#322 - Bone health for life: building strong bones, preventing age-related loss, and reversing osteoporosis with evidence-based exercise | Belinda Beck, Ph.D.
Professor Belinda Beck, an expert in exercise science and bone health, discusses bone physiology and development, emphasizing the critical role of mechanical loading. She provides actionable strategies for optimizing bone health in children and adults, highlighting the transformative power of high-intensity resistance training for osteoporosis.
Deep Dive Analysis
14 Topic Outline
Belinda Beck's Background and Research Focus
Personal Journey into Bone Health Research
Physiology of Bone: Types, Microstructure, and Wolf's Law
Bone Development from Birth to Adulthood and Peak Bone Mass
Bone Cells: Osteoblasts, Osteoclasts, and Remodeling
Optimizing Children's Bone Health: Diet, Sunlight, and Activity
Best Sports and Activities for Bone Health in Youth
Impact of Corticosteroids on Children's Bone Health
Preserving Bone Density in Middle Age Through Activity
Bone Loss During Menopause and Estrogen's Role
Interpreting DEXA Scan Results: T-score and Z-score
The LIFTMOR Study: High-Intensity Exercise for Osteoporosis
Broader Benefits of Weight Training Beyond Bone Density
Guidance for Implementing Bone-Building Exercise Programs
8 Key Concepts
Wolf's Law
This principle states that bone will adapt to the nature of mechanical loading to which it is chronically exposed, changing its shape to best withstand forces and prevent fracture. It describes how bone reacts physically to loading stimuli.
Ossification
The process where bone cells invade a cartilaginous model, exuding osteoid (new bone tissue) which then becomes mineralized. This transforms soft cartilage into hard bone tissue, forming the skeleton.
Osteoblasts
These are bone-forming cells that attach to a bone surface and excrete osteoid, which is the unmineralized new bone tissue. They are responsible for laying down new bone material during growth and remodeling.
Osteoclasts
These are large, multi-nucleated cells that attach to bone surfaces and resorb (break down) bone in packets. This process is crucial for bone remodeling, repairing micro-damage, and releasing calcium into the bloodstream.
Bone Remodeling
A continuous process throughout life involving the coordinated action of osteoclasts (resorption) and osteoblasts (formation). It is essential for maintaining the skeleton, repairing micro-damage, and adapting bone to mechanical loading.
T-score (DEXA)
A measure used in DEXA scans to compare an individual's bone mineral density (BMD) to the average BMD of a healthy young adult (typically 20-30 years old) of the same race and sex. It is the primary metric for diagnosing osteopenia or osteoporosis.
Z-score (DEXA)
A measure from a DEXA scan that compares an individual's bone mineral density (BMD) to the average BMD of someone their same age and sex. It provides information about where an individual's bone density lies in relation to their peers.
Aerial Bone Mineral Density (BMD)
The two-dimensional measure of bone density obtained from a DEXA scan, expressed in grams per centimeter squared. It is a projected image rather than a true volumetric density, serving as a proxy for bone mass.
10 Questions Answered
Childhood and adolescence are incredibly important for bone development, as individuals reach their peak bone mass by the late teens to mid-twenties when growth plates fuse. Optimizing bone health during this period is key to preventing osteoporosis later in life.
Approximately 70% to 80% of the bone an individual will have is determined by their genetics, meaning there are reasonably tight bounds within which one can optimize their bone health.
Calcium and vitamin D are the most important nutritional components. Teenagers need about 1,000 milligrams of calcium daily, with dairy being the most bioavailable source, and sufficient vitamin D is necessary for calcium absorption, ideally obtained from sunlight.
Yes, high-load activities that involve jumping, landing, and strong, varied muscle movements are most effective for bone adaptation. Sports like basketball, volleyball, tennis, and gymnastics, which involve dynamic and diverse forces, are more beneficial than activities like swimming or cycling for bone density.
Weight training is safe for children and teenagers, and there is no evidence it stunts growth. It's beneficial to start teaching proper technique at a young age, and the best approach is to encourage activities they enjoy, gradually incorporating bone-loading exercises.
Corticosteroids are detrimental to bone health at any age, and their use should be minimized. If a child requires them for a medical condition, it becomes even more critical to maximize other bone-supportive measures like diet and diverse physical activity to mitigate negative effects.
While peak bone mass is achieved early in life, maintaining or increasing physical activity levels, particularly bone-loading exercises, can go a long way towards maintaining bone density and preventing the decline often attributed to aging, which is often a sedentary effect.
Estrogen largely inhibits osteoclasts, keeping their bone-resorbing activity in check. When estrogen levels dramatically decrease during menopause, osteoclasts become more active, leading to a rapid acceleration of bone loss for several years in women.
The LIFTMOR study showed that high-intensity resistance and impact training (30 minutes, twice a week, 85% 1RM) could significantly improve bone mineral density at the spine (over 4% net benefit) and enhance hip bone geometry (e.g., 13% net benefit in cortical thickness) in post-menopausal women with low bone mass.
Participants experienced significant improvements in quality of life, posture (leading to increased perceived height), back and leg extensor strength, balance, and overall independence. These functional improvements substantially reduced their risk of falls and fractures.
19 Actionable Insights
1. Implement High-Intensity Resistance Training
For adults with low bone mass or osteoporosis, engage in high-intensity resistance and impact training (HIRT) twice a week for 30 minutes, focusing on compound, weight-bearing free-weight movements like squats and deadlifts at 85% of one-rep max (1RM) to stimulate bone adaptation and improve balance.
2. Seek Clinically Trained Supervision
Individuals with osteoporosis, especially those at high fracture risk or with co-morbidities, should seek supervision from a clinically trained professional (e.g., physical therapist, accredited exercise physiologist) who understands both strength and conditioning and clinical management to ensure safety and proper execution.
3. Prioritize Proper Lifting Technique
When starting a high-intensity resistance program, especially with osteoporosis, begin with light weights (e.g., a broomstick) to master proper technique, as correct form is crucial for safety and effectiveness, particularly avoiding spinal flexion during lifts.
4. Recognize Broad Benefits of HIRT
Understand that high-intensity resistance training not only improves bone density and geometry but also dramatically reduces fall risk by increasing muscle mass, balance, motor control, posture, and grip strength, significantly enhancing overall quality of life and independence.
5. Utilize Onero Program for Osteoporosis
For supervised, evidence-based training, seek out an Onero-accredited physical therapist or exercise physiologist (via The Bone Clinic website) or contact The Bone Clinic for telehealth advice if an accredited provider is unavailable locally.
6. Maintain Lifelong Physical Activity
Sustain or increase levels of bone-friendly physical activity from early adulthood throughout life to maintain bone density, as bone loss often attributed to aging is largely a consequence of sedentary behavior.
7. Exercise Over Drugs for Bone
Prioritize exercise and physical loading for bone and muscle health, as no drug can fully replicate its benefits, and drugs likely require exercise to be effective.
8. Address Bone Health Pre-Menopause
Women should proactively address bone health and consider hormone replacement therapy (HRT) during the pre- and perimenopausal stages, rather than waiting until full menopause, to maximize estrogen’s protective effect on bone.
9. Interpret DEXA Scores for Progress
When tracking bone health, consider stabilization of the T-score and improvement in the Z-score (compared to age-matched peers) as a significant win, even if the T-score doesn’t improve, as it indicates effective mitigation of age-related decline.
10. Optimize Childhood Bone Growth
Focus on helping children achieve their maximum genetic bone potential before growth plates fuse (late teens/early 20s) because osteoporosis is often considered a ‘childhood disease’ where the foundation for future bone health is laid.
11. Daily Outdoor Activity for Kids
Ensure children and grandchildren are outside and active every single day, engaging in ‘bone friendly activities’ to build strong bones.
12. Engage in High-Load, Varied Activities
Encourage children to participate in vigorous, dynamic, and varied high-load activities that involve jumping, landing, and strong muscle movements (e.g., basketball, volleyball, tennis, gymnastics, soccer), as these impart high strain on bone, stimulating adaptation more effectively than swimming or walking.
13. Introduce Resistance Training Early
Allow children to engage in resistance training, as there is no evidence it stunts growth; focus on teaching proper technique (e.g., deadlifts) and making it enjoyable to foster lifelong activity.
14. Model Weightlifting for Kids
Parents can encourage children to lift weights by having them join in home gym sessions, allowing them to naturally pick up weights and copy movements, providing an opportunity to teach proper technique.
15. Ensure Adequate Calcium Intake (Teens)
Teenagers should aim for about 1,000 milligrams of calcium daily, primarily from bioavailable dairy sources like milk (e.g., three 250ml glasses), yogurt, and cheese, as most kids may not consume enough naturally.
16. Prioritize Vitamin D from Sun
Facilitate safe, regular sun exposure (e.g., before 10 a.m. and after 2 p.m. in Australia) for children to obtain vitamin D, which is crucial for calcium absorption, avoiding sunburn.
17. Avoid Unnecessary Vitamin D Supplementation
Rely on milk, dairy, and sunlight for children’s vitamin D needs, as supplementing kids is less advisable due to difficulties in measuring levels and potential risks of hyperdosing.
18. Minimize Corticosteroid Use
Reduce corticosteroid use (inhaled or systemic) as much as possible throughout life, for both children and adults, as they are detrimental to bone health; if medically necessary, use for the shortest duration possible and titrate down when feasible.
19. Intensify Bone-Building Efforts with Steroids
If corticosteroids are medically necessary for a child, double down on other bone-building strategies: ensure adequate calcium (e.g., 750ml milk daily), regular sun exposure, and engagement in diverse, load-bearing sports and weightlifting.
7 Key Quotes
Osteoporosis is a childhood disease.
Belinda Beck
The horse may have bolted for you, but you have children and grandchildren, and this should be your mantra, get them outside and active every single day and doing X, Y, Z bone friendly activities.
Belinda Beck
Swimming isn't going to do it. Walking isn't going to do it. You need something that is just much more dynamic, varied, and will impart a high strain on bone.
Belinda Beck
This is a sedentary problem. This is not an age problem.
Belinda Beck
Oh, my God, Belinda, I can see my shoulders in the mirror again because their posture changed.
LIFTMOR study participant (quoted by Belinda Beck)
My husband is hiking the Kokoda Trail and I just thought I was going to be cheerleading. I can go with him now. I've got this incredible strength. I've basically got my life back.
LIFTMOR study participant (quoted by Belinda Beck)
It is the most potent drug available.
Peter Attia
1 Protocols
ONERO Program (High-Intensity Resistance and Impact Training for Bone Health)
Belinda Beck- Start training with a broomstick to ensure proper technique for compound movements like deadlifts and squats.
- Gradually increase the load, aiming for heavy lifting at 85% of your 1-Rep Max (1RM).
- Perform compound, weight-bearing movements using free weights to engage multiple muscle groups and improve balance.
- Conduct training sessions twice a week, with each session lasting 30 minutes.
- Seek supervision from a qualified professional, such as a physical therapist or accredited exercise physiologist, who has clinical training to manage co-morbidities.
- If an ONERO provider is unavailable, contact The Bone Clinic for a telehealth appointment to receive a tailored, unsupervised program.
- As a last resort, go to a gym with supervision and perform some form of weight training, as anything is better than nothing.