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

The bones are mechanical sensory entities that are going to remodel in proportion to how much mechanical stress they're under…so lifting heavy stuff matters.” —Peter Attia

Read Time 35 minutes

In this “Ask Me Anything” (AMA) episode, Peter dives deep into the topic of bone health and explains why this is an important topic for everyone, from children to the elderly. He begins with an overview of bone mineral density, how it’s measured, how it changes over the course of life, and the variability between sexes largely due to changes in estrogen levels. From there he provides insights into ways that one can improve bone health, from exercise to nutrition supplements to drugs. Additionally, Peter discusses what happens when one may be forced to be sedentary (e.g., bedrest) and how you can work to minimize the damage during these periods. 

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We discuss:

  • Overview of bone health topics to be discussed [1:45];
  • Bones 101: bone function, structure, and more [5:15];
  • Bone mineral density (BMD), minerals in bone, role of osteoblasts and osteoclasts, and more [8:30];
  • The consequences of poor bone health [13:30];
  • The devastating nature of hip fractures: morbidity and mortality data [17:00];
  • Where fractures tend to occur in the body [23:00];
  • Defining osteopenia and osteoporosis [24:30];
  • Measuring BMD with DEXA and how to interpret scores [27:00];
  • Variability in BMD between sexes [34:15];
  • When should people have their first bone mineral density scan? [36:45];
  • How BMD changes throughout the life and how it differs between men and women [39:00];
  • How changes in estrogen levels (e.g., menopause) impacts bone health [44:00];
  • Why HRT is not considered a standard of care for postmenopausal bone loss [47:30];
  • Factors determining who may be at higher risk of poor bone health [50:30];
  • Common drugs that can negatively impact BMD [54:15];
  • How children can optimize bone health and lay the foundation for the future [57:45];
  • Types of physical activity that can positively impact bone health [1:02:30];
  • How weight loss can negatively impact bone health and how exercise can counteract those effects [1:10:45];
  • Nutrition and supplements for bone health [1:14:15];
  • Pharmaceutical drugs prescribed for those with low BMD [1:17:15];
  • Impact of extreme sedentary periods (e.g., bedrest) and how to minimize their damage to bone [1:22:00]; and
  • More.


Overview of bone health topics to be discussed [1:45]

Today’s episode is all things bone health: bone mineral density, osteopenia, osteoporosis, things of that nature

  • Why is this important? 
  • Why should people care about this?

Our hope is in the beginning at least we’ll walk through why they should care about this and why they should focus on it early on in life.”

  • We’ll talk about how bone health changes as people age, the differences between sexes in men and women
  • Then we’ll also focus on things on how people can improve or help their bone health become better from physical activity to nutrition, supplements, drugs, and more


Bones 101: bone function, structure, and more [5:15]

What is bone?

  • Bone is a living tissue
  • It’s easy to forget this fact and think of bone as somewhat inert
  • But bone is heavily vascularized
  • Bone is an organ that plays a very important role in a lot of things

Common bone types

  • Cortical/compact bone is what forms the “shaft” and the exterior of long bones
    • Femur, humerus, etc. — they have the long shaft and then the nubbins at the end
    • The shaft of that is the cortical or compact bone
  • You also have the trabecular bone/spongy bone
    • There are some differences amongst those in terms of their vascularization and things like that
  • For the purpose of this discussion…
    • when discussing the compact or cortical bone, Peter is referring to the shaft
    • And when speaking about the spongy/trabecular part, he’s talking about the end

Bone marrow

  • Marrow is important because it is what’s producing our white cells and our red blood cells
  • In a post COVID world, it’s important to understand that the memory B cells and memory T-cells that are going to provide lasting immunity against this virus and other viruses, reside in the bone marrow
  • The whole purpose of being infected and then having a subsequent infection that’s less devastating, (and purpose of being vaccinated) for the same reason is to have memory B cells and T-cells that are sitting there in the bone marrow that can respond immediately and quickly upon reintroduction of the same antigen


Bone mineral density (BMD), minerals in bone, role of osteoblasts and osteoclasts, and more [8:30]

Osteoblasts and osteoclasts

  • Osteoblasts—“B” for blast
    • These are responsible for building bone by producing collagen bone matrix and mineralizing it
  • Osteoclasts 
    • These remove bone by reabsorbing calcified bone and the matrix
  • So osteoblasts contribute to increasing bone mineral density
  • Osteoclasts the opposite
  • This exists in an equilibrium—We’re constantly remodeling bone, adding to and subtracting from this and basically turning over calcium

{end of show notes preview}

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  1. Doesn’t high-intensity training like MMA and football raise testosterone levels? I’m guessing that is a contributing factor to higher BMD.

  2. Great episode! Like a lot of your subscribers, I’ve been waiting for this one FOREVER! Thank you! Three questions: 1) I’d always been told that taking thyroid medication, which I have for 20+ years, can mess with BMD; is this held to be true today? 2) Does weight-bearing in yoga help, e.g. in planks, downward dog, etc.? 3) Does joint replacement pose risks to BMD (besides a difficulty in getting measurements)? Thanks again for a wonderful episode!

    • And in a future AMA, could you comment on growth hormone treatment to reduce fractures in the absence of GH deficiency for decreasing fracture risk in post-menopausal women?

  3. In 2006 my neighbor was the Bone Health chair of the American Academy of Sports Medicine. Her and Dr Barry, MD at University of Colorado were interested in the bone health of endurance athletes. I was a triathlete and I volunteered to be tested. The DEXA scan revealed I was already osteopenic at age 44. I my testosterone level was tested and I was very low and have been on TRT ever since. My bone density did make a nice recovery after introducing bone mineral supplements and weight bearing exercise in addition to the TRT. When I reverted to more endurance exercising my BMD dropped again. Dr Barry et al published my results (see link below). This year my combined T score was -.1 and my Z score was .8 so an early osteopenia diagnosis can be reversed.


  4. Golf in USA is most of the time done with a golf cart. I would think the European or namely Finnish version of walking with the clubs in your back, would be closer to rucking?

  5. Great overview of the topic!

    I am a dentist with a special interest and niche of my practice in surgery and medically compromised patients– many requiring management in the hospital OR. Your discussion of antiresorptive therapy is spot-on with regards to it being a last resort option. We are seeing marked increase in patients on bisphosphonates and other antiresportives, mostly due to osteoporosis. We see relatively rare complications (BRONJ and increasingly called MRONJ, primarily with the use of Prolia). These patients usually need antiresorptive therapy due to delayed preventive and management of the early stages of osteoporosis, however the dental impact (though rare) can be devastating. This usually presents as exposed bone of the maxilla or mandible without a predictable means of surgical management. My preference would be that all patients, but particularly females, would be assessed and managed 1-2 decades early than the current trends to avoid these medications. The half-life of the bisphosphonates is many years and I’m finding many of these patients are later treated with prolia, which can compound complications in the event of spontaneous or surgically exposed bone. Adding other factors, such as xerostomia (medication induced or otherwise), steroid therapy, diabetes, hormonal inbalance, etc… will make patients higher risk as they progress in life and more likely to require oral surgery procedures due to failing dental restorations.

    Avoiding antiresorptives is my preference as someone on the front line of management, but we are often 1-2 decades late in preventing osteoporosis by the time it is addressed.

  6. This was a wonderful episode, and I subscribed because of it! I had hoped there would be more of a discussion on the osteoporosis medications used today. The graphs are helpful, albeit a more difficult thing to navigate..

  7. I see a lot of vibration plates at gyms (like https://powerplate.com/). I’ve always assumed that they were a gimmick.

    Would this be useful for increasing BMD? Do they provide a meaning full value to the user (in this case a fit 48 yr old male)?

  8. Maybe I missed it but what about the relevance of the flexibility or resiliency attribute of bone? Is there a strong correlation with BMD and flexibility of said bone? Not as easy to measure as BMD (DXA) but it certainly must be relevant.

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