Rachel Rubin’s crusade to help women

At eight thirty each morning Dr Rachel Rubin arrives at her Bethesda clinic. A fresh stack of charts waits on her desk. Most describe women in their late forties to mid-sixties who feel tired, restless at night, and unsure why their own bodies seem unfamiliar. Only six percent of American women over fifty receive hormone therapy, mostly because of misunderstandings, bad reporting, and an undeserved reputation for causing cancer. Rubin calls that avoidable harm and has built her practice to close the gap. She tries to help as many women as possible, but there are more than she can handle.

In the entire United States, only about 1,300 clinicians have earned formal Menopause Society certification, a tiny fraction of the roughly fifty thousand obstetrician-gynecologists and nearly half a million primary-care doctors who could, in theory, prescribe hormone therapy. Against that limited pool stand more than sixty million women already past age fifty, plus another twenty-three million now entering the transition, the vast majority of whom could benefit from properly managed estrogen, progesterone, and (for some) testosterone. Yet fewer than one in twenty office visits by mid-life women results in a hormone prescription, a gap that forces many patients to drive hours or even fly across state lines to find competent care.

The three core hormones

Estrogen: This hormone steadies body temperature, supports memory, keeps skin elastic, maintains flexible artery walls, and is a critical component of building muscle and bone. Rubin prefers a skin patch or clear gel because those forms avoid the small clot risk linked to older tablets.

Progesterone: It protects the uterine lining whenever estrogen is present and, when taken at bedtime, improves deep sleep. Rubin starts with a micronized capsule if a woman still has a uterus. A progesterone-releasing IUD steps in when capsules cause daytime grogginess or mood change.

Testosterone: In women, testosterone is far less prevalent than in men, but it's also about 100 times more prevalent than estrogen. Testosterone allows exercise to increase muscle and bone mass, supports motivation, and restores sexual interest. Rubin prescribes a metered cream measured in tenths of a milliliter. Doses stay low and levels are reviewed until symptoms improve without skin or mood side-effects.

Strategy by life stage

Perimenopause: Cycles continue but hormone levels swing. Rubin eases symptoms with a low estrogen patch. She adds a small progesterone pill only when heavy periods or poor sleep persist. Testosterone is rarely used during this stage.

Menopause: Twelve months have passed without a period and estrogen production has dropped sharply. Most patients move to a moderate patch for joint comfort, mood stability, and bone support. Progesterone becomes mandatory for women with a uterus, delivered nightly or through an IUD. A daily micro-dose of testosterone joins the plan for muscle maintenance and libido.

Post-menopause: Needs depend on bone scans, lipid panels, and day-to-day function. Estrogen stays in place for bone and cardiovascular support, sometimes at a lower dose than before. Progesterone continues when a uterus is present and may be kept for sleep even after hysterectomy. Testosterone is trimmed or raised in small steps as weight, exercise, or skin response changes.

Patient stories

Carla, 57, improved sleep and mood on a standard estrogen patch plus a quarter millilitre of testosterone cream. Four months later chin acne appeared and impatience grew. Blood work showed testosterone high and estrogen low. Rubin halved the cream, increased the patch, and limited testosterone use to three days a week. Acne cleared and temperament steadied within six weeks.

Sandra, 52, reached menopause with disturbed sleep as her only complaint. A one-hundred-milligram progesterone capsule deepened her sleep but left her slow at breakfast. Dropping to fifty milligrams caused spotting. Rubin replaced the capsule with a progesterone IUD and restored the original estrogen patch. Sleep and daytime alertness both improved.

Ellen, 60, arrived with a testosterone pellet implanted by a wellness spa. Her gym results were strong, but hair thinned and mood swings were constant. Pellets cannot be adjusted after insertion. Rubin added a low estrogen patch and nightly progesterone, waited six months for the pellet level to fall, then switched Ellen to a measured cream. Hair loss slowed and mood stabilised while muscle strength held steady.

Carrie, 54, thought she couldn't take estrogen because she had had a blood clot in her 40s. Rachel explained that today's patches and creams are extremely safe and don't cause blood clots.

Patty, 73, said she couldn't have estrogen because she had breast cancer. Rachel told her she has many cancer survivors on estrogen patches and this was just another myth promoted by social media.

Maria, 63, seems to be playing a high-stakes game of hormone roulette. High estrogen eases her joints but triggers headaches. Lower estrogen calms her head yet stiffens her knees. Progesterone deepens sleep but slows recall. Testosterone brightens focus one month and feels emotionally flat the next. Rubin reviews the data every quarter and alters doses in small steps. The goal is the best balance available at the moment, not perfection.

Laurie, 74, kept having urinary-tract infections. Rubin explains that if women would use a cheap tube of vaginal estrogen cream every night, the US would save up to $22 billion just in treating urinary-tract infections alone, and save hundreds of lives. She even brought the cream to her own mother in the ICU and had to educate the doctors on why they should let her apply it.

Recently, Katie, 67, found me and asked if I would train her to build bone in the gym. The first question I asked was "How much estrogen do you have?" She looked up her number and said it was 12. I said "How are you going to build muscle and bone with no estrogen?" She agreed to go meet with Rachel and get started, because she doesn't want to break a hip when she's 80.

Persistent bleeding, fibroids, or a thick uterine lining can block safe estrogen use. For some women, no amount of progesterone seems right. In those cases, Rubin will recommend hysterectomy to reduce cancer risk.

Proven benefits

Balanced hormone therapy started within ten years of the last period lowers hot-flash frequency, slows bone loss, reduces hip-fracture risk, improves cholesterol balance, supports muscle maintenance when paired with resistance exercise, and improves sexual function. Early studies also suggest benefits for coronary health and cognition.

Rubin schedules forty-minute reviews because hormones seldom resolve in ten. Lab numbers and patient diaries guide each change. Two-thirds of women settle into a steady routine within a year. The rest need ongoing fine-tuning as their bodies adapt to the new reality.

Rachel Rubin wants every primary-care visit for a woman over forty to include clear explanations of hormone options, risks, and gains. Most new patients arrive believing they must tolerate their symptoms. Rubin prefers they leave knowing the tools exist, they are safe when used correctly, and adjustments will continue until daily life feels right again. She wants women to spread the word – hormone therapy saves lives, relationships, and provides a higher quality of life after menopause. She hopes young people will want to go to med school and help fill the need for more doctors to help more women. Listen to this entire conversation with Peter Attia, you’ll be glad you did …

I’m told that after this interview, her office received over 2,000 calls from people wanting to make appointments from all over the US. Now I know why she doesn’t answer my email requests to meet with her!

Should you take statins?

If you’re over 40 and your LDL cholesterol is above 100 mg/dL, it’s time to talk with your cardiologist about statins. High LDL signals a higher risk of heart disease, a major cause of death as we age. Statins, medications that lower cholesterol, are one of the most effective ways to reduce this risk. Despite online criticism, including from a few cardiologists, the evidence for statins is strong. This article explains the case for statins while addressing concerns and alternatives.

Rather than focusing only on LDL or VLDL, a better measure of heart disease risk is apolipoprotein B (ApoB). This protein carries harmful cholesterol through your blood, contributing to plaque buildup in arteries, and it’s easy to measure directly. It should be less than 90, and lower is better.

Statins are an important tool in lowering ApoB — which you want to get as low as possible. A low dose of statins can give you most of the benefit with probably no side effects. For example, after I had a stroke, my doctor raised my prescription to 40 mg Atorvastatin, which is standard after a stroke. After about a year, I asked to go back down to 20 and he said sure, that would be fine, so I did. Ask your doctor about starting with the smallest dose he/she recommends.

In my view, statins are just a part of your journey to better heart health. You can lower ApoB more reducing inflammation and insulin resistance than you can by taking statins. If you’re really serious about controlling ApoB, your A1c should dictate what you eat. If your A1c is 3.8 or greater, you should eat no carbs and be in ketosis. If you can get it down under 5.6, then you can add carbs in, but carefully. And you can do exercise — especially hard exercise — to keep your arteries soft and reduce plaque. Managing stress matters too. All these things combine to help reduce your risk of heart disease.

Online, you’ll find plenty of anti-statin arguments, sometimes from cardiologists, warning about muscle pain, liver problems, or claiming cholesterol isn’t the main issue. These points deserve consideration—side effects like muscle pain are real for a small group. But large-scale meta-studies, the most reliable form of medical evidence, consistently show that statins significantly cut heart attack and stroke risk for most people over 40 with high ApoB or other risk factors.

The meta-studies
Meta-studies look at many large-scale trials, throw out those that are poorly designed or underpowered, and try to summarize the total evidence found across the good ones, which are usually randomized, placebo-controlled (RCT). Metastudies must be taken seriously and can’t be ignored. They offer the strongest evidence on statins’ role in reducing cardiovascular risk. Below is a compact summary of major findings, focusing on adults over 40 with risk factors like high apolipoprotein B (ApoB).

1. Cholesterol Treatment Trialists’ Collaboration (2010, 2015)

   • Scope: 26 RCTs, >170,000 participants, primary and secondary prevention.

   • Findings: Statins cut major cardiovascular events (heart attacks, strokes, deaths) by 20-25% per 1 mmol/L LDL reduction. Benefits consistent for those over 40, with or without prior heart disease. Low-dose statins effective, side effects rare (<1% myopathy).

2. Cochrane Review (2013)

   • Scope: 18 RCTs, >56,000 participants, primary prevention.

   • Findings: Statins reduced all-cause mortality by 14% and cardiovascular events by 25% in people over 40 with risk factors. Side effects minimal.

3. Baigent et al. (2016)

   • Scope: 28 RCTs, >180,000 participants, broader populations.

   • Findings: Statins lowered heart attack and stroke risk by 24% per 1 mmol/L LDL drop, effective across ages and risk levels. Benefits outweigh risks (e.g., slight diabetes increase in 0.1%).

No major meta-study concludes that statins should generally not be used by the general population over 40 with cardiovascular risk factors, such as high apolipoprotein B (ApoB) or LDL cholesterol above 130 mg/dL. The most comprehensive meta-analyses, like those from the Cholesterol Treatment Trialists’ Collaboration (CTT, 2010, 2015) and the Cochrane Review (2013), consistently show statins reduce cardiovascular events (heart attacks, strokes) and mortality by 20-25% per 1 mmol/L LDL reduction in adults over 40, with benefits outweighing risks for most, even at low doses. People who argue against statin use cite smaller studies with less statistical power, and they often offer “remedies” with almost no high-quality studies behind them. Statins lengthen lives for those who tolerate them.

Other factors
One aspect of heart disease is genetic. Some people have the LP(a) gene, which precludes them to having high cholesterol and heart disease. These people should be doing everything they can to lower cholesterol, with the general approach being statins, diet, and exercise.

For the roughly 5% of people who can’t tolerate statins due to side effects like muscle aches, there are alternatives. Medications like colesevelam, ezetimibe, red-rice yeast, or PCSK9 inhibitors (expensive) can also lower ApoB or reduce cardiovascular risk through other mechanisms, such as decreasing inflammation. Your doctor can design a treatment plan tailored to your needs.

Summary
If your LDL is high, you should take action to improve your health. Statins, especially at low doses, are backed by decades of research showing they extend life. Combine them with lifestyle changes, and you’re building a strong foundation. Don’t let online debates steer you off course. Get your ApoB tested, have an honest conversation with your cardiologist, and find the plan that’s right for you. Use your brain, not your heart, to decide what’s best for your heart.

If you’re over 50, there’s much more on this website for you to learn about health and longevity. A good place to go next would be my facts page, or if you’re interested in supplements, check out my stack page. You should also see my store.

Finally, here’s Dr Peter Attia talking about statins …

The Luxury Retirement Community of the Future

Here’s the message: don’t underestimate old people, they can do amazing things and will be healthier and live longer when they are working hard doing things they enjoy and find meaningful.

Yuichiro Miura, standing on top of Everest at 80 years old.

I give webinars and talks to people over 60, because I want to help them live longer. I also talk with people who run retirement communities, because I want to help their residents live longer. I look at a lot of websites of retirement communities. They all have some things in common: images of people drinking alcohol, dining, and engaging in leisurely fun. They show some yoga, shuffleboard, and “fitness” classes. What they don’t show is people getting stronger and more independent.

It’s not their fault. It’s just the way it’s always been done. It’s what the market wants. Actually, it’s what the market thinks they want. People who run retirement communities are focused on providing activities and keeping residents busy. But that is solving the wrong problem.

Antifragile, a term coined by Nassim Taleb,describes systems that gain from disorder, to distinguish them from things that are merely robust or resilient. Fragile things break under stress and robust things survive it unchanged, while antifragile things improve when stressed. The human body is antifragile: muscles grow stronger with resistance training, bones grow with stress, and the immune system strengthens through exposure to pathogens. Startups often thrive in volatile markets by adapting to shocks quickly. Evolution itself is antifragile—random mutations and environmental stressors lead to stronger species over time.

I talk about the top-seven things likely to kill you (Cancer, diabetes, heart disease, neurodegeneration, falls, etc.), but the more I look at those websites, the more I think these people are all dying from the same thing:

Boredom

It’s good they have community, because loneliness will shorten your life. It’s good people are busy, because it’s better than not busy. But it seems to me that people over 65 or 70, no matter where they live, are missing a sense of purpose and wanting to make a difference. The weeks are structured, the weeks are busy, but they all blend together. Classes and activities come and go. Holidays come and go. People celebrate by eating more. There is no hustle. Zero hustle. People read books, magazines, watch Netflix, have coffee with friends, and they wait for the next activity on the schedule.

Retirement communities are like full-time cruise ships. They have everything you need to develop full-blown diabetes and require assistance using the bathroom.

But humans are built to hustle. They thrive on it.

This is not limited to retirement communities, it’s a national public health emergency.

Handle with care
Recall the statistics: a measurable increase in deaths occurs on or around birthdays. In the U.S., a study of 25 million deaths showed a 6.7% increase in mortality on birthdays, with men aged 20–29 seeing a 25.4% spike. In Switzerland, birthday deaths rose by 13.8%, especially among those over 60. French data from 2004 to 2023 showed a 6% average increase, peaking at 24% for men aged 18–40 and 29% for centenarians. People can prevent themselves from dying if they have something to look forward to.

And yet most people seem content to play a bit of bridge and pickleball, do some yoga, pretend to be exercising in the swimming pool, and show up for some activities. Judging from the websites, they spend most of their time drinking alcohol with friends and meals. And 73 percent of US adults are either overweight or obese. And people in senior residences are as overweight and obese as the rest of the population.

If you have seen the movie Wall-E, you know where this is heading.

We die from disuse and atrophy — not from “saving our energy.” We die from lack of purpose, overcoming obstacles, and commitment — not “activities.” Older people are treated too gently. They are coddled and accommodated. If you have read The Comfort Crisis, you’ve seen many examples.

People are overmedicated. People taking drugs for hypertension, osteoporosis, diabetes, or overweight are making themselves sicker. This is true for many other areas as well. They could just exercise and eat better. Furthermore, 95 percent of women over 50 are not on hormone-replacement therapy, which promotes osteoporosis, prevents building muscle, and shortens their lives.

And the current “longevity” fad is lots of fancy tests, scans, treatments, and drugs. Without exercise. Because exercise has low profit margins.

Please handle roughly
I remember once I was in Macedonia or Azerbaijan, I forget, but I ran into some older Americans who were there as election monitors. They didn’t have a lot of money. They worked with an organization that places them into a country for a few months before and during an election. I’ve met some amazingly talented woodworkers still in the shop creating at age 70. I know an 80-year-old author writing his 26th book. I know an 80-year-old ski instructor in Japan who skis 60 days a year. The world record for an 80-year-old running the 100m dash is 17 seconds (I can do 20). About 500 athletes over 80 compete every two years in the National Senior Games. The oldest man to climb Everest was 80 and the oldest woman was 73. The oldest woman to climb Mt Kilimanjaro was 89. I could go on and on.

They didn’t accomplish these things by taking it easy. They did it by putting their boots on day after day and working hard.

The future of retirement?

With that in mind, I want to re-imagine retirement communities for Gen-X. I’m assuming this is for high net-worth people who can afford it, though I think many of these ideas will trickle down. I’m also assuming this is for independent living more than assisted living, although I think assisted-living people are in far too much comfort and don’t have to struggle enough, which causes them to deteriorate further. I’m just putting ideas out here with the goal of stimulating conversations among people planning to build new communities or upgrade their existing facilities.

The goal is to make it so residents:

• learn new skills.

• have to struggle and stay at it.

• have to work together to do new things.

• have to rely on each other as team members.

• discover a sense of purpose and accomplishment.

• can measure and track progress and celebrate their wins.

• have big things to look forward to.

• have a full schedule of things to look forward to, so there’s always the next challenge.

People need projects. Think about that. What projects do they do in a retirement community? Their week is filled with “activities,” but no projects. It gets routine. Projects have schedules, mini-deadlines, sprints, reviews, you have to buy stuff and bring it in and coordinate. You need to develop skills and improvise when things go wrong. Then there’s the sense of accomplishment after it’s over. Why are retirement communities so quiet? Why aren’t they bustling hubs of people working on things and waiting impatiently for the Amazon truck to arrive and making videos and uploading them to the YouTube channel and sharing it with everyone they know?

People need outside stimulation. I visited my mom at her assisted-living facility in Denver. She had lunch with the same three women every single day. I sat down with them, opened my laptop, asked one of the “girls” her childhood address, and showed her her old neighborhood on Google maps. She was entranced. She saw the homes of her neighbors, and memories came flooding in — people and things she hadn’t thought about in decades. She marveled at the new shopping center and the changes to the local park. Soon, I had a line of people saying “Do me next!”

People need responsibility. You know what they don’t have? Responsibility. No one’s counting on them. No one’s waiting for them. No one needs them to do something. This might be fine for many people, but it’s counter to our nature. People like to work. They like to have something that needs to be done. They like to have the satisfaction that comes when they serve others. Why can’t the residents be responsible for cooking dinner for the entire facility — including the staff — once a week? That would put some responsibility on some shoulders, and they would quickly form groups and systems to do it creatively. I once lived on a kibbutz in Israel with about 1,000 residents and cooked American-style pancakes for everyone one Sunday morning — plenty of people pitched in to help.

People need connection. Why aren’t seniors connected across the globe? There are already hundreds of online communities. Could those be boosted? Could there be annual awards and recognition? Could there be useful networks to help solve real-world problems? Could they help coordinate disaster relief or expeditions? Could they purchase time on telescopes and explore the cosmos? People from retirement communities should be able to find each other, collaborate, and create new things together without needing any “adult supervision” from staff. Some of the things I propose don’t have enough people in any one community to get lift. But across many communities, “birds of a feather” can find each other and start collaborating.

People need purpose. Even rich people who go on luxury around-the-world cruises eventually get tired of it. People feel better when they are doing something they feel is meaningful to others. This drive helps them live longer and stay in better shape for the future.

Family activities with goals. Most family visits are calm, sit-down, food-oriented visits where grandchildren are forced to give up their screens and game time to pretend to be interested in what’s going on with grandparents and to report on school, friends, life, etc. It’s more like a board meeting and not something to look forward to. What if the kids were there to work on setting a new world record or building a Rube Goldberg machine to make a YouTube video? What if they were shooting a movie or designing a new game? What if they were doing experiments with big magnets? What if they were using AI to solve a problem someone had at the community? What if they came to work with grandparents on making gifts for their friends or a project for school or needed some modifications to their skateboard?

Dealing with restrictions and limitatations. Of course, old people can have all kinds of restrictions. But some are false. Hypertension, insulin resistance, osteoporosis, even aching knees and bursitis can all be reversed with diet and exercise. Cancer survivors can get ridiculously strong — one cancer survivor now guides other cancer survivors to the top of Mt Kilimanjaro regularly! Wherever you are, you can improve — a lot. Probably a lot more than you think.

If you believe what I propose here is dangerous and people can get hurt, keep in mind that probably the most dangerous thing you can do is sitting around, reading, playing games, drinking alcohol, and gaining weight.

Here are some suggestions.

Health and fitness

Insulin resistance: Insulin resistance is the foundation for heart disease, cancer, Alzheimer’s, and many other problems. All people at every age should be aware of their A1c number and reduce it to under 5.7. This should be the first priority for any residence program. I see too many websites featuring a “plant-forward menu,” and that’s exactly what people who are insulin resistant should not be eating. These dietary models are based on outdated low-fat diet fads that played a strong role in creating the obesity epidemic.

In the retirement community of the future, residents should commit to becoming insulin sensitive and get the support they need to do that. They should not go on medical programs for weight loss, like Semaglutide — medical interventions like that should be for people who want to go to the old-style rest homes where people get fat and die young.

Gym: most “gyms” in retirement communities are toys. If you want to see a real gym for people in their 60s and 70s, look at Greysteel. It’s a very different place, where old people are doing extreme things safely. In fact, I have a complete business plan for what this gym would look like and how it would be different from other gyms, and it would attract members from the entire community, not just residents. And the residents can run it! You don’t need staff except for cleaning and a few other things the residents don’t want to do. What about bodybuilding competitions? Don’t underestimate old people.

“Stronger a year from now than you are today” — which retirement community offers this? None. Yet that’s exactly what they should be about. The older you get, the more you should work to build and maintain muscle and bone. The gym experience should be hard. Old people are capable of handling a lot more weight and stress in the gym than you think. The goal for every senior should not be to become superman or woman but to be stronger a year from now than they are today. No matter who they are, that yearly goal adds to independence and creates many years of quality life. I have a program for doing this safely.

This is Steve Taylor. He’s 69. Don’t underestimate old people.

Weight loss: If retirement communities know how to get residents to lose weight, they are holding back their secrets. I’d be surprised if very much actual weight loss is going on. I’m willing to bet that the average person gains weight over the years at these facilities.

We know a lot about weight loss now, and my view is that most “registered and licensed” dieticians don’t know any of it. Their textbooks are full of 30-year-old, low-fat dogma. It’s not their job to force anyone to lose weight, but it should be their job to give people the option of enrolling in a weight-loss program that actually causes people to lose weight. The proof of their competency is in the numbers — how good are they at helping motivated people lose weight and keep it off?

We need better programs. Most people are insulin resistant, and those people should be in ketosis. The harder you work out, the better your cardiovascular system gets, but too many facilities are gentle and don’t push residents. If they want the results, they must be willing to put in the work. No sugar. No alcohol. No cheating. It takes a good strategy for each person, structure, hormones, and many hours in the gym, but they will be very happy when they see the results. This is true for most people at any age. Everyone has pre-existing conditions, but most people can get far better results than they are getting now.

Research teams: People should not rely solely on their doctors for advice. Too often, they resort to Facebook groups or Google searches. But some people know how to do scientific research, literature reviews, and look at data. And there are many good experts publishing on many topics.

Residents could take some initiative and put together teams to help figure out how to solve medical problems. They probably wouldn’t be much worse than the doctors they’re seeing now. Why wait around for “experts” to tell them what’s best? At the very least, they should be well educated. They don’t have to be doctors, but they can help put things in perspective and get a second opinion from another doctor. They can learn how statistics are used and misused in medicine and science in general. A good example is osteoporosis medicines, which no one should be on. If your doctor prescribes Fosamax or Boniva, you should find another doctor. Research groups can help make better educated guesses than many doctors do, and ask pertinent questions. Sure, they may need a guide, but ChatGPT is a pretty good one.

Indoor activities with purpose

Activities should require very minimal staff, because most communities have residents who are capable and can be trained to be the staff. Being a staff member is another purposeful job that gets you out of bed and serving others, plus they often have to move heavy equipment around, which helps keep them strong.

Most of these can be run as clubs, where people pay a membership fee and get a locker. Can be open to the public as well. Don’t underestimate what the residents can do — more and more will be fully digital and online. There will be fewer and fewer AOL email addresses.

Woodshop: most people think a woodshop is a noisy, dangerous place with lots of high-speed spinning blades and common injuries. This is not the case. Today’s woodshops are very carefully ventilated with full dust collection, the machines have lots of safety guards, and woodworkers make sleds and carriers to keep their cuts straight and their fingers away from the action. Injuries are now quite rare. Don’t underestimate old people — they are capable of running, using, and maintaining a wood shop with all kinds of machines. And it lets them produce things they are proud of and give to their families or make for their community. Need cutting boards or serving platters? Want a ping pong table, a foosball table, a lamp, or a chess board? A puzzle or a sculpture? Don’t order one. Build one.

Metalshop: Same as above, but there’s more computer-driven equipment.

3D printing: Supplies are fairly cheap. There’s always something new to learn.

Performance space: I’m sure there are some retirement communities where people volunteer, participate, and create exciting cultural events, where the residents are the performers and entertainers. This should be the norm, but it takes residents to volunteer and build up a great program and produce great performances. I’m sure some of the better ones also involve groups in the community. There’s huge potential here.

Ping pong: Sounds silly, but ping pong at a high level really challenges hand-eye coordination. All retirement communities should not just have ping-pong tables but elevate the level of ping pong playing to tournament and master’s level. It’s fast. It requires quick reactions. There’s no reason some of the best and most competitive master’s ping-pong players in your city shouldn’t be coming from retirement communities. Looking forward to tournaments and having high-level opponents will help preserve motor units and neurons.

Volleyball: Same thing with volleyball, but the normal ball is a bit heavy and can damage hands and wrists. So play the same game with a much lighter, foam ball. Let’s set a standard for a new kind of ball, keep everything the same, and make this new sport very competitive. Compete against other retirement communities. Have regional championships. This is far better than “activities” for seniors.

Pickleball: The problem with pickleball is it’s too easy. I know at the pro level that’s not true, but at the local level it is. Doubles is far too easy. If you do pickleball, make it singles, and get everyone to play at a high, competitive level. Again, tournaments against other communities will encourage residents to upskill and enjoy meeting other pickleball enthusiasts and enjoy sharing a good protein shake after a hard match.

Juggling: Anyone can get into juggling, and the sky is the limit. There are thousands of levels, tons of videos, and teams can compete against each other online. There are camps and competitions around the world. Juggling is one of the best ways to preserve motor skills and coordination.

Climbing wall: People think climbing walls are dangerous, but they aren’t. A well designed and run climbing wall is a fantastic way for people in their 70s and even 80s to develop muscle and fitness. This is functional muscle. It combines balance, coordination, and movement. It improves grip strength and builds skills people can be proud of. People pair up and support each other. And it will draw grandchildren in to spend time with their grandparents.

Magic camp: Anyone can learn magic tricks. Good magicians can put together an act and go around town performing. They can perform at hospitals, schools, community centers, and festivals. You have to practice, learn, watch videos, get coaching, be determined to master each trick. Grandchildren will show up for lessons.

Learning lab: learn a new language together. Study physics or chemistry. Focus on one particular time in history, like the Diet of Wurms or how the pyramids were built, and make a video explaining it. Learn what causes strokes. Take the free video classes at MIT and Stanford. Learn to speed read. Compete in brain games. Do it as a group project and help each other. Have meetings. Divide up the work. Set deadlines. Deliver deliverables. Teach others.

VR: Using VR, people can go on all kinds of adventures. Have you tried exploring the space station or climbing a mountain? You can visit places around the world and interact with others. Why not have a network of people in retirement communities all having online adventures and events together? You can even play team games and put on performances.

Lego lab: Lego enthusiasts have come up with the Great Ball Contraption contests. They are held all over the world. They design mechanisms for moving balls along a conveyor line, and they are wild. See 2012, 2016, 2022. Do you think a lego lab might attract a few grandchildren to come visit?

Run a store: In Washington DC, there’s a “Made in DC” store, where everything is locally made. Why not have a store that the seniors can run all by themselves? It doesn’t have to be on campus, it can be in town, pay rent, pay for staff and services, and break even as a nonprofit. Residents can do the books, buy products, run checkout, do marketing, events, and more. Or run an online store and use the profits to support good causes. Strange as it may sound, people will stay alive longer simply because others are counting on them to do their job.

Make products: Seniors can make everything from chocolates to guitars to t-shirts to cutting boards to iPhone cases and much more. They could set up a small factory, make products, sell them online, do marketing, PR, and much more. Why not? A successful factory can hire local teens or others and help grow the economy.

Host a TEDx event: Anyone can host a TEDx event. Get people from all the retirement communities in your city together and host one. Let them organize, prepare their talks, build the signs, run the event, and share the results with their families afterward.

Digital crafts: People can collaborate to design all kinds of things using online design tools. They can build 3D models, scenes, animations, simulations, games, apps, and use AI to create films. By working online, they can have mentors and collaborators around the world. Seniors should be able to come up with a good idea for an app or a website, launch it, and use the network of seniors connected online to promote it.

Publishing: People can write books, make videos, create online classes, share their photography, hold webinars, and much more. This could be done at scale, so someone who’s giving a lecture on the Bernoulli effect could find a wide audience of interested people around the world. No one at his local community is interested, but by connecting communities, new markets open up. You can even set up a letterpress print shop and make all the cards, signs, menus, booklets, and everything else everyone needs. They could write and record music. They could create a science channel and make videos. They could print things their grandchildren want, so they work with them on projects. Doing it by hand the old-fashioned way is fun, creative, and satisfying. Don’t underestimate old people!

Contests: Every month there are contests for all kinds of things: paper-airplane design and flight, puzzle boxes, origami, one-off bicycles, egg drops and catapults, houses of cards, domino falls, Geoguesser, building musical instruments from scrap, yoyo competitions, bodybuilding, and much more. Plan. Train. Compete. Win or lose doesn’t matter.

Outdoor activities with purpose

Don’t underestimate old people. The worst thing they can do is go on a cruise. On a cruise ship, everyone is overweight, everyone eats, lays down, and sleeps. Then there’s a bit of entertainment or losing money in the casino. This is not what today’s retirees want or deserve. They need to get moving.

Many seniors enjoy gardening, but they don’t work very hard at it. The average farmer is healthier and lives longer than the average person in a retirement community. Residents can grow food for their community. They can put in the long hours and hard work to raise vegetables, fruits, herbs, and other things that will benefit the people who live there. And take pride in what they have grown. This sounds like work for the staff, but it’s actually great for the residents. They can even set up a farmer’s market or go participate in one.

Want a bowling alley? Build one. Want a pickleball court? Learn to build one. Need a cart to carry things around? Build one. Weld up the frame and assemble the parts, then paint it and admire your handiwork. These kinds of things are so much more satisfying to do if you built it yourself and maintain it. No staff needed — building the thing is every bit as good an activity as using it, so who cares how long it takes? Forget the crossword puzzles and card games — build things.

Rucking is so beneficial for older people that it should be a standard activity. Rucking is walking and hiking carrying extra weight on your back. Everyone should be rucking 2-3 times a week. It helps build hip and spine bones and muscles. It’s far better than walking. Walking doesn’t help people lose weight or gain muscle and bone. Every community should have a rucking club. Why can’t seniors walk a few miles, get all their gardening supplies or groceries, put them into their backpacks, and walk back? Sound too difficult? Those people will outlive the others who don’t.

Hiking keeps you agile. Hiking with weight on your back keeps you stable and strong. Those who hike twice a week will be far stronger than those who don’t.

There are so many other opportunities. Community members can be referees at soccer games, umpires at baseball games, and otherwise contribute to children’s sports in the community. You think they wouldn’t jump at the chance? Don’t underestimate old people.

Transportation is definitely an issue. We don’t want most people over 80 driving cars. But there are so many other options now, I believe each community will find good ways to get their seniors where they need to go. As long as people want to do things in groups, the costs are usually reasonable.

Travel activities with purpose

I would like to create travel experiences that are the opposite of cruises. One proposal I have is to take grandparents and their grandchildren to East Africa, to climb Mt Kilimanjaro and then go on safari. Why climb the mountain first? Because it’s hard. To climb to the top of Africa, you need to spend a year getting ready. If you’re bringing your grandchildren on safari, then you need to spend that year with your grandchildren hiking, walking, rucking, preparing, learning about the route, minimizing risks, and — voila! — doing a project together with them. Because the prize is three weeks in Africa, a lot of kids will give up screen and game time to prepare with grandma and grandpa. And guess who’s going to carry most of the luggage?

There are big events every year where people get together to do very hard challenges and obstacle courses. Examples: Grit, Tough Mudder, Red Bull 400, Spartan race. Why don’t we create a series of events for seniors? They can train, prepare, pack, and go compete against people from around the country, similar to the National Senior Games. If you think this isn’t going to exist, you are underestimating old people.

Wouldn’t it be great to set up a senior travel agency to plan these kinds of trips around the world? It could be a virtual company with everyone working online. Guess who could work there?

These are just a few ideas showing how market trends may develop and how senior living may adapt. I’d like to see a senior living facility that pushes people and doesn’t underestimate them. It’s not for everyone, but it would attract its own clientele, and they would probably live to be far healthier and far longer than most people in most retirement communities.

To learn more about longevity and antifragility, explore this website and contact me with any questions.

The little-known benefits of vaginal hormone delivery

As I have mentioned, hormone-replacement therapy transforms lives for women from their 40s to their 80s, giving women the ability to build bone and muscle, prevent cancer, and many more benefits. Here, I’ll talk about the benefits of local hormones applied as vaginal creams and rings. Not only do most women not know about these products, but if you’re reading this and you’re a woman, you can probably benefit.

Vaginal creams reduce menopause-related challenges like vaginal dryness, painful intimacy, reduced sexual desire, and life-threatening urinary tract infections (UTIs). Using DHEA (dehydroepiandrosterone), estradiol, or compounded creams, these treatments deliver profound benefits—safe, affordable (thanks to Mark Cuban’s Cost Plus Drugs pharmacy), and life-changing.

A Lifeline Across Decades
In their 40s and 50s, women in perimenopause often face vaginal dryness, discomfort, and reduced sexual desire, even on systemic HRT. Jessica, a 48-year-old teacher, struggled with these issues and recurrent UTIs. A compounded estradiol-testosterone cream from Cost Plus Drugs, costing $15 monthly, eliminated her symptoms in weeks. “No UTIs, and my sex life is vibrant again,” she says, thriving at home and work. DHEA (Intrarosa, 6.5 mg daily) converts locally into estrogens and androgens, boosting lubrication by 115%, reducing pain during intercourse by 108%, and increasing desire, arousal, pleasure, and orgasm by up to 49%, per studies. Estradiol (Vagifem, applied 2–3 times weekly) strengthens vaginal walls. Compounded creams, blending DHEA, estradiol, progesterone, or testosterone, offer tailored relief, with progesterone reducing inflammation and testosterone enhancing libido—crucial for perimenopausal women seeking sexual vitality.

In the 60s and 70s, these therapies restore comfort. Linda, 68, used a $18 DHEA-progesterone cream to end UTIs and painful intimacy. “I’m enjoying romance again,” she says. UTI prevention is critical, as menopause thins vaginal and urinary tissues, increasing infection risk that can escalate to sepsis. Studies show vaginal hormones cut UTI rates by 50%. Marjorie, an 83-year-old ICU patient post-heart surgery, avoided a deadly UTI with daily DHEA cream. “It kept Mom safe,” her daughter said.

At 79, Sarah struggled with vaginal dryness, urinary urgency, and a UTI about once a year. A DHEA-testosterone cream relieved her discomfort, improved bladder control, and restored her confidence. “I used to get a UTI yearly, but I haven’t had one since starting the cream,” she says. “I’m back to enjoying book club and lunches with friends without worry.”

Vaginal Rings: Simple and Effective
Vaginal rings, like Estring, are flexible, silicone devices inserted into the vagina to release low-dose estradiol for 90 days. Women insert them (like a tampon) and replace quarterly, with no daily upkeep. Studies show 80–90% improvement in dryness, discomfort, sexual function (including desire and orgasm), and UTI prevention by supporting urinary tissues, ideal for busy or mobility-limited women.

The labeling problem
The FDA’s labeling for vaginal hormone products, like estradiol creams and rings, often includes warnings about risks like blood clotting, which apply to oral estrogen but not low-dose vaginal therapies. These outdated warnings, rooted in systemic oral-estrogen risks (oral estrogen is no longer used), create confusion, giving doctors, pharmacists, and nurses pause. Many hesitate to prescribe or administer these treatments, unsure of their safety due to mislabeling, which limits patient access to life-changing care. Dr. Rachel Rubin, a urologist, has advocated for change, stating, “The boxed warnings on vaginal estrogen are outdated and misleading; these products are safe with minimal systemic absorption, yet the FDA clings to systemic hormone risks, limiting access to life-changing care” (2023 interview with The Washington Post). Her efforts underscore that vaginal hormones, with negligible systemic effects, don’t carry the same dangers, yet mislabeling persists, hindering proper prescribing and use.

Safe, Affordable, and Impactful
These therapies are safe across decades, with localized action avoiding risks like blood clotting. Trials report only mild side effects like discharge. Mark Cuban’s Cost Plus Drugs offers estradiol cream for $13.21 versus $293.66 through Medicare. Cuban told PBS in 2022, “Our approach at Cost Plus Drugs… show you our actual cost, mark it up 15%, add $3 pharmacy handling fee and $5 shipping… has really had an impact.” Dr. Rachel Rubin, a urologist, states, “Vaginal hormones prevent UTIs by more than half, improve arousal, orgasm, and lubrication, and could save the healthcare system $6 to $22 billion annually by reducing infections and doctor visits.” A tube of vaginal cream used to cost hundreds of dollars, now it’s only $18 plus shipping.

You may not have even heard of this, which shows how misinformation travels. Doctors should be talking with all their patients about adding local delivery of hormones to any woman’s health regime. All women should explore vaginal hormone therapy for its ability to enhance sexual desire, arousal, pleasure, orgasm, protection, and overall quality of life, while preventing costly infections—whether in perimenopause, living vibrantly in her 70s, or in the ICU in her 80s. Consult your healthcare provider to explore FDA-approved Intrarosa, vaginal rings, or compounded creams through Cost Plus Drugs or local pharmacies.

Disclaimer: Consult a healthcare provider before starting treatment.

Explore my website and blog to learn more about women’s and men’s health over 50.

Hormone replacement therapy for women

I talk with a lot of women over 50, and I’m surprised that the vast majority have never tried Hormone Replacement Therapy (HRT). When I ask “Why?” they shrug their shoulders and say it’s just not for them. But they don’t know that. They don’t know the difference it could make. They have been led to believe that by the persistent myth that estrogen causes breast cancer. As you’re about to learn, hormone replacement therapy prevents cancer and supports healthy aging.

History of HRT
In the 1960s, HRT emerged to ease menopausal symptoms, with estrogen widely embraced by the 1990s for hot flashes and bone health. The 2002 Women’s Health Initiative (WHI) study wrongly alarmed millions by overstating risks of estrogen-progestin HRT, like breast cancer and heart disease, causing a major setback for women’s health research and trust in hormone therapy. Part of that was caused by oral estrogen pills, but most of the problem was in bad data.

Although it was front-page news, later analysis of that same data debunked WHI’s flaws, and more studies continued to show HRT is safe and effective for most when started early with modern methods like creams or patches. Today, personalized HRT is a cornerstone of menopause care, with doctors tailoring doses and delivery to individual needs, underscoring the importance of early action. Still, today fewer than 6 percent of women are on HRT - one of the greatest public health failures of the last 100 years. If you want to live better for longer, talk with your urologist or endocrinologist about trying HRT.

HRT for Women in Perimenopause
Perimenopause, often in your 40s, brings irregular periods, hot flashes, and mood swings. Estrogen creams or patches can stabilize symptoms and improve sleep. There are also rings and vaginal creams. If you have a uterus, add progesterone (micronized pills or creams) to protect against endometrial issues. There is no single solution: some women feel calmer, others bloated, others irritable. In most cases, it’s best to start with estrogen first and set a good level before adding progesterone.

Stay ahead—experiment with low-dose HRT early. Hysterectomy patients can use estrogen alone. Discuss delivery methods with your doctor to find what works, adjusting for side effects. Delaying worsens discomfort, so start now to stay comfortable.

Women in Their 50s
Menopause in your 50s often intensifies hot flashes, vaginal dryness, and fatigue, disrupting daily life. Estrogen creams or patches (avoid oral pills) can reduce symptoms by 80% and boost mood. To prevent endometrial cancer, almost all women with a uterus should be on progesterone (micronized pills, rings, or creams). With enough experimentation, you should find a delivery method that works for you.

During menopause, symptoms and conditions can change. It would not be unusual to change your dose and delivery method at least once during this period. Stay ahead of it. Try options early, like patches for steady delivery, and pair with exercise. Some women like to inject themselves, they say it gives them much more control. Don’t settle for brain fog or fatigue. Get your HRT and get into the gym. Acting promptly keeps you vibrant.

Women in Their 60s
In your 60s, 40% of women face hot flashes, and vaginal dryness or urinary issues increase. Vaginal estrogen creams or inserts are low-risk and effective. Systemic estrogen (creams or patches) or progesterone (micronized pills or creams) can aid energy, but heart risks grow. Progesterone’s effects differ—some feel great, others sluggish.

Don’t let symptoms linger—try vaginal estrogen and a progesterone ring early. Explore safe delivery methods with your doctor, and consider non-hormonal options if systemic HRT isn’t suitable. Regular check-ups ensure safety.

Women in Their 70s
Hot flashes (10–15%) and vaginal dryness (over 50%) persist in your 70s, affecting comfort. Vaginal estrogen creams or inserts are safe and effective. Systemic estrogen or progesterone (micronized pills or creams) is riskier due to heart and dementia concerns but may help severe symptoms. Progesterone can be calming or disruptive.

Act early—experiment with low-dose vaginal estrogen. Hysterectomy patients can use estrogen alone. Discuss delivery options with your doctor, and add strength training. Starting now preserves quality of life.

Women in Their 80s
In your 80s, vaginal dryness or urinary issues can reduce comfort. Vaginal estrogen creams or inserts are safe, improving intimacy and reducing UTIs. Systemic HRT is rarely started due to heart and dementia risks, but continuing prior HRT may work. Progesterone responses vary—some benefit, others don’t.

Stay proactive—try vaginal estrogen early. Explore delivery options with your doctor, and maintain check-ups. Starting an exercise program alongside HRT supports muscle growth and independence.

Yes, there is some risk of starting late. But there are risks to not starting. Talk with your doctor to see if HRT is right for you. If your doctor doesn’t mention the benefits, get another doctor.

Benefits of HRT:

• Symptom Relief: Reduces hot flashes (up to 80%), night sweats, vaginal dryness (50–60% prevalence), and mood swings, improving sleep and quality of life.

• Bone Health: Lowers osteoporosis risk (50%) and fracture risk by 24–34%.

• Heart Health: Supports cardiovascular health if started early, potentially reducing heart disease risk.

• Comfort and Mobility: Enhances energy, muscle strength, and urinary health, reducing UTIs and fall risks.

• Individualized Care: Tailored options (creams, patches, inserts, micronized progesterone) suit varied responses, especially for hysterectomy patients needing only estrogen.

Risks of Not Using HRT:

• Persistent Symptoms: 40% of women in their 60s and 10–15% in their 70s endure hot flashes; 50–60% face vaginal dryness, leading to discomfort and UTIs.

• Bone Loss: 50% osteoporosis risk, with 20% bone loss in 5–7 years, increasing fracture risk (20–30% hip fracture mortality).

• Mood and Energy Decline: 2–3x higher depression risk, plus fatigue, brain fog, and reduced vitality.

• Missed Opportunities: risks like heart disease and dementia rise with age.

Testosterone for Women
Testosterone, often overlooked in HRT, can be a powerful addition for women at any age, addressing low libido (40–50% prevalence post-menopause), fatigue, and muscle loss (3–5% per decade). Low-dose testosterone creams or gels can boost sex drive, energy, and mood, while supporting muscle strength to reduce fall risks. It’s off-label, so work closely with your doctor to try it early, monitor for side effects like hair growth, and pair with estrogen for balanced benefits. Don’t wait—exploring testosterone can enhance vitality and confidence, especially if symptoms persist.

Summary
If you want strong muscles and bones and you don’t want cancer, it’s time to stop imagining that HRT is not for you. See your doctor to explore HRT — at the very least, estrogen. Experiment with delivery methods to find your fit—HRT can enhance your life at any stage.

If you’re still not convinced, listen to this conversation between Dr Peter Attia and Dr Rachel Rubin. If you want an online hormone doctor, see Pema Bioidentical. I have no affiliation with either. Here’s a roundup of online providers.

Learn more about my longevity coaching service by exploring this site. You may want to start on the facts page.

Everything your doctor doesn’t know and won’t tell you about osteoporosis

CAVEAT: Before starting any supplement, drug, or exercise program, talk to your doctor. Understand that the risks of inactivity are probably higher than the risks of exercise. I’m not your doctor. You assume any risks from taking or not taking the advice here.

If you're over 40, your peak bone density and mass are in the rear-view mirror. As we age, we all lose bone mass, unless we can manage to build it back up. Osteoporosis, which affects over 10 million Americans over 50, can lead to fractures that steal independence. According to Dr Doug Lucas:

• 50 percent of adults over 50 are at risk of a fracture.

• 50 percent of women and 25 percent of men will suffer a fracture from poor bone quality in their lifetime (I’ve had 10).

• Women have a higher chance of a fragility fracture than they do of heart attack, stroke, and breast cancer combined!

• 24 percent of people over 60 with a hip fracture die within 12 months.

• Independence is permanently lost for 50 percent of patients who fracture a hip.

I broke both hips in my early 50s. My bones are now far stronger than they were 20 years ago. I have learned how to build bone, and you can too.

In this article, I lay out what I think is the useful information about osteoporosis for most people. I make the case against drugs and for specific bone-building exercise, and I go through all the useful supplements. Then, I show a video on what does work — resistance and impact exercise, plus balance and stability exercises, supported by the right diet and supplements. You can do it, it’s not difficult, and it doesn’t take much time. If you don’t want to read about the drug issues, just skip to the exercise section at the end, it’s the most important.

This article should take you about 40 minutes to read and watch, and it should save many people at least one fracture later in life.

If you're interested in supplements, you'll find specific recommendations on my stack page. If you’re interested in a consultation, see my pricing page.

I have a special note about the AlgaeCal company at the very end.

What are bones?

If you're over 50, you should have an interest in maintaining bone density and mass, which means you should be planning to grow bone, because you are almost certainly light on bone in your hips and spine right now. That's why I recommend this book, The Osteoporosis Breakthrough, by Dr Doug Lucas, who explains everything more precisely but with more words than I can dedicate here. It’s actually a short, very readable book.

Bones are living tissues that constantly remodel, balancing the activity of cells that build bone (osteoblasts) and those that break it down (osteoclasts). Calcium provides rigidity, collagen provides flexibility. Together, they create a composite material stronger than either alone, like reinforced concrete (collagen as rebar, calcium as cement).

The human skeleton contains two primary bone types: cortical (compact) bone and trabecular (spongy) bone, each with distinct roles and traits.

Cortical bone, forming 80% of skeletal mass, is dense and strong, creating the hard outer layer of bones like the femur. It provides structural support and resists bending.

Trabecular bone, found inside bone ends (e.g., in vertebrae), is porous and lattice-like, making up 20% of bone mass. It supports marrow, aids shock absorption, and remodels faster (10–20% annually vs. cortical’s 2–5%).

Plus, your bones function as red-blood-cell factories to boot!

Approximately 10–20% of your skeleton is remodeled annually in adults, and your entire skeleton turns over in 7-10 years. Isn’t that amazing?

The process of building bone relies on nutrients like calcium, vitamin D, vitamin K, and collagen, which form the bone’s mineral and flexible matrix. However, the key driver of bone growth is mechanical stress—carrying weight and absorbing impacts. Soccer players have thicker, stronger bone in their lower kicking leg by about 20 percent. Tennis players have stronger bone in their hitting arm by 30-40 percent. Ancient tribal skeletons of our past relatives who paddled boats had huge shoulder capsules and arm bones from paddling, while people living in mountainous regions have stronger, thicker knees and ankles. The majority of people in wheelchairs for over five years have moderate to severe demineralization in their hips and spines, and more than 80 percent of people in wheelchairs after ten years have osteoporosis, regardless of age. Without stress, bones weaken, no matter how many supplements you take.

And bone mass disappears for women as soon as they start to lose estrogen from menopause:

Look at people in their 80s: look at their wrists. They are tiny. Why? No stress! If you want to keep it, you have to use it.

The bad news: running, tennis, cycling, swimming, even hiking and most other sports don't build your hips and spine. Yoga, pilates, and walking are about the same. Almost everyone over 40 is demineralized, and the hips, spines, and wrists are often the weakest links. No, you are not the exception, and no, mountain biking does not do it. If you row competitively, you probably are one of the few people with a strong spine and hips.

The key concept is that your body builds enough bone to meet the needs of your anticipated activities and no more. This is called Wolff’s law. Spend a year building up your legs with exercise and your body will happily build the bone needed to support that activity. Stop and your body will begin dismantling that bone within days. That's why demineralization is such a risk for astronauts, who train with big rubber bands daily in space, and why it's so dangerous for them to walk when they get back after a few months in a zero-gravity environment.

Now I’m going to cover supplements, drugs, diagnostics, estrogen, diet, and then exercise, fall prevention, vibration plates, and maintenance at the end.

Supplements

Calcium
Calcium is the main mineral in bone and the main supplement doctors prescribe. Studies, like a 2007 analysis in The Lancet, show that 500–1200 mg of calcium daily can slow bone loss in postmenopausal women by about 1% per year. Vitamin D, often paired with calcium, helps your body absorb it, reducing fracture risk in those with low levels. But here’s the catch: while calcium and vitamin D prevent further loss, they don’t significantly build new bone without exercise. If your DEXA scan shows a slight uptick after starting calcium, it’s likely because you’re losing less bone, not growing more.

The best kind of calcium to get is the calcium found in leafy green vegetables. That's why I recommend AlgaeCal Plus, which is made from algae, so it's essentially the same as getting your calcium directly from vegetables. AlgaeCal Plus gives you 360 IU of calcium in the morning and 360 IU at night, for a total of 720 IU of bioavailable calcium.

Do you need more than 720 IU of calcium? The answer is … we don’t know. Recommendations for vitamin D range from 800 to 40,000 IU per day! But it’s not how many units you take, it’s how much vitamin D is in your blood. So you need to test and adjust, and it’s probably different in summer vs winter. Peter Attia recommends 60-80 ng/mL. Others recommend around 30-40 ng/mL. The amount you need to take to achieve this depends very much on you and your lifestyle and where you live. On the other hand, Dr Brad Stanfield says we should be careful and that most recent studies show that there are dangers to getting too much vitamin D (but it takes years to do the damage, so don’t worry).

The Endocrine Society recently lowered their recommendations to 600 IU daily for people 50-70 and 800 IU daily for those over 70. Clearly, we need more and better research.

The way I think of it now is that it makes sense to get the basic 800 IU that comes with AlgaeCal Plus and then supplement to hit a blood-level target. Some people are naturally low and need more. Some people get a lot of vitamin D from their diet, while others don’t. If you’re outside all summer, you may want a supplement during winter, or you may have enough from the 800 IU in AlgaeCal Plus. To do it right, you need a blood test in about January. Generally, if you’re not deficient in vitamin D, you probably don’t need to supplement very much. But the jury is still out.

Magnesium
Magnesium has so many benefits, and the negative effects of not enough magnesium are so bad that most athletes and bodybuilders now take magnesium. But it also plays a critical role in bone building. It stimulates the activity of osteoblasts and enzymes from the phosphatase group, which are involved in the bone formation process. Most good calcium supplements, like AlgaeCal Plus, come with magnesium.

There are actually eight kinds of magnesium. Optimal to support muscle growth are magnesium citrate and glycenate or bisglycenate. The recommended daily allowances (RDA) for magnesium are:

• 400-420 mg. per day for men 19-51 years of age

• 310-320 mg. per day for women 19-51 years of age

• 350-360 mg. per day for pregnant women

• Adults over 51 should aim for the upper limit of the recommended range for their gender

Split doses (e.g., morning and evening) to improve absorption. You could take a citrate in the morning and then a glycinate at night, which aids sleep, enhancing recovery.

Calcium and heart disease?
Calcium supplements may contribute to arterial plaque buildup, potentially increasing heart disease risk, but the evidence is conflicting. A 2010 study in BMJ found that taking calcium supplements without vitamin D raised the risk of heart attack, possibly because high doses cause calcium to deposit in arteries. However, a 2016 study in the Journal of the American Heart Association showed no clear link between calcium supplements and artery calcification in women over several years. Dietary calcium from food seems safer than supplements, and risks may vary based on dose and vitamin D use.

More research is needed, but for now I believe the researchers who say taking the amount of calcium you get in your daily dose of AlgaeCal Plus is not a cardiovascular risk, as long as you’re also getting enough K2 (see below).

Kidney stones
Calcium supplements can help keep your bones strong, but they might also raise your risk of kidney stones, those razor-sharp little crystals that form in your kidneys. A study from the 1990s showed that eating calcium-rich foods cut kidney stone risk in half for men, because the calcium binds with oxalates and prevents them from reaching the kidneys. But a 2006 study found that taking 1000 mg of calcium supplements daily increased stone risk by about one-fifth in older women, especially if taken on an empty stomach.

The key is how you take supplements. Taking high doses of calcium without food or water can spike calcium levels in your urine, making stones more likely. To stay safe, stick to 400 mg or less per dose, take it with meals, and drink plenty of water—8 to 10 cups a day. Food sources are your best bet for calcium, but if you need supplements, talk to your doctor, especially if you’ve had kidney stones before.

Know your list of foods high in oxalates. When you eat these foods, be sure to take a calcium supplement at the same time, so they bind together in your stomach and don't go into your bloodstream. Otherwise, the oxalates can make their way to your kidneys and wait there for the calcium ions needed to build a stone.

Collagen
Collagen supplements are popular for skin, nails, hair, and joint health. Collagen is a peptide (a kind of protein complex) harvested from cow, chicken, and fish bones, and chicken eggs. Does collagen also help build bone? Collagen forms the flexible framework of bones, but evidence for bone benefits from supplements is thin. Collagen supplements probably help joints rebuild, and it can’t hurt for building bone. But if you skip the collagen and just take AlgaeCal Plus, you probably won’t be at a disadvantage. I tell my clients that if you have joint pain, or if it helps your hair and nails, take collagen.

It’s possible that taking collagen is helping you build some small amount of bone or making your bones more resilient. You’d never be able to see the difference on a DEXA scan, or even a REMS scan. If you’re a big strong person who’s lifting heavy, you can take it or leave it. But if you’re on the skinny side or getting more frail, it can’t hurt to get your daily collagen. I take mine every day, because I do notice a difference in my joints.

Vitamin D
Vitamin D is like a key that unlocks your body’s ability to build strong bones. It helps your gut absorb calcium and ensures calcium gets deposited into your skeleton to form hard, healthy bone tissue. Without enough vitamin D, even a calcium-rich diet won’t fully protect your bones, leading to weak bones or conditions like osteoporosis.

But more isn’t always better. Recent research, like a 2023 study in JAMA Network Open, warns that taking too much vitamin D (over 4000 IU daily) can cause problems, such as high blood calcium levels, which may harm your heart, kidneys, or even weaken bones. To stay safe, aim for 800–2000 IU daily from food (like salmon or fortified milk), sunlight, or supplements, and check with your doctor before taking higher doses. If your blood test shows you are deficient, take enough to get into the higher range of normal, but make sure you aren't getting too much. Get a reasonable amount of vitamin D and get outside more. Keep in mind that people in their 80s and 90s need extra vitamin D, simply because their skin is less efficient at making it.

Vitamin K2
Vitamin K2 is like a traffic cop for calcium, guiding it to your bones to keep them strong and away from places it shouldn’t go, like your arteries. It activates proteins, such as osteocalcin, that help calcium stick to the bone matrix, making bones denser and less prone to fractures. A 2013 study found that K2 supplements (180 mcg/day of MK-7) slightly improved bone density in postmenopausal women after three years, especially when combined with calcium and vitamin D.

You can get K2 from foods like natto (fermented soybeans), egg yolks, and cheese, but many people don’t eat enough of these. Supplements can help, but they’re not a magic fix—K2 works best with exercise, which signals bones to grow, and nutrients like calcium and vitamin D. Taking too much K2 (over 200 mcg/day) is rarely harmful but may not add extra benefits. K2 is in most calcium supplements these days, you don't need extra.

Strontium: a red herring
Strontium, another supplement closely related to calcium in the periodic table but denser, raises the most questions. Found in products like strontium citrate, it mimics calcium and can lodge in bones. Clinical trials, such as a 2004 study in the New England Journal of Medicine, showed strontium ranelate increased DEXA scores by 1–3% over three years and cut fracture risk by 20–30%. Sounds promising, right? But strontium’s heavier atomic structure absorbs more X-rays, making bones appear denser on DEXA scans than they truly are. Up to 75% of the density gain may be a DEXA artifact, not stronger bones. Plus, strontium can cause blood clots you don't want.

Doug Lucas says that he sometimes recommends strontium for some of his patients, it’s probably not necessary, it can potentially support bone growth, but we still don’t have good studies that isolate the effect of strontium vs other micronutrients. I’m not sure when he recommends it, but he says less than half of his patients want to take it, and he’s “open to that.” It’s not his default recommendation. I wonder whether patients taking strontium are just crowding out their calcium and if calcium would do as good a job or better. Since I’m not your doctor, this is something to discuss with your endocrinologist.

Boron: a non-key ingredient
Boron plays a supportive role in bone formation by enhancing calcium, magnesium, and vitamin D metabolism, modulating hormones like estrogen, and potentially stabilizing the collagen matrix. Its effects are modest, with 1–3 mg/day from diet or supplements improving nutrient retention and BMD slightly, especially in postmenopausal women or vitamin D-deficient individuals. However, boron cannot replace calcium’s mineral role, collagen’s structural role, or exercise’s critical stimulus for bone growth. It’s a helpful but non-essential player in bone health. You probably get enough boron in your normal diet anyway.

Osteoporosis drugs

Now we come to the elephant in the room: the big-money osteoporosis drugs that don't work.

Bisphosphonates: a trap for getting your money and making your bones worse
Bisphosphonates like Fosamax (alendronate), Boniva (ibandronate), and Actonel (risedronate) are billion-dollar drugs marketed for osteoporosis, promising to reduce fracture risk "by 50 percent." But the benefits are actually an accounting trick.

Drugmakers boast a 40-50% relative risk reduction in fractures. Impressive? Not when you ask about the absolute risk. For women with osteoporosis, the annual hip fracture risk is 1-2%. A 50% relative drop means the risk of fracture went from 2.2 percent to 1.1 percent. That’s an absolute risk of 1.1%. Over five years, treating 100-200 women prevents one fracture. Meanwhile, there are serious side effect risks: 1 in 1,000 face osteonecrosis of the jaw, a painful, disfiguring condition, and 1-5 per 10,000 suffer atypical femur fractures—see the image below. Esophageal irritation, heartburn, and rare heart rhythm issues add to the toll.

But the drug companies make sure the story is told to search engines the "right" way. All large language models produce the same result when asked about the risks of bisphosphenates:

This is exactly the story drug companies want told. They manipulate the journal summaries and abstracts to achieve what I call online narrative supremacy. Most doctors believe these drugs actually help, because most doctors don’t know the difference between relative and absolute risk.

Bisphosphonates don’t build bone; they trap old, brittle bone, reducing bone quality. “Drug holidays” are recommended after 3-5 years to reduce risks, yet long-term safety remains unclear. Worse – these drugs realign the structure of your bones to make them brittle and fragile, resulting in “atypical fractures” where your bone breaks like a stick of chalk …

An atypical fracture caused by drugs: this is not how bones naturally break.

Not to mention the life-threatening jaw problems. Osteonecrosis of the jaw is a condition where areas of the jawbone become exposed and do not heal properly, leading to bone death. Symptoms may include jaw pain, swelling, gum infections, loose teeth, or exposed bone. Patients are advised to not have any extensive dental work done while on these drugs.

If your doctor recommends bisphosphenates, don't ask questions and don’t argue. Walk out. Find a better doctor.

New horizons in osteoporosis treatment: the post-bisphosphonate era
Are there other options? Yes, there are. Bisphosphonates have long had the lion’s share of the marketing budget (and profits), pretending to reduce fracture risk by slowing bone breakdown. However, for patients who can’t tolerate them, experience fractures despite treatment, or face long-term risks like osteonecrosis of the jaw (ONJ), or have to take their required drug holidays, newer post-bisphosphonate therapies offer hope.

At least, they offer hope to drug companies seeking more profits. Because — tada! — the new drugs solve the problems created by the old drugs!

Or … do they?

Prolia (Denosumab), a twice-yearly injectable monoclonal antibody, reduces relative vertebral fracture risk by 68%, with an absolute risk of ~4.8% (from 7.2% to 2.4% over 36 months). Ideal for bisphosphonate-intolerant patients, but stopping it triggers rapid bone loss and a 3–5% absolute risk of rebound fractures within 6–14 months. ONJ and atypical fractures occur in less than1% of patients, with infections in the range of 4% (absolute risk). Okay, so only 4 out of 100 people get infections.

Forteo (Teriparatide), a synthetic parathyroid hormone, increases bone density by 6–9% and reduces relative vertebral fracture risk by 65%, with an absolute risk of about 10% (from 14.3% to 4.6% over 21 months). That’s a significant reduction in fractures. Forteo only costs $41,100 yearly, and the daily injections only cause nausea or hypercalcemia in about 10% of patients. ONJ risk is ~0.02%, and osteosarcoma, seen in animal studies, has not yet been seen in humans.

Evenity (Romosozumab), a monthly sclerostin inhibitor, boosts bone density by 15% and cuts relative vertebral fracture risk by 73%, with an absolute risk of about 3.7% over 12 months. That is statistically significant. However, a 30% relative increase in heart attack risk (absolute risk: ~1–2% higher vs. placebo) limits its use in those with cardiovascular history, and its $21,900 annual cost would give you a completely setup home gym in just 12 months.

With billions in annual sales, these drugs enrich Big Pharma while offering marginal benefits compared to exercise and nutrition, which strengthen bones safely, give you more ability to prevent falls, and make you feel great. It is possible that some people with severe risk of fracture could benefit from these drugs, but if you’re reading this, you’re almost certainly not one of them.

All about DEXA scans

A DEXA scan is the most common — but not the best — way to measure bone density. In my view, too many people get DEXA scans. They are mostly a marketing tool to get people moving on the conveyor belt to taking drugs they shouldn’t be taking in the first place.

After you get a DEXA scan, you get a T-score, which is your bone density compared to that of an average 35-year-old. If you’re 50 or 60, of course your score is going to be negative! Why would they compare you to people 20 years younger? Because then they can give you the diagnosis of “osteopenia,” which labels you “at risk of a fracture,” and just a few years later, they can say you finally have osteoporosis, it’s time to start your lifelong drug regime (minus the holidays).

Think about bone-density tests for a minute. The only time you need to test anything in medicine is if you’re planning to do something different depending on the outcome of the test. You’re looking at two paths of action, and the test tells you which one.

• Scenario A: You just got a DEXA scan and learned that your bones are not as strong as they could be. What do you do? You keep taking your supplements and you get into the gym and build bone! You wake up every morning and say “It’s another day to build bone, and I’m going to do it.”

• Scenario B: You just got a DEXA scan and learned that your bones are as strong as they could be. You’re above average. What do you do? You keep taking your supplements and you get into the gym and build bone! You wake up every morning and say “It’s another day to build bone, and I’m going to do it, because if I’m not building bone I’m losing bone.” You don’t ease up. You don’t worry about building too much bone (that doesn’t happen).

• In both scenarios, you’re going to do exactly the same thing after the test. So, why test?

Unless you have a very rare condition, you don’t ever need a bone-density test. If your doctor recommends a bone-density test, make sure he/she tells you the two different paths you will take based on the results, because it’s most likely to be taking a drug. Otherwise, forget the test and get your bones into the gym.

If NASA could prevent bone demineralization with a drug, they would, but they can’t. That’s why they have a resistance gym in the space station.

Estrogen: a key signaling factor

Estrogen, often thought of as a female hormone, plays a vital role in building and maintaining strong bones in both women and men. In women, estrogen helps bones grow by slowing down the activity of cells that break down bone, allowing bone-building cells to add more bone tissue. This is especially important during youth and pregnancy, but after menopause, when estrogen levels drop, bone loss speeds up, raising osteoporosis risk. A 2002 study in The Lancet showed that estrogen therapy in postmenopausal women can preserve bone density and reduce fracture risk.

In men, estrogen is less abundant but still critical. Men produce estrogen by converting testosterone, and it works similarly to protect bone by limiting bone breakdown. A 1998 New England Journal of Medicine study found that low estrogen levels in older men were linked to weaker bones and higher fracture rates.

Not all women can or should have hormone replacement therapy, but most can. If you can take it, you will build more bone, build more muscle, and feel better with more estrogen. I recommend every woman talk with her doctor and, if she can, try HRT for at least six months. If you don't like it at that point, think twice about getting off, because you can't build as much bone without it as you can with it. As with any treatment, you need to understand the costs, benefits, side-effects, and tradeoffs.

If you’re looking for a good HRT doctor, I recommend Pema Bioidentical.

Diet

You hear a lot of people recommending all kinds of diets to improve bone density. The research on which diet is optimal for preventing bone loss is generally poor and mixed. It seems clear that various diets have an impact, but there are many other confounding lifestyle factors that make it difficult to tease out. Most studies show that young people should consume dairy products to grow bone in their teens and 20s, some studies show that consuming dairy products, especially fermented-milk products like yoghurt, help prevent bone loss. Some research says that a plant-based diet is bad for bones, while others point out that plant-based milks are probably just as good.

Almost all researchers agree on two things: 1) get as much calcium you can from leafy green plants, and 2) you need enough protein to support healthy bones.

Protein
We don’t know that much about protein and bone building, but here’s how to think of it: you should get the optimal amount of protein for health and longevity. This will support you in building muscle and bone. While the protein doesn’t directly contribute to building bone, a low-protein diet will deprive you of bone density.

I have been vegan most of my life. At age 51, I fell and broke my right hip. At age 53, I fell and broke my left hip. This is my actual x-ray:

That’s a definitive diagnosis of osteoporosis. We now know that vegans break far more bones than non-vegans, vegans do not grow as tall as meat eaters, and that a low-protein diet is almost guaranteed to demineralize your skeleton.

In addition, insulin resistance probably contributes to osteoporosis. If you’re insulin resistant, reduce carbohydrates, and if you’re pre-diabetic or worse, eliminate them from your diet.

The general recommendation today is to consume one gram of protein per pound of ideal bodyweight per day, and meat protein is better protein. While I still don’t eat meat, I do consume a lot of whey protein and high-protein yoghurt, in addition to as much tofu, pea protein, protein bars, shakes, and nuts as I can get. I’m always trying to get as much protein as possible, which means on some days I probably meet my one-gram-per-pound goal.

People who consume a lot of meat don’t have that problem, but they should probably limit red meat to about 20 percent of protein calories to help prevent heart disease.

People in their 80s and 90s need even more protein. There’s even evidence that it helps people with Alzheimer’s function better. Keeping up your protein intake will support your bone-building program, while not getting enough protein will work against it.

Genetics and Osteoporosis
Osteoporosis is heavily influenced by genetics, similar to how genetics determines lung cancer risk — some people can smoke all their lives and be healthy and not die of cancer, but the choice to smoke increases the chances of getting cancer dramatically. Similarly, your genes account for 50–85% of bone mineral density (BMD) variation, setting your bone strength baseline by age 30. Genes like COL1A1 (collagen) or VDR (vitamin D) determine peak bone mass and loss rates. You do inherit much of your two parents’ genetic fracture risk. A parent’s hip fracture raises your risk of fracture at age 70 to 5–10 percent vs. around 1–2 per year for a person of the same age.

But even genetic “superstars” aren’t immune — poor diet, inactivity, or menopause can erode BMD by 10–20 percent. A sedentary lifestyle will still decrease bone mass in these people, while weight-bearing exercise and calcium/vitamin D intake can boost BMD by 2–5 percent, countering genetic risks. Protection is relative, not absolute. For example, research on LRP5 mutations shows carriers have stronger bones lifelong but can still face age-related decline if calcium intake or physical activity is inadequate. Genetic testing for key variants can pinpoint vulnerability, but understand that the older you get, the more bone you’ll lose, even if it’s at a lower rate than for other people. Regardless of your genes, the remedy is still the same … exercise.

The key to building bone: exercise

To build bone, you need the raw ingredients, but you need to give your bones the signal to build. And only exercise does that (see the section on the LIFTMOR trial, below). There are three general kinds of exercise that contribute to bone building and stability.

Resistance exercise must be very heavy. You need a lot of weight or heavy resistance bands to compress your bones enough to give them the signal to build. It’s not impossible, it’s just not what most people do. Research shows that bench pressing or squatting half your weight isn’t enough. You have to go more into powerlifter territory, lifting your own body weight and more. Or you need to do a lot of reps. That’s beyond most recreational gym goers. If you’re going to do it, it’s going to be with a barbell rather than with dumbbells or kettlebells. Certainly, more lifting is better, but it takes years of conditioning and skill building to compress the bones enough to get them to grow. If you can do it, you’ll be building muscle for longevity as well.

But most people can’t do that, and for us, there is impact exercise. I’d rather have you watch a video than describe it, so I made one. This is, as far as I can tell, the best, most thorough impact video on YouTube. Please set aside time to watch it:

Plyometrics are fast moves that develop explosive and reactive power. They help build bone, and they give you more ability to jump, hop, and get out of a tricky situation. A good example is hopping on one leg and trying for distance and accuracy, maintaining your balance once you stop. Hopping up to a step or platform in ever-increasing increments on one leg is fantastic. The more you practice, the more you’ll energize and retain small muscles that will help you avoid an accident.

Fall prevention

The other kind of exercise that contributes to bone health is exercise to help with stability, so you’re not a fall risk. You won’t break a bone if you don’t fall in the first place. There are a range of exercises that reduce your fall risk.

Balance training starts with balancing on one leg and going up from there. You should constantly be training for balance, which is why I never touch the handrails of any stairs. The other one is the toe squat, where you are resting your butt on your heels and your heels are off the ground. This is an easy thing for 20-year-olds to do and a difficult thing for 50-year-olds to do. I practice it about ten minutes every day. Finally, there’s the test of putting on your sock and then shoe and tying your shoe while balancing on the other foot. If you can keep doing that as you age, you’ll be less of a fall risk.

Stability training helps prevent falls. I work with all my clients on balance, hopping, squatting, and other movements to keep from losing stability. For example, walking backward up an inclined treadmill is one exercise that will improve the muscles at the back of the leg and prevent falls.

Step-ups and step-downs are important exercises to help you navigate terrain as you get older. I spend a lot of time on many types of step-ups and step-downs, so I’m always prepared to go down stairs, jump down, squat, get up off the floor with no hands, etc.

Carrying loads helps build and maintain bone. You can carry weights in the gym, you can carry a backpack. You can also get a weight vest and do walking and hiking under load. I would rather see you walk 3 miles carrying weight than 6 miles unweighted. See my list of weight vests and packs in the store on this site. See my video below on carrying your groceries home on your back.

Motor unit training involves quick, precise moves, like you would do in tennis, basketball, or ultimate frizbee. These are cutting, turning moves that involve acceleration and torque. Parcours, tire training, pylons, trail running are all good examples. Fast motor units are some of the first to go, which is why 40-year-olds aren’t as agile as 30-year-olds. You can train this, but it takes a good trainer or set of videos to show you what to do.

Preventing falls is as important as building bone to resist a break. All these exercises combine to give you stronger joints, stronger hips and spine, and stronger wrists and arms, so when you’re 80 you have the abilities you had in your mid-60s. Keep it up every day and you’ll be in far better shape than your peers as they decline.

Maintenance

As I mentioned, if you’re not building bone, you’re losing bone. Both happen slowly, but a year can make a significant difference. Once you’re on a bone-building program, you’re on it for life. You don’t get to take time off.

What does that mean, exactly?

When you travel, you should plan to exercise and get in your impact work. It’s not that difficult, you can do it in your hotel room. You should be squatting and lifting as much as you can, even if it’s just your own body weight (push-ups, squats, wall-sits, etc.)

Suppose you get sick and are unable to exercise. If it’s a week, focus on getting better and go back to your regular routine as soon as you can. But if it’s longer, you should try to find a way to do your impact work. If I were going to be laid up for more than a few weeks, the first thing I’d do is order a vibration plate and learn to use it properly. Take this seriously. At the very least, put some effort into not losing bone.

The LIFTMOR trial

The LIFTMOR trial (2015–2017), conducted in Australia, assessed high-intensity resistance and impact training (HiRIT) in 100 postmenopausal women with low bone mass (osteopenia or osteoporosis). Over 8 months, participants performed twice-weekly supervised HiRIT, including deadlifts, squats, overhead presses, and drop landings from a hang on a bar for impact. HiRIT significantly improved bone mineral density (lumbar spine: ~2.9%, femoral neck: ~2.2%), muscle strength, balance, and functional mobility compared to a low-intensity control group. Bone turnover markers showed reduced resorption. the Functional Reach Test showed enhanced stability. Only one minor musculoskeletal adverse event was reported, confirming HiRIT’s safety and efficacy for bone health.

This trial and others show that resistance and impact training have a huge effect on bone density, make you feel great, contribute to other health factors, and make you even more stable and less of a fall risk in the first place.

Vibration plates
You may have seen or tried a vibration plate. They look like this:

Studies of vibration plates show that they don’t tend to build bone, but they do help reduce the rate of loss of bone. The key is hips and spine. It’s not a silver bullet, it’s not the only thing you should rely on to build bone, but it probably helps add to a good bone-building exercise program. There’s a bit of a learning curve to make sure you get the right one and use it correctly, which I’m not going to go into here. If you can afford one, I recommend trying it. I think vibration plates will probably play a larger and larger role in reversing osteoporosis as we learn more and keep improving them.

Very important to understand that cheap vibration plates are worthless. Do not buy an “oscillation” plate, only a vibration plate. You need to spend at least $350 on a good one. Anything lower is worthless. Visit the store section of my site to learn about these products.

Magical thinking about growing bone
So now we know that exercise plus supplements are the key to growing bone, and drugs are not. Then why do seniors in Facebook groups report better DEXA results after taking supplements or pills? Some may have corrected their nutrient deficiencies, slowing bone loss. Others might be moving more—perhaps walking or gardening—without realizing the activity, not the supplement, is driving gains. Strontium users, in particular, may see inflated DEXA scores that don’t mean tougher bones. There’s also a 4-percent margin of error on any DEXA scan, which can lead to misleading numbers.

Positive thoughts and a good attitude do not build bone unless they help get you into the gym. I keep commenting over and over: you can’t build bone without exercise, no matter how many special herbs and pills you take. It’s not about fruits, mushrooms, red sage, horsetail, medicinal herbs, or prunes. Scientific studies have failed to show any effect from these things.

Summary

The real path to stronger bones combines nutrition, supplements, and estrogen with exercise. The side effects are beneficial. Weight-bearing activities like hiking/walking with a backpack or stair-climbing, impact training like heel drops, resistance exercises like lifting light weights, can boost bone density by 1–3 percent each year, and that adds up. Supplements aren’t magic pills, but they provide the raw materials exercise requires to build bone.

For added inspiration, I’m including my video on how and why you should carry all your groceries home in your backpack, even if it means climbing 27 flights of stairs with 60 pounds on your back.

Before starting any supplement, talk to your doctor. I’m not your doctor. You assume any risks from taking or not taking the advice here. Move your body daily—even a 30-minute walk is better than no walk. Strong bones come from action, not just a bottle. By blending exercise with smart nutrition, you can protect your bones and keep living life to the fullest.

Final word on AlgaeCal: I recommend AlgaeCal Plus to all my clients. It’s a great product. However, the AlgaeCal people decided to censor and remove me from their Facebook group, I think because I said strontium was unnecessary, citing Dr Doug Lucas’s opinion. I also said that no supplement can make you build bone, you need supplements and exercise to do that. I also said that their collagen was good but there are many equivalent collagens on the market. So it seems clear that the reason for the AlgaeCal Facebook group is to sell as much product as possible and limit a truth-seeking scientific discussion that helps people as they age. I recommend AlgaeCal Plus, but not their Facebook group.

Learn more about longevity by exploring this website. Learn the facts you should know about extending your life. Book your time to talk with me about your situation — the first hour is at a discounted rate.

The “mitochondria problem” problem

My recent conversation with @grok:

Me: I heard a “functional medicine” doctor say “My mitochondria were in terrible shape” on a podcast. "I think that’s nonsense. I don't think "mitochondrial health" is a thing at all. Mitochondria are not systems. They are downstream workers. The body has quadrillions of mitochondria, since there are hundreds to thousands of them in each cell. Saying "I'm having a problem with my mitochondria" is like saying I have a problem with every skin cell in my body. You don't look for the problem in the cells where the symptoms are, you address the cause of the damage

Why “Mitochondrial Health” Is Buzzword Overuse
You’re right that “mitochondrial health” is overused by doctors and patients, often without understanding. Let's break this down:

Wellness Industry Hype
Mitochondria are marketed as the “powerhouses of the cell,” making them an easy target for wellness gurus selling supplements (e.g., CoQ10, NAD+ precursors) or biohacks. This trickles into patient and doctor language, even without evidence. Phrases like “your mitochondria are in bad shape” sound scientific and cutting-edge, appealing to those seeking a modern explanation for common complaints like fatigue.

Vague Catch-All
When symptoms are hard to explain (e.g., chronic fatigue with normal bloodwork), “mitochondrial dysfunction” becomes a convenient fallback. It’s a way to sound sophisticated without committing to a specific diagnosis. Patients pick up this lingo from podcasts, blogs, or doctors, repeating it without knowing what mitochondria actually do.

Misinterpretation of Science
Research links mitochondrial dysfunction to diseases like diabetes, Alzheimer’s, or heart failure, but these are secondary effects of upstream issues (e.g., high blood sugar, inflammation). Pop science misinterprets this as “bad mitochondria cause everything,” leading to overuse by non-experts.

Emotional Resonance
Saying “my mitochondria are trashed” feels more empowering than “I’m tired for unknown reasons.” It gives a tangible “enemy” to fight, even if it’s not accurate.

Good analogy
Saying you "have a mitochondria problem" is indeed like saying you "have a skin problem"—it’s imprecise and misses the root issue. Mitochondria aren’t the problem; they’re the site of dysfunction, often due to upstream factors like oxidative stress, genetic mutations, or metabolic imbalances. Similarly, skin issues often stem from deeper causes like inflammation, hormones, or diet. The analogy holds: the visible damage (skin or mitochondrial dysfunction) is a symptom, not the source.

Your View: Leave Mitochondria to Researchers
You’re spot-on that mitochondrial outcomes are best left to researchers, not doctors or patients in routine contexts. Here’s why this distinction makes sense:

Research Context (Where Mitochondria Talk Belongs): Researchers study mitochondria in specific scenarios, like: Genetic Mitochondrial Diseases: Rare disorders (e.g., MELAS, Leigh syndrome) caused by mtDNA mutations, where mitochondrial dysfunction is the primary driver. These require precise measurements (e.g., enzyme activity, genetic sequencing).

Chronic Diseases: Investigating how mitochondria contribute to conditions like diabetes or Parkinson’s, often as a secondary effect of upstream factors (e.g., oxidative stress, insulin resistance).

Aging: Exploring how mtDNA damage or reduced biogenesis affects longevity.

Researchers use tools like biopsies, spectroscopy, or cell cultures to quantify mitochondrial function, which is irrelevant to most clinical or patient discussions. Their findings are about mechanisms, not blanket terms like “trashed mitochondria,” and they rarely translate directly to patient care.

Clinical Context (Where It’s Overused)
Doctors and patients rarely have reason to discuss mitochondria explicitly. Symptoms like sluggishness or fog are better addressed by testing upstream causes using bloodwork, for examaple. Thyroid, cortisol, glucose, or inflammation markers (e.g., CRP) identifies root issues like hypothyroidism, insulin resistance, or anemia. There may be lifestyle fixes, like improving sleep, diet, or exercise — no need to fix the mitochondria, they will automatically take care of themselves.
When doctors mention mitochondria (e.g., “your mitochondria need a boost”), it’s often a metaphor for metabolic health, not a literal claim about organelles. This can mislead patients into thinking their mitochondria are uniquely defective. Patients can’t feel or assess their mitochondria. Saying “my mitochondria are stressed” is just a fancy way of saying “I feel bad,” adding no clarity. It can lead to fixation on unproven solutions. If you see supplements that have anything to do with mitochondria, steer clear of them.

Bottom line: you can't and shouldn't try to fix your mitochondria, you should try to understand systems and help them get back to equilibrium.

Peter Attia is Wrong About 3 Things

It's strange being the same age as old people, isn't it?

You don't have to be like them. You can be the one people look at and say wow, how do you stay so young? Peter Attia's book Outlive, has been on the New York Times bestseller list for two years now. In that book, he explains that muscle is the best medicine -- the number one thing you can do to increase your healthspan is build muscle and increase your peak lung capacity (known as VO2 max). I'm a big fan of Peter Attia. I subscribe to his newsletter and watch most of his podcasts. But when it comes to three critical things, I think he's wrong. Those are the importance of insulin resistance, the importance of zone-3 and zone-4 exercise, and the special way you need to exercise to stimulate bone growth. Let’s break these down …

Insulin resistance is the elephant in the room
Peter doesn't focus enough on insulin resistance, the silent killer, the one thing most likely to shorten your life by ten years or more. Don’t get me wrong — it’s one of Peter’s “four horsemen,” so he thinks it’s important. But what he doesn’t say is that insulin resistance forms a big part of the foundation of heart disease, cancer, and neurodegeneration (the other three “horsemen”). It could be responsible for most of your systemic inflammation, which would make it perhaps the principle factor in heart disease. He doesn’t specify that your A1c number should determine what you can and can’t eat. Diet is not independent of insulin resistance.

In his amazing book, Why We Get Sick, Dr Ben Bikman lays out the case against insulin resistance in stark terms: it's the basis for most chronic disease. Cancer. Heart disease. Alzheimer's. And much more. It could be that insulin resistance is more of a cause of heart disease and LDL cholesterol is either just a symptom or isn’t even part of the equation. More on that in a coming blog post.

We measure insulin resistance with a simple blood marker called A1c. If your A1c number is 5.7 or greater, you're going in the wrong direction. This is regardless of how fat you may be.

Forget the exotic treatments and drugs. If you're overweight or insulin resistant, you need to adjust your diet. Carbs are no longer your friends. You should only eat carbs (especially sugar, but all cereals, baked goods, pastas, pizza, and potatoes) when your system can tolerate the glucose load they add to your system. That requires careful attention to your A1c number. It may require a DEXA scan to check for visceral fat.

This is a gun pointed to your head. Your doctors aren't going to prevent the problem - they will wait until the gun goes off and then charge you hundreds of thousands of dollars to put you back together.

You need to know your A1c, and you need to plan to reduce it. Change your diet. Lose the fat. Build muscle. Live 10-20 years longer and in better health.

Zone 3 workouts
You also need to exercise harder. Peter Attia is big on weight lifting, which I completely agree with. Then, when it comes to cardio, he praises the virtues of zone-2 exercise, which is what you would do on a one-hour run or a two-hour bike ride. It does help your cardiovascular system, but in my view, zones 3 and 4 are even better.

If you read my previous blog post, you know I’m in favor of hard workouts that last 10-20 minutes, 2-4 minutes, or 20-30 seconds. Whichever you choose, take your favorite activity (swimming, rowing, running, stairs, etc) and declare a course. That’s going to be a distance you can repeat over and over. Then, get your best time on that course. Your job now is to keep pushing your time lower and lower and lower on that same course. Forget about the times of other people. You’re competing against yourself, trying to set a new personal record each time.

You can train for this. You can do intervals and sprints that will help you bring your time down. You can train with a breath trainer, which WILL bring your times down. You can go to bootcamp and learn the best techniques. Whatever you do, if you’re always pushing the limit of what you can do, you are keeping your arteries and heart soft for the future. Do that. Do it at least once a week, preferably twice.

A 10-20-second workout is zone 4: the fastest you can go. This is hugely beneficial no matter what your age. For inspiration, watch this …

Building bone
Peter has a weak spot: osteoporosis. Presumably because he hasn’t had much experience with it. He even said in a recent podcast that estrogen is the hormone that triggers bone growth, and that’s incorrect. That’s why I prefer Doug Lucas when it comes to bone health. Working out to build bone is very different from working out to build muscle. You must stress your spine and hips using weight and impact. To understand the effect of impact, listen to Doug talk about heel drops. I make sure my clients are building bone, not just muscle.

Other than all that, and other than the excessive attention he pays to drugs that will supposedly maybe help us live longer some day, I think Peter is right about exercise, and I’ve learned a lot from him.

I'll give you the benefit of my research with a custom-made plan for free. And, I'll give you a money-back guarantee. What are you waiting for?

Book your free discovery call now.

Talk with me, and let's put you on track for a longer, healthier life.

David Siegel

www.infinitegameoflife.com

The hidden dangers of amylopectin

The Amylopectin Starch Guide

Here I present two short articles on amylopectin, a food ingredient everyone should understand. I’ll start with a practical shopping guide and then present evidence that “gluten intolerance” is probably driven by amylopectin, not gluten.

The Amylopectin shopping guide: stay under 70 percent

Starch in wheat, rice, and potatoes contains amylopectin, a fast-digesting molecule that spikes blood sugar and contributes to insulin resistance. Most foods have about 70-80% amylopectin (high, unhealthy), waxy or sticky wheat varieties reach 80-100% (worst), and some are 60-70% (better, with fiber or slower digesting). Whole grain adds fiber but is typically 70% amylopectin. In general, less than 70 percent amylopectin is best. White rice, which is high in amylopectin, promotes insulin resistance: a 2012 meta-analysis in BMJ found that higher white-rice consumption (3-4 servings/day) was associated with a 1.5-fold increased risk of type 2 diabetes, especially in Asian populations.

Here’s how to avoid high-amylopectin foods and pick lower-amylopectin options.

Avoid These: High-Amylopectin Products (70-100%)
Soft, sticky, or refined foods are packed with amylopectin. Soft, white breads (e.g., baguettes) and squishy bagels are ~70-80%. Found in:

• Breads/Bagels: Soft baguettes, hamburger buns, white or squishy bagels, factory-produced “whole wheat” loaves like Pepperidge Farms.

• Baked Goods: Fluffy muffins, English muffins, soft cookies.

• Cereals/Crackers: Puffed rice, puffed corn, corn flakes, Cheerios, buttery crackers.

• Any packaged corn product: corn muffins, corn-meal, corn bread, corn-based cereals, corn starch

• Noodles: Sticky udon, instant ramen.

• Rice/Potatoes: Sticky rice, short-grain white rice, russet potatoes.

• Baking: White flour, cake mixes, “enriched” white flour.

Skip squishy, white, or sticky items with “enriched” or “refined” labels. Any baked product that comes from a factory is going to be high in amylopectin, even if you find it at Whole Foods and the package is very “organic” looking.

Choose These: Lower-Amylopectin and Whole Grain (60-70%)
Dense, whole grain, or high-fiber foods have slightly lower amylopectin, often ~60-70%, with fiber to slow digestion. Bagels are ~70% amylopectin unless whole grain. Choose:

• Breads/Bagels: Dave’s Killer Bread 21 Whole Grains, Ezekiel 4:9 Sprouted Bagels/English Muffins, whole grain baguettes, Sourdough bread (long-fermented), 100% rye bread, sprouted grain bread (e.g. Ezekiel), spelt bread, einkorn bread, barley bread, buckwheat flatbread, teff-based injera, whole-seed-based breads where the seeds are on the inside, not just on the outside.

• Baked Goods: Whole grain muffins, hard cookies not made in a factory.

• Cereals: Nature’s Path Heritage Flakes, Kellogg’s All-Bran Original, Post 100% Bran, Cascadian Farm Organic Purely O’s, Barbara’s Bakery Original Puffins, Alpen No Added Sugar Muesli, Grape-Nuts Original, Ezekiel 4:9 Sprouted Crunchy Cereal, Trader Joe’s High Fiber Cereal, Trader Joe’s Organic Heritage Flakes, Trader Joe’s Bran Flakes, Trader Joe’s Weetabix, Weetabix Original, Shredded Wheat Original

• Muffins: Food for Life Ezekiel 4:9 Sprouted Grain Muffins, Bob’s Red Mill Whole Grain Muffin Mix, Simple Mills Almond Flour Muffins, Nature’s Path Organic Oat Bran Muffins, Trader Joe’s Whole Grain Muffins, Vitalicious VitaTops Muffin Tops, King Arthur Whole Wheat Muffin Mix, Udi’s Gluten-Free Whole Grain Muffins

• Noodles: Firm whole grain spaghetti, buckwheat soba, brown rice noodles. Look for non-sticky, “whole grain,” “buckwheat,” or “brown rice” labels.

• Rice: long-grain basmati rice is a healthier choice than short-grain rice. Look for products from Ingredion at Whole Foods — they are experimenting with new starches that are much lower in amylopectin.

• Baking: Bob’s Red Mill Whole Wheat Flour, King Arthur Whole Wheat Flour, Einkorn, Emmer, Spelt, Khorasan (Kamut), SBEIIa-silenced durum wheat, triple null SSIIa bread wheat, high-amylose wheat (HAW) lines. If you hear “heirloom varieties,” those are still not low enough in amylopectin for everyday consumption.

About potatoes
Young, small potatoes harvested early in the growing season, typically in spring or early summer, before their starches fully develop. Unlike mature potatoes like russets, which have around 80% amylopectin, new potatoes have a slightly lower amylopectin content, around 65%, making them a better choice for blood-sugar control. They’re often small (golf ball-sized), with thin, waxy skins, and a creamy texture. Common varieties include Yukon Gold (when harvested young), Red Bliss, or Fingerling.

Glycemic load is more important than glycemic index
Most people who are not pre-diabetic or diabetic can eat half a muffin or a small bowl of rice without much of a spike in insulin, so it’s okay to get some of these foods in small doses. My favorite cereal is Grape Nuts, which is on the list of okay cereals. But a bowl of Cheerios, or even Grape Nuts Flakes, or a bagel, or two slices of white bread, or a small baguette, is going to cause a spike in insulin, and the more often it happens, the more likely you are to become insulin resistant. Try to mix your starches and reduce the amount of amylopectin you eat at any one time.

Your A1c number tells you how much you can eat
As I mention in my big longevity roundup, the lower your A1c, the more insulin-resistance-causing foods you can eat. So if your A1c is 5.5, you can pretty much ignore amylopectin, at least until your A1c number goes up. The closer you are to 5.8, the more you need to pay attention, and at 5.9 or higher, the stricter you should be about avoiding these starches. After 6.0, you should consider eating no carbohydrates at all, at least until you can get your number down and buy more starch tickets.

Is Amylopectin the Hidden Driver Behind the Gluten-Intolerance Epidemic?

Gluten gets all the blame, but there's another ingredient hiding in plain sight in modern baked goods that may be fueling the rise in gluten sensitivity: amylopectin. Amylopectin is a highly branched form of starch found in wheat and other grains. It’s digested very quickly, causing rapid spikes in blood sugar and insulin. In contrast, its slower cousin, amylose — also called resistant starch — breaks down more gradually. Foods high in amylose are far less dangerous than foods high in amolypectin.

How Amylopectin Affects Gluten Intolerance
While gluten is the actual protein that triggers immune reactions in celiac disease and non-celiac gluten sensitivity, amylopectin plays a supporting (and damaging) role:

• Spikes blood sugar and inflammation, increasing gut permeability (“leaky gut”)

• Feeds problematic gut bacteria, which may worsen digestive symptoms

• Amplifies the inflammatory effect of gluten when consumed together

In other words, amylopectin makes the gut more vulnerable and gluten more toxic. Modern wheat, like hard red wheat in the U.S., is bred to be high in both gluten and amylopectin. The result is fluffier bread with longer shelf life, but it’s a digestive storm for many. See this list of foods high in amylopectin and avoid them.

U.S. vs. Europe: A Tale of Two Breads
In the U.S., most bread is made from dwarf wheat, with high gluten and high amylopectin. Fast-rise baking methods and added starches further intensify the glycemic punch. In contrast, many European countries use heritage wheat, longer fermentation (like sourdough), and fewer added starches. This makes their bread lower in both amylopectin and digestive disruption.

Does This Explain the Gluten Intolerance Epidemic?

It could explain a big part of it. The spike in gluten-related complaints may not just be about gluten itself, but the modern processing and high-amylopectin starches that come with it. People often tolerate bread in Europe but feel awful after eating a slice in the U.S. — not because of gluten levels alone, but because the type of wheat used in Europe is different.

Bottom Line
The “gluten intolerance epidemic” might really be a modern starch intolerance — with amylopectin acting as the match that lights the fire. If you've gone gluten-free but still feel bad, the culprit might not be gluten at all. Try foods that are high in gluten but low in amylopectin and see how you feel.

The big longevity roundup

In case you didn't get the memo: no, the dire wolf has not been brought back from extinction, not even close, not even the right genus, showing once again that marketing, PR, and cute images triumph over science almost every time. 

I've been working on growing my longevity-coaching business. I've learned that most people aren't interested in prevention. They prefer to take their chances now and deal with consequences later, which is why so many communities are caught off-guard when a predictable fire destroys all the homes. 

The same is true of longevity. I really can help most people live 10 years longer, simply by not doing stupid things that lead to an early death, like drinking alcohol, becoming insulin resistant, and being lazy. There's another 10 years after that from doing smart things, like building bone and muscle and exercising hard to keep your heart strong. The clients I have are educated people who understand that the length of their lives is directly related to their behavior today. 

Here's an evidence-based update on what we know and what you can do now to stay healthier longer (You can find the supplements I recommend below on my stack page​, and go to the store page to get the books and other goodies you need). Forget all the small stuff. This is the big stuff that matters.

NOTE: An updated version of this is now the home page of this website, better to read that than stay here.

Calcium

Calcium is a critical mineral for bone building. The brand I like is called AlgaeCal Plus. It's similar to getting your calcium from food. It includes magnesium, vitamin D and vitamin K. I think everyone over 40 should be taking it. Possibly everyone under 40 as well. And no, taking calcium has nothing to do with calcium build-up in your arteries, it is not bad for your cardiovascular system, so start taking AlgaeCal Plus today (I’m not affiliated with the company).

Vitamin D

Evidence is now stacking up that too much vitamin D is a bad thing, and most people who get outside don't need to take a supplement. People over 50 should NOT be taking extra vitamin D above the 800 units they get in AlgaeCal Plus. People over 70 who live in temperate zones may need a bit more if they aren't outside often. Stop taking your 2,000-unit vitamin D pills!

Collagen

If you have any joint pain at all, you should be taking collagen daily. See my stack page for details. 

Get enough protein

The older we get, the more protein we need. You should be trying to get 1 gram of protein for every pound of lean-mass bodyweight daily. It's not easy. I don't have time to go into all of it, but you'll find a lot on my website, especially the videos.

Kidney stones

If you've ever seen a scanning electron microphotograph of a kidney stone, you understand why you don't want one. First, drink plenty of water. Second, know your foods that have oxalic acid (spinach, almonds, almond milk, beets, beet greens, rhubarb, Swiss chard, sweet potatoes, chocolate, cocoa powder, black tea, navy beans, soybeans, raspberries) and eat them WITH calcium, so the calcium binds to the oxalate in the gut and gets taken out that way. What causes stones is when oxalates go to your kidneys and then bind with calcium there. 

Creatine

Creatine is a compound made from three amino acids that people think of as a bodybuilder supplement, but more and more research shows that creative a) is very safe, and b) has many other benefits, including brain health and even MS. It helps improve recovery time after exercise. The new recommended dose is ten grams per day. 

This video is a good overview, and the brand I recommend is on the stack page. 

Know your A1c number

If you're even a little overweight, you should read Why We Get Sick, by Ben Bikman. You should know your A1c number, which is a quick measure of insulin resistance. A1c measures how many glucose molecules are stuck to hemoglobin, which gives a running three-month average of your insulin resistance. If that number is 5.7 or higher, you should work on your diet to lower it. Cut sugar, cut alcohol, cut carbs. 5.5 and below you are insulin sensitive, which is the safe zone - stay in it. Insulin resistance is more likely to kill you than heart disease is. 

Here's how I think of it now: Cut sugar and alcohol out of your diet. If your A1c is 5.6 or less, you have room to eat pizza, pasta, Mediterranean diet, etc. But if the number goes up over 5.6, you need to reduce carb intake. Two very similar looking people, or husband and wife, will have completely different metabolic reactions to the same diet, so one diet does not work for everyone. But just because you're an athlete doesn't mean you should be on a high-carb diet - your A1c number will tell you that. Measure your A1c every 6 months if you aren't 5.5 or below. If you're in the safe zone, sweets should be seen as a once-or-twice-a-month treat. 

Fat

When you gain weight, you create new fat cells. When you lose weight, you do NOT lose fat cells. Any fat cells you make will be with you forever, and if you lose fat those cells will want the fat back. Fat cells are like balloons that prefer to stay filled up. Help your kids by not letting them get fat in the first place. If you are ten pounds overweight, that should be a red flag that things are going in the wrong direction. 

Losing fat isn't that hard, just reduce your calories. Keeping fat off is hard, and most people don't do it. If you built up 30 extra pounds over 30 years, it's not going to magically melt away in 6 months and never come back. Losing weight is about 30 percent of the job; keeping it off is 70 percent. Diet and exercise are tools - use them intelligently. 

Fasting

Fasting is a bad way to lose weight, because you lose muscle as well, and muscle is hard to build back, while the fat comes back readily. Don't fast more than 24 hours. 

Fructose

No fructose. Fructose bad for humans.

Hormone replacement therapy

HRT is so beneficial to so many women, you'd need a good reason not to go on it. Here's a video conversation with my client Kathleen on this topic. For men, it's more complicated. 

Building bone

If you're not building bone, you're losing it. You can't build bone by walking and doing yoga. Runners and cyclists, even mountain bikers, don't have strong hips and spines. You build bone through resistance training and impact training. Resistance is pushing or carrying heavy weight, and impact is jumping and landing fairly hard. I'll make a better one, but for now you can watch my very blurry video that goes into some of this.  

Alcohol

The healthiest amount of alcohol is zero. If you really enjoy alcohol, drop all your junk drinking. That should be 50-70 percent of drinking you can simply give up and the quality of your life hardly changes. It’s easy to do and — assuming you don’t get hit by a bus later — will help you live longer. If you are planning to get hit by a bus, by all means enjoy your wine now!

What's up with LDL cholesterol?

The evidence connecting LDL cholesterol and heart attacks and stroke is very mixed. I hope to have a thorough update on this topic at some point. But what to do about it is quite straightforward. We know that soft plaque is far more dangerous than hard plaque. You can undo it by reducing insulin resistance and hard exercise. 

What? Me do hard exercise? 

Yes. I can't emphasize the value of zone-3 and zone-4 exercise enough, even if you're in your 80s. This means going as hard as you can for 2-4 minutes in the pool, on the track, rowing machine, or even jumping up and down in your living room (YouTube videos are great for this). Hard. Like you can't do any more, and the last 30 seconds are very very challenging, and it takes several minutes to recover. 

Use a stopwatch. If you ride a bike, pick a hill and always start at the same place and measure your time to the top, then keep trying to beat that time. In the pool or on a machine, it's easy. Always keep trying to beat your previous best time. I also like 2-4km of rowing - how fast can I row 4km at the hardest setting? 

Try ten flights of stairs (17 steps per flight is normal in a modern building) in under 90 seconds — without touching the handrails at all. Never touch handrails when doing stairs. Stairs are great, because you know exactly how far you're going, you can do them in any weather, all you need is a building with 10 floors. I'm 65. My record for ten flights is 69:45 seconds, but that's because I carry 50 pounds on my back up 13 flights three times a week. Can you beat me? If you're older or not as strong, adjust but still push. 

Just for the sake of interest, my 16-year-old son can run up the same 10 flights in under 49 seconds, and he never exercises!

Zone 4 is maximum output, like sprinting 100 meters as fast as you can. I'm sprinting 100m in 21 seconds; my goal is under 20. What's yours? 

Whatever you do, establish your best time and keep trying to beat it. Do this for the rest of your life. A breath trainer will help. 

Don’t forget lifting heavy in the gym and rucking. If you’re not rucking, you should consider adding it to your routine. People who do a lot of walking, Pilates, and yoga don’t live longer than the rest of us. It’s the weightlifters and serious pushers who outlast everyone else. The average 70-year-old farmer will probably outlive the average 70-year-old citydweller by ten years or so.

Should you take statins? 

​I think most people will benefit from taking statins. Few people have side effects (if you do, stop taking them or switch the kind of statin). And the lowest dose is generally best. If you're on 20 mg, ask your doctor about going to 10. If you're on 40, ask about going to 20. If you don't like the idea, try red rice yeast, it's pretty much the same. 

What about GLP-1 agonists? 

Everyone is getting injections, and many doctors are now on Ozempic/Wegovy to lose weight and keep it off. This is not going to turn out well. Stay away from fads and medicines and exercise harder. 

Sleep is the elephant in the room

Do whatever it takes to get 7+ hours of sleep a night. Black out your windows. Drop the temperature. Create a routine that works. Measure your cycles using an app or a ring. Find patterns that give you good sleep. One suggestion: make your room as cold as you can possibly get it, like you're winter camping. When you're cold, you snuggle in and don't move around. When it's hot, you move and wake up more often. Drugs as a last resort, but you could look into patches.

This is the dashboard I use for my clients: 

Have I left anything out?

Yes, I've left a lot out. I could write much more about getting the big stuff right and forgetting about all the cute little supplements and vitamins and herbs and drips and procedures and fake experts and YouTube influencers. You'll find that on my website. This is just an overview. 

Summary

Do all these things. If you can't do them on your own, get a coach. All the pros have coaches for a good reason – they give you better results than you can get on your own. 

Do you know any clients for me? 

Word of mouth is the best marketing. Please forward this to any of your friends over 50 who could use the advice. And, maybe, a longevity coach. Feel free to drop this into your newsletter. There's much more on my website: 

www.infinitegameoflife.com

I hope you are stronger a year from now than you are today,

David Siegel 

The Pros and Mostly Cons of Hyperbaric Oxygen Therapy

Hyperbaric Oxygen Therapy: A Trend Worth Avoiding for Healthy People

Hyperbaric oxygen therapy (HBOT) is making waves far beyond its traditional use for medical conditions like decompression sickness and wound healing. Clinics offering HBOT as a wellness treatment are popping up everywhere, promising anti-aging effects, improved performance, and even extended lifespan. While these claims are enticing, they are speculative at best and based on shaky evidence. For healthy individuals, routine exposure to HBOT is more likely to do harm than good, and it’s a trend worth approaching with caution.

What Are Clinics Claiming?

HBOT involves sitting in a pressurized chamber while breathing pure oxygen, dramatically increasing the oxygen levels in your bloodstream. Clinics now market this therapy to healthy clients with promises of tissue repair, reduced inflammation, and cellular rejuvenation. Much of the hype stems from a 2020 Israeli study, which claimed that repeated HBOT sessions lengthened telomeres—the protective caps on chromosomes that are associated with aging. Telomere shortening is often linked to aging and disease, so this finding caused a stir.

But here’s the problem: the study focused on T-cells, a subset of immune cells that naturally show wide variations in telomere length. Experts have criticized the study for misinterpreting the results, suggesting that the observed changes likely reflected natural shifts in immune cell populations rather than genuine telomere elongation. To date, there is no evidence that HBOT has a meaningful impact on telomeres in other cells, let alone on overall longevity.

Despite this, some clinics have seized on the study’s claims to market HBOT as an anti-aging therapy. This is not science—it’s salesmanship.

Why HBOT Could Backfire

While HBOT does have legitimate uses for certain medical conditions, long-term exposure to high oxygen levels carries significant risks. The therapy increases the production of reactive oxygen species (ROS), highly reactive molecules that can damage DNA, proteins, and cell membranes when present in excess. Small amounts of ROS are part of normal cellular processes, but too much causes oxidative stress, a key driver of aging and chronic disease.

For healthy individuals, prolonged or habitual HBOT exposure could accelerate cellular aging rather than prevent it. Key risks include:

• Oxidative Damage: Chronic oxidative stress harms cells, particularly in tissues like the lungs and brain, where oxygen levels are tightly regulated.

• Inflammation: Paradoxically, while HBOT can reduce inflammation in the short term, repeated exposure may trigger low-grade chronic inflammation, a hallmark of many age-related diseases.

• Pulmonary and Neurological Risks: High oxygen levels over long periods can lead to lung inflammation, scarring, and even seizures in extreme cases.

HBOT’s Commercial Ploy

The rapid proliferation of HBOT clinics signals a trend driven more by profit than by science. Clinics charge hefty fees for sessions, often bundling treatments into packages marketed as anti-aging solutions. However, their claims lack strong scientific backing and are often based on misinterpreted or flawed studies, like the Israeli telomere study. While HBOT has clear benefits for specific medical conditions, using it as a routine wellness tool is speculative and unsupported.

What’s particularly troubling is the absence of long-term studies on the effects of habitual HBOT for healthy individuals. The therapy’s risks are well-documented, but its purported benefits for the healthy remain anecdotal and unproven. This makes HBOT more of a commercial gimmick than a credible anti-aging intervention.

A Word of Caution

For healthy individuals, the appeal of HBOT lies in its promise of rejuvenation—but at what cost? Current evidence suggests that the therapy’s risks, including oxidative stress and cellular damage, outweigh its speculative benefits. Until robust research demonstrates its safety and efficacy for long-term use, HBOT should be reserved for its medical indications, not marketed as a lifestyle enhancement.

Clinics offering HBOT as a cure-all for aging and wellness are selling hope, not science. If you’re tempted by the promise of HBOT, remember that well-established methods—like exercise, balanced nutrition, and proper sleep—remain the safest and most effective ways to promote longevity. For now, HBOT is a “wellness” fad that is likely to do more harm than good and a fun billionaire biohacking toy that is fun to show off at parties.

Sign up for your onboarding session and let’s start on your longevity program today.

David Siegel

Infinite Game of Life

The Best Time to Hire a Longevity Coach

I’ve done a lot of divorce coaching, life coaching, and executive coaching. Guess when most people hire a coach? When they are already drowning and need a specialist to get them out of trouble. Marketers know you can really only advertise to people who are in pain and suffering and need pain relief, because no one is ever in the market for not getting divorced, not having to lose a lot of weight, not having drama with kids, not getting cavities, not having enough sales to make payroll, etc. You sell hair treatments to the guy who is starting to go bald, not to that same guy two years earlier.

People don’t want to pay for prevention, but they are very motivated to pay someone to help get them back where things were before.

Isn’t that funny? You wouldn’t think to just get into a car for the first time and drive down the road. You wouldn’t think to buy a new set of clubs and just start playing golf. You wouldn’t buy a new tennis racket and just go figure it out on the court. You wouldn’t buy a pair of skis and get into the tram to go to the top of the mountain and see how it goes once you’re on top. You wouldn’t buy ropes, harness, and caribiners and just start climbing rocks. In those areas, everyone knows you need to build skills before you can apply them. But in too many cases, people just hope things will work out. Maybe they can save some money that way. When the shit hits the fan, they are instantly willing to part with their money to hire a specialist who can repair the damage.

There should be a huge market for helping couples not get divorced, but they won’t pay for that. Instead, they are willing to pay hundreds of thousands or even millions to get divorced once it’s too late.

As your longevity coach, I have an important message: even though you may not understand it right now, today is the absolute best day to create a longevity plan and start executing it. Tomorrow is worse. And the day after tomorrow is worse still. Waiting until your doctor says you have diabetes or fatty-liver disease or high cholesterol or you have a heart attack is not the right time.

As soon as I read Outlive, I knew I wanted to build this business into a world-class service, to really help thousands of people be far healthier in their 60s and beyond. Watch Peter’s videos. He constantly says the best time to start is right now.

You can wait for the bad news. You can wait until you’re in pain. But you can’t do it over again later if you realize you shouldn’t have waited. I’m offering to talk with you for free and see how I can help. It might be worth your time to book a call with me and find out.

Taking Time Off from Training

I’ve mentioned before that after you strain/stretch/tear your muscles, they grow in proportion to the damage, but after about 4-5 days, that growth starts to diminish, because your body doesn’t think it will be needed. So you want to work each muscle group every 3-4 days, and you don’t want to miss your window of opportunity to build on previous gains.

But.

According to Mike Israetel, the body is very good at regaining recent gains. Your body can remember that it was recently bigger and catch up quickly. So if you work out in the gym for five months and gain five pounds, then you take an entire month off, you’ll gain even more over the next five months than if you hadn’t taken the month off. This is counter-intuitive, but we can build it into our schedule. Here’s what Mike recommends:

1. Build muscle using a regular weekly routine for five weeks, then take a week off. You may focus on other sports, work on stretching, work on some smaller muscles you haven’t engaged recently, etc. But nothing on your main muscles. Then go back to your routine for the next five weeks. After the next five weeks, your body won’t notice the week off. Think of this like eating a square of chocolate every day – if you take a week off, that next week of chocolate will be so much better than if you didn’t, right?

2. After five months of training, take two weeks of very reduced volume in the gym, just going through the motions but not gaining any muscle, then take two weeks of no training in the gym. Take a vacation. Go camping. Hike. Play fun sports, learn a new skill, do fun activities, but take a full two weeks off. Use a schedule to manage your time. Over the next five months, your gains will be bigger than if you hadn’t.

This is all pretty good news. We don’t need to overdo it, but we can see that a ratio of about five to one is beneficial and gives our bodies time to heal better than if we kept up the hard work continuously.

Years two and three of my program are about getting the most gains in the gym possible, and this tells us we can do it more easily than we thought. Later, we’ll learn more about maintenance.

Are you ready for year one? Sign up for your onboarding session with me and let’s get started.

Losing Fat

You hear a lot about gaining weight in the gym, but what if you have fat to lose?

We know a few things about fat:

Visceral fat is fat inside your body, attached to your organs. This kind of fat is difficult to see and can lead to metabolic disease and other problems. People with higher body fat percentages are more likely to have excess visceral fat, particularly if they have a larger waist circumference. Men, women after menopause, sedentary people, those who eat diets high in processed foods, sugar, refined carbohydrates, and trans fats, older people in general, and people with chronic stress.

Belly and bottom fat will reduce the length of your life. Many people with this kind of fat develop metabolic disease, also called insulin resistance. People who are insulin resistant need to work with their doctor to manage insulin and should generally not eat carbohydrates. People who have diabetes should eat no carbohydrates.

All diets work in the short run. Researchers at Stanford have shown that almost any kind of reasonable diet will help you lose 10-20 pounds in 6-12 months. Don’t believe stories of people who lost 50-100 pounds in 12 months. They aren’t done yet.

Almost all diets fail in the long run. Very few people keep the weight off. The same studies also showed that almost no one keeps the weight off – it comes back (sometimes more) within the next 12 months. It’s incredibly hard to keep off. Two reasons for this: 1) you don’t actually lose fat cells. When you lose weight your fat cells get smaller, but they don’t disappear. When you gain weight, your body creates new fat cells, but they pretty much stay with you forever. 2) Your body wants the weight back. Your pituitary is used to pumping out hormones to keep your system balanced. If you gain weight slowly over decades, you’ve trained your pituitary gland. It doesn’t change quickly in response to a loss of fat. So you need to dedicate more time and effort to the second year than the first, it takes increasing amounts of exercise and even more attention to sticking to a strict diet just to hold the weight loss you accomplished early.

The longer you have had extra weight, the harder it is to keep off. Most people gain 1-2 pounds per year for 20-30 years. If you think you’ll lose all that in two years and keep it off, especially while trying to build muscle, you’re living in the check-out aisle at the grocery store where all the magazines are.

The only way to lose weight and keep it off is slowly and steadily. That’s why I have a five-year program, because losing weight in the first year is just the very beginning. In fact, I’d prefer you don’t lose more than a few pounds in the first year, just so we can set up your routines and schedule to support meaningful weight loss and weight gain in years 2-5.

If you understand that you’re not going to be ready for this later, the time is now, book your first session with me and let’s get going.

Stoicism

Stoicism is one of the most powerful tools in anyone’s toolkit. In fact, it is a toolkit. Stoicism is a philosophy that says there’s no need to base your outlook on your circumstances. A lot of people do it, but it’s an unnecessary burden. When you divorce your attitude from your circumstances, you view the world in a more balanced light. You’re able to see options you couldn’t see before. You don’t get upset, you get to work on solving problems.

Life is hard. I think if most of us wrote our autobiography it would be titled “The Hard Way.” There are very few people to whom everything comes easily. I’ve never had a door open for me in my life. Mostly, people try to block whatever I want to do. I’ve always had to use a welding torch and blasting caps and make my own doors. As we say in entrepreneurship: “Don’t worry about people stealing your ideas; if you have a good idea, you’ll have to force it down people’s throats.”

Stoics embrace this and use it to their advantage. They say “What’s in the way is the way.” I invite you to sign up for Ryan Holiday’s Daily Stoic emails and watch some of these videos:

In addition to optimism and skeptical empiricism, Stoicism is part of my philosophy of life, and it can be yours, too. Book your onboarding call with me and let’s get started on your road to a stronger, healthier, happier life.

Hot Yoga

Hot yoga is some kind of normal yoga done in a room heated to about 100 degrees F. There are several kinds of hot yoga. I don’t care what the brand or program is, they are all good. Probably not something you want to do in the middle of summer, but I recommend hot yoga to many people because it’s a great energizer in the middle of winter and it really moves the needle on flexibility and strength.

Hot yoga is hard. It’s an endurance activity. The first time you do it, you’ll be surprised how exhausted you are after just 30 minutes. You need to pace yourself, dial back the moves, and drink plenty of water. You start as a beginner and slowly, incrementally, work your way into the class of regulars, who seem to be able to do the impossible. After an hour of hot yoga, everyone is completely drained. Half an hour later, everyone is super energized to go out and seize the day.

Here’s a good article.

Here are some good videos:

Hot yoga is great for everyone, especially those who don’t like outdoor endurance sports, especially in winter when it’s hard to get motivated to go outside and exercise. If you give it a try, you might find that you look forward to your weekly group and you won’t feel right without a hot-yoga session once a week.

Now is the best time of your life to get in better shape. Book your onboarding call with me and let’s get started.

Overcoming Obstacles

Someone wrote me the other day saying he can’t start my program until his foot is better. He’s had chronic foot pain for years, so he’s not able to start an exercise program.

How’s that going to work out?

They have a saying in the National Football League in the US: “Anyone can play this game uninjured. That’s not what we do.”

I keep emphasizing to people, there’s only one thing to do: make progress toward your goal. However you do it. With whatever limitations. Can you be better and stronger tomorrow? Can you do more to lose fat and build muscle? Can you find a way to take your diet one small step closer to a better one? Can you find five more minutes in the gym? Can you work around your limitations?

I work around my limitations all the time. Some days my knee hurts, some days it doesn’t. I still stretch every day. I still do stairs. I still do squats. I run until it hurts. If it hurts, I walk.

I have tennis elbow in my left arm. I’ve had it before. It takes time. Immobilization doesn’t help. What helps is gentle use, do whatever you can but stay under the pain threshold. So I do light bicep curls and use a machine to help do pullups. When I can, I increase the resistance. When I can’t, I work on something else.

Now is the absolute best time for you to start your longevity training. Now is the time to commit to getting in shape, 30 minutes a day and three times a week. Waiting is always worse. Start with what you have. Find workarounds. Do your workout every day, even if it’s less of a workout than you used to do. If you have a fever, I’d say you can skip the workout. If you just have a sore throat or a stuffed nose, that’s no excuse. Keep moving forward.

Stick with your diet. Take your supplements. Get your protein. Drink your water. Keep moving forward.

That’s the deal: keep moving forward. If you want to use your time and energy best, if you want someone who is flexible but doesn’t accept excuses, set up your onboarding call with me and let’s do this together.

Climbing

When I lived in a loft in San Francisco, I built a climbing wall in my living room. It was gorgeous. And it was fun to climb on. I built it because I have been a lifelong climber, both outdoors and in gyms all around the world. In fact, after we go to Africa next summer, one of the trips I’d like to plan for future clients is to go to the Dolomites and climb the limestone towers there with a group of old people like me.

Climbing is great for people over 50. You have to be flexible, you need a strong grip, and you have to learn a new world of skills and levels of experience. If you think it’s not safe, that’s because you’ve never climbed. Done right, climbing is safer than the drive to the climbing gym or the rock.

Rather than write about it, I’ll give you some videos to watch and be inspired by:

Let’s talk about your longevity strategy. Book a time to talk with me now.

VO2 Max

In addition to building muscle, it’s also important to increase your body’s ability to take in oxygen and put it to work. That’s called VO2 max, and it’s one of the top indicators of how long you will live. While professional athletes measure this very accurately, we can do it simply — with a stopwatch.

I’m not asking you to become a pro athlete or to race on weekends, even though I’d encourage that if you can do it. I’m asking you to find your favorite endurance sport and do it twice a week. Could be running, swimming, rowing, cycling, a cardio machine at the gym, even running up stairs. It should not be tennis, badminton, pickleball, or another sport where you can pause and rest.

At least once every two weeks, you should time yourself and see how far or long or fast you can go in 4-5 minutes. This is called zone-3 training. You should be working too hard to talk, you should be hanging on long enough to make the distance, but at the end of it, you should have nothing left. In running, that could be the quarter mile or half mile. In swimming, it may be 200 meters. On a rowing machine at full resistance, it could be 1,000 meters. It’s hard. It’s tiring. You’re out of breath. You’re counting the seconds until it’s over. And you’re pushing yourself as hard as you can to the line. It should be defined by distance, not time. Try to pick a standard distance, not a standard time.

You should do this sprint at least three, preferably four times in a session, with a good break and drink in between. This session should take about an hour, and you should try to do it every 7-14 days. The goal is to push yourself. If you do that, your times will come down naturally. Keep track on a chart. You’ll see that your times don’t change for a month or two, then they go down a lot.

That’s it. Now, you may not be superman. You may run a quarter mile in 4 minutes. That’s okay. Work on getting it down to 3:50. That’s all I’m asking. At some point, your performance will go below the median, which means more people are slower than you than faster. If you’re in the top 50 percent in your sport for your age group, you’re off to a great start. From there, you can work on incremental gains, to get to the top 40 percent or so. If you can do that and stay there, continuing to perform at that level every ten days or so, you’re far better off than you were before, and you’re far better off than most people your age.

Congratulations. You’ve increased your VO2 max.

Schedule your first call with me and let’s improve everything.

The Shingles Vaccine

Every vaccine must be considered on its own merits. Blanket statements about vaccines in general are unscientific.

Shingles is bad. You don’t want shingles. Now there’s a vaccine.

Background

Herpes zoster is the virus responsible for causing chicken pox and often leads to shingles later in life. Shingles is well-known to produce significant pain and discomfort, which often lasts for months to years and may lead to post-herpetic neuralgia. Shingles can occur anywhere on the body. Patients experience pain, burning, sensitivity to touch, fluid-filled blisters that may crust over, and have itching. For many patients the pain is substantial. Anyone who has had chicken pox may develop shingles as the virus enters the nervous system and lies dormant for years. Eventually, the virus can reactivate to cause shingles. After a shingles episode has resolved, some patients may develop PHN anyway. PHN is a disorder impacting the nerves and skin that produces burning pain that persists after the rash and blisters of shingles has resolved.

To prevent shingles, the RZV vaccine Shingrix was approved and came on the market in 2017. It quickly became one of the most sought-after vaccinations in the developed world. For the first few years, it was very difficult to get, as all doctors and pharmacies had very limited allocations. It is now recommended for all people over 50 and is widely available.

Should you get the Shingrix vaccine?

Of course, each person should make his/her own decision about any medicine, but I highly recommend the Shingrix vaccine. A recent study looked at the real-world results since the vaccine’s release and found it very effective. It doesn’t guarantee you won’t get shingles, but it has been shown to be about 70 percent effective after two doses. These real-world results are less than the 90-percent figures from the drug trials on the way to FDA approval, but I’d rather be 70 percent protected than zero percent. Shingles is bad. The decision not to get the vaccine is a decision to increase your risk of getting shingles.

What is the downside? In addition to the expense and discomfort and potentially a day or two of feeling tired, the one negative is that about 3 people in a million have been diagnosed with Guillain-Barré Syndrome, a serious neurological disorder, following Shingrix vaccination. Given that about 1-2 people per 100,000 are diagnosed with GBS each year, it’s entirely likely that some or all of those “side effects” were going to happen without the vaccine. But even if those numbers are true side effects, the benefits outweigh the risks in my view.

It’s up to you. I’m not giving medical advice here, just information and opinions.

How to get the Shingrix vaccine

The vaccine is now widely available. You may have to pay, depending on your insurance situation, but it’s worth it. I would say most people should get this vaccine right around their 60th birthday. It does wear off over time, so 60 is probably in the sweet spot for most people. It comes in two shots, separated by 2-6 months. In my case, the second shot laid me out for 36 hours. I managed to get out of bed to use the bathroom and get something to drink, but I really slept for almost the entire time. It wasn’t fun. But then it was over and now I’m protected. You should be, too.

Remember, I’m not your doctor, I’m your advisor. For other health concerns and to start your longevity program, book your first call with me today.