oh hold on I forgot to read the subject line and this is astronauts and they're they're precipitously losing large amounts of bone mass because they're in space or coming back and regaining it oh or they're all being supplemented with this pharmaceutical mobile drug would you say it's an accurate representation of kind of what you're trying to communicate I think that I think what I'm trying to say is that bone changes are very slowly and also there are many sources of error indexes so what that means is and you longer trials and you need larger samples to be able to detect very small differences especially in the the presence of that variability because the larger amount of variability you have and the smaller the change the larger sample size so you know in the bone world we have lots of studies where the groups are less than 25 people each and that's just not enough so you have you have peak studies that are too short you have sample sizes that are far too small to be confident in these estimates and it's in small studies are often more likely to exaggerate spurious or on estimates that are positive when they're not actually positive right so you're more likely to see that and see larger changes so and they're more likely to get published because they seem very exciting that you see these large changes right so so I think that you just have have to be a bit cautious when you see a small sample size or with a shoulder. duration when you see these bone density changes. I'm much more confident when you have larger samples, larger duration, and also that they do the other things to get rid of bias as well, right? Like an intention to treat analysis and those sorts of things, a little bit more confident. But unfortunately, when you look at many of the studies that have looked at exercise interventions in bone, the study arms have less than 50 people in them or are you less than 25 people in some cases? And they're often short. Yeah. So we actually salute that analysis, any studies that are shorter than six months and six months is a stretch. I would go eight if I to be conservative. Right, just maybe just to have a meta-analysis exist, right? You might have to concede to the timeline on that given the limitations of the data. Yeah. And I think that in sometimes what we'll do is we'll do a sensitivity analysis where we'll actually remove studies that are high risk of bias or that are short or have these other issues. But you're right, like, you end up running out of studies if you start excluding too many. But then it's like, okay, do I include these studies that are probably wrong? Or so it's tricky, right? You have to find a right. You have to kind of just make some decisions in advance based on good thinking and then stick to your guns. Yeah, I mean, this is probably something that has been a more recent methodological renaissance, if you will, or at least maybe coming out of the dark ages, I'll be slightly less favorable towards us in the last four or five years where we've kind of acknowledged some of the meta-analyses we're doing just shouldn't have been done. And we weren't ready for that in terms of understanding of how to do them. Nor was the literature robust enough to do it. And I mean, we just recently, after a systematic review, I initially drafted in 2012 for submission, did a renewal of it on lean people dieting while lifting weights and then seeing whether higher or lower protein intake preserved muscle mass more. And we went in with the pre-registered a priority decision to do an actual categorical meta-analysis. But we only got five studies. So we said, hey, no, we're not going to do that. But we will do a meta-regression and we'll properly couch that as a exploratory rather than confirmatory finding. So even over a 13-year period, the literature didn't, you know, evolve enough to move from, you know, systematic review to an actual quantitative synthesis of the highest caliber. So it's it's a pretty, you know, the more, when more niche your topic or the more challenging it is to capture true changes, this is the norm. And it's why when we got asked last week on our Q&A episode about, you know, do we see meaningful bone differences between heavy and light training? I didn't answer with a literature-based answer because I didn't think there was sufficient data in let alone comparing not resistance training to resistance training to give meaningful point specific estimates of the type of resistance training, let alone compared to someone who has been powerlifting for five years and someone else has been bodybuilding for five years into their sixth year. But maybe, maybe just maybe Dr. G. Am I wrong? Is there a robust amount of literature on, you know, load absolute load versus relative relative load specific adaptations to resistance training and highly trained individuals that I don't know about? So that's a tricky question to answer. So I would say most of the work that I've done and the kind of my wheelhouse is the work that's been done in sort of 50 plus and often in people with low bone mass. But not always, like so either the 50 plus heterogeneous for bone marrow density or people with low bone mass. And I will say that in people with low bone mass, there's definitely not enough data to make any conclusions about you know, this intensity is more effective than this intensity. If we look at people who are more, and often the studies in the 50 plus are done in postman apostle women because, you know, when you do clinical trials, you often target the people who are at higher highest risk. So they, a lot of the trials have targeted postman apostle women. Some of them have included men, although far, far fewer studies and men. And those studies can kind of eke out a signal that probably it has to be moderate to high intensity, but I would also argue that many of the studies combine resistance training with impact training. So it's also hard to tease out whether it's the impact training, the resistance training, or both, because they often combine them. So once you start teasing that out and trying to tease that out, you run out of studies because you, it's hard to, you know, categorize, well, this is a high intensity impact only. And this is a low intensity impact only. And this is a hot rate. So, um, Belinda Beck's group tried to tease it out a bit. But when you actually look at, like if you look at the funnel, like the certain other funnel flat, the forest flat, like, and you look at the, there's in the high intensity group, there's like two studies or three studies, like there's not that many. And one of them is hers, right? And it's a combined impact resistance, right? And then if you look at all of the studies in the moderate group, there's maybe one or two that are actually adequately powered, right? So again, you're starting to like trying to tease this out, but the large number of the studies are way too few participants combined interventions, etc. So I would say based on my, like, read of the literature, like I would say probably if you, if you're trying to build bone, and you are over 50, probably your best bet is to combine resistance and impact training and probably moderate to high intensity resistance. But I would also argue that we have to be clear about what are we talking about, like, effort, right? Like, because again, like are, are people actually getting people to train at that specific intensity throughout the period of the intervention? Because we actually read the interventions. There's not good data on how they kept people at the right that, like how they actually prescribed intensity and how they kept it and did the progressive overload as well, right? So it might initially have been assigned to that intensity, but dude, did they actually do it? So just we just completed a trial. And it's really hard in a large trial of heterogeneous people who are new to strength training to get them to train at a prescribed intensity for a long period of time consistently with good adherence. Because these are real people. Like, think about the people you personally train, right? And think about, like, you got to get them in, you got it. And so we get them to, so the way we do it is we do, we get them with a phase where we get them used to the exercises. These are people who have never resisted training before. We're introducing this is what it did lift us in, right? So we get them used to good form the three to four weeks, kind of working through building, these are also people who are fearful sometimes of extras of resistance training, right? Because they have low bone mass. So you've been used to it confident. Then we start increasing. We progressively increasing the lows. We spend about four weeks, kind of gently increasing their weights and then we test them. We do a multiple around tests that we set their intensity. And then we use, because, you know, from a manpower, we're not doing one-on-one training, they're kind of in small groups. So we do a repetitions and reserves. So we get them to say, like, track their workouts and at the end of each set, what were your repetitions and reserve? And when they're, you know, at, you know, when they got to, then we increase the weight. And we try to increase the weight over time just in general. And then we retest them again, but a few months later, we're not testing them all the time. So we don't have the manpower for that, right? But we are kind of, every kind of time they're in the gym going, I can we push it a little bit and, you know, that, so this is probably more real world, right? This is probably how it happens in the real world. You track, you add, you know, that sort of thing. But even then, you have people who are just like, I'm not comfortable lifting more. And what do you, you can't force them, right? So you're going to have variability in how well people actually hit the targets. Some people are super motivated and they want to increase their weight before you're asking them. And other people are like, I don't feel well today. I'm only going to do two exercises, right? You've been in the gym with those people. I'm sure, right? So, so that's probably happening in trials. And that's not accounted for either. But I, yeah. Yeah. And I think there's some, like, like this is sort of the, the difficulty in communicating all of those individual participant level sources of variance that contribute to the overall picture of the literature. And why it's sometimes useful to take a look at, given the limitations of this field, something like a case study, not that it is causal in nature in terms of what it can tell us. But I remember the first time I thought about bone and a really, really cool way in a literature basis, I read a study in 2012 and it's by Walters. You might be familiar with it. You might not, but it's a case study of bone and obesity of two elite senior female powerlifters. And it was a really cool publication. It's a good one. It's a good one because it's a 49 year old and a 54 year old, still competing competitive powerlifters. And this is also their competing before the classic era. So they were using bench pressure squat suits, which enable you to use higher absolute loads because they give you elastic resistance in the in the bottom of both of those. So the absolute loads that are handling and walking out with axial loading is massive, especially, you know, through like the arms and then the spine and the hips. So these are women who have been training for more than 30 years in specifically the IPF. So this is like a drug tested, like natural federation. They both at least stated like I'm not using anabolic steroids and never have. and the Z-Series. scores in the T scores of the 54-year-old woman at the time in 2012 were the highest that had ever been reported for age matched women in the literature period ever and I want to say I think I have them right here they were like lumbar spine 2.8 Z score and like 2.2 for the T score and the femoral mean Z was 1.4 and T was 1.9 so it was it's it's a cool study because you're looking at women who are maybe ostensibly we were to assume at least perimenopausal and I think that's something that people can maybe not relate to and relate to like it's just good to know like hey this is potentially possible to have really high you know bone mineral density even though you're in a population that we typically think are at risk while the research has been done in this population and it's difficult to know what would be like if we had their twin and alternate universe who decided to be a triathlete you know their whole life but at least mechanistically we think probably lower right or you know if they weren't you know consuming a a muscle and bone support of diet and training in this manner and these are women who have you know high 300 to low 400 kilo totals across squat mentioned deadlifts they were these are world-class elite power lifters there's obviously a genetic component or they wouldn't have got there in the first place but I think that's like interesting I think one of the things though is to think from the on the flip side understanding like if I deliver kind of what it would probably be done in the real world and and also like T first of all T's out like it does resistance training alone work so that's one of our study objectives was no impact just does resist to trainer so a lot of people can't or won't do impact training because they have arthritis or other issues right so and then it's like is isn't intervention that is probably more aligned with what would be done in the real world in a jam if a 65-year-old person with osteoporosis walked in and got a personal trainer you know is that effective because it's great like yeah sure power lifting and lifting and good gillian pounds while wearing a suit you know we'll get you great bone density but is like a real-world intervention actually effective because that's what we really need to know and so what we actually did was we have three arms in our study so one is an attention control where they do posture balance exercises that we don't think are gonna affect bone and we're just basically give them a home program and tell them to do it there's not a lot of interaction or supervision there's a little bit but not a lot and no progression and then the other group gets a moderate intensity program and then the other group gets a high intensity program and so the primary question is actually if we combine the two resistance training groups does resistance training increase bone density compared to control and then we can ask as a secondary question this is how we get around the power thing and secondary question does intensity matter right but it's only resistance training there's no impact other than they do some step-ups but like other than that there's it's not an impact intervention and we and we do very a very pragmatic progression method like we do the repetitions in reserve with a little bit of testing because they get nuts probably closer to what would happen in a real gym and people working they have some individual sessions and then they work kind of in small groups with some supervision which again probably a bit more realistic and probably would be more cost effective if this if we show it's effective then you could go to you could say like pay this is something that we might actually fund right so I think that these case examples can be really helpful but I think what we do need is adequately powered trials with real-world interventions so that we can can say hey yeah actually going to this personal trainer and learning how to do this is going to increase your bone density right that's what you want for someone yeah so let me ask you then on the the science comm side of it and maybe a potentially controversial question but I don't intend it to be like oh let's let's make people fight I'm aware of people in this space who have specifically claimed primarily based upon the mechanistic understanding of absolute loading being what primarily stimulates bone or high impact in the case of you know like plyometric or drop jump style training well you should probably be doing heavier lifting even if the trials don't show it and in my mind even if there is a mechanistic argument for that even if you couch that in terms of I don't have the data to prove this to be true but it is my hypothesis that it may be better to lift heavier I feel like personally and I'd love to get your thoughts on this that you risk creating a barrier to entry that might have people misinterpret that and go well I don't want to let alone I don't want to have a team of people help me into a squat suit and then do one RM three times a week you know like like it's you know Louis Simmons era I would much refer to do some band-based training or group exercise class and I want to know how that is right but if I must even for not being that if I've got to do you know five by five's at 80% of one RM or higher but I don't even want to test my one RM maybe it's not worth it at all and I think to me I get concerned about that that that's the risk but how do you feel about when you hear a science communicator even maybe properly couching the data but speculating or providing advice that people who maybe have never considered lifting ever need to use this very specific modality of resistance training of lifting heavy from like a public health uptake perspective yes I would say that like from again from my kind of look at the data in sort of mostly postmanopausal women we could probably say that it low intensity is probably not that effective but moderate high probably is and ideally combined with the impact rate so that's that's what we can say confident me well not confidently that's that's that's as confident as I'm going to get in terms of breaking it down and I do agree with you that like these people who are promoting it must be heavy are really creating a barrier I tend to promote that it has to be high effort it has to you have to be working hard right you have to be working to the point where you're almost can't lift anymore that's that's what I tend to promote rather than the it must be heavy because there are some people who then think of they have to go lift heavy barbells but for that person actually a 20 pound goblet squat might be quite hard right and it's not that heavy comparatively right so we had a woman in our trial our trials not published yet but we're just analyzing the data now so we had a woman our trial who and again we were very pragmatic in our approach so we were very inclusive so we had a woman who had osteoporosis spinal stenosis and arthritis in her hips so when she started in the study she could not get out of a chair without using the arms right and she had a lot of pain back pain and hip pain okay so that person would have been excluded in most of the trials that are in the metanocies we didn't exclude those people but we started with just so her you know kind of modern intensity was getting out of the chair with a few pads you know to help you know basically like a modified box squat and that was hard for her right because she couldn't get out of this right so it's not about heavy it's not hard right we eventually her goblet squatting partial goblet squats with 30 pounds which is pretty good I think right let's go but again she couldn't ever get to parallel ever because of her hips like she just couldn't do it and that wasn't realistic for her and that's okay right we don't all need to be as to grass we can as long as we're building strength in the ability that we have and then we have other people with arthritis where we might do their warm-up sets with greater range and then in their lifting sets are less range because they don't they can't tolerate it so we modify accordingly right but yeah we had some people you know dead lifting over 120 pounds and these are people with low bone mass I mean this is awesome right people who never drink before right so and then other people won't get there because that's not in their range of ability but we get them working as hard so I guess what I'm trying to say is I like to emphasize high effort as opposed to heavy weight and and working like moderate to high intensity and the other reason for that is not only a reason I kind of try to push towards the high year not necessarily high but is because I think people if they're on left to their own devices or left to their own rating perceived exertion will often underdose right so you know if you say you know you're gonna work as hard as you can they'll do 10 reps and call it okay that's enough but if you actually say do as many as you can they can probably push out 15 or 16 and then you're like okay we need to be smarter so I feel like if you have a lower rep target you're spending more time at a higher intensity just in it because you're going to end up lifting heavier does that make sense so that's where it can be more efficient and more effective I think people will be more likely to underdose the higher the rep range target gets right so because you're effectively tuning in progressive overload yeah yeah you're not going to fail your fatiguing or you're getting bored right and so I think that you're more likely to to overload the muscle at the lower rep ranges so so for me like I will tend to split the difference and go aim for eight right if you can do ten it's too easy and that makes it you know it kind of fits the moderate to high intensity target while not making it a bit overwhelming that has to be super heavy. No, that makes a ton of sense because now you're targeting kind of like that I'm accomplishing a higher absolute load and I'm also building in even if you're under-cooking it now and you don't have the self-efficacy or belief in your strength that eventually you will because in my experience when I first started training and I worked with a lot of older people who were just starting lifting weights for the first time, they almost had more of a perspective of exercises like a leisure activity, which was hilarious because I'm a 22 year old bodybuilder and they're a 62 year old retired or near retiree who has been told by their doctor and you probably want to go to the gym, get this personal trainer, I've got a good referral and I remember having this very specific conversation with she was probably closer to 72 and I was talking about like we're going to push exactly what you're saying and she was like well it's not supposed to feel hard though right and I was like you kind of is yeah I'm like all right I mean you need to be respectful I understand this is a generational difference and also maybe a generational gender difference you know based upon I'm trying to relate to someone who's 40 years older than me and has lived their whole life as a different gender than me and I'm like okay I can't just be like bro hard enough you know like and obviously it's a 20 year old me that probably was my knee jerk but at least I'm respectful my elders enough so I I remember having that conversation and eventually trying to work her towards understanding that um not only does it should it be kind of hard but it needs to stay hard because as you get stronger and you feel because that was the first step she was like okay well then then it'll get easy because I'll be come stronger and I'm like yes now we make it and then and and I and there was this there was a bit of grief like there was actually kind of this acknowledgement understanding that I just realized how how different it were like that's the part I like that's the thing that I'm chasing and I want to see the load go up and progressive overload for me it's it's built in but you have to kind of create systems for it and create the mind the mindset and mentality for someone who is just not used to this stuff right so I think that's a really intelligent pragmatic and very like practical way of encouraging like hey you know we're gonna do what's you're adapted to that's currently heavy enough but it's not intimidating and then it should feel this hard each time but not like complete failure and also we know that you aren't an experienced athlete so telling the difference between being out of breath versus being close to failure is going to be a challenge so it does really solve its own problem I like that I think that's um something that hopefully a lot of trainers can adopt um so yeah treks any thoughts there yeah well while we're on the topic of programming exercise we've mentioned this idea of impact training a few times I think it'd be very helpful to get an assessment that's probably the one piece of terminology our audience may not be fully up to speed on so when we look at these trials um that have an impact training component how is that usually programmed what does that really look like and how would somebody who's listening go about actually doing that in a way that I guess I would say is maybe safe or has like an acceptable risk profile where they can actually ease their way into it yeah it's a great question so in some of the studies they just said things like we did dancing or we did skipping um and that's what they called impact exercise which is totally fine so anything that was weight bearing um and so that term is used a lot and I hate it because it's very vague um but anything that was you know involved um ground reaction forces um some of them were a bit more specific so they would say we would choose exercises that at higher ground reaction forces like X or like in the case of the lift more trial they started with you know sort of heel drops and then eventually increased the so they would do like a pull like a kind of a pull up and then drop sort of thing um and so and some of them would do like drop jumps where they jump off of boxes of progressively higher heights so I think there's a variety of uh things that are called impact exercise so it also then makes it challenging when you're trying to figure out what actually works because they all they don't characterize it well um they don't characterize the progression well some of them do I'm not saying not everyone does but a lot of don't especially some of the older studies um but even a lot of newer ones don't um I always hate when people bash on older studies because sometimes like some of the best trials are the ones done in you know a did two decades ago and they just did a really good job um and some of the newer trials are not done well so anyway so that's an aside so um what I I actually um I get this question all the time and so I actually created like almost like an infographic um to kind of show that you start with the foundation so you have to build strength you have to condition your muscles to be able to tolerate those high forces and sometimes that means strength training sometimes that might mean um just moving a bit more quickly or doing like a power type movement right where you're you're doing a rapid muscle contraction but you have to kind of create the foundation first before you start jumping off of boxes um especially if you think about people who are middle-aged or older because our connective tissue gets stiffer with age right so now you're running the risk of taking someone and starting impact exercise and someone who doesn't have the same connective tissue as a 20-year-old and you increase the risk of achilles tendinopathy and all kinds of other issues or exacerbating a like an arthritis or a problem they may not know that they had right so um you want to create that foundation first of building strength building that tolerance for high forces in muscles and tendons and bone but also muscles and tendons and then slowly increasing the forces whether it be a ground reaction force or a muscle pull for some people impact is not tolerated well because they have arthritis they have the tendonopathy they have some other condition or they are fearful of it and so for those people they may need to stick with the you know strength training or the maybe um like a power type training where they're doing rapid contractions against resistance but not necessarily doing the hard landings right um so so those so that's that's an off route right like for people who can't do it they may just do a you know a cycle of you know they do their strength cycle and then they do a power cycle so that they're kind of changing the loads on bones and on muscle and get building that tolerance and then some people may actually be able to progress to higher ground reaction forces um but that's kind of how I would see a progression is like you start with a foundation of strength then you know get your body tolerating the higher muscle contractions and then building in the ground reaction for this is but I actually created an infographic to explain this because I felt like there wasn't something out there that kind of helped people understand that there's a continuum of impact exercise and some people are not going to get to this end and they shouldn't because you see these social media posters like it must be four times bodyweight and it must be this and it's again to your point creating this disincentive to participate at all because do like I'm never going to do that because I have this foot problem or whatever so you can show someone to continue and say figure out where you're at now and start there and then move along here and you may never get here and that's okay um you know you you make those compromises but at least you do the best you can with your abilities right yeah now you mentioned uh you made an infographic where can people find that um I posted it on a blog in our in our on our website like I'm I started a little website because people kept asking me for this information so like I need a place to put it so I uh both lab.ca we created I created a little website um and I have a couple blog posts and that was one of them hoping to do more it's just a matter of like finding the time to do these things off the side of my desk in addition to the teaching and the research and all that but we do a little content creation and and that's where I'll I I put it when they have it yeah that's the thing most like because because I'm back in you know on faculty full time again back in the saddle and the biggest problem I think a lot of faculty members have you can relate to this we just we need more things to do you know to research the teaching the administrative stuff the service it's not enough and it's like I I'd love to run a website I'd love to you know grow a social media channel so thank god there's some opportunities for us to finally get off our ass and do something you know we started I started a I started a YouTube channel and I I post occasionally um and on Instagram I'll post occasionally so I I do a little bit but I really wish I had more time because there's so many like questions that I get from patients and things and so we do a little bit of creation contact creation will post that stuff so the the impact thing was one because I just kept getting these questions about what is it and what do I do if I can't do it and all this other stuff and so we created that and I what did a blog post where I broke down kind of this sort of stepwise approach um but also like random questions like bracing for um after a vertebral fracture like the evidence um is actually quite bad and the only study that shows a benefit is um was funded by a bracing company um and actually there was an academic dishonest issue where they published their data twice but made it look like it was two separate trials uh and those two trials are included in a lot of meta analyses right but it's the same uh double printed uh and when you say bracing just just a little terminology clarification yeah you mean a physical brace yeah yeah yeah yeah yeah a lot of people in our audience they hear bracing and they think tightening up your cold I mean like wearable brace is what I stress out um and so like but you if you have a spine fracture in many countries they will put one on you and send you home because it makes you feel more stable and it gets you out of bed um but it's actually not an evidence based strategy so anyway so like [BLANK_AUDIO] I spent a few, we're working with this special interest group and with people from multiple countries. And we're creating this infographic. There's a please stop using braces. And so because I feel like this is the way now. There's, there's to get information out there. You know, scientists have to start becoming science communicators and better science. You can publish your work in a paper and hope that people are going to read it. It's not going to happen either. There's so much misinformation and people on Instagram who think they know science and, and unfortunately, there's not enough scientists who put themselves out there because we don't have time. So we have to find ways to carve out that time and put ourselves out there a little bit just to kind of say, oh, by the way, (laughs) this is things based off doing it, please. - And it's, and it's hard too. Like I've been working very hard to, ironically, increase impact in the research that my colleagues do. And they very much like some of the participants and the studies who are intimidated by just how steep the learning curve or adaptation curve is for exercise or dietary change. When they realize how quickly the social media landscape is changing and what does it mean to be a science communicator in the time investment and the initial stuff, they just go, can I just go back to making the one sentence thing on Twitter? Is that reaching everyone? And unfortunately, it does take some effort in time and there's no easy way to do it. And also a very different demographics. So I had a really interesting experience. I was just on Radio New Zealand. I think a couple of days ago talking about creatine, which is, it's such a fever dream for me to have like my mother and her generation asking about creatine when previously or astronaut creatine to make sure that I wasn't taking a steroid. Like it's a very, it's like this resurgence is a totally different community. And the language and the messaging is very different, but nonetheless. So I went on Radio New Zealand, and this is an actual radio show. It does get syndicated on the podcast, but something like 80 to 90% of New Zealanders over the age of 50 and 60 listened to this podcast. And I had my wife, like some of her colleagues were older, like, oh, your husband was on Radio New Zealand. She didn't, like she didn't know 'cause I kind of downplayed it because I'm thinking like I've had a few YouTube videos that have gone viral and I've had 2.4 million views, but I guarantee you, not a single person who listens to Radio New Zealand is aware of that YouTube video. So then you have to think about what demographic am I trying to reach? So if I was to start doing research on, you know, Sarcopenia or osteophenia, and I get on, you know, Jeremy at the A's channel or something like that or Jeff Nippard, it's not gonna have nearly the impact of me reaching a quarter of the very, very specific population I got on a radio show. So it's not an easy thing to do, to be a science communicator, even if you do have the time. So it's a tough thing to do with a different view, and I'd recommend you for it. - Yeah, it's been a learning journey. So I've done a little bit. And so we did, for example, I did one on Weighted Vests because the menopause on Instagram, you know, we're talking about Weighted Vests and you see all these like influencers wearing a weighted vest. - And please, please talk about that more. - I won't density and dada dada. And they all cite this trial, it wasn't even a trial. They all cite this observational study that showed that women, after five years, increased their bone density, after wearing a weighted vest, for five years, increased their bone density. So what they don't tell you is that was a follow-up study from an original trial that was done five years before. And the original trial showed no effect of the weight of the weighted vest. So they recruited a bunch of people, they randomized them. It wasn't a well-done study to begin with. And I'm sorry, I don't wanna throw the authors under the bus. This was like, our understanding of how to do clinical trials was evolved immensely, so a lot of that is just, it was, for its time, it was probably fine, but there were lots of sources of bias in the original trial. That trial showed no effect. Then what they did was they asked people to come back and they had a very small subset of people who came back and were still wearing the weighted vest. Now you wanna tell me that the people were still wearing those vest five years later are not different than the people who were in the trial who didn't come back, right? So it's a very kind of subset of the original trial and which was already had many sources of bias and now you're adding those layers, right? So I really can't make strong inferences from that. And if you actually look at the body of literature, looking at the effects of weighted vest on bone, it's largely negative, right? And it's hard to tease out exercise plus fate weighted vest versus weighted vest alone as well, there's those issues as well. So if you look at it, like I would not advise people by weighted vest for bone density. I wanna use it for, you know, building capacity for hiking in the mountains or whatever the hell, but burning extra calories, sure, fill your boots. But if you're talking about, and the reason why I don't like this is because people will think, oh, I can buy a weighted vest, wear it on my walk and then I don't have to strength train. (laughing) And that's the problem, right, that I have with weighted vest. So I don't care if people want to use weighted vest, like if they think it's, they like it or whatever. But, and so anyway, so we did a, I did an animated video about weighted vest and then all of a sudden I was like the cut, which is a New York magazine affiliate or something like that, interviewed me. And the title of the article was, I hate my weighted vest. And it wasn't me that said that it was the actual person who wrote the article by. And it got like people are angry because they think, oh, you're why are you being so negative and did it? I'm like, I'm not being negative. I'm just trying to make it clear. This is what the evidence says, right? And so people are misleading you if they're telling you that you can wear a weighted vest and it's gonna increase your bone density because that's not what the evidence says. - Yeah, I like that new trend, sort of trend, but the new thing these days is, there is a large group of people pushing a fairly unsupported intervention and then if you apply publicly a reasonable level of skepticism and actually start leaning into sightable evidence, you're like a party pooper. And people are like, why do you want everyone to stop having fun? Why are you trying to harm everyone? We're just having a good time wearing our vest and it's like, well, you have this false sense of security that this vest is giving you health benefits that it's not giving you and I'm trying to make sure that you are not basically skipping all of your bone-oriented workouts because you wore that vest for 10 minutes, which is not really doing it, but it's really been weird because I feel like social media changes over time the way people interact, but I feel like in the 2010s, like the early 2010s, if you came out as a skeptic for any kind of emerging trend on social media, people would say, finally, someone who actually has some principles and really sticks to the data, but it's changed so much that nowadays, you do get a meaningful amount of pushback of being basically your negative, your party pooper and you're basically no fun. So that's been a very strange thing to observe. - But it's people, sorry, just to say, it's often the people who have a vested interest that are making those comments. So vested, yes, so yeah. (laughing) Exactly, yeah. Well, the people who sell the vest are the ones that are promoting it, right? Or I did a video on osteostron, which is a thing that is really popular in the U.S. and is now spread to other countries. I did a video on that and people, a lot of comments, very negative, but you actually look into their profiles and do a little searching, they all own franchises and that sort of thing, right? So they're the ones who are saying, oh, you're wrong, this is the evidence, and instead of that, but it's because they've been sold this story by someone else. So you have to be a bit careful when you look at like these negative comments, like where are they coming from, right? - Yeah. Now, I had one more question, Helms, if I may, if I can jump in, this is going back a couple of answers ago when I was asking about impact training, you mentioned different types of forces that are having the stimulative effect on, you know, bone adaptations. You mentioned specifically like ground reaction force, you meant specifically the muscle pulling force. Something I've heard people talk about, I'd love to hear your take on this. I've heard people justify some pretty low load training as long as it's intense, I shouldn't say intense, as long as it's high effort. So we're talking light weights, sets of 30, even 40, taken near failure. And one of the arguments they make is that when you're engaging in that type of resistance exercise, even though you're not getting, I mean, especially like an upper body exercise, there's no ground reaction force. The actual kind of muscle pulling force is not quite as substantial, just based on the difference in external loading. But they talk about the compressive force of muscle on bone. Like so, for example, when doing bicep curls, not just tendon pulling on humorous, but actually compression on the bone itself, does that seem to play a meaningful role? And if so, do you think that lends any credibility to some of the lighter load training approaches? Yeah, I mean, it's hard to say in a clinical trial, it would be hard to measure that, right? I think we can look at some animal research to kind of look at, like what are the characteristics that are of loads that are osteogenic? And you see, you know, there's data to show that higher magnitude forces, higher rate of force application, shorter, more frequent outlets, so that would count. the argument of like longer. But even if you look at athletes, right? Like athletes that tend to have higher bone density are those that are doing like higher force activities. So you'd look at gymnasts, volleyball players, basketball players, soccer players in lower extremity, you know, think like fast multi-directional movements, right? These are higher force movements, but they're short and they're quick, right? So like you're low, low, real slow kind of thing. I don't know, I don't know, maybe, but we look at runners and swimmers, they tend to have lower than average bone density or normal, right? So I would put my if I was picking a basket to put my eggs in, I would pick the higher force quick movements. And this is why I think your best bet is probably to combine a modern Thai intensity strength training with the impact because then you get, you know, you're maximizing your chances of a benefit, but the impact doesn't have to be like a lot of cycles, right? It's actually the shorter, more frequent, but according to animal research anyway, seems to be what is effective. So they did this study where they, I think it was rats or mice, I can't remember, but they had like 360 cycles all at once or divided up in twice and once in the morning with at night or then three times a day, but smaller number. And it was the multiple cycle, multiple boats a day that was more effective. So I guess to answer your question, I think that higher force, I would, you know, like the higher magnitude modes, and that's going to apply both compression and muscle pull. So you can't dissociate them, right? So yeah. Yeah. Yeah, that makes sense. I mean, yeah, there's, it's an interesting mechanistic idea, but at the end of the day, you know, like you're saying, when you have that high impact training and when you have the high load training, it definitely seems to be kind of the default approach. If you're trying to say, hey, we just want to make sure we're using the stuff that works here, right? So all right, Helms, my apologies for budding in once again. Well, I told you it's going to happen. I said it was okay, and I stick to my guns on both. I was right. I don't know why I don't know why I'm sitting here in front of a microphone and apologizing every time I talk. It doesn't make any sense, but I'm basically just trying to give you the cue. You may keep the show rolling. That works. I can take that very strange cue, and I'll run with it. And honestly, I'm used to it. Like, I don't even know why we're talking about it. I know how this works. So I would just say that I can't think of any biomechanical rationale for where compressive force, even on appendicular bones, wouldn't scale with absolute load to some degree. And I think sometimes, like, if you know one area really well, and you understand it, you kind of naturally want to extrapolate it to other places. And like, so much of the research on load for hypertrophy indicates that so long as you're training near to failure on a set-for-set basis, load is not the factor that's going to dictate muscle hypertrophy. And that's because at the sarcometer level, at least to our best understanding, you're getting similar mechanical tension because different fibers drop out at different times. But in the end, the way muscle transmitting, you know, force the bone is through tendon and other, you know, attachments across the scale with them. And that's pretty much in my mind. It's got a scale, at least maybe not, like, linearly, depending upon, you know, the lever and everything, with load. So I think that makes a lot of sense. So anyway, that was my thoughts on that. I don't know. Honestly, Helms, I don't think anyone asked you to be a jerk. I have thoughts, I have thoughts, Trexler. And the only other thing I was going to say is when you look at a lot of the exercise studies, many of them will show an effect at the lumbar spine, but it's much harder to see a large change at the femoral mark. And there's no muscle attachments there, right? So that's the other thing I kind of think about it sometimes, where I'm like, okay, you know, like, you know, maybe that's part of it. No, that's actually a really good point. And, you know, actually, you know, while we're talking about forces, I think, I totally agree with you like, hey, we need to point out the actual data on weighted vest. And it's not because I'm saying don't do weighted vest. It's that I need you to understand that if you are choosing weighted vest, fantastic, but it is a lower efficacy or a lower level of evidence for the outcome you're trying to get. And then, you know, it's kind of mostly inverse the argument of, I don't want to tell you to do something that could be theoretically better, but isn't clearly demonstrated to be better in the research. If I can get you to do something that you're more willing to do and stick to long term because, hey, we got this five-year, not perfect, you know, follow-up study where maybe there was, if you stick with wearing a weighted vest for five years and have the personality to do that that co-occurs with maybe other things we beneficial for bone, maybe you'll get a benefit. So I'm not discouraging weighted vest use. I'm just making sure you know that it's a distant third maybe to what actually is the main thing. So I'm pretty sure they're out. I'm pretty sure there were exercises they were doing with the weighted vest, so it wasn't just the one walking in your day, right? Like that's the other linear, right? So people forget that. And certainly weighted vest can be very useful, so if you have someone, for example, who's had a stroke and has some paralysis and can't hold on to weights or doesn't have the stability to do, you know, barbell lifts, but you want them to do weight bearing strength training. Like you want them doing squats because you want them to get in and out of a chair better. Adding a weighted vest is a great way that they don't have to worry about holding on to weights and doing other things. So like there are scenarios where in a rehab setting, I might say that's actually a cool strategy. Weighted vest don't scale weight wise very well. So you can only add so much weight before it starts to become kind of uncomfortable for, especially for an older person. And then I would also worry about if you get really low spine bone density, I'm loading you up with this vest and you're not used to carrying that weight. That's also an issue. So what I do think there's, you know, people have rheumatoid arthritis, you can't grip things. Adding a weighted vest to their squat may be a way for them to add load in a way that is feasible for them in a home exercise environment. Like there are scenarios where I think it can be quite useful. But I think, you know, the whole like put a weighted vest on and, you know, you're going to increase your bone density is a misleading message. For sure. Yeah. So on the topic of different types of forces and another one, a far more expensive option that I have seen come up that does have some data behind it is vibration platforms. And, you know, if you're in that kind of economic bracket and you're you're looking for other ways to get, you know, sharp amplitude high speed forces. Maybe that could be something that would replicate kind of the impact side of the equation of lifting. At least that's what I've heard promoted. So where's the data on vibration platforms compared to these, you know, what you're recommending. And I haven't seen quite as much uptake of that obviously because a weighted vest is a lot cheaper. But vibration platforms also seem to be promoted as one of these supposedly evidence-based strategies for increasing bone mineral density or preventing the loss of them. Yeah. So I have not looked at the weighted vestler or so the vibration literature in a long time. So it was really trendy like two decades ago. It's had a few resurgences. Yeah. And so when we looked at it initially, the evidence was quite poor. Like again, a scenario where you have these exercise studies that are poorly designed, that are underpowered. There are a lot of them are doing resistance training exercises while on the platforms. So you have to dissociate the platform from the exercise, which is really hard to do because they don't often have the appropriate controls. So my kind of overall take is that that literature is very messy. Subsequent trials that were published, there was one really good one done by a colleague of mine Angela Chang and Toronto that showed no benefit of the vibration platforms. So you look at the really good trials or you like start teasing out studies that are well done. The effect I think is less obvious or is there is no effect? And there's some sneaky stuff like there was one big group in the US that did a study and they found no effect of the vibration platform. But then they said, okay, well if we do a sub analysis in people who are 80% adhered and they weighed 120 pounds, then it was effective in those people. Like they're fishing at this point in my opinion. Because that I don't think was a pretty planned analysis, right? So I think that sometimes people, you know, there are studies but they're not necessarily well done or they have these nuances that maybe people don't know about or know how to read through the read between the lines and go, oh wait, came maybe that's not actually, they're not saying that the overall trial result was negative. But then people start talking about this sub analysis and that's what then makes the news, right? So I would say like my general take on the vibration literature is that it's messy and I personally wouldn't advise using that as a way to increase bone mass because I think there's better ways and stronger evidence in the resistance plus impact space. No, makes it some sense. So okay, I think I've got basically, you know, one, one last question and And it is related to how much is truly the impact of aging from a more biological perspective versus cumulative time being less and less active over life. Some of the different analyses that we've had say looking at testosterone changes in men when you control for lifestyle obesity or when you look at even "anabolic resistance" when you try to replicate some trials that have been done in Canada or the US being done and I think it was Denmarker, might be a trial done in Copenhagen, they don't replicate to the same degree and it seems to be that when you start to consider someone who might be over 60 or over 70 and they retain a level of activity that much of what we associate at least in a modern society with the effects of age might more so be the effects of continued and chronic lack of physical activity and maybe becoming less robust to that or resilient. So I would love to get your thoughts on for people who do feel a little discouraged by this and they're thinking it's age-related, I think at least from my perspective when I talk to men in a parallel to this who I was literally at a conference in Norway, Trexwell, remember this, and I asked because it came up in a panel discussion, when do you think testosterone starts decreasing in men? One of the people raised her hands, I don't know, 25, 30 and I looked at him like, "Oh my God, you need to get off the internet." I was expecting over 30 and you said a number that started with two, like bro, and I know that is completely due to people's vested interests, like you said, they've got a connection at the HRT or TRT clinic and they want you to believe that their testosterone protocol will help them and that there's this pandemic of men becoming less manly and testosterone is going down, but in reality, like it doesn't meaningfully drop in these healthy individuals until they're in their fifth or sixth decade of life. So anyway, I think when they hear that from me and I go listen, if you do all the right things, this isn't something you need to worry about unless it is and then it's potentially something that's different and clinical and you should actually talk to an endocrinologist not gym the guy with the discount code for HRT on your Instagram for the bone health world. How much of this, and I think obviously the difference between men and women because men not experiencing menopause, how much of it truly is biological and is going to see a more precipitous drop in bone health compared to the often occurrence that we see of people becoming less active as they age? Yeah, it's all of it, right? You have, you know, you have come to a peak bone mass probably sometime in your 20s, flat toe for a bit and then there's a slight decline on average, but the actual decline, there's going to be variability in that decline. And some of that is going to be to cellular changes, biological changes that happen with age age. Some of that is going to be due to variability in how your hormones change. So some people, for example, who experience menopause have rapid, large losses in bone or rapid losses in bone and some people lose less bone. And so there's variability in, you know, what happens? There's variability in men's hormone over time and that will affect bone. There are, you know, you might have an ill prolonged illness where you're in bed for months at a time and that's going to cause, you know, loss of muscle, loss of bone. If you have cycling weight loss, right, like you lose weight, gain weight, lose weight, you're losing muscle in bone, would you gain all of it back? Maybe not, right? There's going to be people who have health conditions like celiac disease or diabetes that will affect bone strength and the amount of bone that you have. So all of these things, so I think you have this kind of average come to a peak and come like this and how what that peak looks like for an individual is going to vary based on a variety of things. I don't think you can kind of say, oh, it's due to physical activity or it's due to age. It's all of it, right? So yes, absolutely. People who are not physically active are going to reach a lower peak bone mass probably. They're probably going to experience more loss of time, especially if they become less and less active. Whereas if you maintain certain levels of physical activity, that's a good stimulus for bone, that's a good stimulus for muscle, you'll retain more, right? It doesn't mean that those biological changes are not happening, they're probably happening too. And they are going to affect your ability to participate. So it's, I mean, we all know this. It's harder to have the energy and hit the gym and hit the, you know, weights that you were able to hit 10 years ago, you know, it's these, you do experience changes in your energy levels and a lot of things, right? So I don't think it, I don't think we can simplify it and say, is it this or is it this? I think that there's many layers, like people who smoke or add higher risk of fractures, people who drink more than three units of alcohol and average per day, right? So there's lots of many, many, many, there's certain medications that affect bone and sometimes you can't choose whether or not to be on a certain medication, like if you have cancer, you will take the treatment that will save your life, but that's going to cause bone loss, right? So there's a lot of variability in how bone changes in a population and it's due to many, many factors, aging, like changes to, like cellular changes to your cells and how, you know, biological processes is one thing, yeah. So if there is an important role of physical activity, obviously, or you wouldn't be on here at all, and we would all just be, you know, wasting away and frailty and trying ourselves to sleep until we fractured and died, but there is an unavoidable degree of the effect of biological aging. Let's go back to you mentioned earlier, hey, unless there's a pharmaceutical intervention, I'm not expecting this kind of change. So to combat the more biological side of it rather than taking a physical activity intervention or a resistance-training or impact intervention, what are the pharmaceutical options? And also how effective is HRT, especially in menopause, for combating bone loss, re-growing bone? And what's the data? What's the risk? Where are we at on the pharmaceutical side of the osteophenia world? Yeah, I mean, there are some, there's, so hormone replacement therapy does have a positive effect for bone, right? It, you know, like people talk about all the negative side effects as one of the positives. But it's one of those things where it's not considered, I think, a first-lined therapy in the sense that someone diagnosed with osteoporosis, HRT is not going to be the first option that a clinician is going to present because there are other medications that would choose first. HRT, to my understanding, and I'm not a clinician, nor am I an expert in, you know, these drugs, my understanding is that if someone has symptoms, menopause-related symptoms, they may, and there's a wide variety of symptoms that might make them fit the eligibility category. They might consider HRT, and they, there's the added benefit of protecting bone. And so for someone, like, and so, so the bone piece is probably part of the decision-making, but it's not, if it's the only factor, then that's not your first choice. Does that make sense? So, like, if you have simple other issues and you also happen to have a high parent who fractured a hip, then that might sway your decision towards going on HRT because it can then also prevent that bone loss, right? But the decision to use HRT is often happening earlier because they usually use it, like, in the early periods rather than, like, the risks tend to be in people who are much further postmenopause. And so, that's not usually when people are being diagnosed with osteoporosis, so, though, sometimes it is. The osteoporosis diagnosis often comes after, like, in the postmenopausal phase. And so, but if a person is diagnosed with osteoporosis, then there are, you know, different medication options depending on, sometimes, the country you live in, the guidelines your particular physician is following or endorses, and, you know, what you can afford or what your health system allows you to afford, right? So, you know, there's best phosphonates, it's a very common class of drugs that are used, tarot paratides and anabolic, which is used kind of less often, I think, at least in Canada, you know, some have, and Rome is those who have been there, other options. And so, there's a variety of options, and usually a clinician will look at the person's risk profile and the potential for side effects and, you know, make a decision around what's, you know, what options to offer based on that, and then the person has to decide whether they want to take the medication, and there's a lot of fear around osteoporosis medications because there are some side effects. So, some of the side effects that are common to several of the medications gone all of them, that several of them, a typical femoral fractures and osteoenocursus of the jaw being the two ones that you'll see in the news, and those are, then they can happen with some of those classes of medications, but they're extremely rare. So, you're taking, you know, this, but people get a lot of fear around them, and rightfully so, like, any decision to go on medication is a personal decision, and people have to weigh the benefits and harms and decide what their risk tolerance is. So, the risk of having a fracture in people who are offered medication is often much higher and then the risk of the adjunct. adverse effect, but if they really that scares them, then that's their decision to choose not to go on it. Sometimes then you're putting yourself at risk of having a very painful spine fracture, for example, or a hip fracture later in life, which then could potentially compromise your ability to live independently. So people have to weigh those risks, but there are choices, and that's what they are. Choices. Gotcha. Now, you very clearly stated you're not a clinician. So if you feel like, "Hey, this is not my bag," you're allowed to punt it right back, and we can start closing out. But you mentioned there are several classes of drugs, and I was curious about what are some of the mechanisms of action by which these drugs do increase bone mineral density or reverse osteoporosis, and as a secondary aside, you mentioned one is an anabolic. Are any of these make it into the world of performance-hanting drugs, and that athletes sometimes play with them as a way to try to improve their bone mineral density if they would think it would improve performance, because it's not something that I'm aware of. I don't know about you, Tracks. No. No, they don't improve performance. They usually target specific aspects of bone remodeling. So some of them basically turn off osteoclasts, and they will reduce both osteoclasts and osteoblast activity, because those two are linked. But the target of many of the medications is osteoclasts. You know, Romasozumab is probably the newest one. It's a sclerostin inhibitor. So, yeah. So some of them will actually increase bone formation relative to resorption, and some will reduce resorption relative to formation. So they all have different, slightly different mechanisms, and I think a lot of it is depending on what someone, because again, it's balancing what the risks are, and which risks they are willing to take, and which ones are appropriate, because there's some things like, this is kind of testing my knowledge. But some of them, for example, with msphosphonates, we can't take them. If you have swallowing difficulties, you can't take the world version of it, because it can cause problems. Or Denosomab is a unique one, because you have to go on it, and you have to kind of stay on it. Like, you can't all of a sudden go off of it, because it can cause bone mass and fractures rapidly if you go off of it rapidly. So it's one of those ones where you kind of have to commit to a long-term plan, and it could be that you commit to, I'm going to go on, and if I don't tell her, willing, and a switch to a msphosphonate, that can be the long-term plan. You don't have to commit to that specific drug, but you have to commit to a plan, and you have to be willing to stay on it. So there's kind of like caveats with each class of medication, and a lot of it is like, which one is the best fit for this particular patient. So for example, if someone is in hospital, and they have a hip fracture, and they have cognitive impairment, and we don't want to add medications that they have to take orally, because they may not remember their, you know, whatever, injection of zoolandronic acid, which lasts for a year, might be a good strategy, right? But there's issues with other body systems, like, you know, I turn and remember now, I think it's like kidney function or liver function that has to be okay for you to go on that medication. So like, there's this, like, you can go on this one, if this is a good fit for you, and you can go on, you know, so a lot of it is kind of matching the patients kind of tolerance for risk and benefits. They're actual risk profile, because there's people who are really high risk that they're like, you know what, I'm going to go right to an antibiotic, because we really need to get this person's bone density up. So, and so I think the decision related to medications is often a combination of what is their health status? What are some contraindications, you know, with these particular medications? Do they want, are they willing to go on this long term plan, et cetera, right? Absolutely. Yeah, I mean, you said a lot more than treacher, I know about this stuff. So that's a guarantee that our audience was, no, I find that very intuitive, but also very informative. So I think that exhausts most of the questions, and I found this very fascinating, at least I had treacher or anything else, you want to pitch the doctorgy? Nope, nothing for me. Awesome. Well, first, Laura, let me just say thank you so much for your time. And before we sign out, the floor is open to you. Are there things that you feel like as the two non-expert asking the questions that we didn't cover that you want to emphasize or that you think should be discussed? And if not, can you help let people know where they can find more of your content if they're interested in digging in further? Yeah, I know. I just want to say thanks for having me. I really appreciate it. It's really nice to chat with you guys. We do have a study that we just finished the Portified Bones Trial. So hopefully that'll be published in the next year. So and you can look for that. If you want to connect with us, I have a newsletter. It's mainly designed for patients, but you know, happy to have people sign up, they can sign up on our web page, which is boneslab.ca, where we have our blog and stuff like that. And we have socials as well. I want Instagram. We post something again. I post stuff sometimes, but I'm not. I wouldn't say I'm like an influencer or anything. Awesome. Well, hey, from one influencer adjacent doctor to another, I really appreciate your efforts. You're doing important work. And I know our audience got a ton out of this. And with that, Tracks, you want to sign us off? Yeah, I just also want to thank you for joining us. A really fantastic episode. And I want to thank the audience for joining us as well, because without the audience, there is no show. So everyone, thanks so much for joining us. Make sure you like, rate, subscribe, review, check out massresearchreview.com, support our friends at Elite FTS. And everybody have a great week. We will see you in seven days with the other episode of Iron Culture.