The most played episodes among Podcast App listeners.

1. 1
   Number 1: Show 1484: Change Your Diet, Heal Your Mind

   Do you suffer with anxiety, depression, or another mental illness? Millions of people do. The usual treatment is a prescription medication. If that doesn’t work, the healthcare provider may offer a different one. Diet is certainly not the first topic on the provider’s mind. But what if, in addition to appropriate pharmacological treatment, you were able to nourish, protect and energize your brain with your diet? Our guest offers evidence that you can heal your mind with a ketogenic approach to eating. We need to acknowledge that this approach is quite different from the plant-rich eating pattern advocated by last week’s guest, Dr. Will Bulsiewicz. Humans around the world have adopted a wide range of dietary regimens that support health. Listen to Dr. Georgia Ede explain why she thinks a paleo or ketogenic diet is helpful for bolstering brain health. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, August 22, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on August 24, 2026. Can You Heal Your Brain with Food? We live in stressful times. More than 50 million Americans take prescription antidepressants, and millions more are on anti-anxiety medication. Unfortunately, while these drugs can be life savers, they don’t always work as well as we would like. In some cases, antidepressants are only about 10 percent more effective than a placebo. Dr. Georgia Ede is a psychiatrist who began her investigation into how food affects mental health serendipitously. She was experimenting with her own diet to address some physical health issues. She used a food and symptom journal to discover the best dietary choices for her own health. To her surprise, the “upside-down” diet that helped her feel better physically also improved her sleep and her ability to focus. She started looking into evidence that a paleo or ketogenic diet could benefit people with mental health challenges. What Is Metabolic Psychiatry? There is evidence that people consuming unhealthy diets full of fast food or ultra-processed products are more susceptible to symptoms of anxiety (Nutrition Neuroscience, May 19, 2026). On the other hand, people participating in a supervised weight-loss program using either a low-carbohydrate ketogenic diet or a low-fat diet reported improvements in mood (Obesity, Jan. 2007). Those on the ketogenic (Atkins) diet reported less hunger and fewer unpleasant symptoms. Researchers have also tested a ketogenic diet in people with schizophrenia or bipolar disorder (Psychiatry Research, May 2024). These volunteers also had metabolic disorders, including obesity, which is often an unwanted effect of the ant-psychotic drugs they take to treat their condition. This four-month pilot study saw participants lose weight, reduce insulin resistance and lower their triglycerides. Even more impressive, they had a 32 percent reduction in the Brief Psychiatric Rating Scale. They also reported better sleep and improved life satisfaction. You may find this recent article from National Geographic of interest: https://www.nationalgeographic.com/health/article/metabolic-psychiatry-keto-diet-brain-science. Unfortunately, it might be behind a paywall. How Does Food Affect Our Brains? Most of our body tissues are accustomed to getting energy from glucose, with the help of insulin. However, years of exposure to high levels of these compounds often makes the tissues less sensitive to the effects of insulin. The consequence is that the body–and therefore also the brain–is flooded with high levels of glucose. This exposure can result in the formation of advanced glycation end products in the brain, which can be harmful. The brain evolved to use either glucose or a flexible mix of glucose and ketones. These are the result of burning fat rather than sugar. A paleo diet will naturally provide more ketones and less glucose. Dr. Ede and colleagues have found that a ketogenic diet can be very helpful even for people with relatively serious mental problems. In one study (which was not placebo-controlled), patients hospitalized with severe persistent mental illness were given a ketogenic diet. Most did well and had significant improvements in their depression and psychosis symptoms (Frontiers in Psychiatry, July 6, 2022). Is Ketosis Dangerous? Ketosis itself simply means that you are burning fat as fuel rather than sugar. This can be achieved by following a diet that is high in animal fat, with moderate amounts of animal protein and low amounts of carbohydrate derived from plant foods. Ketosis is not inherently dangerous. However, Dr. Ede urges anyone who wants to heal their brain with diet to ask a healthcare provider to monitor and supervise the process. Prescription drug doses may require adjustment, and people may need support as they adopt a paleo or ketogenic diet. That is why this is not a do-it-yourself approach. Is Coconut Oil Helpful to Heal Your Brain? Dr. Ede described the benefits of medium-chain fatty acids produced in digesting fat. You may recall a video from a few years back in which a doctor described helping her husband recover from Alzheimer disease, at least partially, by giving him coconut oil. Some researchers consider Alzheimer disease to be a form of diabetes because the AD brain does not metabolize sugar effectively. Dr. Ede suggested that the benefits may be real, but getting medium-chain fatty acids from the diet rather than be taking coconut oil might be preferable. After Dr. Ede told us about Fran, who overcame significant memory problems by changing to a ketogenic diet, we hope there will be trials on this. Future Trials on Diet to Heal Your Brain Dietary trials are notoriously difficult to conduct. People often don’t stick to the prescribed diet, and it can be difficult to find an appropriate placebo for comparison. Nonetheless, Dr. Ede is looking forward to results from a large trial of the keto diet for people with schizophrenia or bipolar disorder. This study is being conducted in Australia. This Week’s Guest Dr. Georgia Ede is a globally recognized expert in nutritional and metabolic psychiatry. Her 25+ years of clinical experience include 7 years at Harvard University, where she was the first psychiatrist to offer nutrition-based approaches to mental health conditions. Dr. Ede co-authored the first inpatient study of the ketogenic diet for serious mental illness, developed the first medically accredited course in ketogenic diets for mental health, and is a recipient of the Baszucki Metabolic Mind Award. Current research collaborations include pilot studies in pediatric bipolar disorder, adult ADHD, and PTSD. Her internationally bestselling book Change Your Diet, Change Your Mind: A Powerful Plan to Improve Mood, Overcome Anxiety, and Protect Memory for a Lifetime of Optimal Mental Health is being translated into 11 languages and is recommended by the New York Times Book Review. The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Dr. Georgia Ede, author of Change Your Diet, Change Your Mind Listen to the Podcast The podcast of this program will be available Monday, August 24, 2026, after broadcast on Aug. 22. In this week’s podcast, we’ll learn how vegetarians can follow a ketogenic diet. How does the evidence Dr. Ede has collected accord with the chemical imbalance theory of mental illness? We also discuss why the standard American diet is not good for mental wellbeing, and we find out what might be in Dr. Ede’s own shopping cart. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

   August 21, 2026·1h 16min
   Play
2. 2
   Number 2: Show 1483: The Gut Immune Solution

   When you decide to grab a bite to eat, do you think about how to feed your gut microbes? Most of us don’t. Even if we did, their only means of stating their preferences is somewhat after the fact. Do you end up feeling less than well? Perhaps the denizens of your gut aren’t happy. In this episode, we consider how to support your microbiota and whether that can reduce the inflammation that seems to accompany modern life. At The People’s Pharmacy, we strive to bring you up‑to‑date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, August 15, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on August 17, 2026. Feed Your Gut Right to Fight Inflammation Dr. Will Bulsiewicz is a gastroenterologist who urges all of us to focus on a healthful fiber-rich plant-strong diet to maintain our microbiome in good shape. He has described his own evolution from a busy medical student relying heavily on processed food products to a whole-food plant-based enthusiast. Eating a wide variety of plants is one of the easiest ways to make sure we are getting the nutrients our gut microbes need. Why are the trillions of microbes in our large intestine so important? Dr. Bulsiewicz (aka Dr. B.) shares the story of a patient who was overwhelmed by a serious C. diff infection. A course of clindamycin for a skin infection had decimated her normal microbiome and left an open field for C. diff to flourish. Instead of treating her with surgery and even more potent antibiotics, Dr. B. and his colleagues utilized a fecal transplant. She got poop from a healthy person into her colon and left the hospital a few days later in good health herself. What Is the Link Between the Microbiome and the Immune System? Inflammation is one of the primary signs that the immune system has gone into action to fight off a perceived foe. There is a close relationship between the gut microbes, the gut barrier and the cells of the immune system. Between 70 and 80 percent of immune system cells are present in the gut (Nutrients, March 9, 2021). There is just one layer of cells in the gut barrier, firmly attached to each other through tight junctions. If those tight junctions break down, pathogens and toxins can get from the gut into the bloodstream and activate the immune system into creating inflammation Medicines That Harm the Intestinal Barrier Diets that are high in salt have a negative impact on the integrity of the intestinal barrier (Nutrients, Nov. 25, 2025). In fact, a diet high in salt can reduce the number of Lactobacilli in the gut by 90%. This also affects the permeability of the gut barrier, which can contribute to auto-immune conditions. When we asked about inflammatory bowel disorders such as Crohn disease or ulcerative colitis, Dr. B. told us he thinks it’s a mistake to classify them as auto-immune conditions. Instead, he suggests we should consider these conditions as due to the immune system rejecting the microbiome. Some of them might be initiated and perpetuated by failures in the gut barrier that allow certain organisms or their toxins into systemic circulation. A number of medications can also harm it, most notably the nonsteroidal anti-inflammatory drugs (NSAIDs). Agents like ibuprofen, naproxen, celecoxib and meloxicam may disrupt the tight junctions that keep the intestinal barrier intact (Gastroenterology, Feb. 2018). In some cases, they may also upset the balance of microbes. Four Keys to an Anti-Inflammatory Diet There are several different dietary patterns that allow you to feed your gut and fight inflammation. Good evidence supports a DASH diet, a Mediterranean diet, pescatarian, flexitarian, vegetarian and some vegan diets. We asked Dr. B. to summarize the four features healthful eating patterns share. They include adequate fiber, plenty of polyphenols, healthy fat and fermented foods (think of sauerkraut or kimchi). Fiber and Flatulence One drawback of a high-fiber diet is that when microbes in the colon ferment the fiber we can’t digest, they produce gases. It has to go somewhere, or it will cause sensations of cramping and bloating. Consequently, fiber is often associated with flatulence. Dr. B. suggests that there may be more gas, and it may be loud, but it shouldn’t be stinky. Smelly farts are born of sulfur, which is more common in a diet containing garlic, onions, crucifers like broccoli or cabbage, fish, eggs or meat. Plant-Powered Plus We wondered what might be included in the “plus” category when you feed your gut and fight inflammation. Dr. B. offers a few things that you might not expect in a book about diet, but they are related to reducing inflammation. One is to go outside early in the day, every day, to get your circadian rhythm in sync. Another is to maintain your emotional connections with family and friends. Still another, just as important, is to nurture your spiritual core. This Week’s Guest Dr. Will Bulsiewicz describes how a plant-powered diet can fight inflammation Will Bulsiewicz, MD, is a New York Times bestselling author, award-winning gastroenterologist and internationally recognized health expert. Dr. Bulsiewicz directs the Gut & Microbiome Center for Excellence, a physician-led executive medicine and telemedicine practice based in Mount Pleasant, SC. Dr. Bulsiewicz is the author of several books, including his latest book, Plant Powered Plus: Activate the Power of Your Gut to Tame Inflammation and Reclaim Your Health. His website is https://theguthealthmd.com/books/ The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Listen to the Podcast The podcast of this program will be available Monday, August 17, 2026, after broadcast on Aug. 15. In this week’s podcast, you get to peek into Dr. B’s shopping cart. Are you buying the same vegetables he does? We also get insights on his favorite recipes for grains like farro. And we discuss the effect of coffee on the gut microbes. If you want to feed your gut to encourage certain microbes, remember that consistency is crucial. You can’t eat a specific food once and expect it to make a difference. But consuming it several times a week will ultimately add up. We also discuss antidotes for flatulence, if you are interested in that. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

   August 13, 2026·1h 11min
   Play
3. 3
   Number 3: Show 1485: What Are We Still Getting Wrong About ADHD?

   A new school year is about to start in many parts of the country. Going back to school can be exciting, but some students may dread it. Perhaps they are struggling with attention deficit hyperactivity disorder, abbreviated ADHD. How can you recognize the symptoms of this problem? What are the most common misconceptions? In short, what are we still getting wrong about ADHD? When we talk about distractibility, trouble missing deadlines, forgetting where you left your keys, it is easy to relate. Likewise, when we look at kids with wiggles and short attention spans, do we see a child with ADHD or just a normal youngster? What constitutes ADHD? Does everyone have it, or is it an all-or-nothing condition? Expert John Mitchell explains that many people have some symptoms from time to time, but once a person is suffering from enough that it is affecting their ability to function, that is when a yes-or-no ADHD diagnosis is made. At The People’s Pharmacy, we strive to bring you up‑to‑date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You could listen through your local public radio station or get the live stream at 7 am EST on Saturday, August 29, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on August 31, 2026. What We Get Wrong About ADHD One of the most common misconceptions about ADHD is that it primarily affects little boys who can’t sit still. While hyperactivity can certainly make a parent or a teacher uncomfortable, the inattention aspect of ADHD could be more disabling in many instances. Moreover, girls too may suffer with ADHD. Though they are less likely to be hyperactive, they can often have difficulty focusing. Another popular myth about ADHD is that it is a pediatric condition. People think kids grow out of it. What we are beginning to see with more research into ADHD is that some people learn effective coping skills they can use as adults. Nonetheless, many older people who were not recognized as having ADHD when they were children may discover that their impulsivity and lack of follow-through, accompanied by anxiety, depression or migraines perhaps, could be a manifestation of this disorder. Failing to recognize the suffering of neurodivergent adults is another thing we get wrong about ADHD. How Do You Treat ADHD? A third misunderstanding about ADHD is that prescribing a stimulant medication is the only treatment necessary. While drugs such as methylphenidate (Concerta, Ritalin) or mixed amphetamines (Adderall) can be really helpful, there is a saying in the ADHD community: the pills don’t teach skills. They do allow a person to focus well enough to learn some new skills they will need. Nonpharmacological approaches are important in conjunction with prescription medicine. However, adolescents with ADHD are much less likely to turn to drugs of abuse if they are taking properly prescribed stimulant medicines in the context of a thoughtful treatment plan. What Is the Role of Emotional Regulation in ADHD? Pediatric ADHD expert Paul Rosen describes another assumption that we can get wrong about ADHD. A child may appear to be doing fine, bringing home As, getting along well in school. But he describes “duck syndrome,” in which you see a duck gliding along the surface of the water. The motion looks effortless, but the duck is paddling like crazy. If it gets into an eddy or a current that’s too strong, it can’t keep up. These students are working much harder than is apparent and at some point, they encounter demands they can’t meet. How will they respond to that frustration? Trouble with emotional regulation is not always part of the ADHD picture, but it isn’t unusual, either. Some kids with ADHD respond pretty much as other youngsters do, but some seem like a super bouncy ball. Their emotions go very high and very low quickly, but they bounce back quickly as well. Still other children may be more like volcanoes. When faced with frustration, they explode, and it may take them many hours to return to baseline. Focusing on Warm and Fuzzies Parents sometimes assume that impulsive or explosive behavior is willful, but that is another thing we often get wrong about ADHD. Most of the time, such behavior is emotional. The child wants to be a “good kid” but may not know how to deal with these extreme emotions. Dr. Rosen recommends unconditional positive attention. He suggests that when parents tuck their ADHD children into bed at night, they appreciate one thing the child has done that day and one aspect of the child, separate from the behavior, that is wonderful. This kind of affirmation can help a youngster keep striving for the skills they will need. (In fact, it sounds like a helpful idea for any parent and child, regardless of whether either of them has ADHD.) This Week’s Guests John T. Mitchell, PhD Dr. John Mitchell is an Associate Professor in the Department of Psychiatry and Behavioral Sciences at Duke University. His research and clinical work are focused on ADHD across the lifespan. He has published peer-reviewed articles and chapters on longitudinal outcomes and the treatment of ADHD, as well as recently co-authoring Mindfulness for Adult ADHD: A Clinician’s Guide. The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Dr. Paul Rosen Dr. Paul Rosen is an Associate Professor of Pediatrics at the University of Louisville School of Medicine, affiliated with Norton Children’s Medical Group. He currently serves as the Director of the ADHD Evaluation Services in the Division of Behavioral and Mental Health with Norton Children’s Medical Group. Listen to the Podcast The podcast of this program will be available Monday, August 31, 2026, after broadcast on Aug. 29. In this week’s podcast, Dr. Mitchell explains why people without ADHD react so differently to stimulant medication. He also describes the multimodal treatment ADHD study for which he served as investigator. What kind of career counseling could help young people find a good fit with the way their brains work? We also discuss the benefits and the challenges of mindfulness as a complementary approach to ADHD treatment. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

   August 27, 2026·1h 23min
   Play
4. 4
   Number 4: Show 1480: The Sleep Reset: How to Fall Asleep and Stay Asleep

   Do you have trouble sleeping? An occasional late night or early morning is probably not dangerous, but too many people get too little sleep on a regular basis. How does that affect their health? Even more importantly, what can they do to change the situation? You’ll want to listen to find out if you need […]

   July 16, 2026·1h 7min
   Play
5. 5
   Number 5: Show 1446: The Science of Strong Bones: Lifestyle, Medication and Movement (Archive)

   Are you concerned about your bone health? Do you worry about osteoporosis? According to the CDC, more than 10 million Americans have low bone density that makes them more vulnerable to fractures. For many older people, a fracture can be devastating, reducing mobility and possibly even leading to death. What does the latest medical science tell us about how you can maintain strong bones? At The People’s Pharmacy, we strive to bring you up‑to‑date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen You may have heard this interview when it was first broadcast on Saturday, Sept. 27, 2025. If you did not, you can download the mp3 using the link at the bottom of the page, or listen to the stream on this post by clicking on the little triangle in the green circle. We have added extra information to these notes, but not to the interview itself. Strong Bones You may have seen Halloween skeletons or even chewed the meat off a bone that you then dropped on a plate with a clatter. No wonder we usually think of bones as hard, unchanging objects. Dead bones are. But living bones are quite different. Strong bones are constantly undergoing change. Scientists call it remodeling. One set of specialized cells, osteoclasts, breaks bone tissue down and recycles it. Another set, the osteoblasts, builds bone back. Ideally, their activities are in balance. But if the osteoclasts start to get ahead, as they tend to do while we age, that can weaken bone. The result is low bone mass, known as osteopenia, or even serious bone loss called osteoporosis. This puts a person at risk for fractures. Who Gets Osteoporosis? Osteoporosis may have been less common a hundred years ago or more, when many people had to do manual labor that put stress on their bones. That helps for strong bones, so today’s sedentary lifestyles can undermine bone health. Although we think of osteoporosis as typically affecting postmenopausal women, men can lose bone mass too. Medications may contribute to the risk for bone loss. Steroids such as prednisone or methylprednisolone are especially risky if taken for a long period of time. Androgen deprivation therapy for prostate cancer is a risk factor specifically for men. Wait–MEN Can Get Osteoporosis? Q. My husband and I have two friends with significant disability largely due to spinal fractures as a result of osteoporosis. One man was always an avid exerciser, including running marathons. Both men are over six feet tall and have always appeared to be muscular. My husband is shorter and is physically active, playing tennis and going to the gym regularly. Because of our friends’ bone issues, I advised him to request a DXA scan to assess his bone health. The nurse practitioner told him that it was not recommended for men. I am still concerned that he may be at risk for osteoporosis. Are there medical studies that determine the risk factors for men? A. The nurse practitioner was mistaken. Men can develop osteoporosis, as your friends discovered. Many medical guidelines recommend that men over 70 be tested with a DXA scan to assess bone health. If your husband has low testosterone levels or has taken medications such as prednisone, he could be at increased risk for a fracture. He would be prudent to have the assessment. Diagnosing Osteoporosis Doctors assess bone mineral density with imaging called dual-energy X-ray absorptiometry, or DEXA for short. Then they compare the results on the scan to the results they would expect from a 30-year-old person. Results more than 2.5 standard deviations from that could result in a diagnosis of osteoporosis. A person who experiences a fracture without trauma, such as falling from standing height, is also suspected and often diagnosed with osteoporosis. Non-Drug Approaches to Strong Bones: People who want to keep strong bones need to focus on exercise. High intensity exercise can be helpful, but brisk walking may be enough. Tai chi and yoga are also popular. If you have been diagnosed with osteoporosis, be sure to check in with your doctor before you start a new exercise program. Building balance and core strength without increasing your risk of a fall (and thus a fracture) would be ideal. Our guest expert, Dr. Kendall Moseley, says the jury is still out on technology such as vibrating platforms, weighted vests or vibrating belts. More studies should show how valuable these could be. Following a diet that supplies adequate protein, vitamin D and calcium is also crucial. If you must take a calcium supplement, calcium citrate may be well tolerated and absorbed. How Do Doctors Treat Osteoporosis? Physicians prescribe several different types of medications to help curb bone less and perhaps even build it back. Some of the oldest and least expensive are the bisphosphonates such as alendronate (Fosamax). These slow bone break down and give the osteoblasts a chance to catch up. They can be hard on the digestive tract, though, and they have been associated with a few rare but alarming side effects: jawbone deterioration and atypical thigh bone fracture. Most people seem to do well on them. Doctors generally prescribe them for up to five years. Did You Forget Evista? Another type of osteoporosis medicine is called raloxifene (Evista). It is appropriate only for women, because it is an estrogen modulator. It acts like estrogen in the bones and reduces bone loss. In the breast and uterus, it opposes estrogen activity. Raloxifene does double duty in reducing the risk of breast cancer as well as osteoporosis. Like all drugs, though, it has some worrisome side effects. It can increase the risk of blood clots that cause deep vein thromboses and strokes. What About Prolia? Denosumab (Prolia) is a monoclonal antibody that also interferes with osteoclasts. That is how it improves bone density. One thing to keep in mind about Prolia is that stopping it requires careful planning and backup medication. Otherwise, a patient can lose all the bone that was built rather quickly and may suffer debilitating fracture. This Week’s Guest Kendall F. Moseley, MD, is Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. She is also Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. In addition, Dr. Moseley is Medical Director of the Johns Hopkins Metabolic Bone & Osteoporosis Center. Kendall F. Moseley, MD, Johns Hopkins University School of Medicine Listen to the Podcast: The podcast of this program will be available Monday, Sept. 29, 2025, after broadcast on Sept. 27. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. In the podcast for this episode, we discuss the pros and cons of estrogen for strong bones. You’ll also learn about a drug that builds bone, teriparatide (Forteo). And you’ll hear about the importance of preventing falls and how to do that. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript for Show 1446: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material. All rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:13 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Joe 00:14-00:27 Hypertension is often called the silent killer, but osteoporosis might be considered a silent and deadly disorder. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:41 If an older person breaks a hip, the consequences can be disastrous. They often lose mobility and they may even die. Joe 00:42-00:50 The focus for osteoporosis is usually on older women, but we should remember that men can also lose bone and become vulnerable. Terry 00:51-00:57 There are drugs that hurt bone health as well as help build it back. What about supplements or exercise? Joe 00:57-01:06 Coming up on The People’s Pharmacy, the science of strong bones, lifestyle, medication, and movement. Terry 01:14-02:32 In The People’s Pharmacy health headlines, semaglutide has gotten a lot of attention over the past few years. If you don’t recognize this generic drug name, you probably do recognize the brand names. Ozempic for type 2 diabetes and Wegovy for weight loss. Both these medications are self-administered injections, but not everyone is enthusiastic about needles. There’s also an oral form of semaglutide called Rybelsus. The FDA has approved it for treating type 2 diabetes six years ago, and so far it has mostly gone under the radar. A new study published in the New England Journal of Medicine demonstrated that oral semaglutide at 25 mg a day helped people without diabetes lose significantly more weight than placebo. The randomized trial included more than 300 volunteers and lasted approximately a year and a half. This could be good news for people who have trouble accessing injectable semaglutide or keeping it cold. People taking semaglutide reported improved quality of life. They were also more likely to report side effects, especially digestive distress. Joe 02:34-04:17 Aspirin has been available for well over 100 years, but the active ingredient has been used by native healers for thousands of years. In 1991, a research article in the New England Journal of Medicine reported that regular aspirin users were 40 to 50 percent less likely to die of colon cancer. Now, 34 years later, another research paper in the New England Journal of Medicine reports that people taking aspirin had a significantly lower chance of colorectal cancer recurrence. Swedish scientists recruited patients after they’d had their tumors removed. The particular hotspot mutation called PIK3CA. The aspirin dose was 160 milligrams, or roughly half a standard strength tablet daily, for three years. 626 patients were randomly assigned to receive either aspirin or placebo. 7.7% of people taking aspirin experienced a recurrence of their colorectal cancer, whereas 14.1% of those on placebo had a recurrence. That was about a 50% relative risk reduction. 43% of the participants taking aspirin experienced a non-severe side effect compared to 35% of those on placebo. Serious adverse events occurred in 17% of aspirin takers compared to 12% of placebo recipients. The authors conclude that low-dose aspirin represents an effective, low-cost treatment approach to prevent colorectal cancer recurrence in high-risk, genetically selected patients. Terry 04:17-04:58 Nutrition experts have praised the Mediterranean diet as a way to reduce cardiovascular risk. It’s also been considered as a way to lower the likelihood of developing dementia and a natural approach to calming inflammation. Now, dermatologists have announced the results of a study showing that four months on a Mediterranean diet can reduce the severity of psoriasis symptoms. Almost half of the participants following a Mediterranean diet reduced their psoriasis score by 75 percent, and none of those on the control diet did so. The researchers conclude that this dietary strategy could be helpful along with medical treatment. Joe 04:59-05:41 A new study of acupuncture for chronic low back pain called Back in Action produced positive results. 800 patients were randomized to receive either standard acupuncture of 8 to 15 treatment sessions, enhanced acupuncture, which included 4 to 6 maintenance sessions beyond the standard, or usual medical care alone. Those in the acupuncture groups had significantly greater reductions in their pain-related disability than those in the usual care group. The authors conclude that, quote, these findings support acupuncture needling as an effective and safe treatment option for older adults with chronic low back pain. Terry 05:42-06:05 Do cocoa flavanols normalize blood pressure? In the COSMOS study, people with systolic blood pressure under 120 were significantly less likely to develop hypertension if they were taking cocoa flavanols than if they took placebo pills. People whose blood pressure started higher did not get the same benefit. And that’s the health news from the People’s Pharmacy this week. Terry 06:14-06:17 Welcome to the People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:29 And I’m Joe Graedon. According to the CDC, over 10 million Americans over 50 have osteoporosis. That means their bones have become fragile and more vulnerable to fracture. Terry 06:30-06:40 More than 40 million Americans have low bone mass or osteopenia. What can be done to prevent fractures, disability, and death from weakened bones? Joe 06:41-07:00 To find out, we’re talking with Dr. Kendall Moseley. She is Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. She also serves as medical director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Terry 07:01-07:04 Welcome to the People’s Pharmacy, Dr. Kendall Moseley. Dr. Kendall Moseley 07:05-07:10 Thank you so much for having me today. I’m very excited to chat with you both about a topic that’s near and dear to my heart. Joe 07:11-07:48 Well, it’s near and dear to our hearts as well, Dr. Moseley, but I suspect that there’s a tremendous amount of confusion when it comes to bones because we’ve all seen skeletons. We’ve all had interactions with bones, perhaps in food. And it just always seems as if bones are so solid. And yet, in reality, bones are constantly breaking down and building up. It’s a very dynamic process. Could you just give us a quick overview on bone physiology? Dr. Kendall Moseley 07:49-09:21 Absolutely. And I think you’ve highlighted something I always try to stress when I talk to groups of people is that bones are not these inanimate objects. I mean, we’re not these walking, kind of lumbering rocks moving down the street. In fact, we have this very important scaffold underneath our skin that enables us to walk and roll and twist and bend. And without a very strong scaffold, we’re kind of in trouble. So you’re right. Bones are dynamic. Our bones are always building up and they’re always breaking down. And it’s that process of kind of building up and breaking down that allows us to be flexible, right? If we didn’t have remodeling of our bones, we’d be very stiff and brittle. But it’s that balance, that key balance of how our bones build up and how they break down that really dictates how strong our bones can be. Clearly, you would prefer a lot more building up than breaking down. And at different parts in our life cycle or different times in our life cycle, we have different balances in that building up and breaking down. If you really want to get into the nitty gritty of the pathophysiology, which I think is important to understand because there are two very different types of cells that treatments for bone disease sometimes impact, we really boils down to these cells, one of which is called the osteoclast. It’s kind of like a little Pac-Man cell that’s responsible for breaking down our bone if it’s an area of injury or a little micro fracture. So that osteoclast will come in and kind of carve out a pit of bone so that the osteoblast, B as in build, can come in and fill in new bone. Again, to rejuvenate that area and to keep your bones flexible. Terry 09:22-09:34 And I’m assuming that as we get older, there are more osteoclasts or they’re moving faster than the osteoblasts building our bones back. Am I wrong? Dr. Kendall Moseley 09:35-10:58 No, I think that that’s a wonderful way to think about it. You know, the life cycle is complicated. You know, when I meet patients for the first time, and again, I’m in a metabolic bone clinic, so I see patients who generally come already with a diagnosis of osteoporosis or low bone density. And when we’re sitting there talking to one another, we say, gosh, why aren’t your bones perfect? And believe it or not, what we do is we go all the way back to childhood because changes happen throughout the life cycle to bones. We build or gain bone. We’re building more bone than we’re breaking down until about the third decade of life. So those osteoblasts are overtaking the osteoclast to give us nice, strong skeletons. So you might imagine how early childhood insults could impact the bones. In midlife, we have kind of a steady state where the blasts in the clasps are kind of remodeling at a usual rate, generally in balance with one another. At around the time of menopause that women go through, there is a steep decline in bone density, which is driven primarily by those osteoclasts, those Pac-Man cells that break down bone at a much more rapid rate than the osteoblasts are able to keep up with. And men have an inflection point later on in life. They don’t go through a menopause per se, but about the time, about 70 years of age or so, again, that imbalance starts to shift, which favors the osteoclast or bone breakdown, where again, it’s kind of like a tortoise and the hare story that the tortoise is no longer keeping up with the hare and the bones will break down. Joe 10:59-11:46 Dr. Moseley, I’m curious as to how things have changed, because I suspect that our ancestors, and when I say our ancestors, I’m not talking about Neanderthals. I’m talking more about our grandparents and our great-grandparents. they were probably spending a lot more time outdoors. You know, farmers and just workers and, you know, both men and women were just physically more active than we are today. Today, I think we spend a lot of time sitting. And I’m curious as to how our lifestyles have affected bone health over the last, let us say, 50 to 100 years. Dr. Kendall Moseley 11:47-13:01 Now, I think that that is a fair assessment. We know that activity movement is critical for bone health. You know, in fact, when we talk about the tenets of therapy for osteoporosis and low bone density, one of the things we always have to discuss in clinic is how can we get you more active? What kinds of exercises should you be doing? Because movement really stimulates those bones to kind of rebuild, grow, remodel. And so absolutely, you know, back in the days when we were out and about, you know, in the farms or, you know, pushing things, you know, down the street. I think we did have a lot more activity related to our bones. I will also counter, though, you know, we didn’t live as long back in the day. And so that graph that I just kind of talked about with this aging process kind of inevitably causing slow and steady bone loss as we get older, a lot of the implications for weakened bone really don’t occur until that later stage in life where women are postmenopausal or men are older. And so did we really see the full effects of osteoporosis and bone loss, you know, in prior generations when perhaps they didn’t live to be the older ages where the fracture started to manifest or people passed earlier from other conditions that we didn’t have treatments for? Terry 13:01-13:19 Dr. Moseley, I want to just revisit something you said a few minutes ago and really bring it back up because a lot of people think of osteoporosis as a women’s problem. And you mentioned men get osteoporosis too. Tell us a bit more about that. Dr. Kendall Moseley 13:20-14:28 Terry, thank you for bringing that up. It is a very important point. And oftentimes, you know, my practice is a lot of women in my practice, and oftentimes women will bring their significant others or their spouses and they listen to my spiel and they kind of turn to their spouse or significant other and they say, well, gosh, Maybe that means we need to screen you as well. And it’s true. So men do get osteoporosis. It is a misconception that this is a woman’s disease. Statistically speaking, about 10 million Americans in the United States have osteoporosis greater than the age of 50. About 8 million of those individuals being women, 2 million being men, although even that statistic I counter. One big point is that we really under-diagnose osteoporosis. We don’t name it when we see it, and secondly it relies upon screening for osteoporosis and as we’ve just said men really we don’t see this as a man’s disease so are we screening men to even be able to make the diagnosis in that portion of the population so absolutely bones thin at different times in our lives but there are still other factors other disease states other medications that can threaten a man’s Joe 14:28-14:56 skeleton just as easily as it can a woman’s well you mentioned medications and of course a lot of men who are diagnosed with prostate cancer are given hormone suppressing drugs, what we call antiandrogens. And I suspect that has a profound impact on bone strength and not just in men, in women too, because testosterone people think, oh, that’s a man’s hormone, but it’s responsible for bone strength in both men and women. Dr. Kendall Moseley 14:57-16:11 Right, right. No, absolutely. So one of the biggest offenders and we, you know, the term is iatrogenic, meaning sadly, we as doctors do this to patients, I mean, deliberately, because oftentimes we’re treating another disease state and we have no choice, but we do give patients oftentimes medications that have side effects that directly hurt the bone. One of those medications, in fact, is androgen deprivation therapy. So on prostate cancer with a goal to get testosterone levels to zero, we give them these hormone blockers. And it’s kind of like a menopause for men that they go through when we have that low testosterone. We know testosterone is converted into estrogen. So that causes low estrogen in men, which can hurt the bones. Women, there’s a corollary with breast cancer. So our breast cancer survivors, we treat with drugs such as aromatase inhibitors, where again, we render estrogen levels to zero. And we see oftentimes a significant amount of bone loss associated with those medications as well. Probably the worst drug that we use, but oftentimes very, very necessary for patients with chronic inflammation or autoimmune disease would be things like steroids. So steroids, I always refer to as somewhat dirty drugs. You know, if you need them, you need them, just like anti-cancer therapies. But those medications as well can really thin bones through a number of different mechanisms. Joe 16:12-16:36 So the anti-estrogens for breast cancer, the anti-androgens for prostate cancer, and the corticosteroids that are used for so many different conditions, including autoimmune disease and asthma and COPD, all of those medications can have a profound effect. Should everybody who’s taking one of those medications get a bone scan? Dr. Kendall Moseley 16:37-18:07 In my humble opinion, absolutely. And I think most guidelines would agree. I, you know, it depends on timing. So the low hanging fruit, the easy answer would be with your anti-estrogen medications and your anti-testosterone medications. And certainly if you know an individual is going to be treated with those drugs, it’s usually for a longer period of time. So anti-estrogen medications upwards of five to 10 years in many breast cancer survivors. Anti-androgen medications oftentimes not as long, but sometimes two years or more. And in those patients, you absolutely do want to get a screening bone density test and anticipate that in fact those medications are going to thin the bones and ideally jump ahead of that problem. And again, we have interventions we can use pharmacologically and lifestyle-wise to anticipate the bone loss and obviously treat it before it becomes a problem. Steroids are a little bit trickier. Steroids in general, we say that if a patient is going to be on a dose of prednisone or an equivalent of 5 milligrams or more for 3 months or more continuously, that would be a dose at which you certainly would want to get a screening bone mineral density test, potentially treat to prevent bone loss, depending on what that screening bone mineral density test shows, and then follow the patient more closely. We’re not as worried about the inhaled steroids. We’re not as worried about steroid injections that patients oftentimes will get for joint pains and arthritis. It really is the systemic steroids that cause the most problems. Terry 18:08-18:15 You’re listening to Dr. Kendall Moseley, Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 18:16-18:21 After the break, we’ll learn the difference between osteopenia and osteoporosis. Terry 18:21-18:24 If you break a bone, does that mean you have osteoporosis? Joe 18:25-18:27 What are the options for treating osteoporosis? Terry 18:28-18:30 Exercise might be helpful. Which ones are best? Joe 18:31-18:33 Should you be wearing a weighted vest? Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 18:51-18:54 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 18:55-19:13 And I’m Terry Graedon. Joe 19:13-19:21 Today, we are talking about bones. How would you know if your bones are strong or vulnerable to breakage? Terry 19:21-19:27 What options are available to maintain bone health? Are some exercises better than others? Joe 19:27-19:52 We’re talking with Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins. She’s also Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Terry 19:53-20:17 Dr. Moseley, I think there are a lot of kind of long, complicated words that we need to deal with in this interview that people may have heard or maybe not have heard, but are not completely certain what does it mean. So let’s start with the difference between osteopenia and osteoporosis. Dr. Kendall Moseley 20:18-24:09 Right. I think that’s a great question. There’s a lot of big words in the bone field, and those would be the big ones that patients bring to the office. So we have to think about bone density and bone health and bone strength along a spectrum. So, you know, spectrums are uncomfortable for a lot of people. We like to have our bins, our diagnoses. And so in the bone world, we divide things into normal. We say osteopenia, although we are getting away from that term. We more so use low bone density and then frank osteoporosis. And the World Health Organization would define those three terms based on a T-score. And what is a T-score? So To make a diagnosis, to screen for osteoporosis, we use a very specialized scan called a DEXA scan. It’s a dual energy X-ray absorptiometry scan. You can see why we call it DEXA. And it’s basically a fancy X-ray. And it’s a 2D interpretation of bone quantity, usually looking at the spine, looking at the hip. And it’s two different locations in the hip. It’s the total hip and the femoral neck. And sometimes we even look at a forearm in certain circumstances and disease states. And it’s that fancy x-ray, again, that we use to follow osteoporosis, but more importantly, to diagnose it in those in whom we’re worried that they have thinner bones. That T-score is really just a standard deviation. And the standard deviation is that individual’s bone compared to that of a 30-year-old, which seems very unfair. But as I said earlier in the segment, we really gain bone until about the age of 30. So we’re kind of comparing that patient to what their ideal should have been back in the day. A T-score, anything between 0 and negative 1 is considered normal, so normal bone density. Anything between negative 1 and negative 2.5 or 2.4, excuse me, is considered low bone density or osteopenia. And anything less than or equal to a negative 2.5, again, negative 2.5 standard deviations from normal is considered osteoporosis. And that’s what spits out on the reports, and that’s oftentimes what patients bring to the clinic. Although it’s very, very important to insert a big caveat here. People with low bone density or osteopenia can still fracture. In fact, the majority of fractures, which is the take-home message, we’re trying to prevent broken bones, the majority of people who fracture actually are in the osteopenia or low bone density range as compared to the osteoporosis range bone density. So if someone comes to clinic and maybe that DEXA scan says the T-score is a negative 1.5 or it’s a negative 1.8, which technically, again, is osteopenia or low bone density. If that same patient has also had a fracture, a fragility fracture, that patient has osteoporosis. So it doesn’t matter to me what this screening scan shows. If that bone has broken in a fragility manner, and gosh, I get that question all the time, too, so I’m going to beat you to it. What is a fragility fracture? This is a fracture of the spine, hip, pelvis, wrist, upper arm from standing height or less. So slipping outside on an icy street and bracing your fall with your wrist, if you break that wrist, that is a fragility fracture. Stepping out of the bathtub and maybe the floor is a little bit slippery and you come down hard on your hip and you have a hip fracture, that is osteoporosis. Falling out of a two-story building or a motor vehicle accident and you break your pelvis, that’s just lucky, you know, walked away with just one broken bone. So, again, fragility fractures, no matter what that bone density test is showing, whatever that score says, if you have a fragility fracture, you have a diagnosis of osteoporosis, that should be treated. It’s akin to having a heart attack, right? I don’t need a cath if you’ve had a heart attack to tell me you have cardiovascular disease and we have to take that seriously. Joe 24:09-24:51 I’ve got a question for you because our grandson, who’s seven, was running the other day at camp and he tripped and he fell and he broke his arm. That happens a lot to kids. You know, they fall off the jungle gym or they fall off their bicycle and they land and out goes their arm and boom, they’ve broken it. Now, they don’t have osteoporosis. Why would a woman who falls in a similar situation, maybe while riding a bicycle, why would she be automatically defined as osteoporotic? Dr. Kendall Moseley 24:53-26:07 Well, a woman who falls off a bicycle, that’s considered traumatic, right? So maybe it’s less than standing height because she’s sitting down on a bicycle, but she’s fallen off of a moving object going presumably at a fairly rapid speed and you get entangled in the wheels, etc. So I would probably talk through the logistics of that particular fall, and I would probably walk away saying that was more traumatic than atraumatic. Getting back to kiddos, they’re a different bird. So again, falling off of a jungle gym, that’s from a height higher than standing height. Kiddos also have just very different bones. So their bones are kind of built to be a little bit more flexible. They’re a little bit more rubbery. They remodel at a faster rate. And so they do oftentimes get these fractures, you know, tripping, falling, bonking their heads. We had that a couple of weeks ago in our household. We know those fractures heal very rapidly. Where we start to worry in kiddos, and this is probably beyond even the scope of our discussion today, is when there are multiple fractures, low trauma fractures, you know, situations in which it doesn’t make sense that that arm or that leg breaks. And then there’s a whole host of genetic conditions that oftentimes we will screen for to make sure that, in fact, that child doesn’t have a metabolic disease. Terry 26:07-26:42 Well, I think it’s important for parents to realize that a situation like that requires extra attention. But we’re not going to follow through on that any further. What I’d like to do is go back to your idea that a fracture might institute treatment. And what I mostly hear from people my age, women my age, is that they have been told by their doctor that they have to take a drug because of the osteoporosis. Joe 26:42-26:47 And a lot of them don’t want to take a drug. Or the osteopenia in some cases. Terry 26:47-27:08 Or the osteopenia. And the most popular drugs are the bisphosphonates like alendronate, which used to be called Fosamax. So what options are there for treating osteoporosis? Is bisphosphonates where you start? Or are there other things people can do? Dr. Kendall Moseley 27:10-29:57 Now, when I talk to patients, I always break it down into, gosh, what are things that you can leave here with? What is your to-do list going to look like? And that can be things like calcium, vitamin D, exercise, protein, other healthy lifestyle interventions, and we can get into that absolutely. And then there’s things that maybe I need to do, you know, when the prescription pad may need to come out. When we think about osteoporosis and how we treat osteoporosis, again, we love our bins in medicine. It helps to organize our thoughts and kind of talk to people about how we’re thinking about their disease state. And osteoporosis is no different. We think about it on a spectrum. So is the osteoporosis mild? You know, in a mild case of osteoporosis, maybe just low bone density, no prior fractures. We sometimes use a tool called a FRAX calculator that comes up in the guidelines. If we’re seeing signals that things are generally fairly positive, we might just recommend lifestyle interventions, calcium, vitamin D, some good exercise, protein, et cetera. As we move further down into the different bins, we get into different categories. So moderate osteoporosis or low bone density, where again, the DEXA scan is giving us data, we don’t like to see the numbers are decreasing. There’s maybe an increased falls happening at home. The FRAX calculations are more elevated. That might be a category in which, in addition to lifestyle interventions, we might recommend medical therapy, usually something more mild. You know, if we think about it as a swimming pool, we start in the shallow end and get a little bit deeper. That might be an oral bisphosphonate. For women, we use things called selective estrogen receptor modulators, which act on the estrogen receptors within the bone. As we wade deeper into the pool, we get into the more, you know, severe osteoporosis or, excuse me, high-risk osteoporosis or severe osteoporosis. In those categories, that’s when we start using, again, in addition to lifestyle interventions, the calcium, the vitamin D, and the exercise, that might be a place at which we do start to recommend more intense pharmacotherapy. That might still just be an oral but it may be an infusion, it may be an injection, depending on the case. What I think, though, doesn’t always matter. I think everything comes down to forming a relationship with a patient and talking through what the patient’s concerns are about their bones, what their concerns are about the logistics of a medication. Because if I think you need a daily injection, but you don’t want to do anything, there’s no point in us kind of not reaching any sort of conclusion in terms of treatment. If you’re in a very high-risk fracture category, we might want to start with a bone-building drug. But if you tell me all you’re willing to do is an oral pill once a week, I’d rather not let perfect be the enemy of good. And we might start with something milder, despite what I think. Joe 29:57-30:24 Dr. Moseley, you’ve mentioned exercise a couple of times, and we’ve gotten all kinds of recommendations with regard to exercise. You know, it has to be bouncy exercise. You have to jump up and down. You have to stress your bones. And then we’ve heard from other experts who say, you know, if you do Tai Chi, it’ll actually be good for your bones. Terry 30:24-30:24 Or yoga. Joe 30:25-30:37 Or yoga will be helpful. And so there’s just a lot of confusion around the best kind of exercise or it’s just exercise in general. Walking, will that be helpful? Dr. Kendall Moseley 30:39-32:45 Yes, yes, and yes. So my take home with patients is always just keep moving. Just keep moving. We all have physical limitations, right? There are patients who can’t, you know, run. They can barely walk. Oftentimes they’ll come in in a wheelchair and a walker, but it’s important that they move their bodies. Walking counts in terms of exercise. There are two, you know, big picture issues when we think about exercise and bone or movement and bone. And the first is, yes, is there a way that we can kind of physically tax or stress bone in a way that promotes healthy bone remodeling and bone building. And there are data in individuals who use high-intensity exercise. There was a trial called the LIFTMORE trial looking at women and men, older women and men, with supervised high-intensity exercise about three times per week and showing, in fact, there was benefit to the bone. And this is heavy weights. This isn’t just your little two or three pounders that you’re using, but in fact, supervise, you know, high weight, high intensity exercise, and they gained bone. Is that possible for all patients, to all patients have access to that sort of exercise and gyms and equipment, et cetera? Not necessarily. So the second thing we need to think about with exercise and the importance of exercise is, gosh, how do we keep you upright and fracture free by virtue of the fact you’re not falling? So if we can strengthen individuals, lower body strength, core strength, and you can get that just through walking or through yoga or through Pilates, you know, really making sure that you have a sense of self in space, keeping you from falling, that’s a victory in and of itself as well when it comes to bone strength. So, yes, I mean, would we love everybody out there lifting, you know, 30-pound weights and a supervised setting and potentially gaining some bone? That would be lovely. But I think realistically speaking, we all bring different limitations to a clinical setting. And just moving, again, just getting those legs working, just getting a sense of balance, sending people to physical therapy for balance training and core and posture, that can be just as important as getting them into a gym. Terry 32:45-33:30 Dr. Moseley, there’s something else I’d like to ask you about while we’re on this topic of physically stimulating our bones. Something that’s gotten some buzz is vibration. And there are people who have purchased pads that they stand on that vibrate to try to help their osteoporosis. there is also a device that I saw, I think it has been cleared or approved, I’m not sure which, by the FDA. You wear it like a fanny pack. It’s a belt called an Osteoboost and it vibrates for half an hour a day, provided you wear it that long. Are these devices of any use? Dr. Kendall Moseley 33:32-35:28 I think the jury’s still out. I get those questions all the time in clinic because, Again, I’m very encouraged that patients want to feel empowered with their health and they want to do things other than just take a pill or do an injection. I think it’s important. It’s a partnership that way. What can you do? What do I need to do to strengthen your bones? So vibration plates and these vibratory belts that are out there now, I think they’re trying to get at the pathophysiology of bone remodeling, which is, again, stressing bone, targeting mechanoreceptors that live in the bone that cause release or non-release of hormones that could be detrimental to bone remodeling and bone strength. And I think there’s promise there in the idea that it’s targeting, again, these mechanoreceptors in the bone. What we don’t have with either the vibratory plates or the belt are fracture data. So there are some data potentially showing stability of bone density with the use of these different devices. There are some data potentially showing some improvement in bone density. With the belt, it was only tested in individuals with low bone density or osteopenia. We don’t know in an osteoporosis population. The vibratory plate data is kind of all over the place. But what we don’t have with those devices is fracture prevention data. And that’s always hard to get. Even in the drug trials, you need thousands and thousands of study subjects to determine if that intervention is going to reduce fracture risk. So we may never have that information. So what I tell patients when they bring those, you know, pamphlets to the office or that printout or that clipping from a newspaper article is they say, I don’t think that these devices are going to hurt you at all. I think, in fact, they potentially could be beneficial to you. And how can we work those devices into our treatment plan so that, Again, you are doing things at home that may be beneficial to your bone, but I’m also keeping tabs on your bone density. And we, again, can decide together if we need to ratchet up your treatment plan to the point where we need pharmacotherapy. Joe 35:28-35:38 Dr. Moseley, I’ve been seeing a lot lately about weighted vests or sort of backpacks that are supposed to be good for you. Any thoughts about that? Dr. Kendall Moseley 35:39-36:37 Weighted vests are going to fall into the vibratory plate category and even these belts. And it’s the idea that you want to put deliberate strain on your bones to encourage them to remodel more actively. And again, this is a space where we maybe have some data showing stability of bone density, maybe a little bit of improvement in bone density. We do not have fracture data showing that weighted vests are beneficial to bone health. My challenge I have with them is depending on the vest, and there’s so many different types out there, they sometimes can cause low back pain. They can cause posture problems. We certainly don’t want anyone falling over from their weighted vest. So if there’s any hint that the vest might cause instability in the patient, I tend to be against them. But gosh, if it’s one more tool hanging by the front door that encourages someone to go outside and take a walk with their weighted vest on, by all means, I’m very optimistic that this could be something, again, to motivate people to take their bones into their own hands. Terry 36:38-37:03 You’re listening to Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is also Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism and Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 37:04-37:08 After the break, we’ll learn about raloxifene as a treatment for osteoporosis. Terry 37:09-37:12 It might reduce the risk of breast cancer as well as of bone fractures. Joe 37:13-37:20 What other drugs do doctors prescribe for osteoporosis? And what are their pros and cons? Terry 37:20-37:24 Are there problems in stopping certain bone-building drugs? Joe 37:24-37:27 Dr. Moseley will share her pillars of treatment. Terry 37:40-37:43 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 37:53-37:56 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 37:56-38:13 And I’m Terry Graedon. Joe 38:13-38:23 There are now numerous medications to improve bone health, but they all have some side effects. Which are the safest and most effective? Terry 38:23-38:41 The FDA first approved a drug called raloxifene in 1997 to prevent postmenopausal osteoporosis. The brand name was Evista. Although other osteoporosis medications approved around the same time are still in wide use, raloxifene has almost disappeared. Joe 38:42-38:52 Why don’t doctors consider raloxifene for osteoporosis? This medication has another important benefit that has seemingly been forgotten. Terry 38:52-39:18 Today’s guest is Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism and Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 39:20-40:00 Dr. Moseley, we’d like to talk about treatment first and some of the medications that you do prescribe. And I’m just curious about a drug that seems to have been forgotten. I mean, it never really gained much popularity, but it’s, I think, kind of an interesting medication called raloxifene because it has both, I’ll call it pro-estrogen and anti-estrogen activity, which seems like an oxymoron. Like, how could that possibly be? But could you just give us a quick overview of a drug that seems to have gotten kind of dusty in the dustbin of history? Dr. Kendall Moseley 40:02-43:08 Sure. I don’t think of it that way as a dusty drug. We actually use a fair amount of it in our clinics because it has a role in osteoporosis care. So raloxifene is what we call a SERM. It’s a selective estrogen receptor modulator. And as you indicated, it has stimulatory properties at the level of the bone and actually inhibitory properties to tissue such as the breast and the uterus. So raloxifene is actually similar to a drug called tamoxifen that many women and men have heard of it that’s used as an anti-breast cancer medication in that patient population. So raloxifene, for starters, because it’s a selective estrogen receptor modulator, is not to be used in men. It is solely to be used in women. And we generally, as I was talking about those bins of risk, the low, the moderate, the high risk, and very high risk, we generally reserve that medication for individuals in a low to moderate risk category. And that’s because we have data showing that raloxifene, in fact, does reduce the risk of vertebral compression fractures. And again, we look at different types of bones and different fractures. We don’t have as much data demonstrating that raloxifene actually reduces the risk of hip fracture. And so when we have patients who maybe have low risk or moderate risk osteoporosis, it’s spine predominant, we see that that’s the lowest site. Oftentimes we will use raloxifene. It’s a daily pill. It’s easy to take. It’s easy to stop. It has a relatively low side effect profile. So probably the first thing I warn women is beware, your hot flashes may come back once you start this medication. Some run for the hills when I bring that up. Others say no problem. It doesn’t typically last forever, but certainly for the first few weeks or so, those hot flashes can come back. The other side effect that’s certainly more serious than the hot flashes would be that it can increase the risk of blood clots and stroke as a result. So if there’s a patient who has a history of blood clots or a clotting disorder or pulmonary embolus, again, that would not be a medication of choice. The reason it is appealing to a lot of women and certainly even our use in clinic is it doesn’t necessarily come with the more scary side effect profile that some of the other drugs have. So, again, you can start it and stop it at any time without any ramifications, no rebound bone loss. You can take it indefinitely as long as the patient is tolerating it without concern for jaw necrosis or atypical femur fractures that, again, come up with some of our other drugs. So it’s fairly easy to use. It’s inexpensive. We don’t typically have to fight the insurance companies too terribly hard to get it prescribed. So that’s helpful. And we actually wind up using raloxifene a fair amount for, again, those patients who come in and they acknowledge that their bones are less than perfect. They’re concerned about their bone health, but perhaps they’re similarly concerned about medication side effects. And again, in the interest of not letting perfect be the enemy of good, if what we decide upon is raloxifene, this daily pill that may not have that hip fracture prevention data, it’s certainly better than nothing. So again, in our bone clinics, we do use it. Joe 43:08-43:51 And the thing that I think a lot of women find very attractive about raloxifene is that it It has a breast cancer prevention piece as well as, as you pointed out, a vertebral fracture prevention piece. So it’s sort of a double benefit. But let’s move on, Terry, to some of the other medications because, as you’ve already mentioned, there are some pretty serious side effects. And you mentioned atypical femur fracture. We want to talk about the tooth problem. And we want to talk about some of the newer drugs that are injectable that once you get them, it may be in your body for six months or longer. Terry 43:51-44:04 But let’s take that one at a time. So let’s start with those bisphosphonates that Joe was alluding to. What drugs are we talking about? When do you use them? What do people need to know about them? Dr. Kendall Moseley 44:06-47:19 Right. So we can start, I guess, with the bisphosphonate category. And bisphosphonates are probably the old guard of the osteoporosis regimen. I mean, they started, you know, greater than two decades ago with use of these. And probably the one most people have heard about is alendronate. Alendronate is a once-a-week pill that’s a little bit challenging to take. You take it first thing in the morning, full glass of water, nothing else to eat or drink for an hour, no going back to bed. And these medications, the way that they work in the bisphosphonate category is they are drugs that effectively get incorporated into the bone, into the hydroxyapatite matrix of the skeleton. And once these drugs are incorporated into the bone and they come in proximity of those Pac-Man cells, see here those cells come back again. When those Pac-Man cells come along and encounter these bisphosphonates, they effectively render the Pac-Man cells, the osteoclast, useless. So they can’t break down bone anymore. they’re incorporated into the skeleton, so they do have a lasting effect. And when I talk to patients about these, we kind of think about it like coats of paint, right? So with each year that you’re on these drugs, you kind of paint the wall once again and once again and once again, and the paint can accumulate, which is why there can be concern about long-term use of these medications. And I’m going to throw five years out there, but there’s no rule that five years is a maximum amount of use you can do these. But after about five years of use, we do start to consider a pause in therapy in the appropriate patient because of these layers of pain and this, you know, potential paralysis of the Pac-Man cell and paralysis of a bone remodeling process can cause adynamic and potentially more brittle bone. You know, if your bones are frozen and they can’t rebuild and remodel themselves, we worry that that’s not healthy either for the skeleton because we do start to encounter very rarely atypical femur fractures where kind of there’s a hip fracture that happens below the, you know, kind of along the thigh, which is not anticipated, or we can see jaw complications with jaw erosion, that things can get infected, all stemming from this idea that brittle old bone can’t rebuild, remodel, and heal itself as easier as, you know, refreshed bone. There’s an IV formulation of that pill now called zoledronic acid. It’s administered once a year. So in patients who really aren’t good at swallowing pills, patients who have esophageal disorders, history of ulcers, which can be a side effect of the alendronate therapy or the oral bisphosphonates, this once a year drug can be quite helpful. It’s given through the vein over about 30 minutes. That one, typically three to five, although again, with an asterisk in the appropriate patient, sometimes we go shorter versus longer. But that drug two, similar side effect profile with rare risk, again, of these atypical femur fractures and jaw necrosis. But I always like to pause there and say, you know, these are rare side effects and we have to always consider the alternative, which are what are our real concerns about you breaking your hip or breaking your spine or losing bone in the context of that new steroid that you’ve been prescribed. So it’s always a balance talking about side effects of medicine, which they all have, and the benefit of the drug at the end of the day and reducing fracture risk. Oftentimes we have to 50 to 60 percent. Terry 47:19-47:32 And I’m supposing that there’s no really good way to predict ahead of time who might be at higher risk for one of those really awful side effects like an atypical femur fracture. Dr. Kendall Moseley 47:33-49:37 Yes, I mean, I wish I had a crystal ball. I mean, we do know that there are certain individuals at higher risk for the more rare but real side effects. So jaw necrosis, in general, the risk will be higher in, let’s say, cancer patients. So they get bisphosphonates at much higher doses, much more frequent doses. But even in osteoporosis patients, and it would typically be in the setting of what we consider to be invasive dental work. So this is if you are having an extraction, you’re having an implant, you’re having a bone graft where there’s kind of deliberate invasion of the jaw bone itself that can become subsequently infected. and the concern is that bone once infected can’t heal itself well and can, you know, erode over time. We get questions a lot about things like root canals or what about, you know, braces. Sometimes our orthodontists are worried about braces or bridges, caps. Those are not invasive. We’re not getting into the jaw in those contexts. So again, we’re less worried about that and the jaw necrosis complication. Atypical femur fracture is something that typically we have observed, and it’s been really since the onset of alendronate. Women used to get a prescription for alendronate in one hand and hormones in the other hand, and it was see “see you again never.” So we’ve learned now that with longstanding bisphosphonate use, we can see these atypical femur fractures. And that’s why I gave that five-year number a little bit ago, which is where after about five years of use, We don’t see a precipitous increase in atypical femur fractures, but we certainly start to consider, is this medication actually necessary? Because that long-term use can be a problem. We see increased risk in individuals on bisphosphonates who’ve also been treated with long-term steroids. Both conditions can cause this adynamic or frozen bone. And we know that Asian women are at higher risk for atypical femur fractures. So that’s something that we always want to consider when meeting with the patient, again, on that yearly basis to decide whether or not it’s appropriate to continue therapy versus discontinue the therapy. Terry 49:38-50:12 Now, Dr. Moseley, let’s assume that your patient has been on a bisphosphonate for five years, has stopped, comes back to you in a year or two, and you say, that osteoporosis, it’s still a problem. We’re going to move on to the next category of drugs. You have those bone-building drugs, but there’s a problem with them as well. You mentioned before that raloxifene, the SERM, is easy to stop, but some of these bone-building drugs, they could be hard to stop. Dr. Kendall Moseley 50:13-50:25 Well, I want to kind of push back a little bit on the bone-building. I think the drug you may be referring to is denosumab, which actually is a drug, which is an anti-breakdown drug, first and foremost. Joe 50:26-50:42 And Dr. Moseley, a lot of people are not familiar with generic names like Alendronate or Denosumab. So we’re talking about Fosamax in the case of the bisphosphonates, and Prolia is the brand name for Denosumab. Terry 50:42-50:46 Or is it pronounced Prolia [pro-LEE-ya]? I’m never sure exactly how, and I’ve heard it both ways. Dr. Kendall Moseley 50:47-52:44 I’ve heard it in both scenarios as well. You could probably use them interchangeably. And I’m glad you said that too. The academician in me has been taught never to use the trade names. But no, the denosumab, the prolia, or prolia, however you’d like to inflect that, that’s the one that’s an anti-breakdown drug that has more anabolic properties. So if you want to gain bone, oftentimes we do see more improvements statistically at the spine and the hip with that every six-month injection. But indeed, and I’m glad you brought this up, Terry, because it’s important, that drug, once you start it, it can be challenging to stop. That drug works very differently from the bisphosphonates. It is what’s called a RANK ligand inhibitor, which basically interferes with how the osteoclast and the osteoblast communicate with one another. But it’s a monoclonal antibody, meaning it doesn’t get permanently incorporated into the skeleton. Rather, it’s given every six months because it’s almost as though the clock strikes midnight when you stop it. And all of these cells, all of these osteoclasts that have been kind of paused for the duration of the use of the medication, if you stop it abruptly, they wake up and have a party and can actually break down your bone at a very rapid rate to the point at which we’ve even seen spontaneous vertebral compression fractures in patients who stop their medication without talking with their doctor first. So that drug gets every six months. It is not impossible to stop. In fact, we’re looking as a society at different transition mechanisms, usually, and almost, actually, I’ll say almost always with the use of a bisphosphonate to try to prevent this rebound effect of the drugs to see if patients can stop the medication. but it can be very challenging. So that drug is not for those who come to see me and don’t want to take anything or those who oftentimes have a difficult time making it to their clinic appointments. That is a drug for individuals highly committed to their bone health and very dedicated to a treatment course of 5, 10 or even beyond that years. Joe 52:45-53:28 Dr. Moseley, what about estrogen? I mean, estrogen, it seems like a roller coaster ride. Back in the, oh, I’d say 1970s, 1980s, Premarin was the number one most prescribed drug in America. Just about every woman who was going through menopause was put on Premarin. It’ll take away your hot flashes. It’ll build your bones. It’ll make you feel sexy. I mean, it’s the greatest. And then of course along came the women’s health initiative and then oh my goodness no estrogen it’s too dangerous and now it seems like estrogen is coming back again tell us a little bit about estrogen and bones. Dr. Kendall Moseley 53:29-55:08 Yes, well I mean, that’s uh, you’re right it’s a very very hot topic now and I think we’re all kind of re-evaluating how we think about estrogen not just for bone health but also women as they’re going through the perimenopause, you know, did we kind of throw the baby out with the bathwater, so to speak? We love estrogen for bones. You know, as I described earlier, women lose a tremendous amount of bone density through their perimenopause due almost entirely to this decline in estrogen. It’s like we take the brake off of the osteoclasts and they wake up and they break down a lot of bones. So we absolutely like estrogen for bones. What’s happened though, is that estrogen is really not first-line treatment for osteoporosis or low bone density, in part due to the fact that we do have these data potentially in older women showing increased cardiovascular risk, increased cancer risk. So we don’t typically use it as a first-line drug to treat osteoporosis or prevent bone loss. But if we do see women who are on estrogen for other purposes, maybe they’re on it for vasomotor symptomatology or mood or difficulty with sleeping, We certainly will keep those women off on their hormones, excuse me, and potentially add additional therapy down the road for bone health if we feel that it’s warranted. So we’re probably going to see that pendulum continue to swing back. There is a committee being formed as we speak to reevaluate this exact question about the role of menopause hormone therapy and osteoporosis treatment to see, again, if maybe we got a little bit ahead of ourselves and underestimated the importance of estrogen and bone health, particularly in younger women. as they go through the early stages of their menopause. Terry 55:09-55:21 Dr. Moseley, unfortunately, I don’t have these generic names on the tip of my tongue, but drugs like Forteo, for example, now, is that a drug that is meant to build back bone? Dr. Kendall Moseley 55:22-57:04 Absolutely. I’m glad we’re spending some time on this because it’s a very important category of medications, these anabolic or bone-building drugs that we use in these high-risk fracture individuals. So very low bone density, multiple fractures, oftentimes failing other drugs, where we have to turn to this category of bone building drugs. And there’s a few, luckily, in that category now. So starting with your self-injection medications for up until about two years, we’ve got abaloparatide and teriparatide, also known as Tymlos and Forteo. And these are subcutaneous injections that patients, in fact, give themselves. And sometimes we see those eyebrows shoot straight up when that seems to be a tall ask for the patient. But it’s a self-injection for up to two years. It’s actually parathyroid hormone, interestingly enough. So we’re harnessing the body’s own hormone, giving it back to patients in a pulsatile fashion, which can increase bone density. And then the other drug that’s slightly newer approved in 2019 called romosozumab or Evenity, which are subcutaneous injections administered monthly in a healthcare setting for up to one year, so 12 sets of injections. It should be noted that all of the bone-building drugs, the abalaparatide, the teriparatide, and the romosozumab, after that one- to two-year treatment duration have to be followed by an anti-breakdown drug. If they’re not followed by an anti-breakdown drug, either an oral bisphosphonate, an IV bisphosphonate, or denosumab, in fact, those patients very sadly can lose whatever bone they’ve gained while on treatment back down to baseline, which is always a very, very sad day when we see those patients in clinic because it’s a wasted opportunity to build good bone. Joe 57:05-57:40 Dr. Moseley, there’s one important area that we have not talked about, and that is fall prevention. You know, we talk a lot about exercise. We talk about other lifestyle changes, but avoiding a fall may be the most important thing of all in preventing a fracture of the hip or even a fracture of arms or legs or goodness knows what else. So how can not just women, but older men avoid a fall that could lead to a fracture? Dr. Kendall Moseley 57:41-59:36 Right. No, I think that’s a tremendous question. In fact, every clinic visit, when I see patients, we go through, have you had any falls this year? The first step is assessing the home. And I think the majority of falls happen in the home and it might be a throw rug. It may be furniture that’s too close together. It may be, you know, plastic toys from the grandchildren underfoot, pets. I’m not saying get rid of the grandchildren or the pets, but we do have to be conscientious about our home environment to make sure there’s grab bars on the shower. Make sure that the impediments to just walking aren’t challenging. Some people choose to move to single-story homes, you know, if stairs become too difficult. I think that’s also something to consider. But then there’s also the strengthening itself, the balance and the posture. So oftentimes we fall when we become unstable. Sometimes we don’t have a choice. There’s neuropathy, excuse me, that sets in due to nerve conditions, diabetes, et cetera. Sometimes there’s low vision that we have very little control over. But those things that we can modify, lower body strengthening, posture, core strength, which certainly over time become weaker, people become more stooped. all of those things lead to increased risk of falls. And then finally, we have to really, as clinicians especially, reevaluate those medication lists. I think geriatricians or, you know, boneheads, people across the board agree that a lot of times falls happen because of the medicines we put people on. And this can be anything from anti-diabetes medications, which can cause dips in blood sugar and cause some dizziness, to different types of nerve medications that may cause dizziness over treatment of blood pressure, where blood pressure is quite low. I see many, many falls in the context of maybe overly aggressive medication regimens, or maybe patients just aren’t talking about how they feel dizzy every single time they stand up after that new blood pressure medicine was added. But we really owe it to our patients to make sure that every drug on that medication list needs to be there, particularly as it pertains to fall safety. Terry 59:37-59:51 Dr. Moseley, we have only two minutes left of time. So I am going to ask you to summarize, please, your pillars of treatment, the things that we all need to take away from our conversation today? Dr. Kendall Moseley 59:52-01:00:03 Oh, so many pillars and so little time. So we started with lifestyle. It absolutely is important that patients really follow as healthy a lifestyle as possible. Calcium is important for bone… Terry 01:00:03-01:00:04 How much? Dr. Kendall Moseley 01:00:03-01:00:09 I know there’s a lot of debate. So calcium, the recommendation… Joe 01:00:07-01:00:09 How much and what kind? Dr. Kendall Moseley 01:00:09-01:01:27 So exactly. So the boneheads and even the cardiologists agree that calcium for those with established bone disease, again, this is not a healthy community dwelling population, but those who make it into a bone clinic who are at risk for fracture, 1200 milligrams a day, ideally through diet, ideally, but there are dietary restrictions. So if you have to take a supplement, calcium citrate is the supplement of choice. It’s better absorbed. You don’t have to take it with a meal. And in fact, it does not require an acidic environment for absorption. Vitamin D, very important. Ideally, we’re shooting for a blood level anywhere between 20 to 30 nanograms per milliliter, depending on what guidelines you look at. And for some patients, that might mean 1,000 units a day. For others, 5,000 units a day. For others, prescription strength. So that’s something to work on with their physician. Exercise so resistance training and walking counts about 150 minutes per week as high intensity is tolerated and then finally protein we really protein is having its moment so we want to aim for 0.5 grams of protein at least per pound of body weight because we know we lose muscle as we get older and that’s critical for bone health so lifestyle factors and then obviously the pharmacologic strategies as we discussed earlier if absolutely necessary. Terry 01:01:28-01:01:33 Dr. Kendall Moseley, thank you so much for talking with us on The People’s Pharmacy today. Dr. Kendall Moseley 01:01:34-01:01:42 Thank you so much for having me. And it’s always a joy to talk to people who are interested in bones. And hopefully people walk away with a few little lessons themselves today. Terry 01:01:43-01:02:08 You’ve been listening to Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is clinical director of the Division of Diabetes Endocrinology and Metabolism. She’s also medical director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 01:02:09-01:02:18 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 01:02:18-01:02:25 This show is a co-production of North Carolina Public Radio, WUNC with the People’s Pharmacy. Joe 01:02:26-01:02:55 Today’s show is number 1446. You can find it online at peoplespharmacy.com. The show notes now include a written transcript of this conversation. At peoplespharmacy.com, you can also share your comments about today’s interview and let us know what you do to keep your bones strong. You can also reach us through email. We’re radio at peoplespharmacy.com. Terry 01:02:56-01:03:19 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In the podcast this week, you can hear how estrogen might be used to make bones stronger. What about other drugs that build bone? What practical steps could you take to prevent falls and avoid breaks? Joe 01:03:19-01:03:43 At peoplespharmacy.com, you can sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We’d be grateful if you would consider writing a review of The People’s Pharmacy and posting it to the podcast platform you prefer. In Durham, North Carolina, I’m Joe Graedon. Terry 01:03:43-01:04:21 And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to The People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 01:04:22-01:04:31 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 01:04:32-01:04:36 All you have to do is go to peoplespharmacy.com/donate. Joe 01:04:37-01:04:50 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

   July 23, 2026·1h 5min
   Play