Podcast episode 2: women and bone health

https://open.spotify.com/episode/17EaWhxNMWNXi3655qeg4w?si=uIRQYY5WS7Cb79kcGfDdsg

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Hi everybody. And welcome back to FKB physio podcast. So today's episode is just me and my own not interviewing anybody today. Because I have a lot to say about bone density. And in particular, I really wanted to talk about the importance of bone density in women. So bone density is important for everybody, but problems with bone health or having poor bone health seems to be more of an issue in women. The reason for this there's a few, one of them is just simply the fact that men seem to start off with a higher bone mass than women.

And I'm not sure why that is, but if you look at the research about this. Men have a higher bone mass initially. For both men and women, our bone density will decline across the lifespan. But because men have a higher bone mass to begin with, that slow decline might not push them into the osteoporotic range. Like it will for women. Uh, and the other thing is that when women go through menopause, they have this sudden drop off of estrogen. And that is quite bad for your bones. So I think I read that women can lose as much as 10% of their bone density in the first five years post-menopause, which is pretty significant. Those are two of the reasons why it does tend to affect women more often than men. Just as a statistic. I think for people over 50 one in three women will develop osteoporosis and one in five men so it's not that rare in men, but it is definitely more of an issue for women.

I also think that women are disadvantaged because women are told constantly their whole lives, that they should be smaller and smaller.  Low [00:02:00] body mass is a risk factor for poor bone health. And that annoys me because women are told their whole lives, lose weight, eat less, be smaller. And then when they get older, It's them who suffer the consequences of such choices. And then things such as, you know, there's all these so-called health social media accounts out there. Claiming that dairy's bad for you, giving women these ideas of how they can get away with eating less and less and less. And on top of that, then women are discouraged often from heavy lifting. And it's seen as a masculine thing and jumping and high intensity sports.

So here are all the things that are likely to help you build your bone density, adequate food, maybe being a bit heavier, maybe having more muscle mass, maybe getting enough dairy, enough calcium. Lifting heavy, jumping, playing sports, and they are things that women are discouraged from over [00:03:00] and over and over.

 I want to fight all of those ideas. We shouldn't constantly be striving to be smaller as women. We shouldn't be told to be afraid of lifting heavy or jumping or building muscle. There's nothing more empowering than these little ladies, over 60, all of a sudden realizing that their bodies can do these pretty epic things that they never thought they could do.

 There is evidence that suggests that improving your bone density a younger age can delay the onset of osteoporosis or osteopenia. Having a 10% higher bone mass to start off with can reduce the onset of osteoporosis by 13 years. So basically you build 90% of your bone mass by age 20. Which is a massive advertisement to have active children because it's active kids that are jumping, running, eating enough that are going to reach a higher bone mass by the time they're 20. Then you [00:04:00] keep building that final 10% throughout your twenties. And from what I understand till about mid thirties and then your bone mass starts to go down. I remember at uni, we learned that you can't improve your bone density after that, which has been somewhat disproven.

But I think the reality is, you probably can make little changes to your bone mass but I do think that building as much as you can before mid thirties makes sense.

Of course there's all the co-morbidities that negatively influence bone density that no one has any control over like, kidney failure, celiac disease, h aving to take steroids for a prolonged period of time, as in corticosteroids, like for asthma things like that. ,

So there's a bit of a background of the whole situation. So why does this matter? The reason that matters is it's actually fracture risk. So the stats in Australia are that one in two women over 60 will sustain a hip fracture in their lifetime. Which is quite staggering, really. It's thought that [00:05:00] 66% of all Australians over 50 have poor bone health and that's from the Australian Institute of health and wellness.

So it's the bone health as well as falls risk that are fracture, risk factors, especially fractures of the hip. So in order to reduce the risk of having a fracture, we need to target improving bone density and bone health. And also look to reduce falls risk in these people.

There are medications out there for osteoporosis. The problem is you can't get those medications until you've had a diagnosis of osteoporosis. So often the first sign that someone has osteoporosis is that they have a fracture from a low trauma, like they sneeze and they break a bone. So often waiting for diagnosis of osteoporosis before you start trying to do something about it is a bit too late.

Something I really like about exercise for bone density is you can start without a diagnosis.

There are also some negatives with the [00:06:00] medications. Like, I know that some of them they don't really know the longterm outcomes and a lot of them, it sort of suggested that you might only go on them for 10 years at a time. But as soon as you stop taking it, i t reverses everything good that it did. And there's a small risk of these really adverse side effects that are nasty. I often think that those medications might be reserved for those people that are very frail and very high risk of fracture and the benefits outweigh the risks. But a lot of people who might be late fifties, early sixties who have osteoporosis or osteopenia who are hoping to live until their nineties, it might not be a great option for them yet, but that's obviously for people to discuss with their doctor or I guess endocrinologist.

What can we do to improve bone health?

So then ESSA guidelines, which have been put out that basically very clearly outline what type of exercise you should do for people with osteoporosis and how often. The main things are high [00:07:00] intensity lifting and high impact loading, i.e. Jumping. And these are things that have traditionally been avoided with people with osteoporosis, because the thought was that you're at risk of fracturing something. And again, with very frail individuals, you would have to be quite cautious about how you begin. But I think what's really interesting is that. In the research where they've trialed these programs on people with osteoporosis or osteopenia, there hasn't been any reported. Adverse side effects. So Belinda Beck, who runs a bone clinic, she just authored a paper this year in April. And she basically states in there that of the seven years they've been running the bone clinic, there hasn't been any adverse side effects , which is pretty good evidence to show that it's relatively safe.

So the recommendations are that people should be lifting 80 to 85% 1RM on compound movements, such as squat, deadlift, bench press, this type of thing. And that they should be including high impact moves like jumping. And that [00:08:00] over time they should get progressively harder. So moving from say, two foot jumps to one foot jumps. To jumping from height, multi-directional jumping and jumping with weighted vests. So I have managed to get some of my ladies in their late sixties, up to hopping with weights in their hands, multi-directional and from Heights, obviously, no, one's going to just start out doing that. It's a very slow progression over time. But it's interesting to see that this is what's advised. And the reason is because your bones apparently get used to cyclical things as in like running or cycling where it's this repetitive cycle very fast. So they need short, sharp intense bursts of load. And it has to be quite different, which is why the multidirectional comes into it. Unfortunately, swimming and walking, don't improve your bone density and running actually doesn't either. Because of that repetitive nature.

 There's this article by warden and colleagues in 2021. And it [00:09:00] talks about this concept. It says basically that in order for your bones to remodel, you need to... It's about the mechano sensitivity of the bone. So I suppose that's the.. the sensitivity of the bone to a mechanical stimulus applied to it like an impact. So bones become, he says deaf to repetitive loading. . So basically, after a few minutes of running, that constant same load on the bones, your bones just get used to it and they don't get any stronger after that.

Another sort of interesting point raised in the article is that swimmers and cyclists have lower bone mass than other athletes, but they actually don't have a high risk of stress fractures because those sports don't have any impact associated with them. So while you might have poor bone health, you won't necessarily get a stress fracture because there's not that bony stress there. But if we're thinking about [00:10:00] longterm, Implications for those athletes. Then once again, we're coming back around to looking at trying to optimize bone health for the future and reduce the risk of osteoporosis. So. For people who do those endurance style sports. This is obviously a consideration that I think i s really important.

And I guess something else to consider with these sports is that. They're also not great for bone health because you also have a really high energy demand while you're doing them. And so your body needs energy while you're exercising and performing those tasks and it has to get that energy from somewhere. It's interesting that those sports where, you know, something like a triathlon where you might be doing all three of those things and exercising for four, six plus hours, it can actually be very hard for your bones. Again, that's why we need that heavy, short, sharp, heavy lifting, jumping, and I honestly think that everyone should be incorporating this stuff as [00:11:00] soon as they can. And again, in the Warden article, it does actually state that incorporating some jumping training or some plyometrics at a different time of day to the running could be quite helpful in the case of endurance runners. Indicating that this concept of multi-directional jumping and landing is consistent across lots of different types of research about bone density. It's not just for people with osteoporosis.

And just as a side note to that, for those people that do do running, in the same article, a  strategy suggested to help manage it among other things is to incorporate a week off that repetitive sport one week out of every 12. I think it says just to give you a skeleton, a bit of a skeletel reset before you re-introduce the loading again. And it does talk about in the article about how people with a b ackground of heavy resistance training, [00:12:00] have a lower likelihood of sustaining a bony stress injury. So a few things to consider there as well.

So going back to the exercise for people who might have osteopenia or osteoporosis. And just for a bit of clarity around those terms, osteopenia is the precursor to osteoporosis. They're basically diagnosed based on your T score, which is determined by a DEXA scan. People often say, okay, I'll lift weights, but why do you keep asking me to lift heavier and partially it's because of the bones needing that new load that they haven't experienced before in order to continue to increase but there's another thing as well that i think is really relevant.

A concept that I think is quite interesting, the thought of a 1RM So. A 1RM a one repetition maximum. So for me, That would be going in a power lifting competition and lifting the max [00:13:00] weight I could possibly lift for one repetition. And I wouldn't be able to repeat that. that I wouldn't be able to repeat it on the day. I wouldn't be able to do it for two reps. I wouldn't be able to do it the next day. It would really tire me out. And the recommendation for this bone health stuff is that people should be lifting 80 to 85% of that, which means the amount you could lift five times, but then not six times. So it's like really heavy. And people might say, you know, why would you be getting older people lifting that heavy? And my sort of counter to that is... you've probably all seen an elderly relative. Try to get out of a chair that might be a bit low. And it might be close to impossible for that person to get out of that chair. And once they've done it, it's a max effort. And really, could they repeat it again straight after? Probably not. That person's doing a one RM to get out of their chair and they might do that multiple times a day. Imagine how exhausting it would [00:14:00] be to be maxing out your capacity multiple times throughout the day.

 That's where I think these intense forms of exercise. You can really see the benefit because you are going to improve that person's capacity so that they're not maxing out day to day. Like for me, I only max out or come anywhere, close to maxing out my movement capacity at the gym. But day-to-day, I don't come close, so it's not going to have a huge effect on my energy levels. Whereas if you're going up the stairs, holding your laundry, sitting down on the low couch and getting out a few times, if that's almost max effort, you want to improve your capacity so that that's not a max effort anymore. So I think that's a really powerful way to see why it's worth doing more intense forms of exercise, even if you are an older adult.

If people are coming to gym classes or physio led classes or whatever you want to call them to improve their bone density. And in the [00:15:00] process, they're doing this heavy lifting. You can kind of tell how the benefits are deeper than just improved bone density, but there's also reduction in sarcopenia which is basically muscle wasting, age-related. And there's an improvement in strength, which is going to be worthwhile, not just for bones, but for fatigue levels. And to reduce risk of falls. , and to keep body mass muscle mass high, which I think is a really important marker of health as well.

One final thing that I thought was interesting from Belinda Beck's 2022 article was that sometimes bone mineral density alone isn't a great measure of bone health. I read an article that said it's only about 60% of the story, and it doesn't tell you about the structure of the bone, which is actually apparently quite important. And Belinda talks about cortical thickness. So my thought is that the cortex is like the. Outside of the bone and it's not the kind of lattice-y stuff [00:16:00] on the inside. Cortical thickness is quite relevant and the LIFT-MOR trial, which is the one the bone clinic is based on in that study the bone density didn't necessarily get that much better, but the cortical thickness of the femoral neck, so like your hip bone, improved. So just bear that in mind, that bone density is about 60% of it. But if you do embark upon some efforts to improve your bone density and you don't see great changes on that it's not necessarily the whole story.

 Just as a final note to kind of recap what I've talked about here. You build most of your bone mass before your 20, you build 90% of it. You can continue to build it until your mid thirties. And from there things start to decline and I'm not a hundred percent on what that looks like if you're someone who does lots of resistance training or anything like that, this is just I suppose the average adult living in [00:17:00] average lifestyle., It's really important to take an interest in your bone health, because as you get older, that slow decline in your bone density over the years can present as osteoporosis or osteopenia as we get older.

And people are more at risk of this if they have certain health conditions, but particularly women are more at risk. With at least one in three developing osteoporosis in their lifetime in Australia. I think that s drastically under reported that statistic as well. And the risk of having poor bone density is sustaining a fracture from something that's not a very big incident.

This is often a fall in older adults. There are ways to reduce the risk of you losing your bone density. And the earlier you start it the better, because the more bone mass you can build or maintain the more you can delay a diagnosis of osteoporosis. So in order to build your bone density. And also just the health of your bones in general which [00:18:00] goes deeper than just the bone density. Heavy resistance training. That's very hard, 80 to 85%, one RM of compound movements. And multi-directional jumping is really important as well as other things such as adequate food intake. And avoiding things that mean you intentionally aim for a low body mass.

You can start this at any age. There's any number of ways you can start slowly and build up, but it's definitely best to do this under the supervision of a professional. So at my clinic, I run bone density classes. They are supervised three or four people to one physio. There would be many physios and exercise physiologists out there running these sort of classes. So it is in your best interest to find one of them and start improving your bone health as soon as possible.[00:19:00]

Thank you so much for listening to this podcast, I'm going to try and alternate between one episode where I interview somebody, I've got lots of Instagram lives to go back and convert into podcasts and every other one. Me talking about something. So. Hopefully that works out all right!