[00:00:00.170] – Dr. Gordon
Dietary calcium is a good thing. And it's the calcium supplements that may be associated with an increased risk of colon polyps, not dietary calcium. But here's the big bad news, is when you supplement with calcium and vitamin D and you reduce your risk of fractures. Oh, slight problem. You have an increased risk of heart attacks, atrial fibrillation, and stroke.

 [00:00:29.530] - Intro
You have found your way to the Lemanne Gordon podcast, where Docs Talk Shop. Happy eavesdropping.

 [00:00:44.990] – Dr. Lemanne
I'm Dr. Dawn Lemanne. I treat cancer patients.

 [00:00:48.330] - Dr. Gordon
I'm Dr. Deborah Gordon. I work with aging patients.

 [00:00:52.070] - Dr. Lemanne
We've been in practice a long time.

 [00:00:54.530] - Dr. Gordon
A very long time.

 [00:00:56.130] - Dr. Lemanne
We learn so much talking to each other.

 [00:00:58.340] - Dr. Gordon
We do. What if we let people listen in?

 [00:01:06.150] - Dr. Lemanne
In today's episode, Dr. Gordon shares some of her pearls and pet peeves about bone health, a topic key to aging. Well, we think of bones as solid and inert, but bone tissue is dynamic with constant turnover. Healthy bones require fine tuned nutrition, and that means more than just calcium. A lot more, in fact. Do you know how healthy your bones are? You'll hear today from Dr. Gordon about important tests of bone health. Some of these tests, like bone density scans, you will have heard of. But prepare to be enlightened. You're going to learn about easy blood tests that will give you a three dimensional view of your bone health. That is, you will learn whether your bone is getting stronger or weaker. So grab a pencil. You're going to come away with a list of actions you can take and tests you and your physician can put to good use instantly for brilliant bone healthy.

 [00:02:10.560] - Dr. Gordon
We decided we were going to talk about bones today, and they've just been rumbling around the forefront and the backstage of my mind all week. And then I had just an alarming experience yesterday at lunch. Can I tell you about.

 [00:02:25.440] - Dr. Lemanne
Oh, please, please.

 [00:02:26.940] - Dr. Gordon
Okay. So I was taking my dog for a walk, and I see this guy and I think, oh, my goodness. And it's one of my friends from my high school class, and I've always known he lives in Ashland, but I hardly ever see him. So I chatted him up a little bit and we went for a walk. And he goes, I want to ask you this medical question. Asked me something about his care with his doctor, and I said, excuse me, can I just ask you a question? Was one of your issues? Did you ever get a bone density test? So he's my age, and he's probably a little older, so he's probably like 77, 76. Have you ever had a bone density test from your doctor? He says, no, I asked him about ten years ago, but he said, you don't need it, you're not going to get osteoporosis. And the reason was, he is a man. It's the only thing he offered as explanation that he's not going to get osteoporosis because he's a man. And this is one of my pet peeves for about three reasons, one of them being, obviously, of course, men do get osteoporosis.

 [00:03:36.970] - Dr. Gordon
20% of people with osteoporosis are men.

 [00:03:40.630] - Dr. Lemanne
And 50% of people are men too.

 00:03:43.000] - Dr. Gordon
And 50% of people are men. But 20% of those with osteoporosis are men. So men do get osteoporosis. But here's the thing. Osteopenia is a lot easier to manage than osteoporosis.

 [00:03:56.950] - Dr. Lemanne
What's the difference? So, for our listeners.

 [00:03:58.930] - Dr. Gordon
Oh, that's really good point.

 [00:04:00.370] - Dr. Lemanne
What's the difference between osteopenia and osteoporosis? And why is it better to have osteopenia?

 [00:04:06.470] - Dr. Gordon
Yeah. So just in the common parlance, you have normal bones that are strong and basically resist falls, and your hips don't break when you fall on something. And if your bone quality, density, calcium content just gets a little more feeble and fragile as you get older or for other reasons, your bones get a little bit more fragile, and that's called osteopenia. And then if they get quite fragile, that's called osteoporosis. And it's actually delineated by scores on a bone density test. That's a really easy test that you can get at the hospital. They'll be done before you even know they've started doing it. It's very little radiation, like, bee in my bonnet: Everybody should have a bone density test by the age of 60 at the latest, and probably 50.

 [00:05:08.440] - Dr. Lemanne
Wow. So let me just recap for everyone. Bones have a certain amount of calcium in them if they're healthy. And as they become less healthy, moving toward osteopenia or less bone, I think in medicalese, some of that calcium leaves. Correct. And if a lot of it leaves. And is gone, the bones are lighter, thinner.

That's, at a certain point, defined as osteoporosis, and that's what we're talking about here. Is that right?

 [00:05:35.310] - Dr. Gordon
That is part of it, but it does a little bit. So it really is bone quality. So you could take. There is less calcium, but there's less architecture, less suppleness, less circulation in a bone as it ages and becomes more fragile. So it is assayed by the amount of calcium that shows up in the dexa, which is a little bit like an x ray. But bone quality is more complicated than calcium.

 [00:06:06.790] - Dr. Lemanne
Than just calcium. So other things are happening besides the calcium leaving.

 [00:06:11.670] - Dr. Gordon
Right.

 [00:06:12.140] - Dr. Lemanne
That weaken bones and make them easy to break.

 [00:06:17.100] - Dr. Gordon
Yeah. So it's pretty routine now that when women get to be 70 or 75, I mean, I don't know what makes doctors wait so long. Excuse my ardor on that one, but it is a pet peeve. We should all have bone density tests earlier than that. It's a simple.

 [00:06:33.300] - Dr. Lemanne
When would you recommend getting a bone density test, then, for women? And is it a different age for men?

 [00:06:38.780] - Dr. Gordon
I would say it is conceivably a different age for both people, for both genders. So there is good reason to think about getting a test for women at the age of. …Sit down, everybody, because no one's had it at this age:  40. And I say 40, because you've got your peak bones between 20 and 30 years old, both sexes. And then they do start to start a general decline by the age of 40. And women's decline is precipitous after menopause. But many women have silent menopause in their 40s, number one. And number two, it's really great to know where you're starting from before you start your downhill slope of losing bone quality. And so maybe for men it'd be 50, but really for women, it should be 40.

 [00:07:33.390] - Dr. Lemanne
So the first test, first look at the bone density and bone health should be at 40 for women and maybe 50 for men. What were the three things that concern you about this issue that you're getting a little hot under the collar?

 [00:07:46.750] - Dr. Gordon
Oh, my goodness. Give me my glass of water. So my pet peeve, number two on this issue. So, number one is they don't give men bone density tests..

 [00:07:55.670] - Dr. Lemanne
Number one is the gender disparity issue with this.

 [00:07:59.370] - Dr. Gordon
Right. And one of the things to remember. So here's an interesting factoid about men and osteoporosis. So they are less likely to get. If you take a typical 70 year old woman, she's more likely to have osteopenia or osteoporosis than a man. But say you take your typical 70 year old man and woman, and each of these people does have bone density problems, and each of them falls and breaks their hip. The hazards for the man are twice what they are for the woman, if not, maybe more so … SO in your first year after breaking a hip because of osteoporosis, not because you got thrown off a bull in a bull-fighting competition. But if you break your hip because of osteoporosis, you have a five-fold to eight-fold increase in your chance of death in the next year.

 [00:08:57.130] - Dr. Lemanne
Okay. And that's higher for men than.

 [00:08:59.760] - Dr. Gordon
Way higher for men. So, yeah, they have less chance of having it, but they have more of.
[00:09:05.250] - Dr. Lemanne
A problem if they do have it. It's the worst outcome.

 [00:09:08.280] - Dr. Gordon
The worst outcome. So my second pet peeve is if you have a bone density test, and I had a bone, I think I told you this story. I had a bone density test a year ago, and first of all, they read it wrong. They read it as osteopenia, and I still had normal bones, which is, whoa, hallelujah. How'd that happen? But they read it as osteopenia. And so I read a little more carefully what the report says. It says, make sure you have adequate calcium and vitamin D, exercise 30 minutes, three times a week, stop smoking, and avoid heavy alcohol. And what? Those are terrible recommendations.

 [00:09:49.870] - Dr. Lemanne
Wait. We should all sit down and not exercise. We should not make sure we don't take any vitamin D and calcium. And we should drink and smoke.

 [00:10:01.390] - Dr. Gordon
We should drink little or not at all. We should not smoke. We should exercise, but with more detail. But here's the thing about calcium, and one of the issues I learned about calcium, I actually had a question for you about. So in the past, those recommendations just used to say, have more calcium. And now they say, have more calcium and have it with vitamin D. And if you take calcium and vitamin D together, they do marginally reduce total fractures. But they, number one, actually don't reduce hip fractures. And they have just a few side effects, like they increase the risk of kidney stones. You can imagine that more calcium going through your body, but this is the one I wanted to ask you. They increase the risk of colon polyps.

 [00:10:49.460] - Dr. Lemanne
Oh, really? That's really interesting. I'm not familiar with that. I've seen some interesting studies suggesting, actually the opposite, that calcium intake is associated with a decreased risk of colon polyps. And that includes dairy calcium. But that's really interesting. I'd love to see that. We'll put these controversies in the show notes. Yeah, that's good. I'm familiar with the idea that it may be important, especially for women, to take some magnesium with their calcium.

 [00:11:18.930] - Dr. Gordon
Oh, that you're getting to my pet peeve number three. But let me just finish pet peeve number two, because the truth, what it comes out to for colon polyps, and it also affects the next category. I'm going to say dietary calcium is a good thing, and it's the calcium supplements that may be associated with an increased risk of colon polyps, not dietary calcium. But here's the big bad news, is when you supplement with calcium and vitamin D and you reduce your risk of fractures. Oh, slight problem. You have an increased risk of heart attacks, atrial fibrillation and stroke.

 [00:12:00.630] - Dr. Lemanne
So something bad is happening with that calcium as well as the good part of helping the bone. Yeah, tell us about that. I think I know where you're going with this.

 [00:12:11.290] - Dr. Gordon
Well, it a little bit gets to my pet peeve number three, which is the medical research proceeds, really, by studying one thing at a time. So they study calcium and they enlarge their purview to study calcium and vitamin D together and kind of scratch their heads that it didn't seem to be the great panacea that they thought it would be. But if you understand how the body works, it gets around to Vitamin K2

 [00:12:42.850] - Dr. Lemanne
Well, I kind of thought you were going to go there. Tell us about K2. K1 is the, you know, people do know about K1, especially if they're on Coumadin (warfarin) for clotting issues of some sort, because it's found in leafy green vegetables as k1, and it can interfere with the action of Coumadin. In fact, it does, because Coumadin is built to interfere with that, with K1.

 [00:13:08.970] - Dr. Gordon
One, which also has to do with improving bone density. So Coumadin is one of the drugs, along with steroids and proton pump inhibitors, that increase your risk of osteoporosis.

 [00:13:20.500] - Dr. Lemanne
Okay.

 [00:13:23.410] - Dr. Gordon
Other than K1, I mean, I never heard about K2 until about, I think, about a dozen years ago.

 [00:13:29.670] - Dr. Lemanne
I think that's about the same for me.

 [00:13:31.720] - Dr. Gordon
Yeah, we didn't hear about it in.

 [00:13:33.510] - Dr. Lemanne
Medical school, but that was a dozen years ago, wasn't it?

 [00:13:37.590] - Dr. Gordon
Maybe a few more. I do remember where I heard about it, it was from the Weston Price foundation, which is an interesting nutritional resource with complicated other issues. But Vitamin K2, what's not to like about it? It keeps your arteries supple and soft. It can help normalize blood pressure.

 [00:13:58.010] - Dr. Lemanne
Well, tell our audience what K2 does, how it interacts with calcium.

 [00:14:03.550] - Dr. Gordon
So it's a very complicated dance between calcium, your bone metabolism, K1 and K2, which gets to another sort of interesting feature. So I think it's probably pretty well understood that from the time we start using our bones until the time we're done with them, they are constantly remodeling themselves. So today, your bones are taking themselves apart a little bit and also saying, oh, they're taking themselves apart by saying, oh, this part of the bones network framework doesn't look so healthy. Let's take it down and enable you to make stronger bones the next day.

 [00:14:50.620] - Dr. Lemanne
So the bones are a dynamic tissue. They're continually reconstituting themselves. There are blood vessels flowing through the bones. The bones are taking up nutrients. They're giving off waste products. The body is continuously responding to stresses on the bones, making the bones stronger. Or if there is not enough stress, then the bones will get weaker, those kinds of things. And I just want to make sure that our listeners understand what a dynamic living tissue bones are. They're not just these hard, inert skeletal structures that hold things up and nothing else happens in them. They're living, and they're literally breathing and giving off products that need to be carted away. And you need to have a good blood supply to your bones. You need to have a good hormone system to give the right signals to your bones. Yeah, it's a really complicated system.

 [00:15:48.460] - Dr. Gordon
That is absolutely true. And I think if you ask people, they'll sort of know, yes, I know that. But to really grasp it, and it always makes me think, every time I start talking about this, I think of, and, Tom (our sound engineer), you're going to have to chime in if Dr. Lemanne and I can't come up with the answer. But wasn't there a Paul Simon song about Hearts and Bones? Tom, everybody's scratching their head.

 [00:16:18.380] - Dr. Lemanne
I only know about Rosemary and Thyme.

 [00:16:21.020] - Dr. Gordon
Yes. No, but I think it's Paul Simon song about Hearts and Bones. Hearts and bones. But I could have totally edited that, because in my mind, if you want to live a long life that's vigorous and vital, you have to take good care of your brain, your heart, and your bones.

 [00:16:38.890] - Dr. Lemanne
Well, you certainly don't want calcium in your brain or your heart, but you do want it in your bones. You have to direct things. I think of the vitamin K's, especially K2, as directors, directing the calcium from the bloodstream into the bones so that it's not available to kind of leach out into the heart or the heart vessels and things like that and get into mischief in places that it's not supposed to be.

 [00:17:04.260] - Dr. Gordon
Yeah, exactly. And I think that is the first way I have always thought of it, that it directs calcium, but I've learned recently that it is also essential. So there's three vitamin K's I'm going to talk about.

 [00:17:18.830] - Dr. Lemanne
Okay.

 [00:17:19.950] - Dr. Gordon
They have varying activities at both sides of the bone equation. So they are also essential to bone maintenance. To not be overdoing bone demineralization, you need several factors. And all the vitamin K's participate in that as they do participate in the bone rebuilding. And, yeah, the three K's are the one you already mentioned K1, which is most well known for its role in blood coagulation.

 [00:17:49.410] - Dr. Lemanne
And that's obtained in the diet, correct?

 [00:17:52.170] - Dr. Gordon
Yes, largely. But, gee, did you know that there was a comment and one article I read, that even in a healthy American diet, you can be deficient in K1 and K2 because it's in what you said it's in green vegetables.

 [00:18:06.950] - Dr. Lemanne
And that's not a big component.

 [00:18:08.510] - Dr. Gordon
Not always. Yeah, not always. And there are actually. Are you holding on to your hat? Two K2’s.

 [00:18:14.490] - Dr. Lemanne
 Oh, my goodness. Okay. Oh, I think I do know where you're going with that.

 [00:18:20.110] - Dr. Gordon
You do know. So the one that's been—

 18:22          Dr. Lemanne                
MK4 and MK7. 

 [00:18:25.040] - Dr. Gordon
Right…So the one that's been best known over this decade or two that you and I may have heard about Vitamin K2 is MK7. And it's been celebrated because it is more enduring. If you take a capsule of MK7 and don't take one for three or four days, you'll still have some in your bloodstream. It is still doing its job. So it's a more persistent K2. So we've all emphasized, I've recommended supplements that had just K2 as MK7, but I've come to learn two things about K2 as MK7. It is more essential in the bone building process. It can be given in higher doses. And if you take too much of MK7, you tend to have a higher incidence of rapid heartbeat, including atrial fibrillation. And. Oh, my goodness, what are we seeing huge surges in these days?

 [00:19:26.090] - Dr. Lemanne
Here we are. Yeah.

 [00:19:27.140] - Dr. Gordon
Atrial fibrillation.

 [00:19:28.870] - Dr. Lemanne
So one of them is from a fungal source, right, mushrooms. And another is from the animal source, like high fat dairy, things like that.

 [00:19:37.360] - Dr. Gordon
So I think of all the K2’s as coming from fermented food.

 [00:19:42.920] - Dr. Lemanne
You do?

 [00:19:43.660] - Dr. Gordon
Oh, yes. So cheese is high in K1. So that's an interesting point. Is one of them more? And if the one comes from animal, what part of animal? The fat. Well, that would make sense.

 [00:19:57.250] - Dr. Lemanne
It's fat soluble. So those are my understanding. And I believe the MK4 is the animal version. But I will look that up and we'll put that in our show notes. It's an interesting topic. I've often recommended that over MK7 if I have a chance, just because it seems to be more available to mammals. (See HERE for dietary sources of MK4 and MK7 versions of K2)

 [00:20:18.690] - Dr. Gordon
Which one? ( The MK4.) Right. Well, it is safer to take in high doses. Just as an aside, have you noticed yourself recently in your conversations with your patients, accidentally saying to them, don't worry about that. I'll put that in your show notes for today.

 [00:20:33.690] - Dr. Lemanne
Not yet, but I will let you know. Is that coming up for me?

 [00:20:38.670] - Dr. Gordon
It's coming up for you.

 [00:20:39.870] - Dr. Lemanne
Okay.

 [00:20:42.750] - Dr. Gordon
I say chart notes. Chart notes. No, I mean your chart notes, because I write down more after the fact than I do when I'm talking to people. But this knowledge about all three forms of vitamin K, which make it safe for you to take calcium and d together, gets to my final pet peeve in this. And I alluded to it earlier, which is nothing works in isolation.

 [00:21:11.130] - Dr. Lemanne
And you, have you noticed that in your practice?

 [00:21:16.170] - Dr. Gordon
Gee, how about if we just give you melatonin at night? That'll fix all your sleep problems.

 [00:21:22.730] - Dr. Lemanne
Yeah, just that one silver bullet fix idea. Yeah, that kind of drives me nuts.

 [00:21:29.930] - Dr. Gordon
And drives me nuts, but it is how, and I appreciate that the research that is done on single element factors that. Okay, let's just look at Calcium and Vitamin D, which is actually two more than most people usually include in a study. But the fact that it was hazardous is only because the physiology wasn't recognized. I'm sure the doctors that did the study were wiser than I was about vitamin K abd knew that it played a role, but couldn't put in a third parameter, especially if it was about dietary recall. We could get that onto that pet peeve as an entire episode. How dietary recall studies should be banned from the face of the earth, right?

 [00:22:18.960] - Dr. Lemanne
Oh, I think that would be probably an improvement, my pet peeve. I think we approach medical research like a physics experiment. You change one parameter, change the weight of the pendulum, and see how that changes the excursion of the swing and those kinds of things. But that only works with non-complex dynamical systems. When you have a complex dynamical system that has many, many inputs and outflows. They adjust right away when you perturb them. And so just a single perturbation is unlikely to give you a lot of information in a human or biological system.

 [00:23:01.710] - Dr. Gordon
Absolutely. We are way too complex for that. It's never a simple fix to anything. And the list of contributors that can help. Well, I actually want to say one more interesting thing about bones before I move on to, I want to go over the list of contributors that can help you keep healthy bones, because I've learned a little bit--something new--about each one recently. There is a pair of blood tests, which I think have been around for ages and why I was never taught them when I was in medical school, I don't know. But there is a test that measures your rate of bone demineralization and another lab test that measures your rate of bone remineralization.

[00:23:46.370] - Dr. Lemanne
Very cool. That sounds quite useful. Go ahead.

 [00:23:49.100] - Dr. Gordon
Yeah. So CTX, proper name c telopeptide, measures your rate of bone demineralization. And in an ideal world, your number is less than 150. And I have had one patient whose number was less than 150. You get a little nervous when it goes over 250, really nervous when it goes over 350. And I think the highest I've seen is about 800. So that person was really demineralizing. Pro collagen-one-peptide (P1NP) is the measure of bone remineralization. And that number, you're in heaven if it's over 75. And I have seen that a few times, 50 to 75 is kind of like my healthier patients. And that is pretty good bone remineralization. But below that, and particularly below 25 is getting into the scary zone.

 [00:24:45.910] - Dr. Lemanne
Oh, my goodness. So I'm assuming that the numbers don't necessarily match up one to one, but you want the demineralization and remineralization to be about the same in real amounts, isn't that right?

 [00:24:58.420] - Dr. Gordon
Well, you're going to always get more. Well, just because of how they measure it, the demineralization number is always going to be higher, but it's really those cut offs that matter, because if you.

 [00:25:11.570] - Dr. Lemanne
I meant the actual process, not the actual, not the.

 [00:25:14.050] - Dr. Gordon
Oh, yes, right. The process.

 [00:25:16.520] - Dr. Lemanne
You want to balance there. I presume. If you're a child, you probably want it to know more mineralization.

 [00:25:23.430] - Dr. Gordon
Exactly. And frankly, what my expert on bone health, Dr. Keith McCormick, who we'll give a shout out to and put a link to his excellent books in the show notes. If you want to keep your bones the same, it's a fool's errand. Once you pass the age of 40, your bones are going to lose density. You just want to do the best job you can minimizing that loss. So it's always going to be more process of demineralization, and you want to slow that. Exactly. And you want to slow that down and you approach each one differently. And if you want to prevent faster demineralization, one of the subjects we've talked about before, hormones and all of the gender hormones really help maintain your bone density. So a woman on estrogen replacement therapy will have estradiol, a menopausal woman will have estrone. Everybody in the world has testosterone. All three of those help, and all three of those can be tweaked in different ways and with different substitutions. But vitamin D and all these three vitamin K's help maintain bone density and one of our favorite supplements. And you and I have both talked about, I think we had a podcast episode about creatine.

 [00:27:02.570] - Dr. Lemanne
We did.

 [00:27:03.370] - Dr. Gordon
Right. So creatine is really the most magical single ingredient when it comes to bones.

 [00:27:11.310] - Speaker 3
That's a strong term.

 [00:27:12.990] - Dr. Gordon
I know that's probably overstating it.

 [00:27:17.450] - Dr. Lemanne
I'm a big creatine fan.

 [00:27:19.220] - Dr. Gordon
Yeah.

 [00:27:19.920] - Dr. Lemanne
So I can believe in magic.

 [00:27:21.590] - Dr. Gordon
Right?

 [00:27:21.870] - Dr. Lemanne
When it comes to creatine. Go ahead.

 [00:27:23.380] - Dr. Gordon
So I think I have thought of. 

[00:27:25.330] - Dr. Lemanne
It as pretty close to magic anyway.

 [00:27:27.440] - Dr. Gordon
Pretty close to magic. I've thought of it as contributory to bone remineralization because it strengthens muscle and muscle strengthens bone. But I've learned recently. Thank you, Dr. McCormick. And thank you, pubmed. It also reduces the rate of bone demineralizing.

 [00:27:47.450] - Dr. Lemanne
So creatine works on both of those blood tests?

 [00:27:50.250] - Dr. Gordon
Yes. And it does one more thing for your bones.

 [00:27:55.450] - Dr. Lemanne
Oh, I'm all ears.

 [00:27:56.870] - Dr. Gordon
It reduces the risk and severity of falls.

 [00:28:02.650] - Dr. Lemanne
Interesting. So that's not directly related to bones, but it's directly related to your muscular health. So are you going to talk to us? I hope. Please talk to us about muscles and bones.

 [00:28:15.310] - Dr. Gordon
Right. That song should be muscles and bones, not heart, but heart muscle. Right. I do want to say separate from rebuilding muscle strength, creatine like vitamin D, in sort of different ways. But vitamin D seems to, if you overdo it, increase your risk of falling. How does that make sense? But creatine reduces your risk of falling separate from its effect on mineral, on muscle strength. So as much as that could be isolated, because that's what medical research loves to do, it was isolated, and I thought that was pretty interesting. But you're right. Number one focusing point for people who want to keep their muscles and bones as healthy as possible is a lot more protein than you thought you needed.

 [00:29:04.720] - Dr. Lemanne
Really? Okay. But that's aiming for the muscles.

 [00:29:08.440] - Dr. Gordon
That is aiming for the muscles. But the protein constituents also go into the bone. Protein drives the enzymes and the process of rebuilding the bone, even if it doesn't become the bone material itself.

[00:29:31.620] - Dr. Lemanne
I see. Well, enzymes are made out of amino acids.

 [00:29:34.930] - Dr. Gordon
Proteins. Proteins.

 [00:29:36.630] - Dr. Lemanne
All right, well, that's really fascinating. So if I have healthy muscles and I'm really strong and athletic, I do not have to worry about osteoporosis or osteopenia is that right?

 [00:29:46.270] - Dr. Gordon
Unfortunately not. What we have just scratched the surface of how complicated these little critters are that we call our bones. Did you know that? One of the elements that we learned about long ago in medicine, but we don't do too much with because it's hard to measure, is the mineral magnesium okay? Right?

 [00:30:16.370] - Dr. Lemanne
Yeah, it's hard to measure it. You can measure red blood cell magnesium, or you can just measure magnesium in the liquid part of the blood, but.

 [00:30:23.260] - Dr. Gordon
Most of the magnesium is not in the liquid part of the blood. And I believe it's like amino acids, where the liquid part of the blood is the most regulated by the body pool of magnesium. So you could have that. If you're deficient in your liquid part of your blood, the serum or plasma, you are certainly magnesium deficient.

 [00:30:43.170] - Dr. Lemanne
You're in trouble, right.

 [00:30:45.170] - Dr. Gordon
But a huge portion of the body magnesium is actually in the bone as part of the bony matrix. So it is important to have enough magnesium, too. So that's been one of my attention points recently, and I noticed that anyone who's constipated has learned the use of magnesium. Anybody who has muscle cramps has learned the use of magnesium. Side note, I recommend topical magnesium for that, for the muscle cramps, for the muscle cramps, but routinely, they might have it in their multivitamin, but many people don't know to supplement with magnesium. And it helps not only your bone density, but it helps your sugar handling, in general, your insulin resistance. And it's key to the process of building the bone like protein. It functions in the enzymes that help you build bones. So people need to take magnesium.

 [00:31:42.130] - Dr. Lemanne
Can we go back to the idea that I'm still stuck on this, that someone who is really, really strong and has wonderful muscles could still have a problem with the bones? And how did that happen, and what do you do about it? What can be done?

 [00:31:58.230] - Dr. Gordon
So, to be clear, that if it is a generally healthy person and they're actually, literally, their muscles are strong, you're probably right almost all the time. They probably are doing enough kind of over the top muscle building to keep good bones. But if that person has asthma and uses a steroid inhaler, if they have heartburn and use a proton pump inhibitor, if they have gluten intolerance and they can't really absorb their calcium, they could have a deficiency in their bone density from something pharmacological that has nothing to do with their wonderful lifestyle.

 [00:32:50.310] - Dr. Lemanne
I see. So I understand about the last two the proton pump inhibitors and what was the drug you'd mentioned just before that.

 [00:32:59.600] - Dr. Gordon
Steroids.

[00:33:00.450] - Dr. Lemanne
Steroids. I can understand how proton pump inhibitors would decrease your absorption of calcium by changing the ph of the stomach and the intestine beyond, et cetera. How do steroids interact with the bones? Do we even know that?  

 [00:33:14.100] - Dr. Gordon
I'm not sure. We know that it is such a.

 [00:33:17.420] - Dr. Lemanne
Strong predictor of osteoporosis as long term steroid use.

 [00:33:20.920] - Dr. Gordon
Yeah. So we will have to look into that and get that answer for our listeners.

 [00:33:26.570] - Dr. Lemanne
Mechanism of that.

 [00:33:27.880] - Dr. Gordon
I don't know the mechanism either. That's not a complete list. The other thing could. There are medical conditions that interfere with your body's ability to keep your bones healthy. Autoimmune disease, okay. Is a big risk.

 [00:33:48.160] - Dr. Lemanne
And not because of the medications people take for that.

 [00:33:50.460] - Dr. Gordon
Exactly. Just the autoimmunity. 

[00:33:52.020] - Dr. Lemanne
Just the autoimmunity itself.

 [00:33:53.320] - Dr. Gordon
So the inflammation. Yeah.

 [00:33:55.050] - Dr. Lemanne
Okay. And gluten. Gluten enteropathy makes it difficult to absorb calcium. 

[00:34:00.130] - Dr. Gordon
Yes. Intestinal problems with gluten come at two stages, and one of them is non celiac gluten sensitivity. And you really have to convince those people to try. So, I suspect it with anyone who's got an autoimmune disease or anybody who would have osteoporosis. And I really say six weeks, absolutely no gluten, be 100% pure and then have a lot of it for three days to convince them that they do have gluten intolerance. But people with outright celiac, they already know they have it because it's a miserable experience to eat gluten if you actually have celiac enteropathy.

 [00:34:36.540] - Dr. Lemanne
Sure.

 [00:34:41.210] - Dr. Gordon
A clue for it. So if I see somebody who has osteopenia and iron deficiency, especially in a woman who's older and no longer menstruating, I think gluten sensitivity, because zinc, iron, B12 and calcium are all absorbed by similar mechanisms in the small and similar locations in the small intestine that can be damaged by gluten.

 [00:35:06.470] - Dr. Lemanne
Okay, so what kinds of exercise would a person who wants to protect their bone density or someone who has bone density problems want to do? I understand that things like swimming and bicycling may not be the ideal way to approach this, although they're wonderful forms.

 [00:35:28.670] - Dr. Gordon
Of exercise, but for bones and even running. So my osteoporosis colleague, Dr. McCormick, was a 45 year old healthy, highly competitive runner who sustained pathological fractures. So he had a congenital problem with his bone density. But if you had looked at him, you would have said, he's fit and strong, okay, he's tall. That's a slightly increased risk for loss of bone mineral density.

 [00:35:57.240] - Dr. Lemanne
Oh, really? Okay. But tall people kind of have the short end of the stick in terms of health in some ways, don't they?

 [00:36:04.390] - Dr. Gordon
Yes, but as we talked about, we get into medical school more often. So you know what? I am going to ask you to talk when I ask people if they're doing resistance exercise. So the short answer is resistance exercise 

[00:36:21.810] - Dr. Lemanne
Which means weightlifting, weightlifting.

 [00:36:24.160] - Dr. Gordon
But if I'm lifting weights, most of the weight lifting I like to do is actually. So there's two points about weightlifting. It has to be upper body and lower body, and it has to be progressively heavy weight. So people say, oh, yeah. And they show me their little five pound.

 [00:36:40.890] - Dr. Lemanne
Oh, those pastel dumbbells. Yes, those drive me nuts.

 [00:36:44.220] - Dr. Gordon
And I said, that's really great for increasing your range of motion with a little bit of resistance.

 [00:36:49.560] - Dr. Lemanne
That's very diplomatic of you.

 [00:36:52.470] - Dr. Gordon
But even bands are a lot better than that because you can get progressively stretched out bands that give you greater resistance.

 [00:37:04.550] - Dr. Lemanne
When I see someone like you who's very athletic using bands, it's a thing of beauty, and you can see all the various exercises and good form and all of that. But when I see someone who doesn't exercise pick up a band, I just cringe.

 [00:37:18.570] - Dr. Gordon
Oh, really?

 [00:37:19.250] - Dr. Lemanne
Yeah. I think it's a difficult way to exercise for someone who's not familiar with good form and types of motions, extension, flexion, range of motion, those kinds of things. So I'm not a big fan of bands unless someone's pretty advanced in their activities.

 [00:37:37.530] - Dr. Gordon
Right. Or coached.

 [00:37:38.510] - Dr. Lemanne
Or coached. Yes, coach, standing there. One reason that I say that is that I have smacked myself in the face too many times with these giant rubber bands. I am in that class that bands are not, maybe not my first.

[00:38:03.610] - Dr. Gordon
I think if not done that, I've done something like that. You just have to consider that a pebble on the road. Right. Keep going. But the question about resistance exercise. So the hardest part, I think, is for people to exercise the muscles that strengthen their hips so their quads, their glutes, their hamstrings.

 [00:38:27.340] - Dr. Lemanne
If somebody's not 

Dr. Lemanne
So everything that attaches somewhere in the pelvis.

 [00:38:30.910] - Dr. Gordon
Right. So if somebody's not doing in a gym where they can do deadlifts or use that sled machine where you push heavy weights uphill, what would you recommend to somebody for strengthening the muscles around their pelvis?

 [00:38:45.310] - Dr. Lemanne
Yeah. So that's a really good question. I am a big one for getting a trainer. If you're not familiar with exercise in a deep way, and I agree with you. I would concentrate on the muscles that cross from the femur, the thigh bone to the pelvis in all parts of that. So squats are a beautiful exercise. I think things like plyometrics, which is jumps from a deep position, like a squat jump, those kinds of things. Jumping rope, I think, are really good ways to get some stress on the muscles and the bones in the legs and also the spine a little bit. The spine seems a little bit more problematic to me. I've looked into something called Osteostrong a little bit, and I'm by no means an expert in it, but that looks pretty interesting. And I think if I had osteopenia or osteoporosis, I would be visiting them and checking that out to see if that might be something. Do you know much about that?

 [00:39:50.480] - Dr. Gordon
Well, I have patients who've been there, and I do only have one patient of maybe ten or 20 who've been there who actually had an injury from being a little too over exuberant. But in general, they watch over you very well. It's highly efficient, it's slightly expensive, so maybe you are motivated to actually keep going with your monthly subscription and go every week as you're supposed to. It's very time efficient. So I think it is a great system for people who don't want to get into the gym.

 [00:40:22.290] - Dr. Lemanne
So it's 15 minutes once a week, right? Yeah, that's pretty wonderful. And you can target the spine, which I think is a little bit difficult for some people to target, I think. Yeah. With their.

 [00:40:33.180] - Dr. Gordon
Yes. Two thoughts around all this. I like all your comments about the muscles that are crossing the hip and a trainer. And one other thing I just thought of is I suggest to people, because I have a lot of patients who go up into the hills around where we live, and some of them who are even-- I'm so excited to see this gentleman's bone density test when I get it back. He's in his 50s. He's a cyclist. Ooh, bad news. If you ask him how much he cycles, he says, well, last week I did 40,000ft in elevation. He only measures his bicycling by his elevation gain. So I'm thinking, oh, maybe my really sturdy hikers and elevation backcountry cyclists are building up their hips. And I've thought, particularly listening to a discussion on Dr. Peter Attia's podcast about carrying a weight on your back. And I suspect that if you carry a weighted fanny pack, it would help your hip joints. And if you carry a weighted backpack. It would help your spine.

 [00:41:41.740] - Dr. Lemanne
So being an undergraduate biophysics major…

 [00:41:46.930] - Dr. Gordon
Wow.

 [00:41:47.720] - Dr. Lemanne
Yeah. Anything above, wherever you put it, is going to affect everything below. So the back pack will help the hips, too.

 [00:41:56.260] – Dr. Gordon
Oh, that's good.

 [00:41:57.060] - Dr. Lemanne
You'd have to have something on the shoulders. Probably the best thing would be to put it on your head.

 [00:42:05.530] - Dr. Gordon
Okay, let me work on that turban for you. Let me put a shout out to another reference that I think people might enjoy.

 [00:42:16.640] - Dr. Lemanne
I think you might be onto something. Deborah.

 [00:42:19.770] - Dr. Gordon
Turban for bone density. Yeah. There's a woman named Stacey Sims who I believe is from South Africa, who's a research physiologist specializing in lifestyle and exercise, specifically recommendations for older women. And she has a book whose name is escaping me now because I keep thinking of what she essentially has as a subtitle for it, which is lift heavy S-H-I-T. Lift heavy. Shit is Stacey Sims phrase that she repeats all the time. But one of the things she says in her book, speaking about spine strengthening, is when we were young, we all do a bunch of sit ups, and she specifically advises menopausal and older women not to do sit ups, but to get double the benefit from doing various forms of planks. Do you do planks?

 [00:43:19.390] - Dr. Lemanne
Yeah.

 [00:43:20.300] - Dr. Gordon
Do you do side planks as well as front planks?

[00:43:22.950] - Dr. Lemanne
I do.

 [00:43:26.450] - Dr. Gordon
I'm going to just share with our audience a little bit that Dr. Lemanne is an incredible, accomplished fitness person. And as an.

 [00:43:37.830] - Dr. Lemanne
I show up at the gym.

 [00:43:39.520] - Dr. Gordon
Exactly.

 [00:43:40.220] - Dr. Lemanne
It's pretty ugly, no?

 [00:43:42.260] - Dr. Gordon
How long can you hang by your hands?

 [00:43:46.250] - Dr. Lemanne
As long as I want to.

 [00:43:49.850] - Dr. Gordon
I invite our listeners, if you have not tried that, I want you to try it. And remember that Dr. Lemanne says she could do it for as long as she wants to.

 [00:44:00.580] - Dr. Lemanne
Well, I haven't really wanted to terribly long, but let's say a minute. A little over a minute. Okay. I've gone that far.

 [00:44:09.100] - Dr. Gordon
I think I'm up. I used to be up closer to a minute, never up to a minute, but I'm down to about 20 seconds now. But I thought of you the other day when I did it. Oh, how does she do that?

 [00:44:19.510] - Dr. Lemanne
Oh, my goodness. Hey.

 [00:44:21.090] - Dr. Gordon
I have two other little.

 [00:44:22.340] - Dr. Lemanne
So I have no illusions that I'm any kind of accomplished athlete. I have done a few things in life, and being an athlete, an accomplished athlete, is not one of them.

 [00:44:34.500] - Dr. Gordon
Well, I think if you're an accomplished.

 [00:44:35.980] - Dr. Lemanne
Thank you.

 [00:44:36.520] - Dr. Gordon
Accomplished gym.

 [00:44:38.090] - Dr. Lemanne
I'm an attendee. Yes, but you do it. I do accomplish getting to the gym. 

[00:44:43.200] - Dr. Gordon
I wanted to add. There's a whole list of other supplements I could talk about for the bone, but there's two that I've learned something about recently, that everything in this bone armamentarian is stuff that I recommend people take on a regular basis anyway. But one of them touches on a subject that you and I have discussed, and I've never even thought of it as related to bone health before, but it's really important to take B vitamins. And what I've learned recently about B vitamins role in bone health is if you do not take B vitamins, you get a high level of homocysteine in your blood. And homocysteine contributes to demineralization, low quality of bone mass, low quality of collagen, and impaired remineralizing of the bone.

 [00:45:44.150] - Dr. Lemanne
Oh my goodness.

 [00:45:45.220] - Dr. Gordon
So homocysteine.

 [00:45:47.630] - Dr. Lemanne
So you want that nice and low.

 [00:45:49.300] - Dr. Gordon
You want that nice and low. And for my brain patients, I like it between five and seven and a half. And for the general public, if it goes up to ten or eleven, it's probably still fine, but you want to keep it lower than that. And while you're on the path to doing it, there is a supplement that is one of the longevity promoted supplements that really helps with the calcium regulation and the use of vitamin K when you have high a homocysteine. Long introductory to the applause for Taurine.

 [00:46:24.080] - Dr Lemanne
Oh, okay.  I was not aware of Taurine. I thought you were going to say trimethylglycine. I did. And the reason is that I have sent you patients for your expertise with high homocysteine. I've sent you patients with high homocysteine and you are able to bring down their homocysteine. And one of the things that you've used in a patient that I'm thinking of right now is trimethylglycine, for that worked beautifully.

 [00:46:53.290] - Dr. Gordon
That's great. And it depends on their genetics. There's about half a dozen tricks. And then with homocysteine, we have something that we say in the brain community because it's harder to get it down to seven and a half. So we call it a Hail Mary when we give people just lots of glycine and N-acetylcysteine, just lots of it. Three to 4 grams each.

 [00:47:15.370] - Dr. Lemanne
Each. So Nacetylcysteine is NAC is something that will help with homocysteine levels in the.

 [00:47:21.980] - Dr. Gordon
Presence of glycine, sufficient glycine.

 [00:47:23.700] - Dr. Lemanne
Glycine. So you have to combine them. 

[00:47:25.520] - Dr. Gordon
And, you know, if you test what.

 [00:47:26.780] - Dr. Lemanne
What are the doses that you've had success.

 [00:47:28.400] - Dr. Gordon
With in that three to 4000 milligrams.

 [00:47:32.230] - Dr. Lemanne
Of which both. Oh, okay. So three to 4000 milligrams a day of trimethylglycine and of NAC.

 [00:47:40.770] - Dr. Gordon
Of glycine? Of glycine.

 [00:47:43.370] - Dr. Lemanne
Okay.

 [00:47:44.050] - Dr. Gordon
So trimethylglycine is great because it's a little capsule. You can take it and it works efficiently for some people, but when it doesn't, the Hail Mary, I hope that's not offensive to anybody, is 3-4000 milligrams. And interestingly so there are a couple of tests I do with my patients that nicely. Medicare covers for my Medicare patients that evaluate what your amino acid deficiency is. And we ask people to stop supplements for a day or two before they take their test. And always the most deficient--And they don't do it by levels on this test. They do it by how this amino acid or how this B vitamin is supposed to function in the body and is it doing what it's supposed to do. Our most prevalent amino acid deficiency is glycine.

 [00:48:34.750] - Dr. Lemanne
Interesting. Okay. And that's the most common one in foods and in our bodies, correct?

 [00:48:39.670] - Dr. Gordon
I don't know that it's the most common one in our bodies. And I think of it as it's in foods that not everybody eats. So it's present in a lot of foods. But to get a sufficient quantity of it, I think you need to eat a lot of animal foods and specifically the connective tissue or the bone broth. Okay, that's a good question. Where does it come in foods? I just know what part of the supplement aisle it comes in.

 [00:49:06.590] - Dr. Lemanne
Well, I feel a little better because you know so much and there's something you don't know. Okay. I don't know where this is on the supplement aisle. Okay, I better figure that out. I mail order my glycine.

 [00:49:23.730] - Dr. Gordon
And the other supplement that I just want to refer to because it shouldn't be forgotten. When we're talking about brains and bones and hearts are Omega-3’s. And omega three s are interesting. So they're in fish and fish oil. And I recommend most people, if you eat enough fish to get a high level of omega-3’s, you're probably also getting a high level of mercury. So in general, I think fish oil is a really good supplement. And the omega-3’s do really help with bone metabolism. And they actually also help reduce fracture risk. So they increase bone density and reduce fracture risk. Great. Like creatine. Almost as good as creatine, but it works the best if you also eat some dietary Omega-6’s.

 [00:50:08.130] - Dr. Lemanne
So relying on supplements alone is just not the way to go for almost everything.

 [00:50:13.750] - Dr. Gordon
Yeah. You can't rely on one thing, and you can't rely on food alone, and you can't rely on supplements alone.

 [00:50:19.550] - Dr. Lemanne
Mix it up.

 [00:50:20.380] - Dr. Gordon
So what's your favorite source of dietary Omega-6’s ?

 [00:50:23.370] - Dr. Lemanne
Omega-3’s, you mean?

 [00:50:24.680] - Dr. Gordon
No omega-6’s. You have to have the 6’s with the 3’s to really be good for your bones.

 [00:50:30.480] - Dr. Lemanne
Oh, you know, I avoid Omega-6’s.

 [00:50:32.770] - Dr. Gordon
But I bet you don't.

 00:50:34.160] - Dr. Lemanne
Oh, yeah, you're right. I think I do have some nuts. So I have a little bit of some nuts almost every day, so not a lot, but walnuts, almonds. Today I had some pecans for breakfast, so I guess nuts.

 [00:50:50.750] - Dr. Gordon
So if you talk to a vegetarian and they start complaining to you about the hazardous components of dietary beef, you know, they'll tell you that they're too high in omega-6’s and it's a different omega six. So the omega six s that are most of interest to me are arachidonic acid. And these are just the ones we can easily measure. Arachidonic acid, which comes from some of your favorite foods. Ribeye steak.

 [00:51:17.490] - Dr. Lemanne
Oh, okay, good.

 [00:51:18.920] - Dr. Gordon
They have omega -6’s in it, and if they're raised in a feedlot and eat.

 [00:51:22.170] - Dr. Lemanne
I had that yesterday, so good. Yeah. And I had egg. Now you're going to say eggs. And I had eggs this morning.

 [00:51:27.610] - Dr. Gordon
That'll be arachidonic acid, but it's the linoleic acid that we get from our nuts.

 [00:51:32.080] - Dr. Lemanne
Okay.

 [00:51:32.540] - Dr. Gordon
And both of those are. So it's the full spectrum of omega three s and sixes that are good for our bones. And probably I'm going to find out when I go home: omega 9’s, too, but I'm not aware of that right now.

 [00:51:44.160] - Dr. Lemanne
Oh, I've heard of omega nine s, but I couldn't say anything intelligent about them.

 [00:51:49.730] - Dr. Gordon
Olive oil. Just say olive oil.

 [00:51:51.850] - Dr. Lemanne
Olive oil. Okay.

 [00:51:53.680] - Dr. Gordon
Omega nine. And then I'm going to say one thing that's a repeat and one thing that's sort of fun that I learned and gets around to one of my favorite foods, which includes ribeye steaks. But I'm going to add something else. So I said that all the hormones help with bone density. And for menopausal women, my recommendation is usually that they do hormone replacement therapy and use estradiol. But many people can't--don't—don’t want to do hormones. They are expensive. They're.

 [00:52:26.490] - Dr. Lemanne
Oh, my goodness. You are going to go into one of your unusual animal meat products, aren't you?

 [00:52:34.610] - Dr. Gordon
I'm not but I'm dying to hear what you're going to say. Oh, no, I know what you're going to say.

 [00:52:42.790] - Dr. Lemanne
Go ahead. I'm sorry.

 [00:52:44.950] - Dr. Gordon
So I wanted to say that there are actually two phytoestrogens that are very well acknowledged to have some beneficial effect on bone density.

 [00:52:55.870] - Dr. Lemanne
I thought you were going to say something like placenta.

 [00:52:57.990] - Dr. Gordon
I know.

 [00:53:00.730] - Dr. Lemanne
We're just talking plants here.

 [00:53:02.250] - Dr. Gordon
Okay. So we talked about genistein and genistein is really valuable, and we know that it activates estrogen receptors in the bone and it works that way. Well, one of my favorite food groups, which is terrible to admit, but I've liked it since I was a kid, is a fermented beverage you can make with hops.

 [00:53:23.330] - Dr. Lemanne
Beer.

 [00:53:24.010] - Dr. Gordon
I love beer. Really?

 [00:53:26.850] - Dr. Lemanne
I'm not surprised.

 [00:53:29.170] - Dr. Gordon
I limit myself and there are some good nonalcoholic ones. But hops have such a beneficial effect on the microbiome. They enhance the flora itself and the motility of the gastrointestinal tract and they reduce the severity of osteopenia.

 [00:53:48.030] - Dr. Lemanne
Really? So people who drink beer have strong bones.

 [00:53:51.850] - Dr. Gordon
They might have some other weaknesses since it is a complex picture.

[00:53:56.530] – Dr. Lemanne
Okay.All right. Well, are there any other foods besides beer that have hops as an ingredient?

 [00:54:04.170] - Dr. Gordon
Yeah, I'm not even sure what hops drive. If you take the freeway over, excuse me, to this end of Ashland and look off to the right at the south end of Ashland, there's a field of plants. And it's funny because they're on those big frames, right? Yes, those are hops.

 [00:54:25.070] - Dr. Lemanne
And that's hops. Do you pick them and boil them up? I mean, unless you're going to make beer, what do you do with those?

 [00:54:30.540] - Dr. Gordon
Oh, I think that. Do they do anything with them? Well, there's one other thing they make with hops, and that is in the supplement aisle: Hops tinctures.

 [00:54:39.730] - Dr. Lemanne
Hop tinctures.

 [00:54:40.910] - Dr. Gordon
Okay, so if you don't like beer and you can't tolerate genistein because it's made from soy, well, first of all, you should get the one made from pomegranate, which life extension does. But you can use tincture of hops and have a little bit of phytoestrogen benefit for your bone density.

 [00:54:59.400] - Dr. Lemanne
Beautiful. Well, that's quite a bit. So genistein, pomegranate, hops, or steak and beer? 

 Dr. Gordon
Steak and beer. 

 Dr. Lemanne
Or in the spirit of this talk, all of them plus a few. Oh, Dr. Gordon, thank you so much. Such a well of incredible knowledge and help.

 [00:55:26.900] - Dr. Gordon
Well, thank you for letting me do a little bit of venting.

 [00:55:29.220] – Tom Freeman (Sound Engineer)
I must say, if I may, ladies, chime in.

 [00:55:32.760] - Dr. Gordon
Yes, please.

 [00:55:33.580] – Tom Freeman
Andy , I just want to say I really appreciate today's topic. As a 69 year old man who has been diagnosed with osteopenia, it is great to hear all you had to say. My doctor gave me a couple three recommendations of things to do, and I've come to realize there's a lot more to it than I thought. After listening to you, I now have a much longer list of things I may never get around to…

 [00:56:03.400] - Dr. Gordon
But the beer and the steak 

 Dr. Lemanne
..don't take the beer too seriously!

 [00:56:10.130] – Tom Freeman
One thing I was glad to hear is I needn't fear all of my beer consumption.

 [00:56:15.050] - Dr. Gordon
Just some of it.

 [00:56:15.910] - Dr. Lemanne
Yes, you needn't fear the first half glass.

 [00:56:21.130] - Dr. Gordon
Exactly.

 [00:56:23.290] – Tom Freeman
And you were just very clear, concise, and thorough. And with today's topic, you guys really cut to the bone.

 [00:56:33.870] - Dr. Lemanne
We should end there.

 [00:56:34.900] - Dr. Gordon
We should end there. Thank you.

 [00:56:37.570] - Dr. Lemanne
See you next week.

 [00:56:38.640] - Dr. Gordon
See you next time.

 [00:56:39.740] - Dr. Lemanne
Yeah, bye bye bye.

[00:57:00.180] - Dr. Lemanne
Everything Presented in this podcast is for educational and informational purposes only and should not be construed as medical advice. No doctor patient relationship is established or implied. If you have a health or a medical concern, see a qualified professional promptly.

 [00:57:26.820] - Dr. Gordon
We make no warranty as to the accuracy, adequacy, validity, reliability, or completeness of the information presented in this podcast or found on the podcast website.

 [00:57:38.850] – Dr. Lemanne
We accept no liability for loss or damage of any kind resulting from your use of the podcast or the information presented therein. Your use of any information presented in this podcast is at your own risk.

[00:57:53.470] - Dr. Gordon
Again, if you have any medical concerns, see your own provider or another qualified health professional promptly.

 [00:58:00.240] – Dr. Lemanne
You must not take any action based on information in this podcast without first consulting your own qualified medical professional. Everything on this podcast, including music, dialog, and ideas, is copyrighted by Docs talk.

 [00:58:16.030] - Dr. Gordon
Shop Docs talk Shop is recorded at Freeman Sound Studio in Ashland, Oregon.