Note: This episode originally aired in May 2022. Loss of both density (osteopenia) and muscle mass (sarcopenia) are two common concerns when it comes to aging. In this episode of The Thorne Podcast, Dr. Frank Lipman and Dr. Robert Rountree explore the causes of bone and muscle mass loss and what you can do about it.
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During this episode you’ll learn about:
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Dr. Robert Rountree
This is the Thorne Podcast, the show that navigates the complex world of wellness, and explores the latest science behind diet, supplements, and lifestyle approaches to good health. I'm Dr. Robert Rountree, chief medical advisor at Thorne, and functional medicine doctor.
Dr. Frank Lipman
And I'm Dr. Frank Lipman, New York Times bestseller and functional medicine doctor. As a reminder, the recommendations made in this podcast are the recommendations of the individuals who express them and not the recommendations of Thorne. Statements in this podcast have not been evaluated by the Food and Drug Administration.
Dr. Robert Rountree
Any products mentioned are not intended to diagnose, treat, cure, or prevent any disease. Hi everyone and welcome back to the Thorne podcast. How are things going for you, Frank?
Dr. Frank Lipman
I'm good. I'm actually quite enjoying winter for a change. I usually hate winter, but it's actually a good time now, spending more time with my grandson, which is wonderful. So forced to do that and I can't complain. And you?
Dr. Robert Rountree
I'm good. Yeah, yeah. Trying to get out. The winter has not really hit us full force yet in Colorado. We've got a little bit of snow, just enough to make it fun to go walking out in the back country. So I've been going for some hikes out in the woods and I always love doing that.
Dr. Frank Lipman
That's great. Yeah. My daughter is obsessed about getting her little son out every day, twice a day, at least. So it forces me to get outside, which is good.
Dr. Robert Rountree
Got to keep his vitamin D up.
Dr. Frank Lipman
Right.
Dr. Robert Rountree
And yours.
Dr. Frank Lipman
Okay.
Dr. Robert Rountree
All right, let's get into the main topic for this week. We actually have a combination of two topics we wanted to talk about, that overlap, and that would be sarcopenia and osteopenia. So Frank, I wonder if maybe you could define what those terms mean, in kind of a general concept for our audience.
Dr. Frank Lipman
Sure. So we'll start with sarcopenia. Sarcopenia means it's a loss of some muscle mess. Usually happens as we get older. And what people don't realize is, as we get older, we lose some muscle and people think, well, muscle is just really all about power and being able to walk around and get up from sitting, et cetera, et cetera. But muscle actually has a lot of metabolic functions as well, and I think that's important. As you get older, apart from the fact that when you lose some muscle mass and it's harder to get around and function, you're also losing a metabolic or some metabolic function, and that becomes more important as you get older as well. And I think most people don't realize and don't understand that. My feeling is muscle has a very important metabolic functions. And that's not even talked about much in medicine. What's your take on that?
Dr. Robert Rountree
Oh yeah, I think it's extremely important. We know as we get older, the risk of diabetes goes up with type two diabetes and insulin resistance. And part of it is the sugar load in the body. Where are you sopping up most of that sugar to deliver in the muscle. So if you don't have the muscles being metabolically active to burn fat and sugar, where's it going to go? It's going to stay in the bloodstream and poison our tissue. Which brings us to an important question I'm hoping you can address, is sarcopenia something that happens in really frail skinny people, or can you be overweight and have sarcopenia?
Dr. Frank Lipman
No, it can happen, in fact, it often happens in overweight people. So it's definitely not just frail skinny people. That's also a point I was trying to make. We assume that frail, skinny people are the only people with this loss of muscle mass. But it's extremely common as we get older. And I think one of those things that's easily addressed with exercise and strength training, and I sort of fit into that category, I'm a little bit lazy. I don't mind going on my bike and walking, but I just don't do enough strength training. And the two of us are old farts, Bob. I think strength training and building muscle mass becomes more important as you get older. And it's one of the things that I just need to keep reminding myself how important it is.
Dr. Robert Rountree
I have to say that I was having this exact discussion with a patient the other day, who's a Pilates instructor, and she's in her sixties. And she was saying, "I really have to work harder than I did when I was younger to maintain the same kind of strength and agility." And I explained to her that this is a phenomenon we call sarcopenia. I said, "I'm really sorry to tell you this, but when you get older, it is more difficult to maintain your muscle mass." That's just the way it is. And we don't understand all of the factors involved, but probably hormones have something to do with it.
Dr. Frank Lipman
Yeah.
Dr. Robert Rountree
It's partly a matter of working out less. We get older, we have more things going on, grandchildren to take care of, that sort of thing. So spending two hours a day in the gym is not what you're going to be doing. So the lack of exercise may explain some of it, but even people that work out can still get sarcopenia.
Dr. Frank Lipman
Right. Which brings me to what I always find a big dilemma in aging and what we do too to age well, because as we know, we should decrease, at some stage, let's say we get into our forties or fifties, we need to decrease the amount of animal protein we eat if we want to decrease the amount of mTOR, which is one of those longevity genes. So theoretically, if you want to decrease your mTOR, you decrease some animal protein and you're going to age well. But on the flip side is, if you're going to decrease some animal protein as you get older and you start losing some muscle mass, because animal protein would be one way to help with increasing muscle mass, you have this dilemma. You want animal protein to increase your muscle mass, but you don't want too much animal protein to trigger your mTOR. What's your take on that sort of dilemma? Because that's a dilemma that I face all the time and I struggle with.
Dr. Robert Rountree
It's a great question. We know that one of the main amino acids that activate mTOR is leucine.
Dr. Frank Lipman
And methionine, right?
Dr. Robert Rountree
Yeah, yeah, leucine and methionine. But leucine is what you find in branched-chain amino acids. Now there have been some great studies on people that have lost muscle mass, and I think some of the earlier studies where people with HIV that had muscle wasting from HIV. And they found that when they gave them branched-chain amino acids that were rich and leucine, it helped them rebuild muscle mass. And so the same strategy has been used in older individuals that have lost muscle mass.
So that's a little bit of a paradox because as you said, we often tell people if you want to live longer then maybe you should not be eating a lot of leucine. And that's the whole theory behind the Fasting Mimicking diet, is that it's leucine restricted.
Dr. Frank Lipman
Right.
Dr. Robert Rountree
If I have an older individual that's lost muscle mass, I'm not so sure that restricting leucine is a great idea. I'm more inclined to go along the lines of giving them the branched-chain amino acids, which I recommend a lot.
Dr. Frank Lipman
Right.
Dr. Robert Rountree
In fact, they're special formulations of branched-chain amino acids that were specifically designed to prevent the loss of muscle mass. So I'm a big fan, we call it amino complex, and its a really easy thing to supplement.
Dr. Frank Lipman
The way I work with that is I suggest people between, let's say 45 and 60 or 50 and 65, before you start losing too much muscle mass and decreasing animal protein is a good idea. And plant, protein has a different amino acid profile. So you don't have as much methionine and leucine, so that may be a good idea. But as you start getting into your sixties, I think getting back on some, if you don't want to do animal protein, what's your take on collagen? Because supposedly collagen would be, in my understanding, is sort of this balanced or not balanced, but sort of a compromise. It's not so high in leucine and methionine, but it does have some.
Dr. Robert Rountree
I'm just not sure how well the connection is established between collagen and muscle mass. I think there's some pretty good studies on collagen and skin health and wound healing. And so I do recommend collagen into people who say they feel like their skin is getting older more quickly. I think there's some data on that. Have you seen studies on collagen protein for improving muscle mass?
Dr. Frank Lipman
I have not, no.
Dr. Robert Rountree
Yeah. I do use it, I do recommend it sometimes for people. But again, I'm more inclined to go with the branched-chain aminos just because it's a lot more specific. Now when you have older people that live alone, they've lost their appetite, they don't want to heat that much, then I certainly think having a plant-based protein supplement every day is not a bad idea.
Dr. Frank Lipman
Yeah, which is what I do. I have pea protein daily just to make sure that my protein intake is good. And it's not that I don't eat animal protein, I just don't eat as much as I used to. So it behooves all of us old farts to do more strength training.
Dr. Robert Rountree
More strength training. Now the other thing I would throw out before we move on to osteopenia and osteoporosis is that there is a supplement called hydroxymethylbutyrate, or HMB, that I think is terrific. It actually prevents breakdown of muscle. And it's got data on it for preserving muscle mass in older people. The dose is about two grams a day, it's inexpensive. I know a lot of younger athletes that use it to bulk up, but I'd say I actually used it more in older people, along with the branched-chain aminos, the amino complex. So it's a nice combination for people that are already working out, they're already doing the basic exercise.
Dr. Frank Lipman
Great. That's a good tip.
As sarcopenia is a loss, when you start to lose some muscle mass, osteopenia is the beginning of starting to lose some bone. And osteoporosis is sort of a more extreme version of that. As far as I understand it, osteopenia, and osteopenia is more related to the osteoclast and the balance of these cells that build muscle and cells that break down muscles.
Dr. Robert Rountree
The blasts and the clasts.
Dr. Frank Lipman
Yeah, the blast and the clast. And inflammation here is more of a factor than it is with sarcopenia. Inflammation triggering the osteoclast to overreact, to be overactive and break down bones a little bit more. So the way I understand it is osteopenia is more, once again, we can't separate, the bone and muscles aren't separate from the rest of the body. But the bone aspect, osteopenia, as opposed to sarcopenia, is more connected to inflammation in the body, which also increases as we get older. As we get older, we tend to have more osteopenia and sarcopenia, but osteopenia may be more related to inflammation, which is going to increase as you get older, than sarcopenia is. Would you agree with that?
Dr. Robert Rountree
Yeah, I think you're absolutely correct. That and the acid base balance in the body seems to be a huge influence, which I find this is interesting because the endocrinologist and the orthopedist, the bone specialist my patients will sometimes see, are very quick to prescribe drugs for osteopenia and osteoporosis instead of saying "What led to this? What are the metabolic conditions or hormonal conditions that led to it? Oh, we did a bone scan. Your bone density is low. Here, we're going to put you on a bisphosphonate," which I'm not saying I'm totally against those drugs, but as the first response, that seems like kind of a knee jerk thing.
Dr. Frank Lipman
Exactly. Which is sort of the way we see the body in Western medicine. The oil light goes on, just put a bandaid over the oil light. When you see someone who has osteopenia, what is your thinking? What do you do?
Dr. Robert Rountree
The very first thing that I do is get back to the exercise, but then it's specifically weight bearing exercise.
Dr. Frank Lipman
Right.
Dr. Robert Rountree
I'm a big fan of mini trampolines. There's pretty good data on them, they're easy on the knees. A lot better than say jumping rope or doing jumping jacks. Why am I talking about that kind of exercise? Because it's working out against gravity. Who gets osteopenia at an early age? Astronauts, right? When they're up in space, they're working out on the space station. They've got a treadmill, they're keeping their cardiovascular system intact, but they lose bone. And why do they lose bone? Because of the lack of gravity. So when they work out, you got to be working out against gravity, jumping up and down. So swimming is fabulous exercise. It's my favorite exercise, but it doesn't do that much for your bones. Right. And I don't even know biking does that much for your bones?
Dr. Frank Lipman
No. I don't think so, either.
Dr. Robert Rountree
Yeah. So it's good brisk walks. But jumping up and down where you get that increased gravitational pull. And mini tramps, love mini tramps.
Dr. Frank Lipman
Yeah. Thank you. I actually have one in the garage I need to put it out. I actually got one for myself, but it used to bother my knees, so I stopped doing it. But I need to get my wife to actually start doing it.
Dr. Robert Rountree
You can do a good workout on a mini tramp.
Dr. Frank Lipman
I know. It's damn difficult. Absolutely, yeah.
Dr. Robert Rountree
So that's the first thing I do. And then I want to look at their overall diet, make sure that they're not eating junk food because we know that the junk food, that too much sugar, and as we've already mentioned, animal protein, sugar and animal protein create a negative acidic imbalance in the body that makes the bones lose calcium. One of the worst things people can do is drink soda, not mineral water, not sparkling mineral water, but carbonated sugary beverages. Coca-Cola, Pepsi, pop. Really, probably the worst thing for your bones is to drink Coca-Cola and Pepsi.
Dr. Frank Lipman
And then obviously the nutrients become more and more important because there's a increased need for certain nutrients as you start getting osteopenic or even osteoporotic. The standard Western approaches here, some calcium. Now they're starting to recognize some vitamin D. But they're many other nutrients. It's as if all the bones need are calcium and maybe vitamin D, ignoring all the other nutrients that are necessary, like magnesium, strontium, manganese. What nutrients do you use? Obviously, there's calcium.
Dr. Robert Rountree
I love vitamin K.
Dr. Frank Lipman
Yes, K and vitamin D are very important. Absolutely. I'm a huge fan of vitamin K for many reasons, heart, bone just being two of them. Yeah. And so many people are deficient.
Dr. Robert Rountree
It's real easy to get deficient in K. You can get some from green leafy vegetables, but if a person's got osteoporosis, I recommend a supplement. I usually use the vitamin K2 form MK-7, which is actually derived from natto. The argument always comes back to, "Well, can't you just get it from food?" And my response is, "Have you ever eaten natto? Have you ever tried to eat natto?" It's the ultimate test of whether you're an authentic Japanese? I was told that by a Japanese waiter, in a restaurant once. He said, "This is how we know if you're authentic Japanese is whether you can eat the traditional natto," which is to get a raw egg yolk and you put up this blob of natto, which is this gray blob on top of that, and then you eat it.
It's the gooiest, stickiest thing you've ever seen. And you'd have to eat that every day, or you can take a vitamin K2 MK- supplement, about 90 micrograms a day is the minimum dose. I think it's 90 to 180 a day. And it's the perfect compliment to calcium. So calcium, I see, builds the foundation. But calcium by itself isn't going to cure osteoporosis. Right? So I don't use massive amounts of calcium. I just used say around 800 milligrams a day, sometimes 1,000. But I usually don't go higher than that. And I use the DiCalcium Malate, which is a very, very well absorbed calcium. It's got more calcium in it per weight than calcium citrate. So that DiCalcium Malate, sometimes called DimaCal, I find a terrific form of calcium.
And then I use magnesium with that, as we mentioned. I either like the magnesium glycinate or the magnesium malate, about a hundred milligrams of that. And then the K2, the vitamin D, certainly important. And then there's a lot of other accessory nutrients as well. So as you said, it's the whole shebang that we need to go with. So we got to take a short break now, and when we get back, we'll take some questions about all this.
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And we're back. So now it's time to answer questions from the community. Our first question this week comes from a listener who asks, "Well, how can you tell if you have sarcopenia?" Frank?
Dr. Frank Lipman
That's pretty simple. You're probably going to feel it first, you won't have the same amount of power when you exercise and strength. And as it gets worse, you can actually see it and you become a little bit more disabled and fragile. You may even theoretically see it in your blood glucose numbers in your metabolic profile. But I think the earliest sign is that you have less strength than you used to.
Dr. Robert Rountree
And if you really want it confirmed, you can do an MRI of the muscles. And interestingly enough, what they show is that muscle is being replaced with fat, right? So it's the thing that makes for a juicy steak, for the people out there that are meat eaters, a juicy steak is marbled with fat. And that's actually what's going on with muscles in sarcopenia, is that the muscle tissue is being replaced with fat. The muscle cells are filling up with fat. And you can see that on an MRI scan of the muscle. So some of the more high-end anti-aging clinics do a regular muscle scan to show that.
Dr. Frank Lipman
Right. I'll ask you the same question about osteopenia. That's another question from our community. How can you tell if you have osteopenia?
Dr. Robert Rountree
Unlike sarcopenia, where you have symptoms, with osteopenia, you usually don't know it. Right? There's nothing you can feel that tells you there's a difference with your bones. So the best way to find out if you've got it is to do a DEXA scan, dual absorption x-ray absorptiometry. I do those scans on my patients pretty regularly. It's one of my favorite kind of screening tests to do for women in their fifties. And I've started doing it more for men. I've been surprised at how many men get osteopenia, which is a little bit harder to explain because the classic thought about osteopenia is that that's what happens after menopause when your estrogen levels drop. But what's going on with the men, I think that's a little bit less clear. Anyway, if you want to know if you've got it, then a DEXA bone scan is the way to go. So what's the difference in osteopenia and osteoporosis? I guess that one's kind of a extension of what I'm talking about with scans. But what's the practical implication of the difference?
Dr. Frank Lipman
Well, the difference is, is just the degree of bone loss. Osteopenia will be early and not so bad. Osteoporosis would be further down the line and the consequences are you're much more prone to fractures. Once you start having osteoporosis, it becomes more of a serious issue to address. And obviously, yes, you start addressing it with diet and nutrients and lifestyle. But if that isn't working, and I'm not one for medications, especially the drugs used for osteoporosis.
But if I have a 60 year old woman and she's changed her diet and she's exercising, she's doing all the right things and the osteoporosis is not getting better, then I am all for using, not that I use it myself, but I send them to a endocrinologist who works with this. And I would be all for that particular patient doing one of the drugs. I think the drugs are becoming better and less or more benign. But I think if you've got bad osteoporosis and it's not responding to lifestyle, diet, supplements, exercise, then I think you definitely need to consider one of these drugs because as you get older, you just don't want to fracture your femur or whatever it is.
Dr. Robert Rountree
I've certainly seen that in people who are otherwise healthy and then they go out and step off the curb improperly and take a fall and break their hip. And that sort of thing can put an end to a person's life. Right?
Dr. Frank Lipman
Yeah.
Dr. Robert Rountree
We tend to think, "Oh, a bone fracture. Well, I broke my wrist. I need to wear a cast. It's no big deal." But a hip fracture can be life-threatening.
Dr. Frank Lipman
Yeah. And I've seen too many healthy women break their hips and they just go downhill after. It's one of those areas where I'm all for medication, if everything else has failed. And now it seems like, from what I see in my patients, there's some of these newer drugs that they get once a year or twice a year, that don't seem to be as problematic as the older ones. Is that your experience too or not? I don't know enough about it, but that seems to be what my experience.
Dr. Robert Rountree
Yeah. I can't say that I'm an expert in them. Suddenly there's been an explosion of them.
Dr. Frank Lipman
Yeah.
Dr. Robert Rountree
Several of them basically are mimics of parathyroid hormone. Right? And I think there's been concerns that they might increase the risk of certain cancers. But I think that's mostly in laboratory animals, so it's hard to say what happens in humans. I will say that having had this discussion with a number of patients, I do get pushback from people who say, "I don't want to take any drugs at any cost." And they're saying, "What else can I do?" And those are the people that I'm going to have a more aggressive exercise program, have them on a really strict diet. The drugs may be getting better and may be getting safer, but I still have a lot of people that say, "I just don't want to do them. I don't trust them."
Dr. Frank Lipman
Yeah. I have the same discussions with my patients. I'm just so scared of, I've just seen so many woman over the years, older woman, who are vital and then they fracture a hip-
Dr. Robert Rountree
And it puts them down.
Dr. Frank Lipman
Yeah. So I'm just always scared of that. Okay. So next question is, is sarcopenia and osteopenia genetic?
Dr. Robert Rountree
Yeah, I think there's a genetic component to both of them. I suspect it's not just one gene.
Dr. Frank Lipman
No. And this 3x4 Genetic tests that I'm doing actually has a number of genes that affect bone health. Part of their profile is determining bone health. And it's how these genes work together as well. So it's not just one gene, there are a number of genes and how these genes interact with each other, which determine your bone health. So you can determine actually, or get an idea if you're going to be predisposed to osteopenia. I'm not so sure about the sarcopenia, how much the genetic component is. I'm sure there is, but there definitely seems to be a genetic component to the bone part, to the osteopenia.
Dr. Robert Rountree
Countless times I've had women tell me, "Well, my mother had bad osteoporosis and her mother had a hip fracture at an early age." So you hear that a lot. You don't hear it as much with sarcopenia. And I think that's just because people haven't been tracking it.
Dr. Frank Lipman
Yeah.
Dr. Robert Rountree
Sarcopenia is not one of these common diagnoses. Everybody knows about their bone density, but who's really thinking about their muscles, they're just saying, "Hey, I'm weaker than I used to be." But they don't realize it's a real condition. Right?
Dr. Frank Lipman
Right.
Dr. Robert Rountree
And I wonder, as it gets more into the popular lexicon, as people talk more about sarcopenia, if they might be saying, "Hey, I heard my mother talk about this," or "I heard my father talk about that." So I think we'll find out more about the genetics of it in the future. So when do you treat osteopenia or sarcopenia? I guess that's a little bit different than saying when would you prevent them? Maybe we should expand that question to say, do you have an prevention program? You wrote a book on age management, so is that something people should be considering early?
Dr. Frank Lipman
Yeah. It's like everything else. The earlier you treat anything, the easier it is to reverse. I see this all as a spectrum. The earlier you can treat on that spectrum before it becomes a problem, the easier it is to reverse. So obviously, the earlier the better. I see this cutoff at 40, when up to 40 you're growing and reproducing and getting strong. After 40, it's more preserving. So from 40 years on, I think we start becoming aware of these things and the muscles and bones become two of those organs that you need to protect. So yeah, I think from forties, not necessarily treat it, but you start preventing and just becoming aware of the factors that can cause the problems and prevent the problems.
Dr. Robert Rountree
So you're saying that these are somewhat part and partial of normal aging?
Dr. Frank Lipman
Yes, absolutely.
Dr. Robert Rountree
And everybody should be expecting to get some degree of both of them.
Dr. Frank Lipman
Exactly. And how much is determined by how you live your life.
Dr. Robert Rountree
So is it ever too late? If you're 70 years old and you want to bulk up, it's never too late.
Dr. Frank Lipman
Never, never too late. I think that's something to remember with aging. They've done actually lots of studies of people in their seventies and eighties, for instance, starting to exercise and building muscle mass. For sarcopenia in particular, it's never, never too late. Osteoporosis, obviously, as we're talking earlier, that's a little bit trickier but in terms of will lifestyle alone do it. But with sarcopenia, for sure, it's never too late to start exercising.
Dr. Robert Rountree
I think we've already talked about this before, but David Attenborough, he's 93 years old and he still seems really agile and spry and has an alert mind, et cetera. And I think it's just from staying active.
Dr. Frank Lipman
Right. In fact, I just saw a documentary. Did you see that documentary?
Dr. Robert Rountree
Yeah. A Life On Our Planet, I think it's called.
Dr. Frank Lipman
Yes. Yeah, he was a narrator and it was incredible, actually. Yeah.
Dr. Robert Rountree
Yeah folks, that's all the time we have this week. Thank you so much for listening. And thank you Frank, once again, for sharing this podcast with me.
Dr. Frank Lipman
Thanks for listening to the Thorne Podcast. Make sure to never miss an episode by subscribing to the show on your podcast app of choice.
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Dr. Frank Lipman
Once again, thanks for tuning in and don't forget to join us next time for another episode of the Thorne Podcast.
Dr. Robert Rountree
This is the Thorne Podcast, the show that navigates the complex world of wellness, and explores the latest science behind diet, supplements, and lifestyle approaches to good health. I'm Dr. Robert Rountree, chief medical advisor at Thorne, and functional medicine doctor.
Dr. Frank Lipman
And I'm Dr. Frank Lipman, New York Times bestseller and functional medicine doctor. As a reminder, the recommendations made in this podcast are the recommendations of the individuals who express them and not the recommendations of Thorne. Statements in this podcast have not been evaluated by the Food and Drug Administration.
Dr. Robert Rountree
Any products mentioned are not intended to diagnose, treat, cure, or prevent any disease. Hi everyone and welcome back to the Thorne podcast. How are things going for you, Frank?
Dr. Frank Lipman
I'm good. I'm actually quite enjoying winter for a change. I usually hate winter, but it's actually a good time now, spending more time with my grandson, which is wonderful. So forced to do that and I can't complain. And you?
Dr. Robert Rountree
I'm good. Yeah, yeah. Trying to get out. The winter has not really hit us full force yet in Colorado. We've got a little bit of snow, just enough to make it fun to go walking out in the back country. So I've been going for some hikes out in the woods and I always love doing that.
Dr. Frank Lipman
That's great. Yeah. My daughter is obsessed about getting her little son out every day, twice a day, at least. So it forces me to get outside, which is good.
Dr. Robert Rountree
Got to keep his vitamin D up.
Dr. Frank Lipman
Right.
Dr. Robert Rountree
And yours.
Dr. Frank Lipman
Okay.
Dr. Robert Rountree
All right, let's get into the main topic for this week. We actually have a combination of two topics we wanted to talk about, that overlap, and that would be sarcopenia and osteopenia. So Frank, I wonder if maybe you could define what those terms mean, in kind of a general concept for our audience.
Dr. Frank Lipman
Sure. So we'll start with sarcopenia. Sarcopenia means it's a loss of some muscle mess. Usually happens as we get older. And what people don't realize is, as we get older, we lose some muscle and people think, well, muscle is just really all about power and being able to walk around and get up from sitting, et cetera, et cetera. But muscle actually has a lot of metabolic functions as well, and I think that's important. As you get older, apart from the fact that when you lose some muscle mass and it's harder to get around and function, you're also losing a metabolic or some metabolic function, and that becomes more important as you get older as well. And I think most people don't realize and don't understand that. My feeling is muscle has a very important metabolic functions. And that's not even talked about much in medicine. What's your take on that?
Dr. Robert Rountree
Oh yeah, I think it's extremely important. We know as we get older, the risk of diabetes goes up with type two diabetes and insulin resistance. And part of it is the sugar load in the body. Where are you sopping up most of that sugar to deliver in the muscle. So if you don't have the muscles being metabolically active to burn fat and sugar, where's it going to go? It's going to stay in the bloodstream and poison our tissue. Which brings us to an important question I'm hoping you can address, is sarcopenia something that happens in really frail skinny people, or can you be overweight and have sarcopenia?
Dr. Frank Lipman
No, it can happen, in fact, it often happens in overweight people. So it's definitely not just frail skinny people. That's also a point I was trying to make. We assume that frail, skinny people are the only people with this loss of muscle mass. But it's extremely common as we get older. And I think one of those things that's easily addressed with exercise and strength training, and I sort of fit into that category, I'm a little bit lazy. I don't mind going on my bike and walking, but I just don't do enough strength training. And the two of us are old farts, Bob. I think strength training and building muscle mass becomes more important as you get older. And it's one of the things that I just need to keep reminding myself how important it is.
Dr. Robert Rountree
I have to say that I was having this exact discussion with a patient the other day, who's a Pilates instructor, and she's in her sixties. And she was saying, "I really have to work harder than I did when I was younger to maintain the same kind of strength and agility." And I explained to her that this is a phenomenon we call sarcopenia. I said, "I'm really sorry to tell you this, but when you get older, it is more difficult to maintain your muscle mass." That's just the way it is. And we don't understand all of the factors involved, but probably hormones have something to do with it.
Dr. Frank Lipman
Yeah.
Dr. Robert Rountree
It's partly a matter of working out less. We get older, we have more things going on, grandchildren to take care of, that sort of thing. So spending two hours a day in the gym is not what you're going to be doing. So the lack of exercise may explain some of it, but even people that work out can still get sarcopenia.
Dr. Frank Lipman
Right. Which brings me to what I always find a big dilemma in aging and what we do too to age well, because as we know, we should decrease, at some stage, let's say we get into our forties or fifties, we need to decrease the amount of animal protein we eat if we want to decrease the amount of mTOR, which is one of those longevity genes. So theoretically, if you want to decrease your mTOR, you decrease some animal protein and you're going to age well. But on the flip side is, if you're going to decrease some animal protein as you get older and you start losing some muscle mass, because animal protein would be one way to help with increasing muscle mass, you have this dilemma. You want animal protein to increase your muscle mass, but you don't want too much animal protein to trigger your mTOR. What's your take on that sort of dilemma? Because that's a dilemma that I face all the time and I struggle with.
Dr. Robert Rountree
It's a great question. We know that one of the main amino acids that activate mTOR is leucine.
Dr. Frank Lipman
And methionine, right?
Dr. Robert Rountree
Yeah, yeah, leucine and methionine. But leucine is what you find in branched-chain amino acids. Now there have been some great studies on people that have lost muscle mass, and I think some of the earlier studies where people with HIV that had muscle wasting from HIV. And they found that when they gave them branched-chain amino acids that were rich and leucine, it helped them rebuild muscle mass. And so the same strategy has been used in older individuals that have lost muscle mass.
So that's a little bit of a paradox because as you said, we often tell people if you want to live longer then maybe you should not be eating a lot of leucine. And that's the whole theory behind the Fasting Mimicking diet, is that it's leucine restricted.
Dr. Frank Lipman
Right.
Dr. Robert Rountree
If I have an older individual that's lost muscle mass, I'm not so sure that restricting leucine is a great idea. I'm more inclined to go along the lines of giving them the branched-chain amino acids, which I recommend a lot.
Dr. Frank Lipman
Right.
Dr. Robert Rountree
In fact, they're special formulations of branched-chain amino acids that were specifically designed to prevent the loss of muscle mass. So I'm a big fan, we call it amino complex, and its a really easy thing to supplement.
Dr. Frank Lipman
The way I work with that is I suggest people between, let's say 45 and 60 or 50 and 65, before you start losing too much muscle mass and decreasing animal protein is a good idea. And plant, protein has a different amino acid profile. So you don't have as much methionine and leucine, so that may be a good idea. But as you start getting into your sixties, I think getting back on some, if you don't want to do animal protein, what's your take on collagen? Because supposedly collagen would be, in my understanding, is sort of this balanced or not balanced, but sort of a compromise. It's not so high in leucine and methionine, but it does have some.
Dr. Robert Rountree
I'm just not sure how well the connection is established between collagen and muscle mass. I think there's some pretty good studies on collagen and skin health and wound healing. And so I do recommend collagen into people who say they feel like their skin is getting older more quickly. I think there's some data on that. Have you seen studies on collagen protein for improving muscle mass?
Dr. Frank Lipman
I have not, no.
Dr. Robert Rountree
Yeah. I do use it, I do recommend it sometimes for people. But again, I'm more inclined to go with the branched-chain aminos just because it's a lot more specific. Now when you have older people that live alone, they've lost their appetite, they don't want to heat that much, then I certainly think having a plant-based protein supplement every day is not a bad idea.
Dr. Frank Lipman
Yeah, which is what I do. I have pea protein daily just to make sure that my protein intake is good. And it's not that I don't eat animal protein, I just don't eat as much as I used to. So it behooves all of us old farts to do more strength training.
Dr. Robert Rountree
More strength training. Now the other thing I would throw out before we move on to osteopenia and osteoporosis is that there is a supplement called hydroxymethylbutyrate, or HMB, that I think is terrific. It actually prevents breakdown of muscle. And it's got data on it for preserving muscle mass in older people. The dose is about two grams a day, it's inexpensive. I know a lot of younger athletes that use it to bulk up, but I'd say I actually used it more in older people, along with the branched-chain aminos, the amino complex. So it's a nice combination for people that are already working out, they're already doing the basic exercise.
Dr. Frank Lipman
Great. That's a good tip.
As sarcopenia is a loss, when you start to lose some muscle mass, osteopenia is the beginning of starting to lose some bone. And osteoporosis is sort of a more extreme version of that. As far as I understand it, osteopenia, and osteopenia is more related to the osteoclast and the balance of these cells that build muscle and cells that break down muscles.
Dr. Robert Rountree
The blasts and the clasts.
Dr. Frank Lipman
Yeah, the blast and the clast. And inflammation here is more of a factor than it is with sarcopenia. Inflammation triggering the osteoclast to overreact, to be overactive and break down bones a little bit more. So the way I understand it is osteopenia is more, once again, we can't separate, the bone and muscles aren't separate from the rest of the body. But the bone aspect, osteopenia, as opposed to sarcopenia, is more connected to inflammation in the body, which also increases as we get older. As we get older, we tend to have more osteopenia and sarcopenia, but osteopenia may be more related to inflammation, which is going to increase as you get older, than sarcopenia is. Would you agree with that?
Dr. Robert Rountree
Yeah, I think you're absolutely correct. That and the acid base balance in the body seems to be a huge influence, which I find this is interesting because the endocrinologist and the orthopedist, the bone specialist my patients will sometimes see, are very quick to prescribe drugs for osteopenia and osteoporosis instead of saying "What led to this? What are the metabolic conditions or hormonal conditions that led to it? Oh, we did a bone scan. Your bone density is low. Here, we're going to put you on a bisphosphonate," which I'm not saying I'm totally against those drugs, but as the first response, that seems like kind of a knee jerk thing.
Dr. Frank Lipman
Exactly. Which is sort of the way we see the body in Western medicine. The oil light goes on, just put a bandaid over the oil light. When you see someone who has osteopenia, what is your thinking? What do you do?
Dr. Robert Rountree
The very first thing that I do is get back to the exercise, but then it's specifically weight bearing exercise.
Dr. Frank Lipman
Right.
Dr. Robert Rountree
I'm a big fan of mini trampolines. There's pretty good data on them, they're easy on the knees. A lot better than say jumping rope or doing jumping jacks. Why am I talking about that kind of exercise? Because it's working out against gravity. Who gets osteopenia at an early age? Astronauts, right? When they're up in space, they're working out on the space station. They've got a treadmill, they're keeping their cardiovascular system intact, but they lose bone. And why do they lose bone? Because of the lack of gravity. So when they work out, you got to be working out against gravity, jumping up and down. So swimming is fabulous exercise. It's my favorite exercise, but it doesn't do that much for your bones. Right. And I don't even know biking does that much for your bones?
Dr. Frank Lipman
No. I don't think so, either.
Dr. Robert Rountree
Yeah. So it's good brisk walks. But jumping up and down where you get that increased gravitational pull. And mini tramps, love mini tramps.
Dr. Frank Lipman
Yeah. Thank you. I actually have one in the garage I need to put it out. I actually got one for myself, but it used to bother my knees, so I stopped doing it. But I need to get my wife to actually start doing it.
Dr. Robert Rountree
You can do a good workout on a mini tramp.
Dr. Frank Lipman
I know. It's damn difficult. Absolutely, yeah.
Dr. Robert Rountree
So that's the first thing I do. And then I want to look at their overall diet, make sure that they're not eating junk food because we know that the junk food, that too much sugar, and as we've already mentioned, animal protein, sugar and animal protein create a negative acidic imbalance in the body that makes the bones lose calcium. One of the worst things people can do is drink soda, not mineral water, not sparkling mineral water, but carbonated sugary beverages. Coca-Cola, Pepsi, pop. Really, probably the worst thing for your bones is to drink Coca-Cola and Pepsi.
Dr. Frank Lipman
And then obviously the nutrients become more and more important because there's a increased need for certain nutrients as you start getting osteopenic or even osteoporotic. The standard Western approaches here, some calcium. Now they're starting to recognize some vitamin D. But they're many other nutrients. It's as if all the bones need are calcium and maybe vitamin D, ignoring all the other nutrients that are necessary, like magnesium, strontium, manganese. What nutrients do you use? Obviously, there's calcium.
Dr. Robert Rountree
I love vitamin K.
Dr. Frank Lipman
Yes, K and vitamin D are very important. Absolutely. I'm a huge fan of vitamin K for many reasons, heart, bone just being two of them. Yeah. And so many people are deficient.
Dr. Robert Rountree
It's real easy to get deficient in K. You can get some from green leafy vegetables, but if a person's got osteoporosis, I recommend a supplement. I usually use the vitamin K2 form MK-7, which is actually derived from natto. The argument always comes back to, "Well, can't you just get it from food?" And my response is, "Have you ever eaten natto? Have you ever tried to eat natto?" It's the ultimate test of whether you're an authentic Japanese? I was told that by a Japanese waiter, in a restaurant once. He said, "This is how we know if you're authentic Japanese is whether you can eat the traditional natto," which is to get a raw egg yolk and you put up this blob of natto, which is this gray blob on top of that, and then you eat it.
It's the gooiest, stickiest thing you've ever seen. And you'd have to eat that every day, or you can take a vitamin K2 MK- supplement, about 90 micrograms a day is the minimum dose. I think it's 90 to 180 a day. And it's the perfect compliment to calcium. So calcium, I see, builds the foundation. But calcium by itself isn't going to cure osteoporosis. Right? So I don't use massive amounts of calcium. I just used say around 800 milligrams a day, sometimes 1,000. But I usually don't go higher than that. And I use the DiCalcium Malate, which is a very, very well absorbed calcium. It's got more calcium in it per weight than calcium citrate. So that DiCalcium Malate, sometimes called DimaCal, I find a terrific form of calcium.
And then I use magnesium with that, as we mentioned. I either like the magnesium glycinate or the magnesium malate, about a hundred milligrams of that. And then the K2, the vitamin D, certainly important. And then there's a lot of other accessory nutrients as well. So as you said, it's the whole shebang that we need to go with. So we got to take a short break now, and when we get back, we'll take some questions about all this.
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And we're back. So now it's time to answer questions from the community. Our first question this week comes from a listener who asks, "Well, how can you tell if you have sarcopenia?" Frank?
Dr. Frank Lipman
That's pretty simple. You're probably going to feel it first, you won't have the same amount of power when you exercise and strength. And as it gets worse, you can actually see it and you become a little bit more disabled and fragile. You may even theoretically see it in your blood glucose numbers in your metabolic profile. But I think the earliest sign is that you have less strength than you used to.
Dr. Robert Rountree
And if you really want it confirmed, you can do an MRI of the muscles. And interestingly enough, what they show is that muscle is being replaced with fat, right? So it's the thing that makes for a juicy steak, for the people out there that are meat eaters, a juicy steak is marbled with fat. And that's actually what's going on with muscles in sarcopenia, is that the muscle tissue is being replaced with fat. The muscle cells are filling up with fat. And you can see that on an MRI scan of the muscle. So some of the more high-end anti-aging clinics do a regular muscle scan to show that.
Dr. Frank Lipman
Right. I'll ask you the same question about osteopenia. That's another question from our community. How can you tell if you have osteopenia?
Dr. Robert Rountree
Unlike sarcopenia, where you have symptoms, with osteopenia, you usually don't know it. Right? There's nothing you can feel that tells you there's a difference with your bones. So the best way to find out if you've got it is to do a DEXA scan, dual absorption x-ray absorptiometry. I do those scans on my patients pretty regularly. It's one of my favorite kind of screening tests to do for women in their fifties. And I've started doing it more for men. I've been surprised at how many men get osteopenia, which is a little bit harder to explain because the classic thought about osteopenia is that that's what happens after menopause when your estrogen levels drop. But what's going on with the men, I think that's a little bit less clear. Anyway, if you want to know if you've got it, then a DEXA bone scan is the way to go. So what's the difference in osteopenia and osteoporosis? I guess that one's kind of a extension of what I'm talking about with scans. But what's the practical implication of the difference?
Dr. Frank Lipman
Well, the difference is, is just the degree of bone loss. Osteopenia will be early and not so bad. Osteoporosis would be further down the line and the consequences are you're much more prone to fractures. Once you start having osteoporosis, it becomes more of a serious issue to address. And obviously, yes, you start addressing it with diet and nutrients and lifestyle. But if that isn't working, and I'm not one for medications, especially the drugs used for osteoporosis.
But if I have a 60 year old woman and she's changed her diet and she's exercising, she's doing all the right things and the osteoporosis is not getting better, then I am all for using, not that I use it myself, but I send them to a endocrinologist who works with this. And I would be all for that particular patient doing one of the drugs. I think the drugs are becoming better and less or more benign. But I think if you've got bad osteoporosis and it's not responding to lifestyle, diet, supplements, exercise, then I think you definitely need to consider one of these drugs because as you get older, you just don't want to fracture your femur or whatever it is.
Dr. Robert Rountree
I've certainly seen that in people who are otherwise healthy and then they go out and step off the curb improperly and take a fall and break their hip. And that sort of thing can put an end to a person's life. Right?
Dr. Frank Lipman
Yeah.
Dr. Robert Rountree
We tend to think, "Oh, a bone fracture. Well, I broke my wrist. I need to wear a cast. It's no big deal." But a hip fracture can be life-threatening.
Dr. Frank Lipman
Yeah. And I've seen too many healthy women break their hips and they just go downhill after. It's one of those areas where I'm all for medication, if everything else has failed. And now it seems like, from what I see in my patients, there's some of these newer drugs that they get once a year or twice a year, that don't seem to be as problematic as the older ones. Is that your experience too or not? I don't know enough about it, but that seems to be what my experience.
Dr. Robert Rountree
Yeah. I can't say that I'm an expert in them. Suddenly there's been an explosion of them.
Dr. Frank Lipman
Yeah.
Dr. Robert Rountree
Several of them basically are mimics of parathyroid hormone. Right? And I think there's been concerns that they might increase the risk of certain cancers. But I think that's mostly in laboratory animals, so it's hard to say what happens in humans. I will say that having had this discussion with a number of patients, I do get pushback from people who say, "I don't want to take any drugs at any cost." And they're saying, "What else can I do?" And those are the people that I'm going to have a more aggressive exercise program, have them on a really strict diet. The drugs may be getting better and may be getting safer, but I still have a lot of people that say, "I just don't want to do them. I don't trust them."
Dr. Frank Lipman
Yeah. I have the same discussions with my patients. I'm just so scared of, I've just seen so many woman over the years, older woman, who are vital and then they fracture a hip-
Dr. Robert Rountree
And it puts them down.
Dr. Frank Lipman
Yeah. So I'm just always scared of that. Okay. So next question is, is sarcopenia and osteopenia genetic?
Dr. Robert Rountree
Yeah, I think there's a genetic component to both of them. I suspect it's not just one gene.
Dr. Frank Lipman
No. And this 3x4 Genetic tests that I'm doing actually has a number of genes that affect bone health. Part of their profile is determining bone health. And it's how these genes work together as well. So it's not just one gene, there are a number of genes and how these genes interact with each other, which determine your bone health. So you can determine actually, or get an idea if you're going to be predisposed to osteopenia. I'm not so sure about the sarcopenia, how much the genetic component is. I'm sure there is, but there definitely seems to be a genetic component to the bone part, to the osteopenia.
Dr. Robert Rountree
Countless times I've had women tell me, "Well, my mother had bad osteoporosis and her mother had a hip fracture at an early age." So you hear that a lot. You don't hear it as much with sarcopenia. And I think that's just because people haven't been tracking it.
Dr. Frank Lipman
Yeah.
Dr. Robert Rountree
Sarcopenia is not one of these common diagnoses. Everybody knows about their bone density, but who's really thinking about their muscles, they're just saying, "Hey, I'm weaker than I used to be." But they don't realize it's a real condition. Right?
Dr. Frank Lipman
Right.
Dr. Robert Rountree
And I wonder, as it gets more into the popular lexicon, as people talk more about sarcopenia, if they might be saying, "Hey, I heard my mother talk about this," or "I heard my father talk about that." So I think we'll find out more about the genetics of it in the future. So when do you treat osteopenia or sarcopenia? I guess that's a little bit different than saying when would you prevent them? Maybe we should expand that question to say, do you have an prevention program? You wrote a book on age management, so is that something people should be considering early?
Dr. Frank Lipman
Yeah. It's like everything else. The earlier you treat anything, the easier it is to reverse. I see this all as a spectrum. The earlier you can treat on that spectrum before it becomes a problem, the easier it is to reverse. So obviously, the earlier the better. I see this cutoff at 40, when up to 40 you're growing and reproducing and getting strong. After 40, it's more preserving. So from 40 years on, I think we start becoming aware of these things and the muscles and bones become two of those organs that you need to protect. So yeah, I think from forties, not necessarily treat it, but you start preventing and just becoming aware of the factors that can cause the problems and prevent the problems.
Dr. Robert Rountree
So you're saying that these are somewhat part and partial of normal aging?
Dr. Frank Lipman
Yes, absolutely.
Dr. Robert Rountree
And everybody should be expecting to get some degree of both of them.
Dr. Frank Lipman
Exactly. And how much is determined by how you live your life.
Dr. Robert Rountree
So is it ever too late? If you're 70 years old and you want to bulk up, it's never too late.
Dr. Frank Lipman
Never, never too late. I think that's something to remember with aging. They've done actually lots of studies of people in their seventies and eighties, for instance, starting to exercise and building muscle mass. For sarcopenia in particular, it's never, never too late. Osteoporosis, obviously, as we're talking earlier, that's a little bit trickier but in terms of will lifestyle alone do it. But with sarcopenia, for sure, it's never too late to start exercising.
Dr. Robert Rountree
I think we've already talked about this before, but David Attenborough, he's 93 years old and he still seems really agile and spry and has an alert mind, et cetera. And I think it's just from staying active.
Dr. Frank Lipman
Right. In fact, I just saw a documentary. Did you see that documentary?
Dr. Robert Rountree
Yeah. A Life On Our Planet, I think it's called.
Dr. Frank Lipman
Yes. Yeah, he was a narrator and it was incredible, actually. Yeah.
Dr. Robert Rountree
Yeah folks, that's all the time we have this week. Thank you so much for listening. And thank you Frank, once again, for sharing this podcast with me.
Dr. Frank Lipman
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If you've got a health or wellness question you'd like answered, simply follow our Instagram and shoot a message to @ThorneResearch. You can also learn more about the topics we discussed by visiting thorne.com and checking out the latest news videos and stories on Thorne's Take 5 Daily blog.
Dr. Frank Lipman
Once again, thanks for tuning in and don't forget to join us next time for another episode of the Thorne Podcast.
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