Strong to the Core: Bone Health, Menopause & Midlife Strength with Dr. Kristi DeSapri

In this episode of The Body Pod, we’re joined by Dr. Kristi DeSapri, founder of Bone and Body Women’s Health, to dive deep into bone health during perimenopause and menopause. Discover why osteoporosis prevention starts earlier than you think, how hormones and family history influence your bone density, and what women over 40 can do to stay strong.

We cover DEXA scans, bone scores, strength training, calcium, vitamin D, and lifestyle tips for optimal bone health. Walk away with practical strategies to support healthy aging, improve posture, and reduce the risk of fractures—so you can feel strong, confident, and active through midlife and beyond.

Episode Transcript

Speaker 1 (00:00):
Hi.

Speaker 2 (00:00):
Everyone. My name is Haley and this is Laura, and
welcome to the Body Pod. All right, welcome to the
body Pod everyone. We are thrilled to have doctor Christy
Dysaffary on to talk about all things bone health. This

(00:22):
has been such a hot topic and I'm anxious and
just excited to dig into your mind because you're on
the front lines. We are a little bit in a
different way in the trenches, but you are You're the
first line of defense. So first of all, welcome to
the Body Pod.

Speaker 3 (00:42):
Thank you Haley and Laura. I'm so excited to be
here talk to you about what you do and share
what I do so we can reach more women.

Speaker 2 (00:49):
Yes, absolutely, So what inspired you to specialize in bone
health in this midlife women's area.

Speaker 3 (00:58):
Yeah? I love that question because I get it often
when I started my practice Bone and Body Women's health
here in little Little Winnaka, Illinois, which is a suburb
of Chicago, and people often say why bone, like you know,
and now I feel like I don't actually need to
answer why bone, because, like you mentioned, more women care
about what's happening at midlife and menopause and beyond, So

(01:22):
you know, my focus in osteoporosis. Bone health started back
when I was interested in guynecology and menopause and midlife
women's health, starting when I was you know, in college
and medical school, and then went on to do a
fellowship with the Cleveland Clinics specifically focusing on menopause and perimenopause.
And that was before I say it was cool, you know,

(01:43):
I was trendy. You know, I used to you know,
sort of like not want to share what I did,
or it was kind of like, oh, that's a weird focus,
you know, sort of get like a kind of conversation stopper.
But now it's obviously a conversation starter. And I try
to tell, you know, my friend, I get a million
messages and texts from friends about herey, menopause, menopause, and

(02:03):
bone health. So my areas just just sort of, you know,
trickled down from the menopause. And I also just saw women,
you know, who had osteoporosis and they weren't really sure
who to go to, you know, they went to a
roe metologist or an endocrinologist, or they'd had a fracture
and they'd seen an orthopedic surgeon. And I sort of
felt like you know who takes care of osteoporosis, and

(02:24):
some guynecologists did it, and I had some amazing mentors
at the Cleveland Clinic who you know, I got to
learn from, And I thought, this is a really neat field.
It matches you know, clinical you know, we have to
take a good history and talk to women through the
health of their lifespan and health span. But also there's
some science involved with the DEXA scan and with the
you know consideration of meta you know, some labs and

(02:45):
medical work up that we have. So it's really a
nice field. And the people in this field are amazing
as well. I have some great mentors and colleagues, So
it's just been really great. And I think with the
avid of more doctors, clinicians, allied health professionals like you're
cells that you know, want to talk to women about menopause, midlife,
muscle and bone makes my job easier too.

Speaker 1 (03:06):
Well, you've been in this space for a while, then,
how has it most changed from when you started to
right now?

Speaker 3 (03:16):
Yeah? So yeah, I mean I think that the change
has literally been sort of like the sea change of
women educating and you know, sort of advocating more for themselves.
You know, I had a patient even tell me that yesterday.
Sort of like the cart, you know, is the horses
out of the bar. Now for women, we just have
so much more information, we kind of still have to
parse out what's true, what's related, and what's for us,

(03:40):
you know, which is you know, individualized because there's no
one size fits all. We know that in pretty much
every sphere of women's health, right from our hair, skin nails,
to our pregnancy and delivery choices. So, you know, I
think what's changes there's just more options. There's more advocacy obviously,
you know, podcasting, social media, soelebrities money poured into this area.

(04:02):
I mean, I think science is always a little behind, right,
and so we need more research, more interest, more clinicians
to understand, you know, all about you know, what happens
at menopause, in midlife and beyond, so we can all
be on the same page. I think that's really important
and where I think a lot of the discussion is now.

Speaker 2 (04:22):
Yeah, well, I know we've this is a question I'm
sure everyone asks. You know, we know in at least
the United States, it's what sixty two sixty five where
you could get a DEXA scan or when it's recommended
for you to get a DEXA scan. And I think
the message is pretty clear for most women that we've

(04:42):
got to attack this earlier. But can you go over
because I know that the women in perimenopause that still
feel or are almost into per menopause, still feel like
you know, that is light years away. That's like a
world away and it's not going to come up, but
it's a coming. So can you talk about the difference

(05:04):
between the T score and the Z score and what
we need to know with those numbers?

Speaker 3 (05:10):
Okay? Sure? So there was a lot of good questions
tucked in there, So I would start with, you know,
parsing out a little bit about what you said, like
a baseline screening DEXA. So I think, you know, most
of the medical societies, you know, recommend that you get
a women, you know, get a baseline bowmen oral density
at sixty five. But when we look at like the

(05:30):
World Health Organization and we look at the statistics of
you know, the amount of women that then have osteoporosis
or low bone mass by the age of sixty five,
it's close to forty percent of women. So we're missing
then a lot of women, and we say the statistics
of one in two women over the age of sixty,
over the age of fifty excuse me, who have an
osteoporosis related fracture. You know, we're missing a lot of

(05:52):
years that we could you know, intervene. And so when
we think of, you know, when we should be getting
or when we should recommend or when women should advocate to,
you know, to get a DEXA scan for themselves, it's
generally around the time of the menopause transition. So that
could be the two to three years before and the
two to three years after menopause. That's sort of what
we consider the menopause transition. Because you're right that we

(06:17):
know that, you know, menopause isn't a light switch, it's
not an on and off, right. We do know that
in the bone health world, specifically that bone mineral density
starts to decline two to three years before the final
menstrual period and then the two to three years afterwards.
And so that and some women can you know, lead
to up to ten percent bone loss, which is a
whole t score on your bone mineral density or DEXA testing,

(06:40):
which again helps us sort of standardize bone strength and
bone density. So that's a lot, and it's certainly a
lot for women who might be coming to the perimenopause
with a low peak bone mass, or a family history
of osteoporosis, or you know, any secondary cause of bone loss.
And so maybe you were shadowing me in clinic today
because I had a patient who was you know again,

(07:04):
you know, forty six, with a strong family history of osteoporosis,
with low you know, a low lower body mass, just
constitutionally lower calcium intake. She wasn't really considering vitamin DA
is important. No one really educated her on that, but
she knew that she'd seen her mother and her grandmother
have osteoporosis and some sequel and so naturally when we

(07:25):
do her bone density, it's lower on the lower side,
and it was lower than maybe her someone who's a
similar age, race, and sex match, which is her Z score.
So that compares, that's what you see on that testing,
and we know that if the Z scores are starting
to drop, you know, below minus one or minus close
to minus one point five, you know, and then we

(07:46):
go through menopause, then we're setting ourselves up for low
bone mass osteopenia or osteoporosis later down the road. Especially
if we wait to do a dex at sixty five, right,
we've missed the boat completely. So it is important, especially
important to know your family history and some of those
things that I mentioned. You know about you know, calcium,
vitamin D, exercise, your reproductive status, if you had earlier

(08:10):
menopause or skipped a lot of periods we call amen arehea.
That's really important too for bone health. So it's all
kind of connected, right. It's why we take a good
history and we understand what happened before menopause is important
to help us understand how that's going to look. Things
are going to look later as well, and so critically
important in the I would say the fortieth you know,

(08:31):
forties to early fifties. Does that answer some of your questions?

Speaker 2 (08:36):
I want to know how much does genetics play? Is
it fifty percent?

Speaker 3 (08:40):
Is it?

Speaker 2 (08:41):
Is there a way to know?

Speaker 3 (08:42):
Yeah, a round of percent. Yeah, So you know, genetics
is a huge percentage. You know, there's you know a
lot of what we call like our studies when we
look at the variability, it can be anywhere from like
thirty to seventy percent of our bone mass is inherited.
So that's a pretty big percent. But again, when you
start to hear like my mom, my grandmother, my sister,

(09:03):
you know, things like this, this is a clue, right,
And I think that's the one of the one of
the you know, the pearls that we have, you know
now going through you know, perimenopause and menopause for a
lot of women, I would say in their fifties and
sixties that maybe we didn't have for women in their
you know, sixties, seventies, eighties, that the clue of like oh,
my mom had osteoporosis, or my mom had rheumatoid arthritis

(09:23):
and then she ended up having a fracture, or my grandmother,
you know, she lost height and then ended up breaking
her hip. You know, things like that. So our histories
can really help us. So again, I mean, I think
educating ourselves, that's why we do these you do this podcast, right,
That's why I do a lot of what I do, right,
so we can make some educated decisions for ourselves for

(09:45):
these decades of life and then beyond. So we're not
just thinking about treating osteoporosis and talking about the medications
when it's you know, maybe too late to prevent.

Speaker 2 (09:54):
Okay, I'm freaking out right now. I just had a
massive light bulb moment. I don't know why this all
just came together, because I'm talking about this all the time.
My grandmother had osteoporosis so bad that they couldn't even
operate on her.

Speaker 3 (10:11):
On her spine or on her hip. Yes, and here
I am.

Speaker 2 (10:15):
I had back surgery when I was seventeen, and I
blame it on my grandma.

Speaker 3 (10:18):
And I don't know why.

Speaker 2 (10:19):
I just assume because I'm strength training all the time,
and I you know that I wouldn't even There's no
way I would have low bone masks.

Speaker 3 (10:28):
But I might. You might. I don't know how old
you are, but I do think forty seven. Okay, Okay,
so you would be a prime candidate for a screening
bone density. The hardest part about that is just here
in the United States, you know, sometimes finding someone who
will order that for you. Sometimes the insurance wants to
deny that. But if you have a family history of mastereoprosis,

(10:49):
and if you have one risk factor meaning like low
bone you know, you low body mass or you know,
menopause or family history or certain medical condition, surgical conditions,
medications that might impact the bone, then that should be
covered right. And it's a dexa scan. Again we're talking
about it, but for most people who understand, but a
dexa scan is a low radiation, painless exam. It takes

(11:12):
about ten minutes and it scans your spine and both
of your hips ideally sometimes your one third forearm, and
it looks at the cortical bone and the tribecular bone,
which are two of the most important bones in our
body that you contribute to bone strength. And so certain
areas have more trabecular bone than cortical bone. Sometimes we
see it change in the bone density, quicker in the

(11:33):
trabecular bone, or there's more remodeling. But this can kind
of give us clues to you know, how what is
our peak bone strength or what is your bone strength now?
And I absolutely think like what you're saying, And I
know you ladies are huge, you know advocates for you know,
strength training, and your you look incredibly strong to me,
and I know this is important part of your life,

(11:53):
which is great and messaging and that can you could
still continue to do that and that's important part of
you know, healthy aging in general, but sometimes all of
our good healthy habits like not smoking and eating calcium
rich foods and things, we still could have low bone mass, right,
and then we still need to like work on that
or still need to understand, you know, components of that.

(12:13):
Maybe it's a hormonal piece, maybe it's something else that
we can intervene on.

Speaker 2 (12:18):
I'm literally so interesting.

Speaker 1 (12:22):
I want to know your results in a world.

Speaker 2 (12:25):
Okay, so if we look at the risk factors, So
obviously genetics is is much bigger than I thought. I
would not have guessed it was that big, but it
makes sense. So we have we have genetics. When you
said maybe didn't get to their peak bone mass, would
that go for women that suffered or girls that suffered

(12:48):
low energy availability, red ass, stress fractures, things like that,
if they were under eating, underfueling, over exercising, that is
a risk that becomes a risk factor from what you
did in previous decades.

Speaker 3 (13:02):
It absolutely can, especially you know, like you said, the
relative energy deficiency syndrome or right overtraining, underfueling specifically for
things like stress fractures, that's pretty common. And actually see
a lot of that and like even you know weekend
warriors or athletes in their thirties and forties, you know,
training for certain things and maybe no one's checked their
vitamin D or talk to them about their calcium demands. Particularly,

(13:25):
you know, as we become a perry and postman, apostal woman,
or footwear or not cross training, these things are all important. Yeah,
I mean sometimes those those stress fractures are those things
come in their twenties, but those can come at any
decade of life. Really again, because when we think about
a fracture, it's either you know, we're having either more
bone breakdown than bone formation, or we're having loading of

(13:48):
the bone in a way that the bone cannot sustain. Right,
So stress fractures and osteoporosis related fractures are actually kind
of they kind of like are in two separate lanes.
I mean, for sure, you can have both, especially if
you're low and calcium and vitamin D. But oftentimes stress
fractures are things like metatarsal like our foot fractures, ephemeral

(14:10):
neck fracture, a tibio plateau which is like your knee,
those are a sacral or a pelvis fracture sometimes can
be signs of a stress fracture versus an osteoporocess related
fracture is more generally a fall from a standing height
or less. So those could be things like a rest fracture,
a hip fracture, but not necessarily. Some women who have

(14:32):
a very low spine bone mineral density or T score
can develop a vertebral fracture, so from inappropriate bending, lifting, twisting, turning,
loading of the bone. So I've seen that in some
women who exercise, you know, have been doing exercise or
inappropriate training, you know, and that's unfortunate. So we talk
a lot about how to exercise appropriately if you have

(14:54):
a low spine bone mineral density, because again, the goal
with all of our thinking about bone health is to
to maintain bone health and strength and reduce our risk
of a fraction, right, because that's the outcome we're trying
to prevent.

Speaker 2 (15:06):
Okay, so let's move onto the exercise uh prescription, because
I want to know from the physician side, what do
you recommend to somebody that says, say, has osteopenia like
maybe a negative one, to someone that has osteoporosis like

(15:27):
a negative three. Obviously that that advice and treatment is
going to.

Speaker 3 (15:31):
Be quite different. Yeah, absolutely, So here here's the like,
here's the state. You know, here's what we understand is
you know, sort of like again clinicians physicians in the
osteoporosis world. And you have to remember that you know, science,
you know, and particularly exercise science. You know, we have
a lot of small studies, less than one hundred women,

(15:51):
short periods of time, so it's not the same quality
of evidence we have with you know, let's say our
pharmacology studies, right with like our drug trial that include
seven thousand women and follow them over years and we
see the medication working. So this is where I think
there's it's a little bit apples and oranges, and potentially
why when we go to you know, like our rubutologists

(16:13):
are endochronologists who are who are you know, classically trained
and we read our medical guidelines, and the medical guidelines
on osteoon exercise in osteoporosis are like three paragraphs, right
versus you know, twenty pages on like medications and calcium
and vitamin D. And it's just because again we don't
have a lot of great research in this area. We

(16:35):
have some to guide us, and the guides are generally,
you know, the one study that has been done that
has been done, you know, and it was done well,
and it was done over you know, a longer period
of time at least you know, eight nine months, was
called the Lift More Study and it was done in
New Zealand and it took women with osteoporosis osteopenion and
randomized those women to an exercise regiment where they did

(16:58):
you know, consistent multi days a week of you know,
doing weightlifting and doing things like deadlifting and overhead press
and back extension and squats and jumping and sort of
like a chin up drump drops and things of that
nature versus women who just did like walking and stretching.
And the women who did resistance exercise naturally, they improve

(17:18):
their bone density and their spine and their femoral neck,
which is the area of our hip that we can
scan with a dexa versus placebo. So that gives us,
you know, some great information that like, yes, we know
loading the bone, we know adding more than your own
body weight makes more of a difference. And it makes
sort of sense right when we think about physiology. But

(17:41):
then we look at like out other things like is
walking enough? What about pilates and yoga, what about pickleball?
What about you know, so because again people you know,
we don't people don't just lift weights, or some people
don't have access to that or don't know how to
do that. So I think it becomes very much an
exercise prescription, like you said, of adding in some resistance
and weight bearing because of the liftmore study that we

(18:03):
have and figuring out a way to do that safely,
whether it's either with a trainer, whether it's hiring someone,
whether it's following you know, you know, a prescription that
I share with some of my patients, whether it's connecting
with like a bone fit or an O narrow program
with these are people who are specifically focused on, like
a trainer or physical therapist on helping them with osteopenia

(18:24):
osteoporosis at varying degrees. You know, I always think, you know,
doing aerobic exercise and some jumping exercise is important. It's
good for our cardiovascular health, it's good for our bone density,
it's good for our brain heart. So doing something of
that nature, you know, within your scope of what you
can do, and then balance and posture things we forget about.

(18:44):
I think the areas of exercise that have helped us
with that are things like pilates, yoga. These are areas
that taichi that are often based in balance and I
mean as we age that can decline a little bit, right,
and so just consistently trying to do that as you know,
as much as doing compound weights, exer with balance, you know,
or just balancing on one leg for thirty seconds and

(19:05):
then taking it from there. But that is something that
is easy and cheap and free, is what I say.
And so adding trying to do some of that and
so really tailoring with what people can do with their time,
their you know, resources, and also what they like to do, right,
because if you don't like to do it, you won't
do it, and why and the why behind it?

Speaker 2 (19:26):
Okay, so how do you feel about there's been a
little bit of research with weight advest and there's some
controversy there. There's definitely opinions and that in that space
as well as like a vibration plate. What do you
think that, what's the outlook from the research there and

(19:49):
is it something that you recommend?

Speaker 3 (19:51):
Yeah, so I think that the vibration plate. Again, we've
had this around for a long time. I mean the
vibration plate. I say, you know, for a of people
if you want to work on like your balance or
have an extra challenge with the vibration. But the reality
is the amount of vibration that's needed to like maybe
affect a change in the Again, the bone mineral density

(20:11):
is quite high, and so you need a lot of
vibration for a long period of time, a certain amount
of hurts to actually you know, change that. And again
when we look at like the research behind the vibration
plate and some of that, it's it's very you know,
small and inconsistent. So if I say, if you want
again practice your balance or add that in, that's fine.

(20:32):
It's not usually my first line of recommendation. Again, just
because I follow the evidence. The weighted vest is interesting.
I mean, I definitely think it is a little bit
of a hack, a little bit of a trend. But
also like again the idea that it's adding resistance or
loading the bone is the same, you know, it's it's

(20:53):
sort of the same extension as you know, doing some weightlifting,
like doing a bicep curl and putting a weighted vest on.
So there is some research against small studies less than
one hundred women who have osteopenia who wore of weighted
best while they were walking or exercising for more than
three hours a week at about five to ten to
up to fifteen percent of their body weight, showing that

(21:14):
it had an effect size on their bone min oral
density more than a placebo. So I say, oh, that's positive.
You know, it's not negative. Starting low and going slow
as long as women don't have back pain. I have
seen it be you know, moderately a you know effect,
you know, having a small effect. I think again, time
will tell, larger research will help us. But I think

(21:35):
if women want to do that, and that wants to
be part of the treatment algorithm in terms of thinking
about lifestyle and potentially medications or hormones and this, they say,
all the power for it. And I see a lot
of women in my neighborhood walking with the weighted FST.
I'm sure you do too, yes.

Speaker 2 (21:53):
Yes, well, okay, So to kind of backpedal a little bit,
back to the relative energy deficiency in sport, okay, with
that being a risk factor when we get post mental puzzle.
The bone is is pretty susceptible. It doesn't like not

(22:13):
having enough calories.

Speaker 3 (22:16):
It can yeah, well, especially calcium. So it's interesting. So
what happens, you know, again when we have more bone
breakdown than bone formation, is the osteoclass outpaced the osteoblast.
And then again the sort of think about like if
you think about bone as sort of like a like
a structure or you know, sort of a lattice structure
that you're starting to take out little pieces and then

(22:37):
eventually sort of if you take out enough, right, the
building collapses when there is less you know, structure there
and less calcium particularly you know, that's mineral helping us
mineralize and strengthen the bone. That can predispose to you know,
to fractures and to again low bone density. So it's interesting,
you know, around the time of menopause where some people

(22:57):
are taking out like dairy or gluten or for whatever
whatever reasons, we actually do need a lot of calcium,
you know, we do need more calcium or enough calcium
to help maintain the bone strength or help when we
have more of that bone turnover. And I think that's
something that we don't hear a lot of messages about,
but it is important. It doesn't need to be that
you're drinking a gallon of milk a day or anything,

(23:17):
but getting close to one thousand to twelve hundred milligrams
of calcium daily, either through dietary sources, plant based sources,
or supplementation is possible, and so I oftentimes you have
women think about that at least and oftentimes two calcium
rich foods have a lot amount of protein, which is
another again thing that we're talking a lot more about.

(23:37):
And of course protein is helpful for restoring muscle, and
that's so important as we also go through the perimenopaus
and menopause, right, we know that there is some muscle
loss that happens, you know, slowly through that period of time,
but then more precipitously, you know, as we get to
the seventieth and eightieth decades of life as well.

Speaker 2 (23:54):
Well. The statistics are pretty I was going to start
with this, but then I got so excited I didn't.

Speaker 3 (24:00):
Okay, we're backtracking.

Speaker 2 (24:02):
Every three seconds an osteoporosis related fracture occurs, and once
an osteoporosis related fracture occurs, one in five women will
refracture in the next five years.

Speaker 3 (24:12):
Right, right, yep, you did your homework, so sad, Yes, statistic, right,
and so and so this is the reason rise so
much number. We talked a lot about prevention, like you know,
in terms of like knowing your numbers, getting a DEXA,
thinking about your calcium, vitamin D, family history, exercise. Potentially again,
if you're a candidate for menopausal hormone therapy and you know,

(24:37):
we know that that can prevent bone loss. We know
that we women who are low absolute risks for fracture
within a time period since the menopause without any contradications
just has a lot of bone benefits in addition to
of course helping with you know, sleep, sexual function, hot flashes,
you know, hair, skin, you know, all these other things.
But if you do have osteoporosis, like the statistic of

(24:59):
if you've had one fracture, you're you know, twenty percent
of women will refracture, you know, in the in the
years following and probably the first one to two years
that the risk is the highest is because whether you know,
you're the bone is a little bit destabilized, whether you're
at a higher a fall risk, whether we've you know,
found that there's a bone mineral density and a bone
quality you know, concern there and it's what I do

(25:22):
see in clinical practice, right, so it's why we want
to prevent the next fracture. And if you have osteoporosis,
and if you've had a fracture, we consider that severe
osteoporosis and then think about treatment. So then you're you're
not just you know, in the realm of you know,
let me do some calcium and vitamin D. I mean
I I always say to him, that's that's fine, and

(25:42):
those are the that's kind of the lowest, you know,
that's the thing that we should all be doing. But
then we need to really address the problem at hand.
Just like if you had a heart attack and we
would just say, okay, you know, you know, get out
there and do a little bit more walking, right, try
not to have another one. You know, we'd say, okay,
let's let's really treat this condition. I think sometimes as
women and right, unless we can see it and feel it,
we don't necessarily do that. But the sequality of a

(26:04):
fracture is is pretty life changing, you know, the hip fractures,
pelvis fractures, you know, not just you know, disability, but
like you know, pain or long term consequences. And I
see it day to day and so even vertebral fractures.
You know, this can change your height, this can change
your vowels. It's these are not just inconsequential. So again
it's like take it seriously, find someone that can talk

(26:26):
to you about it. Think research your options. There are
a lot of great, safe, aft approved effective options to
reduce your risk of another fracture. And that's what's again
really important. When you've had a fracture, we call that
secondary treatment or you know, preventing a secondary frat.

Speaker 1 (26:41):
And is that when you start the medication or once
someone gets you know, a low bone down stay scan,
like when do you treat it with medication?

Speaker 3 (26:51):
Yep? Yeah, so very much like you know many of
our other you know things, maybe menapausal hormone therapy is
one that we you know, we are starting to think
more about, like using us a prevention right of preventing
fractures at helping our sleep and our hot flashes and nights.
What's before they get you know, so bad that we're like, oh,
let's crawl our way back. But for the for osteoporosis,

(27:13):
you know, we have large buckets of medications. A couple
of the medicines you know, prevent more bone from being lost,
so they work on the osteoclast, and then other medicines
work to build new bone or form new bone, and
then we have one medicine that kind of does both
so very much. What we do is we say, okay,
like let's look at the DEXA, look at your fracture risk,
look at all your clinical variables. You know, do you

(27:35):
have any medical history, do you have any aversion to
a medication, any reason we couldn't use this, that or
the other, and then want to match that fracture risk
with the treatment we recommend. So if you're at high
very high risk, we want to think about using the
medications that are going to improve your bone density the
most quickly as and reducing your fracture risk the most
effectively and also quickly. Right, So that makes a lot

(27:56):
of sense. And so those are you know, some of
the bone builders in their name are their brand names
are FORTEO and Timlows and a Vanity And then sometimes
you know, we also use medications like Prolia, which is
an anti resorptive medication or reclass So those are some
medicines that are you know, people might hear, you know,
sort of discussed. If the risk is lower, then we

(28:18):
think about things like hormone therapy or maybe oralis phosphonates
or even a medication called reloxaphene or you know those
circuit of medications. So it just really depends on where
the bonancy is the lowest. Have you had a fracture,
Let's look at your obviously preference, you know, all of
these things go into.

Speaker 2 (28:34):
It a whole treatment plan. So all right, GLP ones,
So how does this affect if any bone bone health?

Speaker 3 (28:47):
Yeah, so I think again, like this is such an
evolving area. You know, I think that the issue is
we you know, we really haven't like done bone mineral densities,
you know, routinely right on you know, women and men
starting g LP one medications because we didn't really know
what we know, like you know, fat loss and you
know that can happen, but we didn't really realize what

(29:09):
the body composition changes might be. And now I feel
like we're understanding. You know, when you lose a fat
mass you or you lose you know, weight, you're going
to lose both fat bone and you know, you know,
muscle potentially if you're not doing things to reverse it,
like adequate protein, resistance training, you know, things of that nature.
So I think there's a wide variety of what's going

(29:30):
on out there, as you probably hear in your landscape too.
So there is a potential that you can lose bone
mineral density. And we've known that from you know, when
we when from bariatric surgery, so you know, prior to
bariatric surgery, most you know, individuals get a whole body
dexa where they look at their bone mineral density and
they get a dexa so they know where they're starting from,

(29:52):
and then after that they do it again. So like,
potentially that needs to be in our algorithm, it's not yet.
I do that personally and I practice. If people are
on a JLP one, I check if they've come to
me after being on it for six months or a year,
I'm like, well, we should, you know, check your bone density.
I mean, naturally, those are many women coming to me
between forty and sixty anyway, so they're going to get
a dexa. But I think that's an important thing. So

(30:15):
I think again, time will tell how much bone you know,
will be lost. I think it depends on where people
are starting from and what they do. I think more
we're can be concerned about the muscle loss and the sarcopenia.
Uh also that that is a huge, you know concern,
especially for long term use, especially as when we know

(30:36):
with aging we're going to lose the muscle mass. So
I think time will tell, Like I think there's not
enough high quality of research to tell us, but there's
some theoretical concerns for sure.

Speaker 2 (30:47):
So then if we are losing and I think that's
a major point to reiterate, is that so many women
have no idea that if they go on this aggressive
or prolonged calorie deficit diet that it can be pulling
from bone. Like that just wasn't it. They, at least

(31:10):
from from the women that are coming in in my world,
there's that they didn't even think that was a thing.
And so you know, if we if we keep building
and we're building muscle, then we're also working on building
bone too.

Speaker 3 (31:24):
Correct Muscle and bone for sure talk to each other.
I mean, I think this is the thing, you know,
that we're going to learn more about in the next
you know, I would say five years, because there's so
much more research and muscle now and like what's contributing
to muscle growth and sustaining motherrooals and what exercise do
we do that to do that and whether it helps
you know, the bone mineral density improve as well, I

(31:46):
think what we'll see so, I think we're going to
see much more of that you know, coming as well.
And I yeah, I think it's really important to think
about both. So bone is not just static, it's dynamic
and it's changing just like muscle is. And the best
way to check it again is the bone mineral density
that we have now or the body composition scan that
can look at all those three characteristics as well.

Speaker 2 (32:09):
Okay, so really the DEXA is what's needed, uh as
the gold standard. But you know, there's there's there's some
different methods out there were some you know skills and
embody that can kind of show bone, but that like
we we we really don't want to rely on that

(32:29):
if we have other options, if women have other options available.

Speaker 3 (32:33):
Yeah, I think I think you know for sure that
there's so, I mean, there's so much out there now. Yes,
the inbody can be very helpful. It's an indirect measure,
you know, a bioimpedance and looking at the different muscle, fat,
and bone. It has a little bit less hydration status
is a little bit less impact than it is with
the DEXA scan. So you know, ideally you could sometimes

(32:53):
say do the Dexa scan in the morning, et cetera.
But again, I think, just thinking about it, you're already, like,
you know, we've already made a change if you're thinking
about or if you're educating your you know, clients or
our patients about saying, okay, are you thinking about calcy?
Are you thinking about protein? Should you maybe meet with
a registered dietitian, what about doing some resistance training? I
think this is all you know important, And I think again,

(33:16):
just we've known even taken from like you know, if
we look at the risk factors for usteoporosis, you know,
sedentary lifestyle is one of the risk factors, right because
again we're not moving our bone bodies, we're not loading
the bone. You know, that's always a concern for me
when I think about like young kids on devices. You know,
That's why I'm always selling my kids get off their devices.

(33:37):
That'll be like probably on my grief, get off your device,
go offside and play, because I'm like, oh my god,
this is bad for their bones and I think that
there's like a lot of the pediatric endochronologists sort of
say the same thing. So it affects all of us
at all levels, right, not just the menopause women.

Speaker 2 (33:53):
Yeah, I didn't even think about that. But I have
another quote from you.

Speaker 3 (33:59):
Okay, I love these.

Speaker 2 (34:00):
I have a bunch of Christi quotes that I'm loving
and I hope I don't mess them up or maybe
you don't remember saying them, but I love this. What
is good for the brain, it's good for the heart,
is good for the bones.

Speaker 3 (34:11):
Yeah. Yeah, so there's so many, so much. I mean,
as we do this more and more, right, you probably
see so many things are connected, right when we talk
to our patients. I mean, I love what I do,
and I think, you know, we can help women in
so many ways when we think about like pillars of health, right, hormones, sleeve, nutrition, exercise,
chronic stress, factors, our medical history. That comes to us

(34:35):
just because right, So, but yeah, I think that is
you know, when we think that pribaby is taken from
when we think about exercise, but also we think about hormones,
it's the same application, right, we think about estrogen hormones,
particularly again, if you're a candidate for those because I
know that there's lots of then out there with estro
receptor positive breast cancer, cardiovascular disease, which doesn't mean you

(34:55):
can't get any treatment or suffer through whatever symptoms, or osteoporosis.
There's lots of options. But right, we do know, right
from a lot of our studies, our observational studies, the
Women's Health Initiative study that you menopausal hormone therapy helps
you know, prevent cardio masters, these helps vent osteoporosis, you know,
helps with again you know, sleep quality helped reduce our

(35:18):
risk of osteoporosis, relative fracturers, prevented diabetes, you know all
of that. So there's you know again, I think it's
it's thinking about you know, the individualized you know, risk
benefit risk ratio when you're thinking about how to make
some of these choices. And I think that's a lot
of the guests you've had on have sort of shared
the same the same line of thinking.

Speaker 2 (35:38):
I'm still kind of blown away that only like under
ten percent of women are taking hormone therapy given I mean,
and I think that's going to change over the next
you know, decade.

Speaker 3 (35:52):
But Wow.

Speaker 2 (35:52):
Yeah, I mean after all of this, I'm like, really
less than ten percent?

Speaker 3 (35:57):
Yeah, I think, you know. I mean now there's shortages
of some of our patches and things like that, so
I don't know. I think it's probably exploded. And again
I think that you know, there was a pendulum and
I think it's coming back more to the middle. And
how great that we have more you know, research information,
and then we just need more clinicians trained, right, I
mean the statistics that you know, even you know, doctor

(36:18):
Rachel Rubin you know shared that, you know when she
was talking with the FDA, And how little we have
you know, prescribing prescribers because the box warning is concerning,
or because we don't have consistent messaging because we're not
trained to know that, right the residents, the fellows, the
medical students. So like elevating that training helps us, all right,
So we're saying consistent messages, not that I'll have patients

(36:39):
come in and say, well, my intern is said never hormones,
like never, I would never, you should never go on hormones,
And it's like, where does that come from? Right, There's no,
there's no that's a personal opinion. Or is this like
based in science. You know, it's like me saying, you know,
never go on you know, antidepressants, like what like why
would I say that? Like that's a visual choice, right,

(37:01):
So I think we need some of those blanket statements
to go away. And I'm so proud of you know,
all my menopause colleagues and friends that we're all sort
of saying some consistent messaging and standing up to the
FDA and some of these other powers that be so
to really help our patients. It's what we do day in,
day out. But it's great to see on like a
massive level.

Speaker 2 (37:21):
Yes, come on America.

Speaker 1 (37:25):
Good for you guys helping us along.

Speaker 3 (37:30):
Yeah, it's fun, but you too. I mean I think
we all, you know, play our part right, consistent messaging,
telling people they could be active, Keith's dating active, give
them the tools, it all matters.

Speaker 2 (37:40):
Yeah. So when we hit like, so the statistic and
I might get this wrong, but it's somewhere once you
are in the menopause transition, so three years before maybe
two to three years after that, you can lose somewhere
between seven and twenty percent or something.

Speaker 3 (37:59):
Correct. Yeah, So again when we mentioned you talked about
that that trabecular bone and cortical bone those bone sites.
The cortical bone is more in our long bones and
on our growing bones like our wrist and our hip,
and trabecular bone primarily concentrated in our spine. But yeah,
so with the remodeling or that outpacing of the bone,
you know, resorption and the bone formation, some women can

(38:21):
lose up to twenty percent of their bone masks through
that time. Particularly you know women, if you're starting with
the low bone density and then you're going through that,
you're going to obviously notice the drop more. You know.
I use the analogy often of like a bone bank.
So if you're starting low and you go through menopause
and you're gonna you know, you're going to you know,
do some more you know, take you know, deposit air
deaficing from your bone density, then you're going to end

(38:43):
up with lower bone mass. Right, It just makes sense
right when we look at the equation. So so yeah,
so it's even more important, right why you want to
know your bone mass, you know, from the start ish
or your risk factors and then where you might end
up because I know the times where I see women
who are like sixty two, sixty three and that's their
first decks or sixty five and they're very you know,

(39:05):
frustrated that they have osteoporosis. It's like, well, you know,
we just you know, the medical system failed you, right,
we just didn't do the deck soon enough. We didn't
capture this. It's like if we did a cholesterol after
your heart attack and showed that your cholesterol was two
fifty and we could have prevented something. So again it's
like knowing or you know, knowing earlier always helpful, right,

(39:26):
you know, getting ahead of these curves is always helpful.
And if you do have osteoporosis, then treating it and
I always say not being scared to treat it. Medicine
is not you know, a failure. You know, it's like, okay,
it's actually it could be preventing a fracture if you
haven't had one, or preventing a second fracture. So I
think sometimes we think it's a failure if we have
to try something or do something. Maybe something this is
more of my patients or in the natural you know

(39:47):
approach versus the maximalist approach. But there's many ways to
come to a conclusion. Where you feel safe and comfortable
treating your osteoporosis, whether it's hormones or medications obviously including lifestyle, calcium,
vitamin D in all of those things. So I always say,
it's not a failure right to treat the osteoporosis it's getting. Actually,
it's treating a condition that you would have a sequalite
from if you didn't. And it's a tough one though.

(40:09):
It's a tough one because I think sometimes that we think, oh,
it's aging and it's a older women's disease. But you know,
when we look at the statistics, like you know, they
think about fourteen percent of women have a diagnosed of
osteoporosis between forty between fifty and fifty nine. Listen, like
twenty to thirty percent when you're sixty to seven, you know,
sixty to seventy. So that's a large majority of women.

(40:31):
It's a large percentage, right, So you're with it. You're
with you know, So it's not like this is so uncommon.
And again the soquality we're trying to prevent us that
is that fracture.

Speaker 2 (40:42):
So for for osteopenia, if somebody comes in with with
low bone mass, is that what it's called.

Speaker 3 (40:48):
Now it is, You've got it right.

Speaker 2 (40:50):
So like the negative one is like just the like
the start of osteo like a very yeah minus one
point one or minus yeah, minus one point one to
minus two point four on that deck set.

Speaker 3 (41:02):
It's done correctly at one of the clinical sites like
the spine or the or the femeral neck or the
hip is osteopenia. Yes, And sometimes there's something called the
trabecular bone score, which is a bone marker of like
bone micro architecture or you could say like bone quality
or how well your bone is organized. Sometimes that can
also push us in one direction or the other.

Speaker 2 (41:24):
Oh okay, good to know. So if somebody comes in
with that, say negative one point one, and they do
nothing over say one to two years, while they might
have just gone through metopause and they have you know,
one to two years where you might have this window
I don't know if windows the right word, but if

(41:46):
you do nothing, no treatment, no exercise, nothing, how like,
is there an average of a percent of how the
bone would change?

Speaker 3 (41:57):
Yeah? So again, like when we I think around you
gave the example around the time of like menopause, so
that woman could lose you know, again, on average in
the spine seven to ten percent of their herbon den
see the largest is probably about twenty percent. We do
know that there's some like age related losses like ABS.
We get further from the time of menopause, which can

(42:18):
be about a half a percent a bone loss a year, right,
So that could be I call that kind of like
the trickle down approach. So like women who like have
a lostiopedia for like fifteen years and eventually they're going
to maybe develop osteoporosis. But it's also where like if
you know they're vitamin D or calcium deficient, that might
speed up the process of bone loss. Or let's say,

(42:39):
you know, if there's medications like an aromatase inhibitor, if
you have a breast cancer diagnosis or a stere you know,
multiple steroids either injections or taken orally if you need
to use them for a certain condition like a rubetologic
or autommune condition, that might speed up you know, bone loss.
And then if we see you know, a recheck ADEXA
in two or three years and you've had war bone

(43:00):
density loss, then maybe we would expect that means we
have to put on our thinking caps and say why
is this? Is it a calcium, is it a vitamin D?
Is it a metabolic bone? Reason? Right, that's mostly what
I spend most of my day doing. You know that.
You know that we're having a change in the bone
densy or is it hormonal or is it age related?
You know that sort of thing. But when you say
do nothing, it's always hard because many no one does

(43:23):
nothing right because most people are like, Okay, I'm going
to try and get some calcium, or I'm going to
get my vitamin D up or I know I need
to be doing some exercise. I hear that often, but
you know, what do I do? So? I think the
most important message from your question is that like that
we re rescan. If we do get like a osteopenia
or an osteoporos we rescan. And if you get a

(43:45):
normal DEXA and you're forty five, then I would say
you're good for at least until the time of metopause,
like around if that's fifty to fifty one for on average.
If it's earlier, we do we could recheck. But if
it's later, great, But we are we are feeling like
we're in a good safety net.

Speaker 1 (43:59):
There are there any other supplements besides vitamin D and
calcium that you recommend to your patients.

Speaker 3 (44:07):
Yeah, so this is when great questions. So you know,
adequate calcium, Vitamin D really important. Vitamin D we can
check on a blood test. Calcium we really can't. There
is something called the twenty four hour you're in calcium
collection that sometimes we do if we're if we again
want to work out an osteoporosis diagnosis to make sure
that there's no like problems absorbing calcium or hyper excretion

(44:31):
of calcium. So there's some two extremes there, so you
might be asked to do that testing and that's some
part important. And then in terms of like you know
again adequate protein probably important again because that muscle bone crosstalk.
We know, you know, certain things like potentially there is
where like again, there's a lot of potential things like

(44:51):
maybe collagen. There's some small research you know that shows
that collagen might be helpful. Our bones are made up
of collagen. Whether ingesting collagen and helps our bones is
a question mark, but there's some small evidence you know
to that. To that standpoint, things like heavy metals like
strontium and boron. Again, they've been studied, but there I

(45:14):
see in my mind more you know, risk than benefit
for those those are heavy metals, they deposit in the liver.
They call some GI side effects, so I don't recommend
those routinely. So again it's mostly you know, calcium, vitamin
D again talking that takes up a lot alliance share
of you know, what we think about in the in
the bone. Sometimes vitamin K two can be helpful if

(45:37):
people are not getting a lot of that in their diets.
So there's some benefit that vitamin K two can help
support the bone cell, the bone forming cells. So these
are small things. I say, sure, we can add the
K two, and we can add the vitamin D and
the calcium and the and the collagen if you want.
There's some studies on prunes. I know, the study is
very like out there that you know, six to nine

(45:57):
prunes a day might help the bone tensity. So again,
and this is the like, if we're thinking, like let's
do the kitchen sink approach, we can add some of
these you know, small things that might make a little
bit of a you know, a benefit. So those are
the things that I think.

Speaker 1 (46:10):
About, and those are things that aren't going to hurt
just out. So even if a friend you're not benefiting
per se, like with your bone, it's going to add something. Right.

Speaker 3 (46:21):
There's even research now going on, like you know creatine, Right,
will that help the bone? I mean it helps the
must a little bit. Again, so will it help the
bone mineral density a little bit? Potentially? That's the same thing.
So I say, okay, if these are the things that
we want to like be adding, if you're not like
they're not hurting, But again, is it another thing we
want to make sure that Again, if it's a supplement,
we're getting a third party tested supplement, we're checking for

(46:42):
you know, the purity. All these things are also important, right,
and then the cost that comes along with it. So
I think, again, like the a lot of the times,
it is a little bit individuals. What are you doing?
What do you want to add? How much do we
want to you know, think about these It's sort of
what I would say supplemental things.

Speaker 2 (47:00):
Is there an area if we look at we know
that we get the wrist, the lumbar, the hip, and
the femoral head. Is there one I mean, none of
them are great, but if you is there one that's worse.
If you're like, this is more of a problem than
the others.

Speaker 3 (47:20):
Yeah, that's a good question. So what we see a
lot in the menopause, you know, is we might see
like a lower spine bone density, and again potentially our
lower peak bone mass might be more reflected in that
trabecular bone, so in our spine or if there's a
lot of bone turnover going on. But when we look
at like big ticket item, I would say, you know,
what you're asking me is if your bone mineral density

(47:43):
you know, is low like minus two point five or
lower really at any age, we know that that's a
very strong predictor of a hip fracture. So again, the
lower the bone density, think about it as more like
you know, fragile or thinner bones, bone micro arctucture being compromised,
you're higher risk for having a hip fracture, and that
just increases as we age. Right, So you know, I'm

(48:05):
less concerned. Maybe someone is I concern in a different way.
Let's put it this way. If someone who is fifty,
you know, fifty two, Let's say you know, postmenopausal and
is fifty two, as a hip a T score of
minus two point five in her hip versus someone who's
maybe seventy five and has a minus three point one
in her in her hip because she's older, more likely

(48:27):
to fracture, maybe have other medical conditions and break a
hip and then have the sequality of you know, not
being able to walk or be live independently or things
of that nature. Versus someone who's fifty. I'm saying, Wow,
your bondency is low to start, and if we do
our math, you're going to live for another thirty years,
because that's on average how long we know women are living,

(48:49):
particularly if there's no other competing you know, risk factors there.
So I'm also saying, wow, we've got a long way
to go, and we don't want you to lose this bondency.
We have to do something to either build your bondency
or be to maintain it over a period of time.
But this isn't just what I'm saying. This is also
our clinical guidelines that say that there is a correlation
with your risk of a fracture and your t score

(49:13):
your hip, and then if you're treated for osteophorosis, there's
also a correlation that you'll fracture your hip less So
we call that on treatment T score also correlates with
reducing your risk of a fracture. So there's there's a
catch twenty two there.

Speaker 2 (49:26):
Wow, So what would be the top maybe two to
three labs or assessments that you would recommend women, you know,
get the screenings that they should ask their physician for sure.

Speaker 3 (49:42):
So first, you know, I think you guys are becoming
like bone heads. You're having excell bone help, so your
minds are blown. I can see for sure. We talked
about the DEXA a lot, so again, find a place
you can get a dexa, ask your you know, guide
to coologist, intern as specialists, you know, whoever to get
a dexa. Checking your vitamin D you know, very easy. Also,

(50:04):
making sure your cerrum twenty five hydroxy vitamin D is
being checked important Again, there's no easy way to do
calcium assessment, but thinking about the calcium in your diet,
the quality of the calcium you know in your diet
very important. You know. If ADEXA is not freely accessible,
there is an online fracture risk tool called the FRAC score,

(50:25):
which is again you can google fracts f R A
X and that can tell you putting in your your
you know, your age and your height and your weight
and some of the other variables we assess for fracture
risks can be something that you can do or even
bring that to your you know, clinician to talk about
bone health and oh maybe my risk is a little
bit higher, or maybe I want to kind of talk
about this, or what do you know about this? I

(50:46):
think that's really important. And of course I see so
many women from all the decades, so I think, just again,
when you say, what one thing I would say, you know,
talking about your menopause symptoms or have being asked about
like how are you period's going? What symptoms are you
noticing when you're between forty and fifty five, sixty seventy?
You know, these are all important things to being asked.

(51:08):
Now we're finally able to recognize some of these, you know,
the myriad of symptoms, and everyone's symptoms are a little different.
But being asked like what's new, what's changed? You know,
what could we correlate to maybe hormones? I think is
hugely important.

Speaker 2 (51:21):
Yeah, I mean, wow, I have I have so much
more on my list. I'm really I'm really more almost.

Speaker 3 (51:29):
Yeah, no, yes, I know, I know, but I think
it's been I think we've hit a lot of great topics. Really,
it's a lot of the highlights. So that's good too. Okay.

Speaker 2 (51:39):
So on a closing note, if you could wave a
magic wand and have every woman forty plus understand one
thing about her health, what would it be?

Speaker 3 (51:51):
Okay, Well, I'm in of course tailor this to like,
you know, bone health, because again bone and body women's
sell this is important. And I think again an area
like you mentioned, even the outset that is getting a
little bit more traction right both, you know, I think
we've talked about contraceptives, and we're learning more about menopause,
and there's so many areas within menopause, you know, thinking

(52:11):
about you know, sexual health, thinking about you know, cognition,
thinking about sleep, thinking about the musco sell little symptoms.
I mean, I would bucket osteoporosis are throughout you know,
joy nakes and pains, muscle changes, all of that is
in that bucket, which I think is great because there's
more identification on that. So I mean, I think if

(52:32):
I could wave a magic wand, I think we've we've
talked a lot about it is to like know you're
you know, think about bone health, you know, before it's
too late. So whether that's a DEXA or a fracture
risk assessment, or say yeah, I need to be doing
some resistance training. I need to know. Ask my mom,
you have osteoporosis, you know, thinking about those those things,

(52:53):
and I think, again, it touches. It's not just in
a silo, right, it touches a lot of the other
parts of the thing that we're talking about before we
hit menopause and after. So that's what I would say.

Speaker 2 (53:05):
Well, I am I'm gonna go look at the fracks test, okay,
and I'm gonna go a DEXA. I mean I was
waiting a couple I mean, I'm almost forty eight, so
I'm not too far away from from, you know, menopause,
so it's a coming. So I don't know why I

(53:29):
was thinking that I would just wait because, yeah.

Speaker 3 (53:32):
Let me know your results. Oh I'm curious. That was
like a I mean, is it right? I mean again,
I think for anything, you know, sometimes we get people.
It's nice to get. Also, let's I'm assuming. I'm just
assuming here's this bone densis being normal because you're a strong,
fit woman. But who knows but it's also if it's normal,
it's like reassuring. I'm like great. Sometimes it's like I

(53:52):
love i love telling people they're bone density is strong.
I'm like, great news. I give them a smiley face.
I'm like, this is amazing. Keep doing you're doing either
hit the genetic jackpot and you're doing the right thing.
So it's also good to get good information sometimes or
or or information that helps guide us or push us
on the right path. Right, it's not all I think
sometimes we came for the doctor. It's all doom and gloom. Right,

(54:14):
it's like, oh, great, tell me my cholesterols. Either tell
me this, that and the other. It's sometimes it could
be positive, but I think that's like you know again, also,
or it can be enlightening, let's put it that way.

Speaker 2 (54:26):
Yes, absolutely well, doctor dysopri thank you so much for
spending your time. I know it's the end of the
day for you. So thank you for sharing, sharing all
of your wisdom and education with us. Where can women
find you?

Speaker 3 (54:43):
Yeah? Great? Of course this is my pleasure too. So yeah,
so I am. I have a website, Bone and Body
Women's Hell. That's my practice, and you can you know,
find that I do some social media, more is hopefully coming.
I'm a busy practicing clinician, so I do a lot
of teaching and educating. I have some of those on
my website and looking forward to sharing this podcast with

(55:06):
my members and I see patients in Illinois. I also
have a Florida telehealth license. I do do some educational
consults as well, so yeah, you can find me there.

Speaker 2 (55:16):
Great, Well, you'll have to get in Colorado and Utah,
so Lauren.

Speaker 3 (55:20):
And I can. Okay, I know, maybe for my retirement
a bunch of years away down the road, but I
the mountains are calling and E're beautiful there.

Speaker 2 (55:29):
Yes, well, thank you so much, Christy, and we will
definitely keep keep doing what you're doing, and we will
definitely keep following you for up to date advice and
evidence based information. So thank you for sharing your.

Speaker 3 (55:44):
Time with us. Oh you're welcome. Thank you, thanks for listening.

Speaker 2 (55:47):
Everyone.

Speaker 1 (55:48):
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