Strong at 40, Fragile at 70? The Bone Health Blind Spot | Dr. Belinda Beck, Bone Health Expert

Ageless Athlete Recording - Dr Belinda Beck
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Kush: [00:00:00] you have spent your life thinking about bones. Why should the rest of us start paying attention to them? 

Belinda: Yeah, great question. probably the first reason is because if you don't actually consciously pay attention to them, you will probably ignore them because they're invisible.

they don't do anything wrong until they fracture, and most people don't have a fracture. But they're so incredibly important. They're not just the structure that holds us upright and allows us to move by having muscles attached to them, but they are really important for, the, the site where red blood cells are created.

they are our calcium storage bank, and we use calcium throughout the body for many things. So, uh, we need to have healthy bones s- available for that, that calcium to be released and reabsorbed and so on. So they're incredibly important, and the [00:01:00] problem is if we lose a lot of bone, it takes a long time to gain it back, and by the time we've lost a lot of bone, we are at really increased risk of fracture.

Now, the fracture in and of itself probably won't kill us because bones are incredibly... They're amazing, and they're able to, to heal themselves. But what happens in the interim between the fracture and healing is what matters. So if you have a hip fracture, for example, that's going to influence your ability to move.

If you can't move around, all those other things that you more than anybody would know are influenced by lack of exercise are gonna go downhill. So it may not be that the bones are directly driving health, but they are the fundamental building block and structure that allows us to move for the health of all our [00:02:00] other systems.

So if you fall and you break your wrist, that's a signature fracture that tells you that your bones are probably weak and you need to do something about it. 

Kush: when I go back to my childhood and I'm looking at, the image of a human body, let's say a skeleton, the first thing you notice are the bones, right?

And at least visibly, they seem to occupy such a large volume, such a large surface area of what we are made of. 

Belinda: Mm-hmm. 

Kush: But it feels that somehow popular culture puts a greater emphasis on muscle. 

And okay, so my first question is, is my perception correct that there's been somehow this disproportionate attention on muscle as, uh, compared to, to bone, which is underneath that?[00:03:00] 

Belinda: Well, absolutely, and that's because muscle is so much more overtly, evident. You know? If, if you don't have muscle strength, you can't do things. You can't lift things. you know, I... A- and the, the more you lose, the less you can do. Plus, if you are, conscious of body image and you wanna look good, then muscles is what, are what give you that beautiful, sort of athletic figure because you can get definition and body shape from muscle, and many people are interested in that.

Whereas bones are just bones. They're just there, and they're, they're underneath everything, and mostly you can't see them except of course in your head. You can see from the shape of your head and so on. They, and they give our, our limbs length and so on. But muscle is also faster to adapt. It has a high metabolism, so we tend to focus on that with eating.

but as, you know, as I mentioned before, bones are so, so important to our overall health that [00:04:00] emphasis is misplaced probably. They are equally important. 

Kush: You make a, a great point that we tend to focus on what seems more obvious and what seems on the outside more malleable. 

I think a lot of us tend to think of our muscles every day.

Maybe it is, just the, the things that you related earlier versus some sort of, perception that we have about things we can influence. But I feel that we only think of our bones when something has gone wrong. Like, I have broken a couple of bones in my life, and honestly, those were the only times, those, uh, those, those moments of, uh, personal , uh, trauma when I really thought about my bones.



Kush: so a lot of us think that, hey, you know, I exercise. There doesn't seem to be, anything that appears to be wrong with my bones, so they must be fine. [00:05:00] Is that a safe assumption? 

Belinda: Ooh, okay. that is one of those questions where I would say for most people, probably. Uh, if they are very athletic and they've never had a problem with their bones, their bones probably are okay.

Because, um, bones will let you know if you're overloading them and under-fueling, you may develop a bone stress injury. So that's your bones telling you you're doing something wrong. If you are training and you're not having those kinds of injuries, then your bones are probably adequately adapted. the wonderful thing about bones, and, and it's the same with virtually every other system in the body, but particularly bone and muscle, is it's very responsive to mechanical loading, and that mainly being exercise loading forces put on it.

And so Wolff's law tells us that bones will adapt to the loads that are put on them [00:06:00] with, in order to best withstand future loads of the same nature. And mostly, athletes, uh, do follow that adaptive pathway. So as they begin to train and overload, their bones are adapting. what happens with some people, and it's normally the people who either are very small-boned, so very small and narrow bones, or if there's something else going on, and typically that would be they're not eating enough.

Mostly the bones will adapt with you as you begin to overload or if you overload too quickly. Because it does take bones a while to adapt. Muscle adapts pretty fast. You can see changes in eight weeks. Bones, we're talking eight months. It's just a much, much slower process because the bone cells will be able to produce the bone matrix, the bone sort of soft tissue, but it takes a while for the [00:07:00] mineral then to go into that tissue, and that is the...

That's the difference, because it's a hard tissue, it needs to be mineralized 

Kush: Quite a few things that you just shared that would love to unpack as we get deeper. But I think before we get too far ahead,I think it would behoove us to learn a little bit about how this became your life's work.

So is there a personal story, Belinda, on, on why you became this person, this authority on bone? 

Belinda: Absolutely. and I'm probably similar to many people, many scientists, in that something that went wrong with me is what put me on this path. And I was one of those people who have reasonably narrow bones, and I was a runner.

And so the, the... When I was training hard, I would get sore shins. And I was getting... I didn't realize at the time, because I didn't know anything about bones. I [00:08:00] was, a, a young teenager. but the pain was in the narrowest cross-section of my tibia or my shin bone. And as I learned more about bone,as I studied, I realized that that is actually the place where the bone bends, at the narrowest cross-section, and that's exactly why I was getting pain there.

That's why most people get shin pain in that particular area. So I was one of those people who had narrow bones, and when I overloaded them too quickly, you know, it started the cross-country season, I just started running like crazy, um, I would create little micro cracks in my bones, and the adaptive process wasn't quick enough to manage that without, becoming injured.

So that was sort of my backstory and, I remember thinking as I was running, "Why can't anybody help me? Why can't anyone tell me how to stop my shins hurting? Um, wouldn't it be great if I could do something about that?" And eventually, it took me a while [00:09:00] to get into that position, but eventually, when I started my master's, I started my research in that area.

Kush: Wow, that's, uh, a, a very personal story. So were you able to get some relief at that time? Or were your, your shin a- and your bone issues severe enough that you had to change the trajectory of your, uh, athletic, pursuits? 

Belinda: Well, I, I probably was pig-headed enough that I used to run through pain, which is, is, the silliest thing to do, 'cause that just makes things worse.

Uh, but I was never at an elite enough level that it mattered. So the, the season would end, and I would stop training, and it would get better. That's what bones do. and so eventually it sort of would take care of itself. But for somebody ... If I had been a higher caliber athlete and I kept training, and, and these people do train year-round, then that is definitely something I would have needed help with.

And, or anybody I spoke [00:10:00] to at that time, and we're talking years ago now, would just say, "There's nothing we can do. You just have to stop running." we can do better than that now, but bones are still bones. Adaptation to loading is still adaptation to loading, so the ... It just you have to be more clever about how you load.

it's definitely not how much you load, it's the lead-in to that. It's not doing too much too soon. 

Kush: a lot of us listening to this podcast, they are active people, fit people. I'm not a runner myself, but some of us would think that as runners we are introducing load and impact to our body, to our bones.

Is that not either the right kind of impact or loading as you put it, or is that not sufficient loading? [00:11:00] Or is it something else entirely that is not providing our bones the stimulus, the, whatever it needs to stay healthy? 

Belinda: It's a really good question, and the reason it's a good question is because, again, ever the scientist, I would have to say there are two answers to that.

So if your goal is to be a runner, a good runner who's doing many miles, then the running training you're doing is going to be almost certainly, if you do it the right way and you lead in slowly enough and avoid the injury, that loading is going to be enough for you as a runner. However, if your goal is to make your bones as strong as possible, that would not be the kind of, loading that I would do.

Now, most people who are long distance runners, they don't want their bo- their body to be huge and heavy because that's just more weight [00:12:00] for them to carry around while they're running. in their running years, as long as they're eating sufficiently and they're training sensibly, that is probably the best training with a little bit of weight training just to work on muscle strength, but not too much.

However, if you are an older person and you've had a diagnosis of either osteoporosis or osteopenia, so low or very low bone mass, then running is not gonna cut it. That's absolutely not the intervention that you need to grow bone because- Bone has a requirement for a certain kind of loading. When it gets that, it doesn't need very much of it.

running is not, of a load that is high enough. In fact, ru- running applies low loads over and over and over. Now, if you think about what happens to regular material, that's loaded like that, just think about a piece of wire that you're bending backwards and [00:13:00] forwards. If you load it over and over and over and over, eventually it's going to break.

So now

bone is not exactly like wire. It's a sort of a composite material, so it's, it's better than that. But the concept is loading at low loads over and over is not a good way to build bone once... if you've never been a runner, and once you've had this diagnosis of low bone mass, and we can talk about better ways to load that, if you like.

Kush: Got it. So two different things. One is if somebody's already a runner and they want to, let's say, run for life as well as make their body and their bones stronger, wanna talk about that. But then secondly, yes, running may not be the best intervention to introduce if somebody already is, suffering from some sort of bone ill health or some signs that they don't have the right, you know, all, all the right,things going for them as they move through seasons of [00:14:00] life.

Okay. I wanna ask this. So people listening to this podcast, generally active between the ages of, say, thirty-five and sixty-five mostly, and some are younger, some are older, and, they run, they ride bicycles, they rock climb. So they train, and, and they train other ways. And those people would think that, I won't say those people, but a lot of us would think that, hey, I seem to be fit because I can accomplish these things.

But is it possible that you can be fit and you can be performing by the parameters of, let's say, your sport or by some general indices of fitness, but still have relatively poor bone health? 

Belinda: Yeah, 100%. And that's one of the sad things that happens when people come into the bone clinic and they...

You've just described them. They [00:15:00] are, people who have spent their life looking after themselves. They've eaten well, and they've exercised a lot, and they're very, very trim and fit from a cardiovascular standpoint. They could run 10Ks four days a week easy. And they come in, and they find that their bone mass is very low.

For them, it's actually quite devastating because they f- they felt like a fit and healthy person, and then suddenly they found out one part of themselves is actually not. we see that all the time, not universally. There are many people who have been runners all their life, and they've got great bones.

But it's typically the smaller framed, very lean person who's never lifted heavy during their life. their, uh, physical activity has involved swimming, cycling, and running. And those low intensity, running doesn't seem low intensity to everybody, but it is actually quite a low intensity act- loading, activities that are very [00:16:00] repetitive and long duration, and that's the...

Unfortunately, that is not going to prevent particularly the bone loss that post-menopausal women see, you know, after going through menopause.

Kush: I have, a lot of admiration for Australia. I am an ardent, devotee of outdoor sports, and, uh, you folks seem to excel in that in different ways. So I'm wondering if we can take just a few minutes and go through some of the more popular sports, some of them you- some of them you've talked about. And if we can broadly identify if practitioners of those sports are at more or less risk of, say, poor bone health.

And you can also say, "Well, hey, you know, all these populations are similar." That's fine. But if you can just go through just this ladder because you see so many people. [00:17:00] So let's say we have runners, we have cyclists, we have swimmers Those were the bigger ones, but let's say a couple more niche ones to throw in there.

Say rock climbers and surfers 

Belinda: Yeah, I can do that. let's say we've got a, a continuum of bone density. So And I should also say a caveat here. Most of your bone health is determined by your genes. So what you inherit is actually determining what, what you've got. so there could be a swimmer who's got really great bones.

So... And I'm not ruling that out. I, I want people to realize that this is a generalization based on what we tend to see. So on that continuum of who has the most dense bones, at the very lowest end are swimmers, and at the very highest end are gymnasts. And this is [00:18:00] because if you look at the nature of the loading, they are diametrically opposed.

So swimmers who only swim, and we're talking about people who spend a lot of time in the water. So varsity athletes who are, doing twice a day, three hours of swimming. They are actually unloading their skeletons for those periods of time because they're in a weight-supported environment. And weightbearing it turns out is really important for bone.

P- if astronauts go into space into microgravity, they lose bone like crazy. So weightbearing loading is important. Now, as we work our way up the, this continuum, then there are other kinds of, aquatic sports, you know, like water polo and, aqua aerobics and all of those type things. They're not- Diving 

Kush: or...

Yeah, 

Belinda: yeah ... yeah. They're all down in the, in the... Actually, some divers have quite high bone mass because they come from gymnastics. and then there would be the other weight-supported activities [00:19:00] like cycling and, you know, seated sports like kayaking and, um, you know, th- those weight-supported activities.

As you go up the s- the scale and you start getting into weightbearing sports, particularly weightbearing sports that are very sudden impulse-type movements. So we're talking racket sports played on a hard court, so the h- that's, that gives you lots of impact. football, all different kinds of football c- a lot of running and sudden changing directions.

hockey. In, in Australia that's, that would be field hockey. ice hockey probably less impact because it's very gliding. Those kinds of sports are sort of the next, and they would be considerably better bone mass than the weight supported. Then next up, the scale would be those weight-supported activities that are played [00:20:00] on a hard surface and they involve jumping.

So things like basketball and volleyball and in Australia and some of the Commonwealth countries, netball. It's a bit like basketball if you don't know what that is. You just can't run with the ball. Those kinds of activities, mostly people playing those sports have really good bone mass, lots of changes of direction, different kinds of loading, and lots of impacts on hard surfaces.

And then we get up to the pinnacle, and this is think about Olympic gymnasts. These guys are... They're muscly little nuggets. They are really, really strong, and they do a lot of tumbling and landing from really high heights and landing hard on the floor even though there's sometimes sprung floors. think about the tumbling runs landing hard onto a beam.

These guys have bones like iron. Now, that's partly self-selection. That is the people with the strongest bones [00:21:00] probably last longer in those, careers because they don't get injured. But, uh, I guarantee that is a very, that it, it's a very osteogenic kind of a sport, something that builds bone like crazy.

And with the caveat that to get the benefit of these, these bone loading activities is that you need to be in energy balance. If you're not, if you're not eating enough, eating... if you're eating less energy than you're expending, and we can talk about this in more detail if you like, uh, your, your body sees that as you being in drought, and that has a very bad effect on your bones.

Kush: Wow, you really have, covered this continuum of sports. And I think a lot of people listening might be shocked to hear that a sport a lot of us think about as a full body sport like swimming is not the best or is amongst the poorest bone strengthening [00:22:00] sports.

Because again, on the outside, if you look at swimmers, they are doing Really difficult things. And- Yeah ... they also look really fit and, if I say sculpted, people who do that, at a- at, at the highest levels. But what you're telling us that, uh, unless they have other factors coming in, genetics and whatnot, just the act of pursuing swimming is not doing their bone health good service.

Belinda: Yeah. and I suppose it's really important to note that most people don't swim at the level of the elite athletes who are actively unloading their bones. If people are just... they go to the pool three times a week, and they swim a couple of miles, that... There's nothing wrong with that. In fact, that's extremely good for them.

That's good for all the other reasons, for their heart and lungs and metabolism and brain health and so on. So I'm absolutely not saying swimming is [00:23:00] bad. It's great aerobic exercise. It's just if they're doing it for their bones, they won't be getting that benefit. And, and a lot of these days, thankfully, a lot of the elite swimmers are now also doing weight training so that they are adding in that, that benefit.

But of course, one of the reasons why, it's convenient for swimmers to have low bone mass is 'cause it also makes them light and buoyant, which is a competitive advantage. So, you know, there's the, the swing- swings and roundabouts when it comes to performance versus health. 

Kush: I appreciate, Beli- Belinda, that you, you keep making sure that we understand that all these sports and exercise as a rule is all really foundationally important.

Mm-hmm. Yeah. But there are important nuances when it comes to protecting and, prolonging bone health. So I want to go back to you mentioned that, uh, [00:24:00] when you were younger, you started having, experiencing, uh, you know, some, some difficulties with running because of, issues that you were having with your shins.

And so what I wanna understand is that, you know, people may think of their bones and their skeletal structure as maybe the frame of a house that, hey, they're young, and at some point they stop growing, and that frame is set. Is that necessarily true? 



Belinda: the height of the house will stay

W- we'll never get any higher. So the length of your bones will not get longer and so on. but as a general rule, once you reach what we call your peak bone mass, and that's sort of anywhere between the second and third decade of life, generally the tendency is to then lose bone across life. there is [00:25:00] some evidence to suggest that if you stay as active doing these bone-friendly things across life, that you can actually hold on to that bone.

But we have shown very clearly that even for people who have lost a considerable amount of bone or never had it in the first place, can actually get more bone l- ve- even very late in life if they start to do the right exercise. So they're not gonna get taller. Their posture will get better, but they're not gonna grow taller.

But they can make their bones more robust and less likely to fracture if they do the right exercise 

Kush: Beautiful. Maybe this is the right time to, to explore that segue into what is the right type of exercise. So we talked about two different things here earlier. We talked about impact, we talked about the [00:26:00] continuum of these sports, but then you also introduced the concept of mechanical loading.

Can you help us understand these two concepts? And then we can talk about what ki- what type of interventions can assist us. 

Belinda: Yeah. So mechanical loading is really just putting forces onto something, anything. In this case, it's our bones. And the way that we actively do that is to either contract our muscles, which then directs force onto our bones, or to land heavily, on typically the ground, but it could be something else.

And typically it's on our feet, but with gymnasts, that can quite often be the hands or, or if you fall, which is not very functional movement. So the combination of impact and muscle force [00:27:00] on bones is this is the perfect sort of recipe for loading bones in a way that's going to keep them strong and make them stronger.

So it is actually a combination of impact activities and resistance training that is key

Kush: When I think of a gymnast, I think of this person executing body weight maneuvers on the ground, right? And the, the image is somebody landing on the ground on the hands or on the feet, for example, like you described. As compared to when I think of somebody, somebody working with weights and doing heavy loading, and by heavy loading, I tend to think of somebody at the gym with weights doing exercises that typically don't have impact on a hard surface, right?

So [00:28:00] how should we think of these two types of activities together? When we think about what we need to start introducing, adapting, shifting 

Belinda: Yeah. Uh, well, with the exception of gymnastics, because those guys are crazily f- freakish in, in what their bodies are able to tolerate, we actually do tend to do impact and resistance training separately.

We don't combine them i- in the same exercises. They are separate, and I can explain that a little more. with gymnasts, yes, they are largely lifting body weight, when they are pushing against the ground or beam or whatever. but they land, with many more body weight. So landing from a very high tumbling run can land with 12 body weights.

You know, it, it, that impact is very high. These are very s- very large spikes, and it's not just the mag- magnitude of that force, it's actually the [00:29:00] rate at which the force is applied. So bone does respond to two main things, the size of the load and how fast it's r- applied. So that's why gymnastics has this amazing ability to really make, to offer osteogenic loading.

Now, the practicalities of that is that that's not something that you can recommend or prescribe to somebody with low bone mass. You would just cause fractures. so we talk about it in awe these athletes are amazing, and they're l- they have wonderful bones because of what they do, but it's not a practical intervention.

So instead, what we do is we try to get people into, um, a gym where they're doing weight-bearing lifting, not sitting down on a leg press machine or, or a lat pull down, actually on their feet and lifting loads so that the load is weight-bearing, and, you know, s- and functional. The functional [00:30:00] activities, particularly as you get older, are so important because we need to be able to, sit down and stand up safely without falling over.

We need to be able to lift heavy things, without breaking our back. so yeah, functional lifting and the impact activity is a little bit more curated because again, it can be dangerous. We know that in osteoporosis people do tend to fracture with sudden impact. So somebody jolting off a curb or walking downstairs and forgetting that there's another step to go and then jolting on that last one, those can cause fractures.

So the way that we prescribe that sort of impact has to be very curated, and by somebody who knows what they're doing.

Kush: Let's talk a little bit about, you know, your research became well known partly because you studied heavy resistance training people with low [00:31:00] bone mass. So, so why heavy and what does a heavy load accomplish that a light load doesn't? 

Belinda: um, you're right. we did, uh, we... I, I got quite frustrated with what, uh, evidence was available in the literature as to what was effective loading for people with low bone mass, and mostly we were wrapping people in cotton wool and, and just loading them very gently because we didn't want to cause fractures.

But this as, as we know from animal research, does not grow bones. So the... as I mentioned before, the two important features of effective loading for bone is the magnitude of the load and the rate of the loading. Now, this is because bones are full of cells. The cells live in little spaces, tiny little spaces in the bone.

They're all connected. They all... so I like to, like to think of them all holding hands throughout the [00:32:00] whole bone. So it's this great big network of bone cells, so they are in contact with each other, and they're bathed in fluid. Now, we're, we're talking a microscopic scale here. You can't see these holes and cells and network with the naked eye.

You just have to imagine. Think of a bone as a hard sponge, if you like, and in the little gaps are these bone cells. Now, when you load a bone, either from weight bearing, just loading, standing, jumping, landing, or by contracting a muscle hard, you cause little bends in the bone. And when you do that, you cause the fluid to move through the bone, and it's that fluid movement which stimulates the cells to adapt.

If the bone bends a lot, the cells become aware that they need to adapt more because bending a lot is likely to fracture. So that this is the, what we call the mechanotransduction signal. [00:33:00] This is what tells the bone cells that the bone is bending too much. It has to adapt and become bigger to prevent that amount of bending because it doesn't want to fracture.

So that was a, was a science-y way to answer your question, which is the reason why we have to put heavy loads on bones is because it takes a lot to bend a bone. If you just put a... you know, for example, I've got my glass of water. That is not making my bone bend. My bones are not going to adapt to that kind of loading.

It doesn't matter if I do that 1,000 times. My bones are not adapting to that. They have to be loaded to the extent that there's a bit of bending, bit of fluid movement, bit of stimulus of those cells and then it will say, "Okay, we need to be bigger and stronger to prevent fracture." 

Kush: No, act- actually that makes perfect sense that the load needs to [00:34:00] introduce that type of intensity that will cause maybe...

Please correct me, but maybe this is analogous to how muscles respond as well. Because if, because in order to stimulate muscle growth, one has to, again, force that kind of adaptation through different modalities. And sounds like in some ways bone responds to the same kind of stress

So the example you gave, not example, the story you related about runners, they are impacting hitting the ground with load, and they're doing it over and over again What I'm hearing is that that type of loading is not sufficient if somebody already is an experienced runner. 

Belinda: Because they will already have adapted to that.

The bones will already [00:35:00] have become as strong as they need to for that kind of loading, and if the person's not putting on weight or doing anything else to increase the impact, they're not going to be... They don't, the bones don't need to adapt anymore. Just, uh, I, I do want to address what you said bec- about bone being like muscle in this respect because there is a very nuanced difference.

And the reason why it's important is because there is a little bit of noise in internet world about, the fact that bone being like muscle means that we don't have to overload it, and we can just overload many times and get a reaction. Bone is not like muscle in that respect. 'Cause at the moment there's a, there's a bit of a controversy about what is the best kind of loading for muscle, and everybody thought for years that the heavier you lifted, the bigger your muscles would be and the stronger they would get.

We have just recently discovered that [00:36:00] actually you can lift lighter loads and load to fatigue, so just l- load more times, and get s- somewhat the same response as l- as lifting heavy. So muscle is not like bone at all in that respect. Bone does not react to that light loading, and in fact, light loading- Oh

many, many times is not good for bone. It's more likely to cause micro damage. So bone is not like muscle, in that way and, and I wanna make that point very clearly because there are many people who are speaking out of turn online about that and, and I wanna correct that, uh, misunderstanding. 

Kush: I really appreciate you pointing out that nuance again because I am likely one of those people who would, who has received different types of education about muscle growth over the years, and you're absolutely right.

Like, there's so much noise [00:37:00] about that kind of growth, about how different types of protocol may stimulate muscle, evenly or provide some stimulus. But what you're telling us is that, we need to introduce those heavy loads which- Cause the bones to bend to the right- Yeah ... degree.

again, this is so important that, like, just light loading, which can int- introduce, I think the term you used is microfractures, those will not not help our bone health. It has to be of that kind of caliber. 

Belinda: Yeah. again, this... it's such a nuanced area and, and I hate uh, to s- state things that are never, always, Because, a lifetime of running is going to be better for a skeleton than no running at all. But starting running when you have low bone mass is not the way to introduce appropriate loads, either [00:38:00] effective or safe. 

Kush: Okay, let's move on. So Belinda, when should we actually start caring about bone health?

Belinda: From the moment you pop out of the womb. It's because the, the nutritional environment, that you provide for bone development is also very important. Now, I'm not a nutritionist or a dietician, and I don't, I know quite a bit about it, just... but I, you know, I don't like to stray out of my lane too much.

But I do know that once you have low bone mass, you are not gonna eat your way out of it. So actually, diet is very important f- for providing sufficient nutrients for the effects of exercise, but exercise is the most important thing. And that matters from the time you're a child all the way through life.

Now, we talked about peak bone mass being, you know, at the, at pretty much the end of [00:39:00] your teens, you've got 90% of the bone you're ever gonna have. So developing that through childhood is so important. And, you know, most people listening to this will, will be beyond the age where they can personally do anything about it, but they will probably have children or grandchildren who they can encourage to stay active.

And we know we have an increasingly sedentary life, we're very screen-driven. But getting out and doing bone-friendly activities while you're growing, particularly during puberty, is very important for maximizing the skeleton in the, in the bone bank, if you like, at the end of growth. And then holding onto it throughout life by keeping active 

Kush: It might be worth just, uh, spending just a minute talking about what are those bone-friendly activities that Parents should start paying attention to for their kids.

And at, and I think you, you [00:40:00] mentioned puberty is the right time for that 

Belinda: Yeah. Yeah. So, uh, pr- strap yourself in, be prepared for some arguments 'cause I know there's some pubertal children who will resist but, but, you know, if you, if you're lucky enough to have a kid who loves sports, then, uh, y- you have people who are amenable to pr- providing them opportunities for all kinds of exercise.

So when a child is very young, uh, and through to about right up to the age of puberty, the best thing you can do for them is to just keep them active in any way you possibly can. Weight-bearing is best if you can get them running and jumping and playing multiple sports and just, just being active, and just encouraging them to enjoy exercise.

That's the main thing, you know? The worst thing you can do is enforce an exercise regime that makes this child loathe exercise so that when they have the opportunity to choose for themselves for the rest of their life, they will never do it again. So [00:41:00] just give them opportunities to do things they enjoy.

Now, during puberty and the teen years, again, you wanna continue with things that they love. But if, say, they are a very good swimmer, and they need... And their coach is telling them they have to train at least four days a week. okay, if that's the path they're going down. But then you need to make sure that they're doing something else that is weight-bearing.

So for example, get them playing basketball as well. you know, maybe swimming has a season, just a, a season during the year. Then in the off season for swimming, then get them playing one of those really good team sports that involves high impact, hard floors: volleyball, basketball, netball. But even playing soccer or field hockey or, you know, something that really applies weight-bearing loading.

That's what I would be recommending. And then as people are getting a little older and are more amenable to [00:42:00] actually doing some resistance training, I would try and add a little bit of that in. 

Kush: No, I think that answer is so well-rounded because, kids' sports need to be well-rounded. 

Belinda: Mm-hmm. 

Kush: Belinda, what about we just spoke about, you just mentioned intensity training. So I think this is one of those topics that, uh, people get all up in the arm- in their arms about with seeing- Weights in the hands of young kids. So where do you stand with weight training For young people or kids 

Belinda: Yeah.

There's no evidence whatsoever to show that weight training is harmful for kids. So where I stand is if they love it, let them do it. If,there's no need to go really heavy. all you'll do is, is hurt them and put them off. but certainly, um, you know, doing three sets of, of 10 repetitions of, [00:43:00] of, uh, a, a good well-rounded, weights intervention, some kids love that.

And if they do, great. Do it. 

Kush: Awesome. Let's move on. Would love to spend a few, few minutes talking about menopause and women's bone health, because yeah, we can't really talk about bone health without talking about menopause. What changes during that transition? 

Belinda: Estrogen. It's all about the estrogen.

Estrogen is, is the bone hormone. it's the thing that, that really controls the bone cells to a very large degree. So, menopause happens because circulating estrogen levels drop to almost zero through this, this period and, and that causes all sorts of physiological changes, and one of them is that it stops regulating the bone cells that resorb bone.

And so they... It's like they have a, a period of time [00:44:00] where they can uninhibited, eat bone and, and reduce the bone mass. So, that is the reason why we lose so much bone for those five to eight years through the menopause period. 

Kush: Should women be preparing for that, before menopause rather than reacting post?

Belinda: yeah. Uh, I guess yes, if they can. I mean, we would all love to ideally,set ourselves up for all kinds of health issues throughout our life. The problem is most women are at their most busy when they hit menopause. They probably have kids in school. They probably, have a job. They're trying to stay fit in other ways, but, you know, they're, they're managing a lot.

so practically speaking, it's probably not realistic to expect them to suddenly around, in their 40s, to go, "Right, I've gotta do something about my bone health." maybe a practical way to think about [00:45:00] it is, just keep bone in mind throughout your adult years and continue to be as physically active in weightbearing exercise And do go to the gym and do your resistance training if you can, so that when you do reach menopause, your, your body, your musculoskeletal system is as strong as, as you can manage within your lifestyle.

And then during that menopausal period, really it is the time to up your resistance training game. It- you've gotta start lifting heavier or you are gonna lose bone. 

Kush: Sure. And then- so men, men will hear the term osteoporosis and assume we are talking about somebody else. Is that correct?

Belinda: Oh, 100%. Uh, not only men think that, but doctors think that, which of course is just not true. 



Kush: so yeah, so, let's say being male identified and [00:46:00] being strong or athletic, can that give men a false, sense of security about their bones? 

Belinda: some men, yeah. I... Look,it's definitely true that men gain more bone typically than women at peak bone mass, and because they don't go through that very distinctive menopause withdrawal of estrogen, their loss is more gradual across life.

So they do end up with more bone at the end of life, and they often tend to remain a little stronger as well m- from, in terms of their muscle, so they're less likely to fall. and falls are what cause a lot of the fractures. So they ha- they definitely have a benefit, in terms of a lower risk of osteoporotic fracture than women across the course of life.

But there are men who are predisposed to osteoporosis because of their genes, and those are typically, and you can tell by looking at somebody whether they have an increased risk because they're typ- typically small built men. They come from small [00:47:00] families of, people, and so they are more likely to have osteoporosis.

But there are also things that may have predisposed them. Perhaps they were on high doses of steroids throughout their life or other conditions, and those are very injurious to bone. perhaps they've been on some therapy for cancer, and that's injurious to bone. maybe they've been extremely sedentary their entire life.

That's not good for bones. So those are three things that if somebody is listening and they think all of those things apply to me, I would be getting a, a bone density test and having a look at your bones because it's rarer in men. it's not, uh, it still happens. 



Kush: well, I guess the, the point that men should take is that just because we, we have this gender doesn't necessarily mean that we are safe- Right

from poor bone health. let's talk about minimum effective dose. [00:48:00] So just to make this a little realistic- We have an active listener who may already have a sport and they have work, they have, uh, kids. Y- typical, again, typical busy lives, people in mid-life. how little bone-specific training can still make a meaningful difference?



Belinda: great question. it's, it's something I've been working on for, for the last decade. because when we did, we did our clinical trials and we tested our, our exercise program, we tested twice a week for 30 minutes, and we found that that was enough to have an effect. But if you don't test one day a week, two days a week, three and four, y- and compare them, you don't know the answer to that question of dose.

So instead, when I opened the clinic, which is my translational research clinic where people come and do the exercise, and they do it as much or [00:49:00] as little as they want, I have this ability now to track dose. And because every time somebody comes to train at the clinic, we track whether they've been there.

And also ... We, we have the ability to test how much of this exercise, is necessary for an effect. So I can say, and I've actually got 11 years of data now which show me that one day a week is definitely better than nothing. Two days is better Three I'm not sure of, but three is the most you should do a week because you definitely need a day of rest in between each exercise session.

So my feeling is twice a week is the sweet spot. I think this is best, but if you can only manage one day a week, it is absolutely still worth doing. 

Kush: Belinda, if you could design the [00:50:00] ideal dosage of exercise targeted towards bone health, what might those two sessions look like for, again, the middle-aged person?

Belinda: Kush, what do you mean if I could design? I have designed. We've been we've, we've been using this, this, uh, the ideal intervention for years, and we know that it works, and I, I'm certain that it is the ideal intervention. So, um, although I can't give you the specifics of that because w- we do pr- protect the program because it is actually dangerous if people do it by themselves without expert supervision.

So I can tell you basically that this is heavy resistance training and impact. These are big compound movements. They are free weights, so you're doing them on your own two feet, and you're doing them with low repetitions, so five sets of five of [00:51:00] these heavy compound movements, and you don't need to do it more than twice a week, and, and you will, you will see benefit.

But again, I just, I want to emphasize that particularly for people with low bone mass, this is not something that you should be doing unsupervised. Um, it, you know, the... We do see fractures in people who do it unsupervised because the technique that you use is absolutely imperative to the safety of the lift.

so that is the ideal program, twice a week of five by fives heavy lifting and impact, we grow bone, especially the spine, but also at the hip and whole body.

Kush: Appreciate that. and again, yes, as we speak about in the show over and over again, yes, if you start any new kind of exercise program, exercises that people are not trained with, familiar with, then they are strongly advised to seek expert guidance. The [00:52:00] research that you're doing, Belinda, like at some point will that type of, uh, ideal ex- like the specifics, would you want to publish that or would you still want people to go through, let's say licensed or, certified trainers in order to get the most benefit from the program?

Belinda: Yeah. We've published it multiple times. It's just that,and, and of course we've licensed the program, uh, as Oneiro and we do sell it to people all over the world who are exercise physiologists or, or phys- physical therapists, so that there are people around, you just need to search online for Oneiro locations and you may find, if you're lucky, you may find someone close to you.

And we've got a lot of coverage in Australia, a growing amount of coverage in the US and, uh, if you don't have one near you, you can just send a physical therapist to us and we'll give them the information. there's never a time when it's safe for someone with low bone mass to do this program unsupervised.

It, it really, it... This is the [00:53:00] problem and it, and it is the reason why doctors have been hesitant to a- about it. When I go to conferences and I re- I talk about our program and, and the responses of people to it, the response of bone to it, doctors used to say to me, "Yes, but people won't do it, Belinda, if they have to go to someone to be supervised."

And we have shown that that is categorically not the case. There are thousands of people around the world going to Oneiro providers and doing safe, effective exercise under their supervision. And, and I'm constantly getting feedback from these people and how grateful they are at the change that it makes.

'Cause it's not just bone that improves, it's, it's the muscle benefits, it's the, the cardiovascular benefits. I mean, we see improvements in, blood pressure in the people who come to our clinic. and just the social engagement in classes of people who are like you doing this kind of lifting and very motivating to see an 80-year-old person, you know, [00:54:00] lifting 50 kilos.

That's, that's, it's really, it's life changing. 

Kush: You know, we spoke about... Yes, uh, I'm glad you talked, you mentioned, the older person who is out there inspiring the rest of us. But in the larger world, sometimes we see this, uh- interesting contradiction because we get older and we are told that, our bones are becoming more fragile, and the natural response is to become more cautious.

So have we become more protective, and what are we hurting by me doing that? 

Belinda: Yeah. Well, this is exactly the problem, and it was the problem for years and years, and it's the reason why it took so long to get the research evidence out there because everyone was too scared to test this.

this is what holds... Fear is what holds science back typically. This is very conservative thinking. We've shown over years and years now that it is safe if it's [00:55:00] done in the right way. It is not safe if it's not done in the right way, and I would never suggest that it is. So I guess the, the take home is, we need, we do need to come out of the Dark Ages, the doctors need to come out of the Dark Ages and start, believing that this is, you know, believing the evidence that this can help their patients.

to be overly conservative is actually withholding effective treatment from them. 

Kush: you 

Belinda: know, sending somebody of, to a Pilates class, for example, yes, that's gonna be great for, you know, a little bit of, strength, coordination, mobility perhaps, but it is not gonna be helping their bones, and all you're doing is making them spend money on a program that is not actually helping the bones and preventing them from fracturing.

So why tell somebody to walk for their bones when it, it won't work, and in fact, for very frail people, it's likely to make them fall and fracture. So yeah, it's, i- it's sort of... You can [00:56:00] tell from the, the passion in my voice, I, I'm frustrated with this enduring belief that we need to wrap older people in, in cotton wool.

You know, everybody's gonna be there one day. Do we all feel like we're gonna need to be wrapped in cotton wool? That is the absolute worst thing you can do. If you start wrapping people in cotton wool, you're gonna need to keep doing that, and, people don't want to be in cotton wool. They want to have independent, full lives, and, and our, you know, our health budgets can't afford for people to be decrepit and not able to look after themselves.

So, you know, if, if for no other reason, think about our back pockets. Taxpayers are paying for this. 

Kush: Okay.

What would you want somebody diagnosed with osteoporosis to understand about becoming stronger?

Belinda: It's a journey. You have to start somewhere. Start low and build up, but you'll be [00:57:00] surprised at what you can do. Make sure that you've got somebody supervising you who knows what they're doing, and just take the chance. But, get somebody who knows what they're doing. That is the key. my advice would be to have an Oneiro trained, licensee te- test you.

if you can't find one of those, then find somebody, another expert who would be able to deliver a, a lifting program safely to you. 

Kush: When we were talking earlier, you had said that, hey, the moment somebody's born, that's when you start worrying about, or we need to start paying attention to bone health.

But is there a broad age range when looking after or paying attention to bone health becomes absolutely critical?



Belinda: yeah, I, I would say if we're getting down to tin tacks, when you- as soon as you find out you have low bone mass, lower than average bone mass, that is your big [00:58:00] flag. Because unless you do something, it's not going up by itself. In fact, it's going to continue to go down. So the minute you have any kind of suspicion that may be you, you need to do something immediately because bone takes such a long time to adapt.

Uh, you're not gonna be protected after just one session. It's gonna take time. I would say the best thing somebody should do at any age is look at their parents and their grandparents. Do they have, a stooped posture? Do they have the kyphotic dowager's hump at the top of their spine? Have they had a fall and broken a hip?

If they have, that is your future unless you do something about it. So the... You might see that when you're age 30. That is the time to do something about it. 

Kush: Excellent. Like we were talking earlier, we don't always notice signs of, poor bone [00:59:00] health unless it comes and stops us from doing something.



Kush: So should all of us, along from looking at our parents and our family history, should we be getting some kind of bone health testing done? To see for those early signs 

Belinda: Yeah. And I would say if you haven't had a bone density scan and you're aged 50, I would definitely be getting one.

Now, if you go to your doctor and say, and ask for a referral, um, so that you can have a reimbursed, um, bone density scan, they might, balk at that and say, "You're too young. You're not at risk." If you think that somebody, uh, that your doctor is likely to say that, then go armed with evidence. "Hey, my mother had a hip fracture age 70," or, [01:00:00] "My grandmother has serious kyphosis.

It- it's in my family," or, "I've had a history of stress fractures as a runner," this, or, "I've been on high doses of steroids. I know that's bad for my bone." Give them the reason why you're there. Or if they're not willing to give you a referral, then you can, uh, at least in Australia, you can just go and pay for a bone density scan.

In Australia, they're not terribly expensive. You just have a hip and spine scan, and it gives you a benchmark. It tells you what l- where you're at, and so you know what you're dealing with. If your bones are through the roof and you're, you're, they're looking really, really strong, then you don't have to be quite as concerned.

But you do have to keep in mind that they are gonna drop as you go through menopause. So you s- it's im- it behooves everybody to, be active and certainly keep your strength up because people will fracture from a [01:01:00] fall even if they don't have what's diagnosed as osteoporosis or, or even osteopenia on a BMD.

So it's not all about bone density. It can be about bone quality. it's important to know that most people who fracture actually have osteopenia, not osteoporosis, just because that's where most people are. That's just statistics. So, yeah, don't rest on your laurels. Just as a general rule, it's never gonna hurt you to do some resistance training throughout your adult years.

Kush: Even in the US, same as Australia, we do have now, uh, fairly affordable, body scans available which will allow, which will also inform us or give us some data about our bone health. I took one earlier this year, and the results were, let's say, both validating and also surprising at the same time. And in my case, some data I [01:02:00] got motivated me to reach out to my primary care physician for a deeper analysis.

So again, I feel I am in generally good health, but there are still things that I have to learn about or I need to keep up with my own health because I wanna make sure that, uh, I am prepared for the decades to come. talking of those decades is there such a thing as too old of an age to start strengthening our bones?

Belinda: Absolutely not. Absolutely not. If you take away anything from this discussion, it's, it is never too late. And in fact, the older you are, the more benefit you're likely to get. Um, the people who start at the lowest levels will get gains that are, are really marked. I just wanted to revisit something that you said about body scans.

If we talk about scans in general, people might not know which one to get, 'cause there are all kinds of different ways to scan. The only way to really [01:03:00] test your bone density is with a DEXA bone density scan. So it actually gives you an output of BMD. So right now, that's the best to- type of scan, a bone density scan.

Kush: That's the kind of scan I received as well, but, I guess you're affirming that is the right type of scan that will give us the right data about- Yeah ... our bone health. 

Belinda: Yeah. 

Kush: Belinda, Has your own relationship with exercise changed as you've gotten older? 

Belinda: Absolutely. I used to loathe working out indoors.

I was a runner and I only liked to exercise outside. A, a runner and a hockey player. And the thought of doing exercise inside was, anathema to me. But, as I learn, I realize that there, there's just no getting away from the fact that to get the real stimulus for your bones, you need to lift weights

Kush: What would you tell [01:04:00] your, your younger 30-year-old self about maintaining physical capacity? 

Belinda: Probably just that. Probably to slot some resistance training into my exercise routine, I think. Yeah. and to You know, I, I was al- always had a very strong physique, but, and, and so you ... when you ha- when you, when you are a strong person you have a mentality that you will always be able to do stuff.

But actually, age will always change your physical capacity. So to always be able to do stuff, you need to keep doing that stuff. Your body will, will just degenerate. Your muscles will reduce in size and strength, as will your bones. To be able to stay as young and fit and healthy as you were, you gotta keep doing those things you could do then.

Kush: Somebody listening who Is getting older and is now scared [01:05:00] of continuing certain types of exercises. I will say this personally that a couple of years I... Uh, a few years ago I used to go to this, trapeze class. I started this trapeze class to learn some new movements, and then I got hurt doing something else.

So part of me now is more cautious about, uh, going back to those type of things. So what would you tell that person who is suddenly now afraid of doing things that seem more risky as they get older? 



Belinda: I, I think, Kush, if you're talking trapeze, you are actually at the, you know, the extremes of sort of risky behavior, risky exercises.

I mean, not knowing that much about trapeze, uh, it's, it sounds risky to me. I 

Kush: think- I was just doing... Sorry, I should clarify. I was just trying to learn some basic drills with being able to- Yeah ... being able to do basic cartwheels. some, some things that I never learned because I was one of those kids who skipped gymnastics class when I was a kid, so I was trying to play catch-up.

Belinda: [01:06:00] Yeah. in general, older age is probably not the time to pick up a high-risk activity. It's, f- if you've been doing the activity all your life, for example, playing golf, and you've been able to do that without injury, keep playing golf. But if you've been diagnosed with very low bone mass, I would not take up golf because this is an activity that in- it involves sudden twisting movements of the spine at quite high force hitting a ball.

So that's probably not a great activity for someone with osteoporosis. But if you've been playing it for 40 years three times a week, there is no reason to stop it. So I guess the answer is you probably can keep doing what you've been doing, if you've been doing it safely and your technique is still good.

But I wouldn't be taking up more high-risk [01:07:00] activities in older age because it does put you at greater risk. Learning the techniques and moder- adapt- adaptations of muscle and bone are slow, and you could get injured in that time period. But there are things that you could start, and that certainly includes starting to lift weights, maybe to take an aerobics class or something that is, you know, things that are different from what you've been doing, but not putting you at very high risk.

Kush: Your advice is well received. But if somebody does wanna take up a new sport, actually to be honest, most people would not think, prima facie of golf being a high-risk sport. But yes, the way you describe it, it can be high risk. But can somebody take up a sport like golf, or it could be, you know, it could be running, it could be, uh, tennis, but introduce the sport and the loads [01:08:00] in this really graduated way to allow 

Belinda: acclimating?

Yeah, theoretically. Theoretically, yes. But realistically, probably no. The, a perfect example that we are absolutely surrounded with now is pickleball. Now, pickleball has had this huge uptake around the world. Many older people are doing it because it's not as hard as tennis. You know, the court is smaller and, and so on.

However, there is an equal increase in injuries. Uh, you know, people, begin to, because they're da- dashing from side to side, they're turning ankles. Oftentimes people turning ankles and then falling. Having a fall, they're fracturing. Even turning an ankle can fracture your ankle. So I'm not saying don't try pickleball, but I'm not saying that it is without risk.

Just because it [01:09:00] seems like a, a sort of a, a dumbed down version, if you like, of tennis, an easier version, it is still with risk, and you just need to factor that in because it's hard to play pickleball at low intensity. You're either playing it or you're not sort of thing. You know what I mean? 

Kush: No, no, I think you're so right because it's one thing to like, theorize that one can do that, o- one can like introduce this i- in this, slow way, which maybe you can do at the gym with, right

with weights. But when one is out there and the adrenaline is pumping, it's hard to like know when to slow down and when not to. So I think, I think those are, again, wise words. Belinda, what are you still trying to understand about bone?

Belinda: Ah, I, I think what I'm trying to understand or, or what I'd like to know is really the best way to image it, to be able to know whether a bone is strong or not because we don't yet have [01:10:00] perfect ways of doing that. If you think of two people with the exact same bone density, they may not be at the same risk of fracture because the quality of their bone is different.

It's actually quite difficult to determine bone quality. There are some ways, but they are high radiation and they take a lot of analysis to, to detect. So You know, I'm not working in this area, but I would love it if somebody came along and, and came up with a really good technique to do that.

And there are a few, there are a few things that are starting to pop up. Aside from that, I would love to know just by, by putting together sort of a, a, an algorithm of all the measures that we take from our clients who really is at highest risk of fracture and who do we really need to be careful with?

Because we take a somewhat conservative ... I mean, it sounds silly to say we're conservative when our, our whole program is, is lifting heavy and doing impact, which is not [01:11:00] conservative. But we are aware of the fact that people are at risk, so we take a conservative approach within that, and there are probably people who could be lifting heavier, but we don't want to 'cause we're nervous about them breaking.

So I really would love to be able to determine who is really most at risk of fracture. Mm-hmm. Is it all about your BMDT score, or is it something else? We know it's a combination of things, but how do we know what that is? 

Kush: Yeah. That's ... Yes, very difficult. Belinda, is there a question about bone you wish you got asked more often?

Belinda: Oh, what an excellent question. I think you asked it really. Uh, the, the one that is, that people don't ask is, are you ever too old to start lifting? That is the most important question really, because the answer being no [01:12:00] means that, well, people would have hope. A 90-year-old who thinks that they can just now sit on the co- couch and that's it for them for the rest of their life, there's hope.

They can get them off the couch, and we can get them lifting, and all of a sudden their world reopens to them. So I think that's probably the most amazing, amazing thing to find out, that there is hope. 

Kush: Amazing. Last two questions I like to ask everybody. What does society get wrong about aging? 

Belinda: Oh, it thinks that old people can't do anything.

It's a... And it's just not true. Old people are just us a few years on. You know? We can do stuff, and we wanna do stuff, and we wanna do it by ourselves. We don't wanna be a burden on our children or society. people can do stuff. What we should be doing is helping them, help themselves. 

Kush: And then last question, which is what does being ageless [01:13:00] mean to you personally?

Belinda: Being ageless is being defined by your capacity rather than your age

Simple.