Posture Bone Density Muscle A Stanford Doctor On Aging

TITLE: Posture, Bone Density & Muscle: A Stanford Doctor Destroys Aging Myths Most People Believe CHANNEL: The LIVING Room Podcast DATE: 2026-04-29 ---TRANSCRIPT--- A baby born today can [music] expect to live 100 years, but the WHO or World Health Organization has come up and said the average health span is 64, which means on average we’ll all be living [music] 15 years in not great health. So, we do have a lot of work to do. One of the studies, around 1990, published in the Journal of American Medical Association, took nursing home residents, they were around 90. They called it high-intensity interval training. Work with a trainer three times a week for 12 weeks. They did CT scans of their muscle, it [music] increased by 174%. It proved the concept that even if you’re late to the party, you can still have a good time.

one cause of injury-related death in adults over 60 is trips and falls. Right. Since 2000, the CDC has shown basically rise in injury-related, fall-related deaths. Exercise is the thing that comes up time and time and again for every single thing we talk about associated with aging. Absolutely. The evidence is absolutely clear, [music] and I think if you don’t get 100% agreement across the board, then that person needs to be checked. What is the most overrated piece of longevity advice you’re seeing at the moment? [music] NAD. NAD in all forms? Correct. Today we are joined by Dr. Deborah Cardo, professor of medicine and co-director of the Stanford Longevity Center, and one of the leading voices challenging how we really think about aging. Her work spans everything from bone health and posture to resilience and the microbiome, but what makes her perspective so powerful is a simple idea that much of what we accept as normal aging may not be normal at all. In this episode, we talk about the impact of posture, bone density, muscle and power, and its impact on length and quality of life, on how we can and should raise our expectations of what we can achieve as we head into our 80s, 90s, and beyond, and the actions you should be taking right now to build a suit of armor to protect against the hallmarks of aging. Enjoy. Deb, first thing I wanted to um say is that I really appreciate the matching socks today. Me, too. I’m just so much more relaxed now. Yeah, yeah. [laughter] So, let’s start here. You are both a gerontologist and a geriatrician. What is the difference? Uh and please explain that as if I was a child. Okay. Are you a child? and then secondly, at heart. Yeah, child at heart. And then secondly, I think how did you get to become both? So, a a gerontologist is someone who studies aging, uh does research on aging, and a geriatrician is a physician who takes care of older adults. So, um there’s some overlap um in that when you think about studying aging, people think about old. Mhm. But in fact, aging starts almost when we’re conceived. You can There’s some debate about exactly when it starts, but it starts pretty young, like when And then it goes for the entire lifespan. So, really you can say you study aging and study any time during the life course, but people tend to think about old. Yeah. Here’s my prediction. I think the geriatricians are going to become the new rock stars. And here’s why, right? Okay. Hear me out. Okay. Six 65’s now the new 45, I think, and we’re seeing so much um uh press, media, appetite for doing anything we can to live healthier, longer lives, and I think part of that is because there’s some of these promising geroprotectors, these molecules and therapeutics that we’re seeing in animal models, and people are now like, “Oh, what if I could maintain function and independence for longer?” And we’re seeing so many examples of that because we know in many ways how to do it, right? And so I think the we should be, if we haven’t already, reframing this definition of aging and what that means for people. Yes, I think we’re at a sea change. I would say about 5 years ago when I arrived at Stanford and looked up geriatrics cuz I left geriatrics for a long time to come back. Um I was shocked and I thought, “Well, the name sounds terrible. Maybe we should be longetivist or something.” Um but in these 5 years I’ve I’ve circled back thinking we have to embrace this term. It’s nothing to be ashamed of. It should be something we should be proud of. We’re the only medical doctors who actually get training in all the different care settings. Meaning from outpatient to inpatient to post-acute care to long-term care to home-based care. Um when you get specially trained in geriatrics, you go to all those settings. Yeah. So So, given that certainly when you began in this space, it wasn’t considered all that sexy or all that cool, why why pick that as a domain? So, the thing that I think that really steered me towards geriatrics, so anybody’s my route was very circuitous, um but is that I trained actually in New York City um in medical school um at Cornell where uh it was the height of the AIDS epidemic where uh well, not the height, but it was coming, and we just didn’t even we weren’t even sure what caused it, but was exposed to a lot of suffering and death through my medical school education. And then once I uh reached residency, I was then responsible for sometimes 80% of my inpatient service were generally young people dying of AIDS. Um and or I had trained at a uh county hospital, Harbor-UCLA Medical Center in Los Angeles, or I I had uninsured adults. So, I had young people coming in with curable diseases like acute leukemia that we had at that time the ability to do a bone marrow transplant, but uh they didn’t have the resources, and so I had to do the next best thing, which was give them think chemotherapy to um you know, get rid of the cancer cells in the marrow, and that would ha- ha- help for a while, but I would get to know the you know, residency is 3 years, so I’d see them come back again with a recurrence and eventually not be able to save their lives. Um this is before palliative care, um and that was something that how do you help as being a doctor who is supposed to be curing people when there is no cure? Or when there’s a cure, but you can’t get it for them. to get. Yeah. And um then the gerontology you asked me how I became a gerontologist, so I was chief resident, and my um chair was saying, “Well, what are you going to do with your life?” And I said, “Well, actually I kind of like the academic center.” And he said, “Well, if you’re going to stay in academic medicine, you need to know how to do research.” And I’m like, “I don’t know. I didn’t do that well in English and you know, cuz you have to write grants and you know, whatever.” But I uh I thought about that, so um uh he introduced me to some He said, “Well, what kind of research would you be interested in?” And I said, “I don’t know. I want I think I went to a women’s college, so I thought I would might be interested in women’s health. So, he introduced me to someone who had um expertise in women’s health, and she had a data set of a randomized control trial of 870 women. It was called the PEPI trial, where they got randomized to hormone versus non-hormones, and look at the outcome was bone density. And And so I met with her, and she said, “I’m an epidemiologist, blah blah blah.” I’m like, “What’s that?” [laughter] And she’s like, “The study of diseases in populations.” I’m like, “Oh, okay.” She goes, “So, think think read all these papers,” which were totally boring on bone. I couldn’t care about bone, but she’s like, “Here’s the epidemiology of hip fractures, blah blah blah.” So, I read this, and I say, “Okay, here’s this data set. I’m supposed to make some correlations here.” And then I thought back to a med school lecture, which was here in New York as a second-year student with a Diet Coke sitting in the second row, and I got called out, me and my roommate, both with Diet Cokes. “Those are phosphoric-containing sodas that are bad for your bone.” And this is a nephrologist. And [clears throat] I sat there, didn’t make me stop drinking Diet Coke, but I don’t know. What it was, it 6 years later, I thought, “Oh, they have dietary data. They have bone density. I’m wondering what these diet diet sodas or phosphoric-containing sodas are doing for your bone.” So, that was my first study question. Put in it into my essay in women’s health to UCSF, the only place where I applied. Um I got I got um um connected to not a women’s health person, but someone who was an expert in osteoporosis, brought us the epidemiology, risk factors for hip fractures. His name is Steve Cummings. He um also helped with the alendronate trial for you know, all the bone drugs. And he was so infectious that I became in love with bone, and um he gave in that first lec- lecture to the fellows about how one in six women over the age of 50 uh will experience a hip fracture, um and the mortality after a hip fracture is somewhere around 25% in the year following a hip fracture, and that vertebral fractures, one study out of Mayo Clinic, Minnesota, demonstrated that if you have vertebral fractures, you’re also more likely to die. But those were clinically diagnosed vertebral fractures, and we know that only about a third of vertebral fractures come to diagnosis. That means 2/3 people are wa- 2/4 of people are walking around, they don’t even know they have a vertebral fracture, and they’re more likely to die. And then they said, “Oh, um [clears throat] So, think of some study questions again, you know?” And I’m thinking, “Oh, wow. Um Well, that’s interesting. He has a cohort or study population of almost 10,000 women. They all have spine x-rays. Um that So, that wasn’t if they’re symptomatic or not. They had a very validated way of grading whether someone had a vertebral fracture. Mhm. And death is a pretty clear outcome. Yeah, yeah. That was my Well, it was my second study question. But, this is only our podcast. So, second study question. What did we find that um the more fractures you had, regardless if you knew that you had them or not, you that more likely you would die over the next 8 years. And if you looked at the severity of the fracture, the more severe the fracture, also the more likely it you would die. And these are women who were over the age of 65 at the time of enrollment, predominantly white. Um and it wasn’t because they were less active or they were smoking or the kind of diet that we could measure or anything that we could easily say why this was the case. So, but that wasn’t the next question. Why is this the case? Yeah. Why are these women dying with a vertebral fracture over 8 years? So, luckily I had another mentor, um Warren Browner, um who then said, “Well, Deb, in 600 women we have measures of their posture.” I said, “Really?” And um it came out for the vertebral fracture data that if you had um pulmonary disease, chronic obstructive pulmonary disease, pneumonia, blood clots to the lung, you’re much more likely to die of those causes. And then that then that begged the question to me, “Why are we dying of lung-related pulmonary causes?” And that’s when I thought, “Oh, maybe because you get bent over, because you get hunched because of um the vertebral fracture.” And that’s when we did the curvature thing. And we replicated it that yes, even in these 600 women, which was a subset of the 5,775 women that I looked at, that the more curved they were, the more likely they were to die sooner. And then the next thing was, “Well, why are they dying?” Also more likely to die of a pulmonary cause. But then the last thing before I left fellowship was 2 years. Um Warren says to me, “Well, Deb, you should see how many women um actually have vertebral fractures.” I said, “Oh, yeah, that’s brilliant.” So, we looked and actually only 1/3 of the women who were who were the most hunched over actually were dying of pulmonary causes. So, then I thought, “Wow.” And he said, “Deb, this has got to be cato non-osteoporotic osteoporosis. Good luck with your life. Go on.” And that’s how how I ended up. So, so the just to get this clear in my head that Yeah, that’s a lot. that Yeah. [laughter] Sorry. That but that that and we call this hyperkyphosis. Correct. Yeah. Um the the they’re hunched over, they’re rounded through their posture, what we typically associate, rightly or wrongly, with older people. Right. Right. And And often osteoporotic. Yeah. But what was that the cause or the signal? What what was the What did you determine? Like are they Is that rounding of the shoulders, that poor posture, causing the the mortality or or is it a product of something else that we’re not unsure of? So, that’s a great question. So, that leaving UCSF and going down to UCLA, that that’s what made me wonder like, “Well, if it’s not the typical definition of osteoporosis, what is it and what is kind of the pathway that are causing these people to do worse?” So, uh thanks thanks to funding from the National Institutes of Health, I was able to be uh refunded for my student loans to continue this line of research and also get funding to better answer these questions. Uh and what we found was that regardless of the cause, the more hunched over you were, the more likely it was that you were going to be walking slower. Mhm. You’re going to have a decline in physical function. That you might even fall. Yeah. That you might get a fracture. And also repeated that um you’re more likely to pass away sooner. So, it was replicated. It was not just one finding, but uh other findings as well. Can we Can we double-click on that? Couple of elements in that. I think one of the frightening things that we associate with aging is this loss of function, mobility, um you know, the capacity physically to do the things that we want to do. And you know, we’ve talked about this in the past and I often reference this that when I think about longevity, I’m not thinking about how do we live forever. You know, I think we’re still a long way off even adding decades to the the total lifespan. And look, I’m optimistic and bullish that those things will come in the future. But, if we’re being realistic and grounded in the evidence we have right now, we’re not even doing a great job of living to 80, 90 and and our 10th decade in good health, right? And so, if there are things that we can do now that can help us retain our physical capacity, Yeah. and we know what they are, then I feel like we should be trying at least to do those with urgency or weave them into our lives in a way that is sustainable. And I think when it comes to this topic specifically, so like bone mineral density and posture and the reduction in likelihood of trips and falls, that that feels more like a math problem to me than it does a science problem because of the work that you’ve done and so many other great scientists. Like we know that we should be retaining as much bone density as we can and building as much lean tissue and strength. I don’t know if you saw the JAMA article that got published this week about women’s strength and mortality correlation. You know, I think it’s becoming kind of um hard to debate that, you know, strength and mobility and power Yeah. are are infinitely important for retaining function. This is a long rambling way of saying, you know, is that irrefutable now? How do we go about protecting against those things? Um and should we be reframing the way that we look at these? So, the short answer is absolutely. [laughter] [gasps] The longer answer is that I think it the time is no better than now. Mhm. So, a baby born today can reasonably expect to have a 100 year-long life. In the United States, as of 2023, the average life expectancy was

Average between men and women. And the WHO or World Health Organization has come up and said, “Well, in the United States, the average health span is 64.” Which means on average, we’ll all be living 15 years in not great health. Which seems like a long time to not be enjoying life at its best capacity. So, um we do have a lot of work uh to do, um but I also have been going around recently saying um questioning what is this diagnosis of health span? Because as a geriatrician, what I see is that people along an entire lifespan get challenges in terms of their health. And they may um have a decrement in their health, but they can still be healthy moving forward. So, as an example, a lot of cancer survivors came to me while I was in my bone clinic at UCSD and they changed their lifestyle, became incredibly um thinking about what they put in their mouth every day and also that they could be more physically active. And we’re talking 15, 20 years later, just looking, you would never know that they had cancer. And and um they made that change and I think they would say, and I would say as their physician, they’re experiencing healthy longevity. Yeah. You’re you’re 80 years old and when you were 45, you were diagnosed with breast cancer that everybody thought would kill you. And there they are and they look great and they’re still totally functional. So, I I say health span is not what I’m looking at, I’m looking at healthy longevity. And also because health span to me would the definition would differ depending on who you are. What’s interesting about what you just said is that the the those of the the cancer um diagnoses, the people with the cancer diagnoses, who came to you and then um felt compelled to take action to do those things, experienced this much um uh this kind of unsurprising increase in healthy lifespan, right? When they were kind of people were probably counting them out. But, they did the thing and and I think one thing that’s a challenge to all of us is there is a difference between knowing the thing that you should do and actually doing it, right? And I think sometimes in the absence of any Like when you’re asymptomatic, when you feel okay or good or free from pain or um uh like any mental health issues, it becomes kind of challenging to then motivate yourself to to carve out time to do the thing. Yeah. And so, even with the evidence and even knowing what we should do, how do we create urgency there, specifically for younger people? Yeah, so I think it’s harder for younger people. And the the short answer for me is time horizons. Mhm. So, let’s just say you’re 30. Okay? And you’re thinking, “Well, I got a lot of time. I don’t even know what I’m doing in my life. I don’t know the purpose of my life. I don’t know if I have a life partner. Am I going to have kids or not? I mean, there’s just so many open-ended questions. But, it feels like you have time. Yeah. When you get struck with cancer or you get to be 60, you’re like, “Ooh, I’m old, you know?” [laughter] Or, I’ve got I’ve got a disease that I’m not looking at Now, I’m 35, and if I make it to 40, I’m happy. Because I have a cancer that the doctors are telling me could kill me. So, then [clears throat] your time horizon changes. And then you start thinking, “My god, what is important?” Well, maybe relationships are important to me. Maybe the fact that it’s sunny outside and not rainy today, I should count that as a a win. And so, um I think that’s the benefit that older people get because they realize those time horizons. They’ve already lived it. But, for young people, it’s really hard because it feels like time is infinite. Yeah. But, I think if they realize that every action that you take has a consequence, and they’re thoughtful about it, then they’d say, “Well, gosh, should I really do this because it could have drastic implications for the rest of my life?” Then it might motivate them to be different. But, I think almost anything that’s worth it in life requires hard work. Yeah. So, it’s a matter of what’s important to them. And am I right in saying, and fact-check me here if I’m not, that the number one cause of injury-related death in adults over 60 is trips and falls? Right. It’s It’s It’s uh since 2000, uh the CDC uh has shown basically a a rise in injury-related, fall-related deaths. So, it is increasing, yeah. Here’s what I find frightening about that as a statistic is that if we take some of the those statistics that you mentioned earlier, you know, like people who fall and break a a hip or I suspect a femur is a similar sort of data set, that so many, I mean, isn’t it like 20 to 30% if not more, are dead within 12 months after the age of 65? So, those are data that stem from the 1980s. Um and the world has relooked at those data. I think they’ve been pretty constant. So, I’m going to say yes, but I haven’t personally re- uh relooked at them.

that number is, it’s a frightening number, I think, even if that has changed slightly. Right. And this is because when you fall and you have an injury such as a fracture, then you’re often laid up. Sarcopenia, yeah. And then and you have to face that. function. And so, it’s tough, and it it can have an impact on your mood and your agency. [clears throat] It may You know, everybody was telling you look old, and now you feel like, “Oh, I guess I really am old.” You feel older, yeah. You feel older, and so, yes. Well, I think one thing that we sort of approach with real urgency with everyone, certainly over the age of 55 and above, but I mean, these numbers start going down in your 30s, is like how do we retain if not build as much lean tissue, power output, heart and lung function, and mobility as we can because those things we are really fighting a losing battle if we’re not doing them. And the rate at which we lose power and strength and lean tissue year by year is is a pretty um a constant and devastating decline if we’re not taking action against it. But, there is so much that we can be doing to not only slow that down, but but reverse those metrics. Well, one thing about uh habits, right? So, we can use like regular exercise as a habit is that it’s a habit, so it is easier. So, if you start sooner, then it’s easier to maintain. But, if you haven’t started, and let’s just say you’re 70, it’s a little It feels a little harder because it’s not part of your lexicon Sure. your vocabulary. Um but that being said, one of the studies, I think I’m around 1990, published in the Journal of American Medical Association, took I think it was only 10, so small, um nursing home residents. I think they were around 90, somewhere maybe the top age was 93, the bottom age was 87, somewhere around there. And they started them and and I didn’t even know this existed back then, but they called it high-intensity interval training. Mhm. Yeah, but in the 90s, that’s just kicking off, right? And they they had these guys who were frail uh in a nursing home work with a trainer three times a week for 12 weeks, and there they did CT scans of their muscle fiber. It increased by 174%. But, more importantly that their CT scans look better, they were walking faster, they were ascending stairs that they weren’t doing before. And so, it just kind of proved the concept that even if you’re late to the party, you can still have a good time and still enjoy uh substantial increments in function. And um probably most people around that age are not interested in being the world-class bodybuilders, but they’re interested in remaining independent and having agency over their lives, and being mobile is a core part of that. So, I think that was a really important study that even though it was so small, it was a proof of concept that it can be done at any time. I mean, I I can testify to that. Like, I we’ve done that with many dozens of people over the last 20 years of of doing this. Like, it’s never too late. We know that for sure. Hey, can I ask you a question about one of these metrics that does feel a lot more challenging to improve um as we get older. I mean, they all become more challenging to improve, but what we see with, you know, building lean tissue, improving body composition, improving power output and strength, these things are feel like more like math problems, I think, you know, when we approach that with precision, we know how to do it in science. Mhm. Bone density Mhm. is a little more challenging, you know, that when we have members or or patients in their 70s, 80s, and beyond where we’re we’re noticing through these um DEXA scans typically markers of that, you know, osteoporosis and osteoarthritis, reversing that number is very difficult. And that we we have seen some improvements in in bone mineral density, typically through axial load, through resistance training, Mhm. um but not to the same degree. Is that a metric that is reversible? And I don’t mean through these lifestyle interventions, I mean, are there promising medicines, therapeutics on the horizon that we think could reverse that number? Absolutely. So, the first one that was FDA-approved in the United States was alendronate or Fosamax, which kind of got a bad name around 2008 because of some well-publicized adverse side effects. Mhm. Um but, yeah, you can see on average a bone mineral density increase by taking any of the alendronate or its related bisphosphonate class of drugs. Um probably the most impressive is a a newer the latest FDA-approved medicine from 2019 called romosozumab, an anti-sclerostin antibody. It’s two shots in the arm once a month for a year. And uh bone density increases in the spine were 12%. And also significant increases in the total hip. Um and but more importantly than bone density increases, they showed a decreased uh risk of all types of fractures. So, um so, bone density is certainly an important measure of risk for who might be going on to have the greatest risk of having a fracture, but it’s not the only metric. Um and it’s nice, just like blood pressure, if you have high blood pressure, we know that’s an increased risk for stroke and and cardiovascular disease. Um and we have medicines that we can use to decrease blood pressure, and you can see that effect. So, bone density is kind of like that. It’s you’re able to kind of see Does it seem like this this drug is working? And you will see increases. Mhm. Yeah. What do you think about I I saw some kind of promising data on these like I think it’s like a hydrogel of some description that they’re injecting into like bone cavity or um Do you have you heard of this or I Um so, I I cannot speak to that yet cuz I’m not sure which hydrogel you’re talking about, but if That as a concept, is that a thing that Oh, no. Um is it a concept? Sounds like a good concept. Um in reality, where it is in the pipeline and of being able to show efficacy in humans, I haven’t heard of it yet. This is the real challenging thing is that sometimes we just want things to be true and ready. And so, and I think this is this speaks to the entire problem and confusion for us as consumers, is that sometimes we’ll see a headline, and it sounds so promising, and it might really hit home, you know, we might have a family member that’s struggling with that specific element or issue. And so, we then want it to be true, and then we might champion that as the truth. And and I think it’s really difficult if you’re not a scientist or clinician to understand where in that pipeline, where from that sort of bench-to-bedside journey are we? And because because if something shows promise, even if it shows promise in a in a small human clinical trial, that doesn’t mean tomorrow I can go out and pay to have it done. Right. And even then, it doesn’t mean I’ll be able to afford to have it Right. done. so, I think if I if if we think about the things that we know today that will protect against bone loss, Yeah. that will protect against the loss of lean tissue, um that will protect against poor, you know, postural deficiencies or movement pattern imbalances, what are some really practical things that people can be doing right now that we can access, that we do know works? So, um just like life has a lifespan our cells and bones does too. So, we’re in the process of really building bone as we grow. Um we kind of peak probably somewhere in our 30s and then for women at perimenopause and menopause, they have a steep decline in the bone density. Men tends to be more gradual. But the idea is if you could put more in the bank earlier and get a higher peak bone mass, then you have it’s just like VO2 max. Yeah. Yeah, yeah, yeah. Yeah, you’re going to go down with age. But you’re starting from a higher point. from a higher point. So, let’s just say this is the fracture threshold. If you’re super high, you may never get to the fracture threshold even if you fall, right? Mhm. So, it’s this idea is in that case, yeah, it’s better to start early and be aware of what you can do to help your bone and that really is diet, healthy diet, fresh fruits and vegetables, getting enough protein, enough calcium and in your diet and um vitamin D and then and then um the activity, right? So, we know there’s a whole scientific areas of inquiry around the muscle bone interactions cuz they’re directly opposed to each other um and they’re talking to each other. Yeah. So, if you have stronger muscles, it’s going to protect your bone. Yeah. So, all those things you said going and keeping your muscles um strong and flexible um and um powerful are all things that can help protect. But but but we need to be really thinking about that. If we want to the the gold standard approach to that is to be doing that in our 30 like I mean before our 30s. Yeah. We can be cuz we can be laying down lots of lean tissue in our 20s. Yeah, yeah. Huh. Yeah, and then even let’s just say you didn’t do that, right? And you went through menopause and you you go to the like I had a lot the OBGYNs are great cuz they all had they were very aware of women’s health. So, they’d be getting your DEXAs right around um menopause and then I’d get referred a ton and the women were like I, you know, other part from menopause symptoms, I feel great, but my doctor says my bone density sucks. Um what what should I do? And that’s when you really take in all those other questions about their lives. Like what are they doing? Are they Are they even walking? Are they Are they taking care of themselves? Are they doing self-care? Um what are you know, now more than ever, you know, what what is their hormones hormonal status? Um and then let’s just say they’re 70 where it’s not such a great idea to start hormones if you’ve already gone through the transition is is that these drugs work. I mean that it’s not like they’re something like like it’s much more dangerous to be injecting other things that are not proven compared to FDA approven drugs that have been there since 1995 and have a benefit and people don’t know me, but I, you know, I started the bone clinic when I came to UC San Diego in 2012 um after I left orthopedic surgery. [laughter] And and and um and also I did in orthopedic surgery I was doing the bone clinic there. So, so really having the longitudinal experience of seeing these people and seeing the effects of the drugs and, you know, if there were side effects which were super rare, um you know, how to deal with those apart from that. What drugs are you referencing specifically here? Well, the number one is still alendronate or bisphosphonate and I do tell people that when we start talking when they come to me with their bone health issues, I ask you what you do for activity. Um I check your balance. I check your posture. I talk about breathing. Um I talk about sleep. I think I talk about a lot of um a lot of different things before we even get to the drugs. Then I do a medical workup because some people are are losing bone mass for other reasons that are beyond just age-related bone loss. And so, want to detect those so that we can identify them and then treat those appropriately as needed. But let’s just say all of that is negative, which most of the time it is. Yeah. Then they’re amazing drugs and and like I said the bisphosphonate is always going to be there if you don’t have a contraindication like super bad kidney disease because it is a medicine that will cause your bones from stopping to be resorbed, meaning um resorption and formation happen kind of coupled and as you get older, there’s more resorption. So, it kind of slows that down and allows for more formation. It’s not forever. And that’s where we ran into some problems with Diane Sawyer in 2008 because Kaiser had done such a good job they just or other doctors they just put them on like a statin and just forgot about it. And then to have no resorption for a long time is also probably not good for a subset of population Right. where they can get those crazy what they call atypical femur fractures. But by the way, because I was a bone health specialist, I saw people who survived those, generally women, and they’re doing great. Yeah. But you wouldn’t want that. I’m not what I mean to say. Yeah, yeah, yeah. But but uh in the correct setting, the the medications are fantastic. And what people don’t hear about bisphosphonates is actually in their trials. The IV form, people had less uh mortality. They died less. Um there so there seemed to be a mortality benefit which we are not talking about. That was not why we did the drug. But there’s some anti-aging even research going on with bisphosphonates as how they work in the cholesterol pathway. So, it it’s just interesting with the media shows Yeah. Diane Sawyer saying, “Oh, this is the woman who’s getting off the subway and she cracked her hip in half.” And then nobody wants to take bisphosphonates. Um and it’s not necessarily the only drug either. So, um there you know, other FDA approved medications that are out there that are quite effective, but none of them are forever. Can I ask you something that might sound a bit naive? I’m going to. Um there’s given that information, given that they they obviously appear very efficacious and that we’re even looking into anti-aging impacts from these drugs, given that there is this age-related decline in bone density and given that when we see people fall, trip, break these bones as they get older, there’s such a high correlation to mortality, why isn’t everyone given these drugs? Well, that was actually a debate at one of the American Society Bone and Mineral Research meetings where they’re like maybe everybody should be on this drug versus not. Um and actually Steve Cummings was on the debate that it shouldn’t be, which was interesting. Um I think we just have to be careful and that might segue to another idea that um in terms of the longevity space, at least at 2026, everybody dies, right? So, all of that part of living is actually dying. Mhm. And I think that’s a part that really is so scary because nobody wants to talk about it. But unfortunately, that hit me in the face when I was in my 20s, right? Because I had to witness death. Not just once, but multiple times in various reasons. And then I realized there can be good deaths and then there can be not so good deaths. But that’s your last show. That is your last on Earth as we know it. So, could that not even be a goal in and of itself to have a death where someone has agency Mhm. over um what’s facing them. And I was just thinking about this in the last day anticipating this podcast. I hadn’t shared the story, but as I said I was a medical student at Cornell. And I I think he was only in his 50s, but there was this lawyer who I was an inpatient and he had a non-Hodgkin’s lymphoma and his wife really um had been treated, but I was the lowly medical student on the service um and he had worsening um respiratory failure to the point where he was not going to be able to breathe on his own. And um I remember his wife there was so heart-wrenching. And basically the doctors are saying, “We’ve tried this chemotherapy. We’ve tried that the chemotherapy and um we’re not really hopeful that you’re going to pull through this time.” And uh and at that time it was my first experience where fortunately for him, even though his body was under such duress cuz he couldn’t breathe properly, in his lawyerly state, he said, “Well, I don’t want to die, but this is my situation. So, if you have to put the breathing tube, I I want to have that breathing tube. Um but if you cannot get me off this machine in 7 days, I want you to pull the plug.” And his wife was right there. He was so clear on his instructions. He said, “Let’s do it.” And he was in his 50s. Yeah, I think he was 56, 58 around then. When all is said and done, what has being around people at that point change the way that you think about mortality? It’s a great You know, this is what they’re saying now and all the people who are pursuing immortality, this is not new. Mhm. This is from ancient youth, yeah. Yeah, it’s from ancient times, you know. Um Plato did not think aging was a disease, but Seneca really understood the ravages of aging and so they were on and that is still a debate that’s alive and well today. Is it a disease or not a disease? Um I guess some of my quips, if I, you know, my some of the talks that I’ve given, I kind of say, “I’ve been in this field for I don’t know, 40 years now, uh 30, 40 years.” And and my quip is that the people who um say that they’re going to defy aging and live a long, long, long, long, long, long life, um none of those people are known for their extreme longevity. Mhm. And even I, for people who don’t focus on this, but now I see patients at the VA in Palo Alto, and I have a few World War vets living. I have a female 102-year-old uh veteran, and um and so uh even though I say a baby born today could expectedly live 100 years, well, we already have those examples Sure. now. Um and I guess what I’ve learned from losing young people, generally over the age of 20 to very old people over 100, is that death is never easy. Mhm. But what it’s taught me is that, like I said, I’m not going to be waiting with baited breath for the the immortality situation. So, I’m going to make the most of what I can do when I’m in good health, or acknowledge that one day, even though I might try to lead a healthy lifestyle, something may happen to me that will not like crossing the street in New York and forgetting that there are bike lanes now and not looking to your right. You know, and some of them go the wrong way down that those bike lanes. Yeah, so um I think it’s changed my way that I know it happens, and I guess I’m accepting of accepting of that. And also, I happen to be, this is a non sequitur, but I’m a dog lover, and dogs live way less than long than humans, so I’m on like, I don’t know, my fifth generation of dogs. And I feel that um how they live is something we humans could really learn from. So. I could not agree more. I think they can teach us a lot about life well lived. Yeah. And I think we we, you know, we spoke we’ve spoken about this in the past, and I think there’s so much I think there’s there’s a difference between living intentionally trying to live longer and then just living a life that is full of abundance and joy and optimism and awe and hope and faith. And like, I think they’re two different things. There is some crossover. Yeah. And I think one of the great challenges we all have is how do we create more crossover? Yeah. And I and I think we should start on this side. For sure. Um because this is what we know how to do. Yes. And you know, sure, there are some things that we can avoid that will likely help us live a longer life, all being well, and that we don’t spend too much time crossing cycle paths in New York. Yeah. Um but also, like, to what end are we doing this? And I think so much of this and and Paul and I spoke about this, so much of this is about how do we create more moments of joy and connection and and hope and happiness, because that that we have real data on that improving lifespan. Yeah. Or healthy lifespan, at least. What What do you think and I know I don’t want to I don’t want to dwell on it for too long, but um you know, this this mortality piece, I know you you teach a course at Stanford. Is that Is that right? Still Being Mortal. Yes, yes. Can you tell us about that? And I cuz I think there’s it’s kind of fascinating. Oh. Well, this is a brainchild of a few uh medical students actually prior to my um coming to Stanford. And then when I came to Stanford, uh the faculty member who sponsored this class asked me to take over, which I did, and I expanded it to kind of be first just first of all, it’s an elective, and they serve food. So, that is a huge uh so, students come during their lunch cuz their their schedules are jam-packed. But it’s really to kind of try to bring humanity back to medicine. So, it’s it is so amazing because every medical student who graduates from medical school, unless they become a pediatrician, is going to take care of an older person. Yeah, I mean, for some. Yeah, and but not everybody has a personality to want to be a geriatrician. Yeah. One thing about geriatricians, we we’re kind of self-selected. We tend to be very happy people. So, actually two academic publications back from the 2000s kind of uh happiness scales, Mhm. geriatricians do very well. Is that right? Yeah. Why do you think that is? and under-respected. to me. If you uh, you know, if you spend a lot of time, certainly for the bulk of your patients who I I and I want to be careful how I word this. Not who you can’t help, but who you can’t help cure. Yeah. Right? So, so how do you sort of reconcile with that? You know, you’re spending time with people and they know and you know they are close to the end of their life. But see, that’s the beauty about things, right? That’s what being a clinician and I’m by the way, I’ve a 25% time clinician. So, I’m not as good as the guys who are out there doing it every day. But I’ve done it throughout my career and continue to do it. Um is that life surprises you. So, you might think even with, you know, prediction of mortality is actually pretty tough, unless it’s in within 14 days. So, I never write anybody off. Yeah. Even if five In fact, probably that’s why some people come back to me because they’ll be like, “My bone density is in the toilet, and they say I can’t do anything cuz I might break in half. So, doctor, I’m really scared, what should I do?” And I’d say, “Well, your bone density doesn’t look great, but have you ever had a fracture?” No. “Have you fallen down?” Not really, maybe once, but I didn’t fracture. Like, I think you can feel reassured about that cuz you’re 73 years old, Yeah. and your bone density does not look good, but does your family have a history of any fractures? Did your mom break her hip? No, they lived to be 102. Like, I think you should feel pretty good. So, so can we quickly talk about this sort of bigger picture ambition here? You know, I think you you referenced earlier, and we’re all acutely aware that there are these super agers. You know, people do live to their 10th, 11th decade. Right. And and actually a remarkably high number of those people do so with great physical function and mental clarity and resilience. Yeah. And I think, you know, if we’re being honest with ourselves, we’d all that’s a true north goal for everyone, right? I think the idea of, Yeah. you know, having 10 great decades and then falling asleep and not waking up one day is probably the gold standard For sure. that we can at least we know is possible right now. The The challenge is, for a whole host of reasons, it doesn’t feel probable even though it’s possible for most of us. Right? Because it is not all that probable if we look at the the population as a whole, especially when we weave in these socioeconomic disparity and access to to medication and care and treatment. But I think that is the true north, is certainly my true north from this project, is how do we help everyone achieve and access 100 healthy years. Yeah. So, I want to ask you two questions based on that. One, for those that are in their 20s, 30s, perhaps early 40s right now, what would you say would be the the the your three top strategies to achieve that? Yeah. And then, the second question is, what about for the people that are in their, you know, 70s and 80s, how should they be approaching that with that same degree of optimism? Because, you know, these these things, as we’ve discussed, Okay. always improve. Great questions. I’m going to go back first to uh validate what you said, because I teach this course. I just finished this winter quarter at Stanford uh teaching about 100 undergrads, and asked them the question via Poll Everywhere, if how long would you like to live? And um the answers were some were a little shocking. Like, not very happy like, they’re 20 and they’re thinking 50. Okay, so that that was an outlier. But most people somewhere around 80. Mhm. But if you said, and I I put little qualifiers at the age. Uh but the one that I think got the most was 95 living independently. Mhm. Like, so if you if you have the qualifier that if you could live and be healthy, everybody wants to live to 100. Yeah. But if you don’t have that, and if you don’t have that experience, then the number comes down to about average life expectancy, 79. Mhm. Um so, in your 20s, what can you do? I honestly worry about our 20- and 30-year-olds because there’s just so much unrest in the world, and there’s so much pressure to be able to figure out like where is life going? That’s a huge stress. And actually, I think out of the UK, they showed amongst 30 340,000 people that it at ages between 18 and 30 are the highest stress periods. So, uh it’s it’s a time to be aware and try to live meaningfully, but it’s hard to be judgmental on that side when you’re just getting hit in so many ways, just about your own self-identity. So, I think if people could find their passion in their 20s and 30s, and then have that be their north star, and then go for that. And it may take some things that don’t sound so healthy to get there, but knowing that it’s a finite thing to get where they want to go. So, that’s for the 20s and 30-year-olds. For the 70- and 80-year-olds, I would say one thing we learn from research on aging is that the older we get, the more heterogeneous we become. Which means is that the the there’s such variability, and it just gets greater and greater the more years we live on the planet. That means your options, if you’re average Joe, like and you’re 72, I mean, yeah, you could decline. You could develop Parkinson’s, and that would be, you know, be very challenging. And then your time horizon of independent functioning, if you’re at 70 to get to 95, is an ask. Um is it possible to do well? Absolutely. Uh and we’re there are therapies now. This is where precision health Yeah. can make these people We’re going to see 100-year-old Parkinson’s people. Um the kinds of things that are coming forth. I mean, it’s just amazing they’re doing at Stanford and other places. Or, you know, they they don’t have any particular health problems, but they’re thinking, “Yeah, I like I don’t ever eat any I hate vegetables. You see anything green, I turn the other direction.” That might be a time to say, “Well, what’s important to you?” Because as a geriatrician, I can tell you all my 95-plus year-olds, they pay attention to what they eat. And there’s usually something green and fruits. And by the way, coffee is fine. So, don’t worry about the coffee from the 1970s that said it was bad. Filtered coffee is actually probably even better. And and and the more coffee unbelievable, most things have a U-shape. You can do too much, and it’s not good for you, but coffee, I’m not seeing the leveling off in terms of uh poor health, but yeah, so you can drink your coffee at will. I believe now that there is This is being done now where they can I think it’s like six or seven hours worth of filming with multiple different cameras, and they ask you a bunch of questions, and and from that data, they can create this like AI model of you. Yeah. And they’ve patented some hologram technology. Yeah. So, if you combine those two, they can create you Yeah. um before you die, and then turn you into a hologram. Yeah. And then you could just follow your loved ones around the house and just annoy them. Well, that’s the thing. I was just thinking, okay, for me, that’s not something I would invest my time and energy in, which is fine if it makes other people feel really excited. I’m good good for them. But, I’m thinking for my kids, I’m not sure. I I’d rather them have my written words or maybe even this video. They’re like, “Oh, yeah, that was Mom back then.” Yeah. Yeah. Yeah, cuz how far do you go at that point? Because I don’t know. when that becomes hyperrealistic, then it’s going to be It’s like weird. dystopic. Yeah. So, I I But, maybe I’ll change. That’s one thing One thing I learned from my older adults, too, is flexibility is good. So, it’s not that I can’t have my opinion be changed at this point. And I’m very excited when you talk about that intersection, because I think that intersection is there. I think when you’re talking about specific diseases, the drive is really huge, like if it’s cancer or Parkinson’s disease. We need to get there. People who need organs who can’t breathe on their own because they need a new lung. We need that stuff. Um the other stuff with longer and healthier lives, I guess I’m excited about it, but I’m already seeing it. Yes, yeah. Yeah? Yeah, there’s so much we can already do. Right. And so, I’m thinking, okay, what if you said, Deb, “Okay, it’s 150,” which is some some demographers think maybe that’s the upper limit. Yeah. Um sure. I guess I, you know, then that would extend my life further, but it’s not a goal. We have so much other stuff. Like, I’m talking a lot about the 20- and 30-year-olds. Mhm. Because they’re the next generation. They’re the next leaders. They’re the ones who are going to see a world that I couldn’t have imagined. And I think that’s where the research should be going. I think if we can um just compress that period of poor health even without extending lifespan. I I I think however we figure out how to do that with real precision will ultimately carry over to a longer life anyway. Yeah. Um but I think if we can do that right now, cuz that’s the thing I think that’s most frightening about getting older is when we look at like someone um in their certainly in their seems like in their 80s onwards is where we see this real sort of turn Yeah. in cognitive and physical function. Like, it feels a bit more dramatic. Yeah. Um if we can slow that down or or even reverse some of those metrics that matter, I think that’s a real win. For sure. So, this is called compression of morbidity, right, by James Fries, who was a rheumatologist at Stanford, who coined this term in 1980. Like, if we could just And he believed in running and showed that if you ran, you would decrease your time of being in poor health for longer. Running and lift weights. Yeah. I’m really excited about this one publication, because I do observational epidemiology, and our older men who there are about 2,000 of them who use the force plate that you guys use. And we asked them to jump. But, they’re mean age of 84 at the time. That was done in 2014 to 2016. So, now we have 10 years of follow-up. And the thing So, we all talk about grip strength, having good grip strength, and being at decreased risk. The thing that was most predictive of who was going to go on to not fracture, so protected, was power. Power, yeah. Power is key, and that’s what we tend to lose more. Yeah, and and a much quicker rate than strength. Yeah. two to three times as quick. Yeah. So, my take home from the research part is like we should be thinking about power as as we would think about muscle. And the issue is muscle is just been harder than bones. So, bones got a lot of traction because we could use a DEXA to measure bone density, which is an imperfect measure, but it’s good enough. Yeah. Um but the muscle component was just harder to define what that means. So, we try to do it in terms of function. Yeah, and so strength I think a combination, like a composite metric of strength, power, and lean tissue Yeah. is is where we should be sort of benchmarking. That would be interesting to see that data Yeah. layered over over a longer period. I think it’s pretty clear now that Yeah. um it And we can maintain and we can improve, sorry, not just maintain, all of those metrics. Yeah. And so, I think that is a really powerful takeaway. That’s agency. Yeah. Like, we can do that now. Yeah, that. And I just want to say because I’m in the age group where a lot of my friends are in having the onset of health problems and issues that some are pretty scary, whether it’s cardiac, cancer, neurologic, um un- previously undiagnosed genetic disorders that have led to a decrease in function. And I guess that would be considered when we talk about healthspan as a failure, but I just really want to say it’s it’s how we frame it. So, each of these people have agency and are going to do the best things that they can do. In fact, I remember one one of my patients was a physician at UCSD who had uh Parkin onset of Parkinson’s, and she was probably one of the early adopters, going to the gym, lifting weights, doing all these things, and her strength improved uh from from that. And then she got triple-negative breast cancer. It was not pretty. But, she was one of those people who persisted. So, yes, health challenges, too much seeing doctors, but living a quality life, absolutely possible. Mhm. And there’s not many of these ailments that are most highly associated with age that aren’t improved, or or your certainly your odds of either getting diagnosed with in the first place, or then once you have, managing that as a diagnosis, that aren’t improved with exercise. I mean, exercise is the thing that comes up time and a time and again for every single thing we talk about associated with aging. Absolutely. Yeah. And we just didn’t think about it before, but now it’s the evidence is absolutely clear. And I think you’d get If you don’t get 100% agreement across the board, then that person needs to be checked. I agree. Yeah. It’s It’s pretty hard to debate now. There’s not much discord, if any. Correct. I mean, about the type and what kind and all that stuff. Yeah, there’s Oh, tennis is the best sport. Whatever. Yeah, but no, doing something. Okay. Deb, I’m mindful of your time. I’ve got some quick-fire questions for you. They’re not all that quick-fire, but you only get 30 seconds to answer each one. Okay. What is the most overrated piece of longevity advice you’re seeing at the moment? NAD. So, the thing that Sorry, say again. NAD. Ooh, that’s been said more than once on the podcast. NAD in all forms? Correct. Okay. That’s a longer than 30-second Well, I’ll have to come up with something it cuz I agree. Oh, really? Yeah. Oh my gosh. You know, this all started with pellagra, right? Dermatitis, dementia, and diarrhea from the 20 when everybody was dying, highest rate of cause of death in the at the turn of the century. Mhm. They didn’t find out it was a nutritional deficiency until about 1930. Then we started fortifi- fortifying with B B6. And um and it’s all part of the same pathway. Scientists are brilliant, and right? They’re like, “NAD, we know NAD goes down with age, and we’ve shown it in our mice and even in humans, and and this is key. So, we need to replace it.” Mhm. Um and and depending on which scientific field they come from, it could be NMN, it could be NR, there’s but if you look at the human trials, right? So forget the mice for a moment or the rats or whatever, the flies. If you look at human trials, they’re for about 24 hours to maybe 3 months and what they all show and this is why you can buy it is that guess what? Your blood levels go up. So must work. Yeah. NAD and it’s in your blood. But they forget to advertise that everything that people care about, whether it’s blood pressure, blood sugar, muscle function, just name it. No difference between the groups. What what would you say is the most underrated thing that we can be doing for our longevity? Underrated? Underrated hack. Yeah, physical activity. No, you’re not allowed to say exercise because we’ve spoken about that. Oh. Aside from exercise. Purpose. Ooh, love. I agree. Two more questions. If you had Wait, no, three more questions. If you had unlimited resources, any amount of funding to answer any question in your field of research, what would it be? Um, right now my So I did musculoskeletal aging for probably the first 16 years of my academic life and I switched to the microbiome. I’m very interested in the mind-gut connection. So I’d I would invest in that. And not just the bacteria, but all the whole pathway of how it gets from what they produce in terms of the metabolomics, the metabolites that they produce to the proteins that are produced all the way to the this is like multiomic data is going to prove to be incredibly compelling. It’s blowing my mind. I was not that great in math. Yeah. Yeah. Well, I think all of these things that were math problems are going to become no problem soon. Yeah, is that crazy? With with AI and quantum computers. I’m so excited. Baffling, yeah. Yeah. And that’s why I’m so bullish on that data collection piece right now because even though we don’t know exactly what to do with lots of those markers, they’re going to become really important when the science catches up. That’s a whole another episode for us, I think like this systems biology and understanding systemically how these things work. Um, but we we won’t get that we’ll do that episode, too. Okay. If you weren’t a scientist what would you a scientist or clinician what would you be doing? That’s a good question. Um, I have that I I’m really I’m really fascinated right now with linguistics. So, for example, when you talk about aging, some people really think it’s a disease and other people don’t think of as a disease. I happen to be the camp, which is about 88% of students who I’ve queried over 5 years, do not think it’s a disease. But I think it’s also the semantics of how you define something. Right. So, I’m really interested in the languages and and how debate still going on? The disease thing. Yeah. Oh, it is. If viewers or listeners of this episode could only listen to the final 60 seconds of this, what would you want them to know about aging, getting older, um, and our ability to protect our resilience and live a life well lived. I think what I’d like them to know because I think people don’t think about it in this way. They just kind of see this huge wave of older people coming down the pipe way and maybe it includes themselves. But in 2026, demographically, we are the most even that we’ve ever been in this world history, meaning those from 0 to 10, 10 to 20, 20 to 30, 30 to 40, 40 etc. And this is an opportunity, I think, to really reimagine aging where especially in America, our culture is that we tend to get siloed. And so we’re in our silos of wherever we are, whereas so many studies show that the intergenerational collaborations benefit everyone. And and so even with living situations like for I’m going on record saying this, I’m not looking forward and I’m getting to that point where people are like, “Oh, what are you going to do? Are you going to plan and be in a senior living community?” And I feel going to lecture in some of these places that literally it’s like high school all over again. And that is not something I want to do. I would rather, you know, be have agency, live in a community where I see a variety of different people with a variety of different interests who are going to say, “Hey, have you ever tried Okay, I have never tried pickleball. Actually, my daughter’s trying to do this get me to do it, but I just have It’s been windy when we’ve been on vacation, so it’s not a good time. But one day, one day. I have Yeah. So just people who are going to expose me things that I’ve never tried before. Like I did archery when I was in ninth grade. I had loved that. Or do do something that I have never done. And the only way to do that is not go live with a bunch of other people who Doing the same thing every time, yeah. Yeah, retired academics, no. No, thank you. Yeah. Yeah. There’s a study I’m going to share this with you direct as soon as we finish the episode about markers of inflammation associated with different types of emotions. And they found that the, you know, with hope and joy and happiness, we saw these decline in these markers of inflammation, but the one that declined the markers of inflammation the most was awe. So like a psychological richness, doing something new. Yeah. And exposure to new things, so Yeah. I think there’s some real science to that. I I completely agree. Someone Ali Crum from um, Stanford um, really has looked at mindset and has shown how powerful it could be in terms of so many outcomes. Yeah. For example, or Becca Levy from Yale who looks at aging specifically and shows how our attitudes really can influence how things really turn out. Yeah. In terms of so And I think we can improve those as we weave in these these elements that make us feel and perform and even look better. Yeah. Yeah. Hey, last question and it really is the last question. [laughter] I can feel the the crew getting anxious for me continuing. Um, what makes you most optimistic about the field of aging research right now and where do you see it going over the next 10 years or so? Well, I think as you said, well, first of all, I think it’s an in vogue topic. Second of all, real people are putting a lot of resources behind it. Mhm. And third of all, we have the technology to do things that we’ve never done before. And and so all those things make me optimistic. I just hope we do it in a human way. Mhm. We’ll make sure of it. Dr. Carrode, you are a legend and it has been a privilege as always. Yeah. Thank you. Thank you.