The exercise that builds strong bones and better balance | Dr Lora Giangregorio

Today we're talking about bone health, something that most people don't think about until after a fracture happens, but fractures can be life-changing. A broken hip or vertebra can dramatically affect mobility, independence and quality of life, and yet bone health rarely gets the same attention as heart or metabolic health. The reality is that the foundation for strong bones is built early in life and influenced by the choices that we make across adolescence, adulthood and into older age, which means that this isn't just a conversation for people in their 60s and 70s, it's relevant to all of us. To help us understand what actually matters when it comes to building and maintaining strong bones, I'm joined in this episode by Dr. Laura Gian Gregorio, the Tier 1 research chair in bone health and exercise science at the University of Waterloo. Before we get into the episode, if you aren't already subscribed, please do go ahead and hit that subscribe button. That is the number one thing that you can do to help us keep bringing the best scientists onto the show for you to learn from. Thank you and advance for your support. It means a lot. Alright, let's get into it. There's never been a dedicated episode to bone health, why matters, what you can do to improve bone health. So let's start with the very obvious question. Why is this conversation about bone health important? Yeah, I mean people often think about you know you have a fracture, you go to the hospital, the surgeon fixes it, you go home, right? They don't really think about the fact that you know 25% and sometimes even higher people will die as a result of having a fracture, especially hip fractures, right? So hip fractures is a significant source of morbidity and mortality in older adults. Spine fractures, you know, you have a spine fracture, 20% of people who have a spine fracture will have another one within a year. They can be very painful and they can lead to chronic pain, which can then be quite debilitating. The other thing people don't think about is, you know, imagine you have a spine fracture and a spine fracture is not something that you go in and always fix. Like sometimes people have a procedure called a chivalp lasty, which is especially like they inject a needle and then blow up a balloon and fill it with cement, but most people don't have that. And so they just essentially have a fractured vertebra now in their spine. And that can result sometimes in chronic pain and that kind of factor ability to do things, but it can also create a lot of fear because now you're you've been told you're this fragile person who may have another fracture and better not lift anything, better not move, better not do anything. Like can you imagine going about life being worried about your spine crumbling? So I think that people don't really think about the fact that a fracture can have on a person both psychologically and physically. And yeah, I thought that's the problem. Most of those those fractures that you're talking about there are they kind of described as fragility fractures. Yeah, as opposed to I'm not sure if you watch the Olympics, but Lindsey Vaughan. Yeah, that would be a traumatic. Traumatically, like sort of a fractured TBR belief. Yeah, so fragility fractures are usually defined by how the fracture happened, but also by like a fracture happens if the load applied to bone exceeds bone strength, right? So you can have really low bone strength and be at increased risk of fracture. And then the loads that you need to apply are much lower, right? So a fragility fracture is usually defined as a fracture that happens in an event that wouldn't normally cause a fracture. At some type of everyday load that that we would hope our body could tolerate. Yeah, so if you normally if I was to say trip on a cord and fall here, I put my arm out and I would probably not break it. But if I had really low bone mass and I did that, then maybe I would break my bones. Other examples would be like I remember interviewing someone who was leaning over their couch to grab the remote control and fractured rib, right? So those would be the types of things or bending over to tie your shoes and fracturing a vertebra. But yeah, fall from standing height is often the like common comparison where like normally if you fell from just a standing height, like not falling down the stairs, that would be that's often used as a discontent. Yeah, yeah, I'm thinking back to go weak and a half ago I was attempting to learn to snowboard for the first time to show if you've ever done that. I have. Yeah. And then you know on day one. It's painful. And a lot of people were telling me to wear butt pads and and risk guards and the butt pads are great and risk guards. Yeah, I certainly I learned pretty quickly to fall in a way where I wasn't just falling on my wrist. Yeah. But the first few times I realized like there is a lot of load going through my wrist and I was very grateful that they were clearly strong enough to tolerate that load. Coming back to the importance of this conversation, if most of these fragility style fractures are occurring in quote unquote, holder people, it's just happening in older people. Yeah, is this conversation just for them? No, no, there are people who have secondary osteoporosis, so that's osteoporosis due to other health conditions or medications that can experience osteoporosis at a much younger age. We have the example of relative energy deficiency in sport where we have athletes who have very high, they burn a lot of calories, they may not be eating enough or maybe they have a clinical eating disorder underlying that and then they can lose a lot of bone and they can have you know, osteoporosis at a very young age. I'm not saying that's the most common type of osteoporosis, but there are scenarios where younger people develop osteoporosis. People who have a spinal cord injury for example will experience substantial bone loss below the level of their injuries. Spinal cord injury is very common in young people, so there are people who can live with osteoporosis for a really long time. So I think, you know, we often envision it as, you know, this hunched over older women, but men get osteoporosis, younger people get osteoporosis, lots of people get osteoporosis. So we have to think, we can't use that caricature and assume that that's who is affected. I want to make sure we're all on the same page as two definitions. When we say osteoporosis, but just before we get there, is osteoporosis similar to let's say, um, osteoporosis, so like the most common form of heart disease in that often when someone has a heart attack or stroke, in fact, pretty much always if it's from osteoporosis. That's been a pathophysiology or a disease that's been bubbling away under the surface for a long time. So it's like decisions and the way they were living, um, also genetics of course, but in early years, in our 20s and 30s and 40s, play a role in risk of heart attack at 50 or 60. Is that the same here when it comes to bone health? Yes, although maybe a little bit more complicated. So, yeah, I've heard osteoporosis referred to as a pediatric disease with geriatric consequences. And in some sense, it's true because you sort of increase in bone mass, you know, throughout your childhood and adolescence and you reach a peak bone mass usually in young adulthood, and then you kind of, at a bit of a plateau and then start to decline, starting in midlife, right? But there are, so but there are things that kind of, so there are things that can affect you reaching peak bone mass, and certainly that would increase your risk later in life. And then there's things that can affect your bone mass throughout your life that can also affect your bone strength. So certainly, it's much more common in older people because they have layered on any of those medications or chronic conditions or things that have affected their bone health or their peak bone mass not reaching it. But then they also have the age-related bone loss, right? So we have, so where people often run into problems is that they have either not reached a peak bone mass and then they're experiencing you know, age-related loss or postmenopausal-related bone mass, or they maybe did, but then they experienced other life events that caused dramatic increases in bone mass and then also layered on these other sources of bone mass. Does that make sense? Yes, it kind of sounds similar to the way that I've had a few different exercise physiologists on talking about muscle and psychopenia. It's very similar. Yeah. It's very similar. Yeah. And building up a bank, that's right. Almost like a, making deposits early in life. And then in that way, when you inevitably get some age-related muscle loss, you started at a better position. Correct. So I think that, you know, if you want to have strong bones, the best way to do it is to maximize your peak bone mass, but then also prevent modifiable risk factors that will cause bone loss. And sometimes they're not preventable, right? So sometimes a person might get cancer and they have to go on a treatment for that cancer that affects their bones. This is not a modifiable risk factor, but now they have to be aware of that risk factor, right? And act accordingly. Who are the most vulnerable people? If you look at all the people that suffer from fragility fractures, and then you look at the characteristics of those people, what do they tend to have in common? There are a number of risk factors for fractures. And, you know, these are often used in risk assessment. So we think about, you know, people who have take an oral, glucocorticoid or sterile. or had medications, age, increasing age is an independent risk factor. So by independent, I mean independent of BMD. So bone mineral density. So you have bone mineral density, certainly the lower your bone density that can increase your risk, but then increasing age, low BMI, oral glucocorticoid use, history of rheumatoid arthritis is an independent risk factor. Diabetes has been shown to be an independent risk factor as well. So alcohol intake, so high, alcohol intake more than three units a day smoking. And then there's a number of causes of secondary osteoporosis. So as I mentioned, and they usually act by reducing bone mass. So they act. So they're they cause lower bone mass. So for example, people who have celiac disease and maybe it was unmanaged for a really long time and they had problems with absorbing nutrients that might increase the risk of having low bone mass. So with kidney disease often problems with calcium metabolism. So there's a number of I could there's a huge list of things that can affect your bone health. And so, but I think that the big ones are the first ones that I mentioned, the ones that are used in risk assessment and then an astute clinician would also kind of identify these other factors. And for the parents that are listening, what are the what are the main things that could result in a child not reaching peak bone mass? And add a quit nutrition. So calcium vitamin D, calories, protein, all these things are important for maximizing health and muscle health and stuff. So, you know, people so for example, I used the example of relative energy deficiency in sport, but there are people who have clinical eating disorders or subclinical eating disorders or even just high cognitive dietary restraints so that they maintain a very low calorie intake because they have body image concerns or other reasons. They may not then reach their peak bone mass, right? And sometimes it's inadvertent, right? So sometimes people it's not like they're intentionally trying to lose weight, but they participate in a sport where they're burning thousands of calories and they just don't adequately consume calories to balance that out. And so then they end up with a really low bone. I see it a lot in distance runners, for example. Is that recoverable? That's a great question. I imagine it would depend on kind of when in their age it happened and kind of when they how much bone they lost and all of that. So I imagine that especially if you're still growing and you identify it and address it, it may be better. But yeah, I don't know that I can speak to sort of the to what extent like that percentage or anything like that. I've been using Woop for over six years and I can confidently say it keeps me on track when it comes to my sleep and exercise routines. The next generation of Woop isn't just tracking your workouts. It's monitoring your sleep quality, your recovery state and even giving you insights into your biological age. No screen, no distractions, just continuous data on what your body actually needs. And here's what matters. Daily Woop where is linked to increased physical activity, to better sleep and improved heart rate variability. I have no doubt that my Woop is helping me train smarter, recover faster and make decisions that support my long term health. Head to join.woop.com/simon. Help me untangle osteoporosis and bone mineral density versus risk of fracture. Because I think a lot of people probably just think that risk of fracture comes down to bone mineral density but there's a lot more to it. Yeah, so it comes down to like when I was talking about sort of the your risk of fracture depends on your bone mineral density and the applied loads that you write. So whether you break something depends on the a load applied to bone and how much the bone can withstand it and other factors as well. So things that can influence applied loads like for example, like if you fall on cushions versus concrete, there are a lot of things can influence it. But bone mineral density is kind of used as a surrogate measure of bone strength. So it's used to identify this is how strong your bones are. But it's really only kind of one measure. But increasingly it's been recognized that if you take say two people with the same bone density and one is 50 and one is 80, the risk of fracture seems to be higher in the older cohort of people versus the younger cohort of people because there may be other factors related to aging. So for example, you may be more likely to fall, right? You may have other health conditions that affect your bones that aren't that or your bone strength that might not be exactly accounted for by bone mineral density. So there's a number of other what we call independent risk factors that are used in screening. So when a physician assesses someone, they will hopefully order a bone density test, but they'll also look for these risk factors. And then they'll use a tool like Fracks, for example, where they put in the risk factors and it calculates a probability of fracture in the next 10 years. And that's based on all of the identified risk factors that are in the kind of looking at what is the likelihood that this person is going to fall and what is it, bone mineral density? Not fall. But they're going to fracture in the next 10 years based on their bone density and the presence of other risk factors. So it's like a calculator algorithm. They calculate a probability based on eons of epidemiologic data that links risk factors to fractures, right? So they'll literally plug in, okay, this is your bone density, this is your age, this is this, and it'll actually spit out a number and it'll say your probability of fracture in the next 10 years is 14% or 23%. And then they'll also do one for hip fracture specifically. And that's actually what's often used to make decisions around medication or other strategies for preventing fractures. So they calculate sort of this probability of fracture that's based on a number of other number of risk factors, which includes bone density, but it's not limited to bone density. Right. Yeah. When you brought up that comparison between the 50-year-old and the 80-year-old, so I like this, they have the same, let's say, bone mineral density for the neck of fema, correct? femoral, that is what is used in the calculations, yes. And yet they have a different risk of fracture because of all these other variables potentially. Potentially. Potentially, potentially. Some one and one, but it's cohorts of people that this is based on not one. And those other variables are in this example, meaning that that 80-year-old, that bone is going to be subjected to greater load beyond its threshold because I feel like the assumption I guess and where I'm getting at is that is the bone mineral density, what the term is, how much load the bone can take or is there actual, is there other properties of the bone? I see. Yeah, there absolutely is other properties. So bone strength is influenced by its material properties. So for example, bone mineral is kind of this beautiful composite of like a collagen-like matrix and then minerals. And so the minerals are embedded in this matrix. So it gives it both this toughness and ability to resist tensile forces, but like tension, like pulling, right? But also good compressive strength. So it's a really nice composite material. I like to use like the example of cement and rebar, right? Like you've got these two materials that provide different aspects of strength. So what can happen is if you have, for example, changes in the material properties, that's not measurable really with bone mineral density, right? So for example, some people who are very vitamin D deficient can develop what's called osteomolecia, which is under mineralization, right, which is reduces the compressive strength of the bone and then they can be at increased risk of fracture. Or with aging, sometimes bone mineral can actually be slightly hyper mineralized and that can actually influence the risk of fracture as well. Then there's the structure of the bone. So it's like not just the amount of bone you have, but how it's organized, right? The structure of it. So you can sometimes have small changes in bone structure that might not be appreciable on bone mineral density scans from year to year to year, but that can actually affect bone strength. So for example, if someone has wider bones versus narrower bones, that can influence bone strength. So there's those factors. Bone mineral density, it's actually not a density, right? It's density's mass over volume and it's a two-dimensional x-ray. But what it is, it's literally just the amount of bone present divided by the area in the x-ray, right? So it's an aerial bone density, it's a mass of area. And so it's taking the amount of bone and trying to control for the person's body size, right? Because a bigger person is going to have more bone than a smaller person. So it's sort of trying to correct for that. But it doesn't really give you an adequate measure of bone structure. And there are structural aspects that can actually affect bone strength. So right now I'm going off on facing. No, this is great. In terms of, as I'm sitting here right now, I'm thinking about the person who's listening and thinking, okay, I've done a dexascane. Is that the best scan to understand how much load their bone, the skeleton, can tolerate? or are there other scans that are accessible outside of research that look at not only bone density but also the quality? Yes, so there are scans that are more often used in research. So quantitative, computed tomography, CT type scans on there's high resolution CT scans where they can actually measure how thick your bone cortex is, how the regular number and spacing between them and that sort of thing, and you can actually do finite modeling of the bone strength. But these are often used in a research context, not as much clinically, one, I think, because of availability. And the other thing is you also need all of that data to make it useful clinically. So there's lots and lots of cohort studies that have linked bone mineral density to risk and in such a way that it can be quantified in this fractal, fract score and give clinicians a threshold to work with. And you'd have to demonstrate that any of these bone quality variables add value in helping to better differentiate people who are at risk. And so a good example is Dracula bone score. So this was a variable where they actually look at sort of the the lumbar spine scan and it looks at the grayscale variation. So it gives you a score based on the grayscale variation in that. So if you can imagine an x-ray, it's like black and white, right? And the whiter it is, the more bone there is, right? So if you, it starts to look at the patterning of the grayscale variation in the lumbar spine and it gives you this score, the trerecular bone score. And that's actually now been added to Fracks. So you can actually pull the, if the person who's doing the Dexa has the software to calculate trerecular bone score, it can actually pull that number and you can add it to the Fracks in it adds value in differentiating who's going to fracture. Like, or it kind of helps to narrow down the probability of fracture a bit better. So that's an example of a bone quality measure, if you will, that where they, there is actual data to show that it adds value. That's interesting. For a few reasons. One, I have to imagine there's a lot of individuals out there that do a Dexa scan and we'll get into maybe what Dexa means and T-scores and stuff. But I imagine get that, get a result, kind of start an exercise program, maybe some medications. And then just use the Dexa as like the north star. But could it be that perhaps their bone mineral density score doesn't change that much, but there are other properties of their bone that have improved? It's possible. And then the same with studies that, if they look at a certain excise intervention, but you only measure bone mineral density, is there a risk that you're missing out on other ways that that exercise may have influenced bone? It is possible, but it's also equally possible that those things didn't change either. And I think a lot of people will use that argument. And I think that it can be problematic because you have to make, you have to know that those variables will change with exercise and also that, like so for example, although a regular bone score is now used to augment fracture risk assessment, the ISCD guidelines do not recommend it's used for following change over time because there's not enough data to suggest that, like those changes are meaningful or what level of change is meaningful. Now that data may emerge, but right now it's not to be used for that purpose. It's only to be used to help identify who's at risk, not necessarily meta change over time. Whereas we do have data if you improve bone mineral density, you're at lower risk of fracture, which is the hot outcome that people care about. But it's not to be used for that purpose. So, I know that there are companies that are promoting screening tools that can be used in lieu of DEXA and that claim to measure other bone properties and that sort of thing. And I think there's probably not enough evidence to kind of say you can use them to replace DEXA. And I would also be concerned about using them even to monitor change over time, especially if you're talking about like a technology where like someone's bought it and now they're higher to tech to do it and maybe the tech is doing it right or not doing it right. Like I always worry about that kind of stuff, right? So DEXA is a pretty standardized technology. I think that other technologies, I don't want to name names, but I think that there are other technologies available and I have less confidence in that evidence. The last time I looked into some of these kind of technologies, I just felt that the evidence of the premature or mostly done by the companies that sell them, right? Yeah. I mean, the tech endpoint for me seems to be that if there was something that was going to replace DEXA or be used alongside it, you would want to know clearly in the research that it's a valid way of measuring something. And it's repeatable and that changing it leads to changes in risk. And actual changing risk. And I just don't think we're there yet with some of these technologies. I think there's, I think there's a need for better research to understand how to better identify people at risk of fracture because BMD or bone marrow density is not a perfect circuit. But you would have to either add value or be so great that it could replace it, right? How reactionary are we as a population when it comes to osteoporosis? I imagine a lot of people find out about this after they have a fracture. Yeah. So, yeah, often the fracture is the first sign that you have it, many people. I think it's getting better. I think there's more awareness of the fact that people, you know, lose bone with age and, you know, lose bone with certain health conditions and lose bone with menopause. So I think probably there's more screening now than there was, say, 20, 30 years ago. But certainly there are people who maybe didn't know they were at risk that find out they're at risk when they have a fracture. I think that probably occurs a lot more in males than in females because there's still this notion that osteoporosis is a women's disease. And so, and, you know, most, at least in Canada, screening for males happens is recommended a later age because they tend to become at risk at a later age. So it's not just not on the radar, right? Right. Can we walk through a dexa? A little bit more. Sure. So, let's say I walk in today to a clinic and I go and do a dexa. What does that look like and what is the results like how are they interpreted? Yeah. So you would, you know, lie on a scanning bed and they shoot some x-rays through you and they measure how many x-rays get through, right? So it's all about attenuation of x-rays. So they're measuring how much gets through and the, the, your, if you have a higher bone mass, it's going to kind of absorb some of those x-rays. So then it, they use that to calculate kind of the amount of bone you have and then divide it by the area that it takes up in the x-ray. So you get this area bone mineral density that I mentioned. And then what they do is they convert that to a t-score. So in that's basically like comparing your bone mineral density to that of a, the average 25 year old female and they actually compare both males and females to the female average. And the reason for that is because most of the epidemiologic studies have done it that way. So they, they determine risk, they calculate a t-score for you. They sometimes also calculate a z-score, which is compared to people of a similar age and sex. And that's done more often in people who are under 50. Because using kind of t-scores and fracks and all that stuff to, to assess probability of fracture is more valid for people kind of over 40 or 50, whereas younger people, so people who might have secondary osteoporosis or these other health conditions, they would, you base their kind of risk assessment on the z-score. So how do you compare compared to people of a similar age and sex? But a t-score would compare you to a average 25 year old female. Which is pretty high, but that's, well, that's close to like peak bone mass. Yeah, pretty much. So it's kind of saying where are you at? And so if you think about like a normal distribution going back to your basic statistics, it's kind of how far are you from that average, right? So if you are minus t-score is minus 2.5, it means that your bone mineral density is minus 2.5 standard deviations below the average for that young healthy female. So they, these kind of thresholds for osteopenia and osteoporosis, which are terms that are defined by the World Health Organization. A lot of them are just based on this epidemiologic data that they've kind of identified and have been used for many, many, many years. So you get your T score and then that essentially tells you if bone mineral density is good appropriate for your age if you Have osteophenia or osteoporosis is the diagnosis made off of that school So Increasingly there so it used to be that they would look at the T score and say are you normal osteophenia or osteoporotic Based on the T score right and it was like minus one to minus 2.5 was osteophenia Yeah, and so minus 2.5 or below is osteoporosis and so they would categorize you as normal osteophenic and osteoporosis And they would do it for the lumbar spine and the femoral neck Because sometimes they're different So some people have really low lumbar spine bone-mint density but normal femoral neck or osteophenic in the femoral neck and osteoporotic in the You know lumbar spine, but the fracks but now Appreciating that there are many other risk factors that contribute to fracture risk and that bone density doesn't by itself Would put a lot of people say on medication or might not identify the right people They now use this kind of you know say fracks or there's other tools available as well There's caroc there's a few other ones, but fracks is probably the most commonly used They would put the bone density in the calculator and then they would put all the other risk factors And then they calculate a probability of fracture and so usually clinical decision making nowadays is based on the probability of fracture rather than just the bone density alone But the bone density is part of that decision making so with all of that in mind These these terms also to a pain area and osteoporosis. What do they actually mean? They're literally just a Do you hit this threshold of bone density and and some people discouraged the use of those terms now because of the fact that Someone might have be have the osteopenech based on their bone density But they may be very low risk of fracture and so you don't want to create fear You don't want to think they need to be on medication, you know So so I think that they're kind of discouraging just You know labeling people with these things and not really thinking about the broader context of what are their risk factors? Because you have to think about as risk of falls, right? There's actually a new version of racks that you can get that actually considers other risk factors like diabetes, history of falls, etc That fine tunes the risk assessment even more Not everybody has access to that for acts I think in Canada, we have to pay for extra pay extra to use it So how do you define osteoporosis then is it simply based on on bone mineral density or do you base it on risk of fall Well if I'm talking just about bone strength and osteoporosis I would use the World Health Organization definition but I think that osteoporosis more broadly is Having either changes in bone density or bone quality like these other measures we talked about that places you had an increased risk of fracture So I think it depends on the context in which you're talking about it So if you're referring specifically to the bone density scan then it would just be based on that t-score and in terms of measuring progress So let's say someone does the dexar they get their fractal and Hopefully they're under the guidance of a evidence-based practitioner and they may be there on medications plus Exercise or maybe it's just exercise and we'll go through like what would differentiate the pathway someone might go how do they How do they reassess and kind of monitor along the way to know that what they're doing is is reducing their risk of fracture? Yeah, so I think I'm each country probably would have different recommendations and even within a country There's going to be sometimes different recommendations, right? So osteoporosis Canada has clinical guidelines around when to screen for bone density or screen for osteoporosis and then how often to follow up and and that sort of thing and a lot of that Follow up and that depends on your risk level and what decisions were made around treatment but even then like you know, there's another group that came up with guidelines That is different than slightly different than the osteoporosis Canada one so it really depends on the clinician they're We're country they're in what guidelines they're following so I don't think there's like one answer for how do you kind of assess and manage someone because it's basically the clinicians interpretation of the guidelines that they've chosen to use but in general you would do a risk assessment and then let's say someone's Determined to be at risk so we osteoporosis Canada has actually an algorithm for like okay, measure these things and then you know Like if they've had a hip fracture they're high risk. We don't need to do the bone density, right? We know this If we you know, they have these risk factors do a bone density and then depending on where their bone density falls and their age and their Fracks probability Here you would make a decision based on whether to strongly recommend medication or not and then But I think that the other Measures like making sure they're getting adequate calcium and D exercise and stuff would probably be recommended across the board Regardless in terms of measuring and follow-up Usually they would be put on medication and then there would be a defined follow-up time So in some cases it might be two years it might be five years depending on which guideline you're following, right? I think some clinicians will use bone biochemical markers also to measure kind of Changes in bone cell activity and I think a lot of that also depends on The person's clinical history so for example If they've got other risk factors that are affecting their calcium metabolism and stuff they might keep a closer eye on Their parathyroid hormone their vitamin D all these other things and measure more frequently than in someone who's like Maybe a little bit lower risk and you know, but they're going on medication and rambling a little bit But you do see what I'm getting out. It's like it's not like a one answer But there would be sort of a A decision around okay, we're gonna follow up with you within two years or five years And you have to give it a bit of time bone takes a while to change So if you're following up with bone density you're gonna want to weigh to year two even five depending on the person To do a follow-up Whereas bone biochemical markers like they change more Rapidly so they might measure that in the interim and again kind of thinking about this this problem broadly whether it's pharmaceutical intervention so medications or its exercise or nutrition The the two things that we're trying to achieve is one How do we decrease the chance of this person falling yeah, and then two how do we increase the The strength of the bone in the so that they can tolerate more load Yeah, and you know, so the medications will usually increase bone mass and so I get people will Email me a lot about with questions and one question I got was you know I wasn't sure if I wanted to go on the medication and I want to try to increase my bone mass with exercise Nutrition my doctors concerned that I'm at risk and I should go on medications if I go on medication I've heard that it kind of turns down bone remodeling So does that mean my bones won't be as responsive to exercise which is a fantastic question right and the truth is Yeah, it depends on the medication So a lot of the medications that are used for osteoporosis management are anti-resorptive meaning they kind of Turn down bone resorption and often bone formation. So they turn down bone remodeling And so yeah, if you're turning off the cells that like bone cells You're probably going to be less responsive to exercise, but we don't know because we don't have studies that They don't have many studies that look at Bone response to medication in people who receive exercise Sorry people on medication and then whether like let's say you randomize Half of them to exercise and half them to no exercise and see if Like you can still increase bone mass. There's very few studies that do that. Yeah, even even looking at like fracture Intense. Oh, there's none none look like they're the fracture incidents one is even fewer, but basically There's very few studies that look at bone response to exercise um in people on medication So it's really hard to know but my guess based on the mechanisms would be that you probably would see a blunted response unless it was um a drug that actually stimulated bone formation Which doesn't necessarily mean increase risk of fracture because even if it blunted the response of the drug a little bit No, no, it's not gonna blunt the blunt the response of the exercise so the drug is gonna blunt the response of the exercise So the drug blunts the response of the exercise. Yeah In in what capacity was talking about like muscle adaptations or bone adaptations. Yeah, and I I want to clear for it I'm not saying it does. I'm just saying we don't really have a lot of evidence to Understand if it does and to what extent right? Yeah, so the I guess the point I was trying to make is that the exercise is also stimulating muscle It could be challenging balance Other other things I guess that play a role in whether someone's going to fall and yeah Actually, we did a study where we looked at um data out of Manitoba and we looked at um How like in people who are losing muscle when you control for all their other fracture risk factors is losing muscle or risk factor and it for fractures and it was um So losing muscle even after you control for bone density and all these other factors is a risk factor for fractures And it was also a risk factor in people on medication So people on medication are at lower risk of fracture because of the osteoporosis medication But people were losing muscle were at higher risk than those who were not So um it just goes to show that yeah, you know maintaining you know physical functioning balance all these things potentially can modify your even if you can't stimulate huge increases in bone mass. Friends, I want to talk about sleep for a second. Because as someone who appreciates all things health span and longevity, I realize how foundational sleep is. And one of the most underrated levers for sleep quality is temperature. Your core body temperature needs to drop to initiate sleep. And if your bedding is tripping heat, you're working against your own biology. I genuinely noticed a difference when I recently switched to cozy earth sheets. I tend to run warmer nights and these sheets that are made from viscous from bamboo, actively wick heat and moisture away from your body. I'm now sleeping deeper and waking up less. It's one of those changes that sounds small until you actually feel it. They also back everything up a 100 night sleep trial and a 10 year warranty. So there's no risk in trying them. Head to cozy earth.com and use my code, the proof for up to 20% off. That's the proof at cozy earth.com. And if you get a post purchase survey, please let them know you heard about cozy earth here at the proof podcast. When I was a teenager, my dad had a heart attack. He was in his late 40s and I was the only person with him. Looking back, I think he just assumed that he was too young for something like that to happen. He really saw a doctor and he had no idea where his risk factors were at. That experience fundamentally shaped how I think about health today. And it's exactly why when I interview experts like Dr. Thomas Daysbring, Dr. Robert Echel, and Dr. Lawrence Spurling, I pay very close attention when they all say the same thing. The most important cutting edge cardiovascular risk factors, markers like ApoB and LP Little A, are almost never included in standard blood panels. That's why I use function. I get over 100 lab tests each year, plus follow up testing halfway through to track my progress. Function gives me the data that my dad never had. The markers that genuinely matter for cardiovascular health. You can't manage your heart health if you don't know your numbers. Standard tests check the basics, but they often skip over the markers that tell you whether or not you need to take action. Through lifestyle changes and/or medication, own your health for $365 a year. That's a dollar a day. Visit functionhealth.com/simonhill and use gift code Simon25 for a $25 credit towards your membership. What do you think the explanation for that is? When you were saying it wasn't explained by bone mineral density, something about having more muscle led to less risk of having a fracture. Is it that when someone falls they have a bit more padding or they're just not falling as much? I think it could be a bunch of things. We couldn't really explore that in that particular study, but I think you have less padding. If you have less muscle, you probably have more impairments in mobility and balance and all these other things. So you may be more likely to fall. It may be also a marker of having chronic conditions or inflammation that affect lean mass. That may also, you know, people who are more medically complex may be more likely to fracture, right? Because they have other things that are affecting their fracture risk. I think it's really important for people to realize that if you are diagnosed with osteoporosis or told you're at increased risk of fracture, that you need to think about not just, okay, my primary goal is increasing bone density because it is possible that it may be hard to move the dial on that, especially if you're on medication with exercise, but also like you can try to achieve other things. You can try to reduce your fall risk. You can try to maintain your muscle mass. You prevent further bone loss from happening. But I think people get really focused on the bone density and whether they can move the dial on that. And for some people, like if you have really low bone mass and you have a history of fractures, especially spine fractures, it may be really hard to then start trying to load your bones really heavily because that might actually increase your risk. Or if you have, you know, some people, for example, have arthritis and they can't do heavy impact loading. So then they're like, okay, I can't do anything for my bones. It's like, well, no, you can actually work on your fall risk. You can try to prevent further bone loss. And don't get so hung up on the bone density numbers. The other thing is like, there's some research to suggest that, you know, maybe with aging or with lower estrogen levels, you know, put in menopause that bones may be less responsive to exercise. So people get really hung up on the bone density. And I think it's great to have a goal to try to do what you can to increase your bone mass or prevent bone mass losses. But let's not forget about the fact that, yeah, at least maintain the muscle you have. Stay strong because that will improve your physical functioning. Improve your balance to make sure you're not falling because the vast majority of fractures occur due to false. So if you can prevent yourself from falling, you have a good shot at preventing the fractures. Like balanced training is one of those things that kind of doesn't get a lot of air time. Yeah, not as sexy as resistance training obviously both are important, but kind of gets shifted to the start or the end of a conversation. Just tacked on as, you know, so I'm hoping today we can we can click on that a little more and kind of understand exactly what balanced training involves on menopause. While we're here, can you explain what happens to bone mineral density as a woman goes through menopause? And what's the kind of best explanation that we have as to why they can, women can experience an increase in bone mineral density loss? Yeah, so estrogen, it gets in simple terms, kind of acts on osteoclasts, which are the bones that those cells that break down bone and they kind of reduce their the amount of osteoclasts we have and also reduce their activity. So when you go through menopause, you know, have lower estrogen levels. And so in the three to five years surrounding menopause, women can experience accelerated bone loss as their body is kind of adapting to this new normal, right? And the some females lose more bone than others. So some experience more loss than others. And there's some people who have early menopause or they have, you know, like has dragged to me where, you know, that happens much earlier. And so they'll have that loss earlier and they they're living a longer period with lower bone mass. And then you layer on to that age-related loss. So it's like you have, you start your peak and then you're going to start experiencing your age-related bone loss. And then females or people with a uterus will have potentially another drop that's related to menopause. But that drop varies in terms of like how long it happens, how, what the magnitude is that that's also variable depending on whether a hormone replacement therapy is commenced. Yeah. So hormone replacement therapy has been shown to be associated with a lower risk of fractures. And so it can be used to prevent bone loss. But I think it's an individual decision because there's benefits and risks of using hormone replacement therapy. And, you know, that's a conversation that people have to have with their physician. Yeah, I know my, my mom actually has history of breast cancer. And was diagnosed with osteopaniac, I think like 70 years ago. But because of that history with the cancer, the hormone replacement therapy was counterindicated. Yeah. Exactly. So it's that it's an individual decision for my understanding and again I'm not a clinician. But is that, you know, they usually suggest that like, yeah, you, if you're going to use it for other symptoms or below a certain age, then there may be a good decision for you. But again, it's a conversation with physician because there may be other factors like you mentioned that may indicate it's not a good decision for that particular person. So what's going on in in Canada up there? Seems like you guys are doing, are you leading the way on a lot of this research? There's lots of people all over the world that do great stuff. I think for me, I like understanding kind of the effects of exercise on bone and on fall risk and all this stuff. But I also am very passionate about kind of knowledge mobilization and science communication. Like, how do we actually take what we know and develop guidelines or develop tools that can help people use the information? And I think there's so much misinformation out there now. And it's getting worse because of mistrust and healthcare professionals and in policymakers. And this explosion of experts on Instagram and whatever that claim to know things. And so it's, I'm really passionate about like, okay, let's get down to what we do actually know and what we can and cannot say. Just so that people are making evidence-based decisions. That's why we've got you here today. What's, is there anything on the top of your head when it comes to misinformation or myths in this space? Bone health, rights, maybe exercise or menopause? Anything that you want to just go through. clear the air on. Oh, there's so many things that have been like there's the whole menopause influencers who are all wearing weighted vests and saying that if you wear weighted vests every day, you're going to increase your bone mass and it's going to be great for you. And there's actually very little evidence that that's a good idea. And I'll say there's just little evidence to make decisions. I'm not saying they work or they don't work. Just saying when we look at the evidence out there, it's either very poor quality or it's mixed like many studies actually show it doesn't work. So there's a recent study done by Dr. Bevers who's in the US who they did a randomized trial and overweight individuals who were going on a diet and they put they had a control group diet and then they had a resistance training group and they had a weighted vests group. And the weighted vests did not prevent bone loss during weight loss, which you would expect if it was this magical bullet that it would. And so yeah, I actually looked at the and we're actually doing a systematic review right now on weighted vests because this this happened on, you know, socials. And so we're now kind of actually kind of say what do we actually know? But my quick look at the literature is that there's not a lot of evidence to support it. And if someone's thinking, well, what's the harm of just wearing a vest, what I'm hearing there is the harm is if someone's wearing it, walking, thinking that that's enough and not doing a resistance training. Yeah, I think that's something people don't get like, you know, oh, well, you know, you can just try a weighted vest and it'll be fine. But if you're not actually then pursuing the medication that your doctor's recommending or the other types of exercise that may actually where there is actually evidence to support their efficacy. And there's a cost, right? And so, you know, weighted vest costs money. And so now you're paying for something that doesn't actually work or may not work. And the other thing is like, I've read, you know, stories of people they go out walking the weighted vest and it makes their back hurt, makes their shoulders hurt. You know, if you're doing balance exercises and you fall or twist funny, like you could actually get injured. I'm not I'm not saying that there's an there is evidence that there's an increase risk injury, but I'm not saying they're necessary without harm. So I just think let's focus on the things that we know work now weighted vest are sometimes used in training like for weight loss or like people who want to go hiking and train learn, you know, get used to wearing a backpack or whatever. That makes sense to me, but in terms of the bone health aspects, I just I don't think we have enough evidence to say conclusively that it's a useful tool. Why? Why? Why did that stuff? Yeah. That would have been pretty funny. That would be funny. Anything else on the on the topic of myths? We published this scoping review on osteostrong recently. That's a company that does that sells franchises and they have equipment that I make it's kind of akin to isometric training where you're kind of pushing against something you're not you know, going through a range of motion that you would in resistance training at similarly. And they there there have been I've seen claims that it can you know, increase bone density and do all these things and that their its evidence based and our scoping reviews suggest that there's not as much evidence as the claims make and many of the studies that are out there are you know, there's a lot of conflict of interest meaning they're influenced by the company. There was actually a really interesting scenario. There's a Greek study that came out earlier in 2025 in the Journal of Clinical Endocrinology and Metabolism. This is a really well respected journal. And I read it and I was really concerned because the quality of the reporting was quite poor. It was missing basic stuff like ethics statements and clinical trial registrations and stuff. And the journal says clinical trials must be registered to be published in our journal, but it didn't have one. So I'm like, that's really interesting. The peer reviewer missed that. So we wrote a letter to the editor inside, you know, how there's all these concerns. Me and myself and a colleague Rob Dele, who's in Australia. And you know, normally in a letter to the editor process, they would actually like publish the letter to the editor. This was an unique case because it was published online, but it had been published fully by the journal. It kind of being accepted fully. So when we wrote in, it was kind of in this interim stage. So rather than publishing our concerns, they gave them to the authors and let them rewrite the paper. And so then they several months later replaced the paper. The problem is that the company did a whole bunch of media on this new revolutionary study that it was a strong or a different company. Well, I don't know. I just saw a lot of news stories. I don't know who I just saw a lot of news stories. But it's on the style of training that is an osteo-strong, which is like isometric. Yes. Did I do the vibration thing as well? I think some franchises promote the vibration, but to be honest, I don't know. I can't answer that accurately. But I just, so the Greek study was looking at this osteo-strong and they made claims that osteo-strong increased bone density and really, they only showed increases in bone density in the people who did osteo-strong and were on medication. You need another group, another arm of people there that are just taking the medication. Well, they did have that. So the people who were on medication had increases in bone density. Yeah. And then they had a group that did osteo-strong plus medications. Yeah. I think that one also increased, but the, I try to understand what it was a while ago, but basically, osteo-strong alone did not see the same increases, but the claims in the paper were pro-Ostertrong. And so I was just really upset that they just kind of republished it. They didn't kind of publicly make it aware that, hey, we took away this old article and replaced it with a new one because of concerns that were raised by the scientific community. And there was a lot of media around the original article. So, you know, this is how misinformation gets spread, right? So that was my concern. So I felt the need to kind of write to the editor and say, this is a problem. And I was upset that like, you know, at least published the concerns next to it. And the new paper still has their still concerns. And we actually wrote another letter and they chose not to publish it. So you think there might be people that are going in and doing this type of program instead of resistance training and not getting it. Or medication. That's actually my bigger concern is that if you have someone who's high-risk and their doctor's saying you need to go on medication and they're saying, I don't want to go on medication because I can try this other thing that's been shown to increase bone density by this large amount and, you know, right, revolutionary changes, or they have a perception that that's going to happen. That's my bigger concern. But yes, I also have a concern that people are going to do that in lieu of other types of exercise that may be more effective. More effective for preventing falls particularly. That seems extremely unethical. If that's the case, going back to the start of this conversation, I think you said 25% of people who have a hip fracture die in the following year. Right. So we're talking about something like that. Yeah. And then to potentially mislead someone into making a decision which puts them at a greater risk of fracture and ending up in that position. Yeah. And I'm not suggesting the company as misleading people because maybe their perception of what works or what the evidence says is different. But my concern is you've got this reputable journal that it was publishing research that did not meet accepted reporting guidelines and also didn't meet their own reporting guidelines. The senior author is an editor for the journal. So I just I and the fact that they didn't sort of publicly publish the concerns as well. So that was a concern of mine. And that's why we wrote into the journal to say like we have concerns about this paper. And then my layer to that is then there's all this news media that kind of picks up the results of the original paper but isn't aware that there's been a correction. Do you know what I mean? Just to be clear, what you would want to see in a study like that is does osteostrong plus medications? Is that better than medications alone? And then a third arm, what happens to bone marrow density with just osteostrong? I think there's a lot of ways you could design a study. And I think it really depends on the types of claims you want to make. So even just to study in people not on medication, you know, a randomized control trial does is osteostrong does it increase bone marrow density compared to no osteostrong or no other exercise? And so that would be nice. But yeah, if you wanted to ask the medication questions a bit more complicated, that would require a much larger sample size because the medication is going to increase bone density. So it detected difference would be a lot harder. And then you'd also it would be interesting to understand the magnitude if there was a benefit of the osteostrong by itself. How does that compare to resistance training as an alternative in terms of magnitude? Yeah, that would be nice too. But again, these studies are really hard to do because bone density changes very slowly and it takes a really long time. So you have to do an intervention for eight months a year longer. And the changes are really small usually with exercise interventions. And so you need a larger number of people to be able to detect a change. And many of the exercise studies that are out there even don't have the sample size really that you need. So now if you want want to add a layer where you're giving a group medication or another type of exercise, that change you're going to observe is even smaller. So now you need even more people, right? It's just, it's really hard to get funding to do those types of studies. So that's where, you know, we really have a limitation and it's just the way it is. Right. If we try to like steal man, it's for a moment. If someone was sitting at this table from osteo strong, what do you think they would say? Would they say, you know, this is, this is isometric exercise is, you know, helpful in the absence of the, when someone has mobility issues or struggles with doing, you know, full range of motion resistance training, like this is an alternative or how do you think they would kind of create a case for this program? Yeah, I don't know that I, I feel comfortable kind of putting words in their mouth or speculating on what they would say. They certainly have a lot of information on their website and they cite studies and a lot of it is based on like they'll cite other studies say animal studies or clinical trials that have shown that, you know, mechanical loading can increase bone mass. And so I think that a lot of their, I guess hypotheses around how their intervention work is based on that. There's nothing wrong with that. Like, we have different layers of evidence, right? We have animal studies that help us understand mechanisms and then we have kind of studies that are clinical trials in humans where we see does it, what we see in the animal studies does not translate to humans. And then we have broader studies where we kind of explore, you know, post-market surveillance, for example, for drugs where they monitor adverse events after the drugs been released. There's lots of different types of evidence and we have to kind of sometimes pull from the evidence we have and say what is our best guess at what's happening. And so I think what they're doing, my understanding of it is based on what's on their website, is that they have a bunch of evidence to suggest that mechanical loading will increase bone mass and that's the premise of the intervention. And then they've, they've done some studies, very limited studies, but to try to show that. And unfortunately, there's just not a high quality study, like a randomized trial that shows that it's effective. There was recently a pilot study where they looked mainly at the feasibility of implementing it, but they also didn't see an increase in bone density with osteostron. There was a group, another group that compared osteostron to exercise and they didn't really see a between group difference either. So, but they neither group increased. So, but it was a different, so I think maybe the exercise program wasn't enough of a stimulus either, but I guess what I'm saying is like, I think that fundamentally they're basing their conclusions on evidence that exists, but they don't actually have evidence with their intervention. Yes. When you look at the evidence, and you go through it in the kind of the way that you've just outlined in terms of looking at all the different types of evidence and then coming to a set of guidelines, I think it was 2014, was at the two-fit, two-fifth-shut. Two-fit-to-fifth-shut. To fracture guidelines. And now we have a new guidelines. Yes. And a new one's coming out. In 2023, they're published. When you go through that process and you look at exercise as it relates to bone mineral density and as it relates to risk of fracture, what would you say is the current best kind of evidence-based program that you would like to see more people follow. So, when we develop the 2023 clinical practice guidelines for the management of osteoporosis, with osteoporosis cannabis, so this was a few years ago, we did a number of systematic reviews and we made some decisions. So, first is we wanted to look at evidence in people with low bone mass because those are the people that were making the recommendations for. And then we wanted to look at effects on falls, fractures, and bone density because many fractures occur due to falls. So, there's very, very high certainty evidence that exercise can prevent falls, especially balance and functional training type exercise. So, I think everyone should do that because very rarely in the exercise world do you have high certainty evidence? We have 80, 90 randomized trials, very good quality trials, low risk of bias, and you know, we have lots of research to say that it works. So, we have this. We can prevent falls. So, it's a no-brainer that everyone should do that. Number one. Number two, when we look at bone mineral density, there's far, there are studies in postmenopausal women looking at the effects of exercise on bone mineral density. Many of them are very small and many of them are at high risk of bias, so it makes it really challenging and the response, the bone mineral density response is quite variable across those studies. We don't have enough evidence to make conclusions about which intensity is vast and all that stuff people say we do. We really don't. We have high intensity, best men do choose a heavy load and do these things. Heavy load or high impact? Yeah, those two layers. But I guess if I was to kind of look at the body of evidence, many of the ones that show and effect tend to be moderate or high intensity, resistance training or moderate or high impact. So, the lower intensity and lower impact less often show an effect. But it's really tricky because I'm talking about generally studies that are underpowered and have high risk, many of them, not all of them, have high risk of bias. So, it's really difficult to navigate this evidence when you have those challenges. So, what we did is we actually limited it just to the studies and people with low bone mass and there's far fewer studies. So, I'm talking like a handful of studies looking at resistance and impact training in people with low bone mass. When you were sticked to only people with low bone mass, right? Many of the studies study heterogeneous groups of postmenopausal women, some of which have normal bone density or they've purposely excluded people with osteoporosis. What is lift more trial form? So, that trial did recruit people with low bone mass. So, that would have been included in our review. And shout out to Belinda Beck for kind of challenging the idea that people with low bone mass shouldn't lift heavy and just kind of trying to change that narrative and doing the study that we needed to know the answer to. So, one of the challenges is that many of the studies that have looked at the effects of exercise and bone mineral density have often combined resistance and impact training. So, what I can say is probably if you want to increase, if you are a person with low bone mass and you want to increase your bone mineral density, you probably best bang for your buck, want to combine resistance and impact training. I can't with very strong confidence say that it has to be moderate or high impact or it has to be moderate or high intensity because we really don't have enough evidence to tease that out. But I would say many of the studies lean moderate to high resistance training intensity or higher impact lower or higher impact or sorry moderate to high impact. But you explain the difference between high intensity impact versus low intensity impact. Yeah, so like a low impact would be like walking, a moderate impact might be like kind of hopping and then like jumping off a box would be a higher impact like high impact. And it's all about how much force is going through the problem. It's the ground reaction force. Ground reaction force. Yeah. So, impact exercise are often classified along a kind of continuum of how much impact is on your body, right? So what I'm hearing here is balance training everyone. Everyone and that is that really speaking to or that's really affecting your risk of having the fall not not as much affecting bone mineral density. Yeah, it's probably not going to affect your bone density. But then if you want to get strong bones. Yeah. There's also going to be some some adaptations in muscle which I have to believe would affect falls here. So you want to build strong bones, you want resistance training and some impact training. Can you explain? I know in your papers you've spoken about like wolf's law and just just quickly like what's if someone's wondering how does resistance training let's say lifting a weight or body weight resistance training. How is that stimulating the bone differently to some type of impact? Yeah. I mean, so wolf's law like in simple terms is you know your your your bones are going to adapt to the forces that are applied to them. So you know if you're applying you know bending forces they're going to get stronger in bending, right? You bring up a good point. So we think about impact exercise as like if I'm jumping I'm applying a force to the ground and there's a reactive force applied to my body from the ground and that's those ground reaction forces. When we're doing resistance training you are your muscles are attached to bone and they're contracting and so they're pulling on bone. So they're generating forces directly applied to the bone and so it's thought that both of them potentially could stimulate bone cells to eventually increase their activity and grow bone. But again, it's hard to in the existing literature to differentiate whether in people with low bone mass one is better than the other or whether one is effective on its own. And where that becomes a real challenge is that there are people who have arthritis, have plantar fasciitis, have disc problems, have really low bone density in the spine and they may be. be concerned about doing impact exercise because they don't want to aggravate those conditions. And so they'll be like, well, what if can I just do resistance training? And it's really hard to answer that question. So I will say yes. So that's why our guidelines kind of front line, like you should do balance exercise and you should probably do strength training. And if it's appropriate for your physical fitness level and your health and your risk of fracture, you know, and you want to do impact exercise because you value that increase in bone density, then you should be encouraged to do it. But it's a bit more of a nuanced thing because there are some people who they might say, you know what, I'm really low bone mass. They may not feel that it's a realistic goal for them to try to really increase their bone mass. And they may decide that they value the prevention of falls more and they don't want to do this impact exercise, which is going to potentially hurt them. So we have to think about people's values and preferences and their existing health conditions when we make these recommendations and not just like, okay, well, everybody should do high impact because that's what the evidence says. Well, those studies are done in pretty healthy people who don't have any of those conditions. Like, if you look at Lyftmore, they excluded a lot of people because they have shoulder problems and disc problems and all that stuff because maybe it wouldn't be safer than, and I've not, you know, dissing them, like they probably should have excluded those people. But again, then you're now trying to apply it to a population that is quite different, right? I think this brings up a great point because often, you know, people hear the broad recommendations and then have these questions where they're like, well, what about me? I've got mobility issues or pain. Yeah. And so you're raising a great point of personalization as well to that. But like, is the main thing that you really need to focus on balance training? Yeah. Or is it strength training? And then individualizing the program from there. So I would say like everyone should do the balance training piece and everyone should do some form of strength training, right? And then my thought is, okay, if you value, if you're trying to increase your bone density, you can start with low impact exercise and then work along a continuum within your ability. So maybe for some people who can't do impact exercise because they have, say, bad arthritis in their feet, just an example, maybe they can do resistance exercise with different velocity, like work towards more power training where their high forces on bone without the actual impact or maybe they limit it to low impact because that's what they can do. And that's maybe where they sit, right? Whereas someone else might go, I really value this potential increase in bone density. Even then I wouldn't push people right to high intensity because if you're not used to like high velocity movements, high impact, you can hurt yourself really easily. You need to make sure you start at it again, where you're at. So in anyone, I would say start with low impact and then you gradually, like you might move to like doing resistance training with faster movements. You might be doing do some agility training where you're doing jump, like little hops in different directions so that you get your tendons and your muscles used to those high forces before you start jumping off boxes or to jump in down off of, you know, chin up bars or whatever it is, right? So I think you have to, that's that nuance is often missed. The idea that you start where you're at and you have to work towards an appropriate progression towards like what they were eventually doing in the Thmoor, which is much higher impact. I want to step through each of these balanced training, resistance and impact a little bit more and have some questions on dose, things like that. There are two principles that you talk about, specificity and progressive overload. Are they important kind of concepts for all of us to understand with all of this training? Yeah. So specificity is this idea that your training is going to, the gains that you get from your training are going to be aligned with the type of training you do, right? So if you're trying to prevent falls, you want to address the risk factors for falls or the things that affect balls. So like some people, for example, have poor balance because they have problems with sensory integration. They might be able to do a tandem walk, no problem. So that's like walking heel to toe, but as soon as they close their eyes, they're really unstable. So just getting them to tandem walk isn't going to address the underlying problem, right? So and you and you design an exercise program, you want to say, what are my goals? And then how can I align my training to best achieve those goals? So if someone wants to climb a mountain, they're going to practice hiking up mountains, right? So we want to improve balance. We want to prevent falls. We need to do balance training. You want to improve bone density. You have to think, okay, what are the things that are going to stimulate bone? So your exercise program is really going to be dependent on what your goals are. And at an individual level, I was trying to think how you make this practical. Because obviously there's a practitioner who's prescribing that can be across all of this, but then at an individual level, you're almost seeking out your limitations and trying to make sure that the exercise is challenging you. That's right. And a lot of people will do resistance training, but they don't challenge themselves, right? So they're trying to build strength, but they're going to the gym and they're doing 15 repetitions of the same exercise for two years. It's like, that's not going to help you. And not getting anywhere near fatigue. Yeah. Now that goes to the progressive overload piece, which we mentioned. But also even just thinking about, okay, if I'm trying to. So a good example is a hip, hip femoral neck bone density is really hard to change. So if you look at studies of exercise, the changes in femoral neck bone density are really small. And possibly one reason for that is like, there's no muscle attachments on the femoral neck, right? So like to try to load it is really challenging, right? So, you know, and that's where specificity comes in. So you think, okay, if I was really trying to improve my femoral neck, BMD, like how would I go about loading it? And so that's where maybe I think, I don't know, I would probably think the impact would probably have more of an impact or more of an impact, more of an effect. But that's what I'm saying. So specificity is about thinking about what am I trying to achieve? And so with bone mineral density, you're trying to either load the bones with ground reaction forces. You're trying to load the bones with muscle pull, whereas with balance training, you're trying to improve balance. It's different types of exercise. And then progressive overload. That's the idea that you're providing, I think in simple terms, is you're kind of increasing the challenge to your body kind of slowly over time so that your body can adapt to that challenge and get stronger, faster, better balance, whatever it is that you're doing, right? So you want to pick an exercise that is hard for you to do so that your body has to adapt and make it easier for you to do. Okay. And before we click into each of these, if we're, again, thinking about the person who has low bone mineral density, and it's like, okay, I want to do the program. What does this look like across a week in terms of how they might position balance training, impact how much time needs to be invested? What's a starting point? Yeah. I'm very much a fan of I would rather a person do the exercise program that they can commit to for five years rather than the one they'll commit to for five days and then quit. So for me, a lot of it is a conversation about like, what is their current exercise program and what are they capable of and how much time do they have? And I would rather build good habits, fit within what they're capable of and then try to slowly progress. So there's no like one way to do it. But I guess if we think about the evidence, many of the studies that have looked at the effects of exercise on falls have done at least two or three times a week training. So I would say I would go with three. So try to train at least three times a week for balance and different aspects of balance. So there was a network metanalysis that kind of tried to pull out the different types of balance exercises. So one's that challenge, anticipatory control or dynamic stability, functional stability limits, reactive control. These are all aspects of balance that are incorporated into balance training. So for example, if you were to try to go up a set of stairs, your body will automatically lift when you lift one leg, your body will shift your weight to the other one. So that's like anticipatory control, right? You're kind of proactively making an adjustment to make you more stable. When you think about dynamic stability, it's, you know, your ability to kind of maintain stability while your center of mass is moving around. So I always use the example of like in kitchen or motorloo, we have the biggest October Fest outside of Germany. And so if you think about polka dancing, you're kind of going, shifting from foot to foot while you're spinning around, right? So you're moving around a lot and you have to stay stable, right? And so that requires really good dynamic stability, or if you're kind of quickly getting in and out of a chair, your center of mass is shifting forward, you don't topple over because you maintain your center of mass kind of over your base of support without toppling over. So these are examples. Whereas reactive control is your ability to maintain stability when you have like an unanticipated perturbation. So for example, again, the polka dancing example, if you're polka dancing with your partner and there's somebody who's had a few too many beers and they bump into you, your ability to kind of reestablish stability and get dancing again is your reactive control. So if you fall over quickly because you can't reestablish stability. than that's not good reactive control. - Yeah. - And then there's-- - I mean, what I'm hearing as well as like, use it or lose it in a sense, like these activities like dancing and playing tennis, where you have to be reactive. - Yeah, so-- - These are training balanced for our life. - That's right. So some people can choose to do activities they enjoy doing that will also achieve some of these goals. But for some people, maybe it's harder to do those things. And so it might be easier to start with targeted exercises that target some of these domains, right? And so many of these kind of studies that have looked at exercise for preventing falls have been sort of designed to target different aspects of balance. They chose an exercise, but they've tailored them to the individual. So one person might do a sit-to-stand activity, whereas another person might do a more complex activity because their balance is a little bit better, right? So it's also tailored to the individual. So some of the features of the balance training programs are they incorporate these different aspects of balance. They are tailored to the individual. They're often led by a healthcare professional initially. So there's certain features. So I'd say with balance training, at least three times a week, challenge these various different aspects of balance. Many of them also incorporated functional strengthening. I know a lot of people hate the word functional, but that's what they called it. So things like stair climbing or getting in and out of a chair or that sort of thing, they also incorporated those pieces. - Yeah, I guess that comes back to specificity. So if we think about this problem at the beginning, where most people are having a full of, actually what are they actually doing? - Yeah. - It's of those everyday things, where they're getting out of a chair or going up and down stairs. - It's that reactive, could they fall because they can't react in time or they were reaching. So functional stability limits is another category, where you, like some people, if I asked you to kind of bend and reach as far as you could, some people would feel very comfortable leaning over very far and be able to maintain stability. Some people would lean a little bit and fall and take a step, right? So that's another type of exercise, like where you challenge your functional stability limits, how far you can reach and lean in other directions. So everyday activity, I'm leaning on a stool, step stool leaning into a cupboard, and I fall over, right? 'Cause I don't have that same stability. - So essentially at the individual level here, it's about finding the edge, like where's the point where you are getting unsteadied? - Exactly. - And that's where you need to train. - You need to train that. - Yeah, but not so unsteadied that you're gonna fall. So put the things in place, you have support objects near you, you pick an exercise. I like to think of it as like, pick an exercise that you have to concentrate to keep your balance, right? So if you can do it and also do other things, and it's probably not hard enough for you. So if you have to really concentrate to stay stable, that's probably a good place for your training. - Yeah, my undergraduate degrees physiotherapy. - Yeah. - And I remember doing some of this in my early, Pots Micahrea, and often we would have people, this was often post-fracture, and we would get people doing very single leg exercises and then challenging them with either, like having some sort of force or getting them to close their eyes or read something. - Yeah. - And constantly like layering on more challenge over time. - Real tasking. - Yeah. What amount of this type of training is needed to get an improvement? It feels like to me, as opposed to like resistance training, at least from a muscle point of view, it's not as fatiguing. - Yeah, it's more like probably mentally fatiguing, but like for some people, maybe physically fatiguing if they really have to work hard. If you have to remember though, a lot of the people in these studies, when you wanna study, does exercise reduce risk of falls, you have to actually recruit people who are at risk of falls. Because you need enough events, fall events, to detect a difference in fall events, right? So you need to have people who are falling off in, and then you have two groups of people, and one gets exercised, so that you can show that one falls less. If neither of them are falling, you can't detect a difference. So they're often recruiting people at risk of falls. So they're recruiting people, and those people already have potentially impairments in balance, and that's why they're falling in these studies. So you know, some people may have, for example, weaknesses in certain muscle groups that may contribute to impairments in balance and mobility. And so they may find the exercise fatiguing, but it's not the same as like going to fatigue, in resistance training, or like, where in aerobic physical activity, where you feel like you're working really hard, I would say it's probably not that level of intensity. - In these studies, generally, are they doing like 10, 20 minutes of balance training a few times away? - It's really variable. So there's a new systematic view coming out. So the most recent one was a cocker interview on this topic was published in 2019 by Kathy Sherrington. She's in Australia, she's amazing. But they are doing a new review, because I saw her at a conference, and she said, "We have a new one coming out, so I'm looking forward to that." But I know that they did a meta regression, and they looked at variables that influenced, you know, effectiveness, and there was one meta regression, the regression, they said that it was like high challenge to balance, and at least three hours of exercise a week. Any kind of exercise wasn't specifically balanced training. But then I think they did a subsequent one that wasn't, that didn't suggest it had to be three hours, but did have to be more challenging. But they did publish kind of data on what did these interventions look like, and most of the time is two or three times a week, and as part of a larger program. So I don't think it has to be like an hour of balance exercise three times a week, but I think if you pick exercises that challenge those different domains, and either work them into your day, or try to do like about 20 minutes or whatever it is, as long as you cover all those domains and challenge yourself, I think you're gonna see an improvement. - Okay, let's move to resistance training. - Okay. - So where do we start here in terms of thinking about the different exercises, how someone chooses the exercises, and how they determine what weight they select and those sorts of things? - Yeah, I think for me, like the way I like to think about it is, most people, if they've never strength trained before, you wanna keep the exercises easy for people to learn and master, and probably you don't wanna have too many exercises 'cause then it's overwhelming, right? So I just think about like when I go to a physio, and they give me, if they give me like 10 exercises, I'm gonna forget half of them, and I'm an exercise geologist, and it's gonna be hard for me to quickly build in 10 exercises four times a week or whatever they want me to do them. So it'd like to be realistic. So what's like the bare minimum? So I think, okay, well, if we wanna hit most of the major muscle groups, you probably want multi-joint exercises because that's gonna be more efficient, right? So I kind of think, okay, well, you wanna have a squat pattern, you wanna have a hinge pattern, you wanna have a push pattern, you wanna have a pull pattern, and then some might, or you would need a press or some sort of shoulder exercise. And I actually really like carries 'cause they're very functional, and you can actually, that is also a way of challenging balance as well 'cause you're incorporating mobility with a destabilizing element. And-- - And you crush yours. - Exactly, so I actually like to add those as well. So I would say like, if minimum, bare minimum, if I wanted to start someone on a strength training program, that's kind of an easy framework, because then you can have a continuum of exercises, say in the squat pattern, where for some people a sit to stand is gonna be very challenging, and that's a squat pattern. For other people, we're getting them gobbled squatting with 20 pounds right away, because they are stronger, and they can learn the squat pattern while holding a weight. So you just wear people on that continuum, but everyone is doing one of those, each of those. The exercise you do really depends on what resources you have available to you. Are they exercising at home with dumbbells, or are they in a gym, or they have everything they need, and then also individualized to their abilities and impairments. So for example, in the lift-more trial, they used overhead presses, barbell overhead presses. A barbell overhead press is a pretty advanced exercise, and in I find anyway that many people, not just older adults, but many people don't have the range, shoulder range of motion to do a overhead press with proper form. Excluded those people from the study? - So well, they excluded people who had shoulder issues, like major problems, but they also allowed people to do a shoulder press where the weight was out in front, right? So, and I've had conversations with Blinda, and not throwing under the bus, we've had conversations about this, and we agree to disagree on this, because she thinks it's fine to do the overhead presses here, whereas I would feel uncomfortable with people who have osteoporosis doing an overhead press where the weight is forward, because I don't like the idea of that flexion moment. - The longalabah. - I'm not a fan of it, and also I feel like that could potentially open you up for shoulder problems, especially as people get lifting heavier, right? So if you think about that then, okay, if I'm trying to do a press pattern, what's a variation, where I can still get them using their shoulders, doing a press, getting some axial loading, 'cause if that's the stimulus, we want axial meaning, like I'm loading my spine, you know, I'm saying this 'cause I don't know the audience's thing, but so if I wanted something like that, that's a similar pattern but maybe not as high a difficulty level or is not restricted by range of motion, can I do a landmine press? So now I'm doing it one arm at a time so that if there's differences in arm range of motion, I'm not worried about it. I can work within the person's functional range of motion and load them up. And then I can give them accessory exercises to work on their shoulder range of motion so that over time we might be able to increase the range of motion and have them lifting through a greater range or whatever it is. So that's the way I would think about it is you're going to have your kind of basic patterns that you want people to target and then you might need to incorporate some accessory exercises to work on deficits or specific goals that they may have. Makes a lot of sense and I have a lot of questions. In terms of load and I know that we've kind of spoken to this already but here on resistance training whether it's the landmine press or it's the squad, how do we think about load whether someone's body weight is enough if they should be adding weight? How does that pose in kind of troubleshoot that at the individual level? I think it really depends on their goals, right? So if a person, their goal is to be able to get out of a chair without using the arms for support, a body weight to stand practice is going to be enough for them. But if they're goal, if they're already able to do that and they want to get stronger or they want to try to improve their bone density and maximize the stimulus to bones then they might need something more challenging. So I think, you know, there are going to be people like I look, you know, my dad when he was following a lot, like uses a walker, severe arthritis. Like my goal for him was fall prevention and I wanted him to be, you know, functional in his home. Like I'm not trying to increase his bone density. He was 90. Like he's, and he actually fell a whole bunch of times and never fractured anything. So his bone density is probably pretty good. But my goal for him was functional strength. So do I need to throw a lot of weights on him? No, I had him doing squats, higher volume, really practicing, not using the arms, giving him some balanced challenges. Like my goal is different there. But if your goal is, I want to get stronger, I want more muscle, like I want to build muscle, then you have to, you have to walk that line of close to fatigue, right? So, and you may want, if your goal is strength, then it may be more effective for you to train at a higher percent of 1 RM. Whereas if your goal is volume, then you might be better to, like muscle volume, I mean, all you have training may be more important. So I think it really depends on what your goal is. What about, let's say, 70-year-old who wants to get to 90 and still be able to go up the steps, still be able to walk down the road with groceries or bring groceries in from the car, getting them down out of seats, in and out of bed, all of those sorts of things and can do that right now. Yeah. Is it enough to just keep sort of training those things or do they need to do more than that kind of anticipating that they're going to have age-related changes? So I would advocate that they do strength training with progressive overload beyond that for a variety of reasons. One, it gives them a bit more of a, they're able to then do those activities at a lower percent of their maximum capacity. So if we think about that, you said they were 70, so they're 70 and they're able to lift their groceries. But maybe with ageing, their muscles get a bit weaker or their neuromuscular function isn't as good, so they're a bit weaker. And now all of a sudden, they're lifting their groceries, but instead of it taking 60% of their effort, it takes 80% of their effort. And they don't do it or they have to take breaks because it's harder or they get someone else to do it because they can't do it anymore. Whereas if they are training at 70 and they increase their strength, so now it's only 50% of their maximum ability, they still see that decline. They're still able to do it 10 years later. So that's the way I like to think about it, is you're building that reserve so that you can still do those activities, but it's less of an effort. And you're also building that reserve of muscle that is important for your immune system and all of these other things. Because you do tend to lose muscle with age, so you want to build as much as you can. So back to earlier, we were speaking about the difference between the resistance training where muscle contracts and then get the tendon pulls on the bone. And that can result in the bone adapting. And then there's impact on the resistance training side of things, thinking about that force. What I'm hearing from you is probably a greater load, so higher intensity, probably better than so choosing a heavier load and doing less reps, like say five reps like a lot of studies do. And that load at five reps, you're like close to fatigue, failure is probably better than choosing a lightweight and doing 20, providing that this person doesn't have an injury and is safely and confidently doing this exercise. That heavy load is going to be superior in terms of the stimulus that provides the bone. I think we don't have enough evidence to say for sure that that's true. So I know that these conversations happen and I just don't think we have enough evidence to say this intensity is better than that intensity. And I feel like the bigger problem in this world is that people are not resistance training because the barrier to entry is challenging because they find it intimidating or they're hearing these messages that you have to train heavy and that's intimidating to them or they don't want to do it. So if you ask me what the study's saying, I will say that you tend to see more of an effect or I hate to say that because it's really challenging because the studies are quite small and there's a lot of risk of bias. But I would say more often there's more moderate or high intensity interventions, resistance plus impact that show an effect. So yeah, moving towards that is great. The other reasons why I tend to, and it's about difficulty level, it's not about load. So that's the other thing is people think they have to lift really heavy weights. It has to be challenging. But for some people, challenging is no way at all. Some people, they can slow the exercise down a bit and make it more challenging without adding weight or they can do a harder version of a body weight exercise. So do a one-legged squat or a kickstand or a beast dance squat without adding a lot of weight and make it more challenging. So I think people can flate load with intensity, but I think we need to think about difficulty level for the person. So more about effort, like your relative effort, you got to exercise it regardless of what weight you choose. Yeah, and eventually you will have to add weight to get to that relative. So that's where it becomes, I think people are not aware of what they're capable of and they consistently under train. And they think that they're expending a lot of effort until you load them up and you show them they can do it. Then they realize that they weren't working as hard as they thought they were. So that's where the load, that's where you may kind of make some gains in kind of convincing people to try load. But I just want to make sure that people understand they don't, if they're not uncomfortable with lifting heavy and that they're, then there are alternatives. Yeah, so you don't have to choose the heaviest weight out there and you can probably do a bit more than maybe you think you can do. And this, I just had Brad show and field on, I'm sure I do know Brad. And this, I mean, what you've just stated completely echoes what he's stated, he said he's not convinced that you need heavy loads for bone. But they also, I just want to underscore this for the listeners right now. That kind of almost tension that you had in communicating that is, like that's what we need more of because it's clear to me, it's clear that you know this area of research so much. You're being very careful not to say the wrong thing. And there's caveats in this context. And that, this is what science communication should look like. Not not absolutes. And so thank you for being an example of that. Thanks. That makes me feel really great. I think like the other layer to that is like we, we see these people doing all these meta analyses and they're often over interpreting this evidence because they've thrown together you know, 10 really small studies and they're looking at the average effect of 10 really small studies that are high risk of bias and trying to make conclusions and that doesn't really help us right. And again creating barriers by saying exercise has to be this way or has to be that way. I think what I encourage people to do is everybody should balance train, balance train, everyone should shrink train, start where you're at but make sure it's always hard. And yeah, for some people I'm going to push the envelope event and say you couldn't deadlift more than you think you can. And it's okay. So we had people, you know, we had one woman in one of our studies that she couldn't get out of a chair without using her arms for support of the start of the study. So we started her with sit to stands with foam pads. So she just had to touch her bum to the foam pad and get up again. So the foam pads make the chair higher, right? Then we took away a foam pad and then took another way and then eventually she could do the sit to stands without the height change. And we started loading it up and eventually we got her to goblas squats with 30 pounds. Right? and it glutes it stronger. Right. But this is a person who was able to eventually get to that place of lifting weight and probably would then see improvements in strength and function and hopefully improvements in bone density. But not all people are going to see a huge increase in bone density. Because maybe there's a lot of variability in physiological responses. And even if you look at the lift more trial, like Belinda's presented data where on average people increased, but some people lost bone, some people gained bone, some people stayed exactly the same. Right. And you're going to see that. And so that's the other variable is like people get hung up on, oh, it's not increasing my bone density. Or is it going to end? And it the reality is, yes, some people aren't going to respond. Maybe they're one of those people that they're estrogen. Now they don't have estrogen and their bones are less responsive. Or their bone density is already really low and it's harder for them to build bone. That doesn't mean the exercise was waste of time. It doesn't mean that you're not more stable. Correct. Because you may be improving your muscular strength. You may be improving your physical functioning, your balance. Maybe you would have lost bone and you didn't. You know, we don't know. Right. So I think that people get really hung up on this. And there are going to be variable responses. So yes, strength train, but you probably are stronger than you think. We have people walk in. I remember when they would be starting the study and they'd see people in the gym doing deadlifts and like, I can't do that. And two months later, they're doing it. Right. But they didn't think they could. And we do these exit interviews with participants. And they'll say, I didn't realize what I was capable of. And that's great. But they are in this situation where they have supervision and coaching. And that's not accessible to everyone. Yeah. That's the implementation question that I have for you. This seems like, yes, there are knowledge gaps here. But there's also enough information known today based on what you're explaining where a huge difference could be made. If more people had access to practitioners and coaches and people that were guiding them and understood specificity and understood progressive overload. And the net result of that would be population people with far greater confidence in their body. Yeah. That's what I'm hearing as well. And far less risk of having a fracture. But it's also even like the awareness to pursue it. Like, you know, we look at people who sign up for our studies. It's primarily middle to high income white females. It's remarkably difficult to recruit males to these types of studies. Is that because men think this is a female problem? I think there's a lot of things. I think one, it's a study recruiting people with low bone mass and men often don't realize they have it because they're not screened for it as consistently. What percentage of fractures in elderly would be men? One in three women and one in five men over the age of 50 will have a fracture in their lifetime due to osteoporosis. That's Canadian data. I don't know about in the US. Probably similar. Maybe one in maybe a bit different, but pretty similar. But still high number regardless, 20%. But they tend to be older, tend to have more comorbidities. Men are more likely to die from a hit fracture than women are. What do you think explains that? I think they're more medically complex when they are having fractures, maybe a bit older, maybe less support. I don't know. On this topic of implementation and getting more people doing exercise that his evidence base is going to make a difference in terms of bone mineral density, risk of falls, fracture. Is this where bone fit comes in? Yeah, well bone fit arose because one of the most common questions that osteoporosis Canada gets in their kind of information line and the things that patients ask for in terms of resources is around exercise and sometimes nutrition as well. Many patients value understanding how they can make choices around exercise and nutrition that are good for bone. They want these resources. One of the challenges is you with exercise and osteoporosis, you want to have a sufficient challenge so that you're improving muscle strength, potentially improving bone strength if that's feasible. But you don't want to increase the challenge so much that you increase the risk of falls or increase the risk of fractures. There is that risk. It used to be many years ago that physicians say you have osteoporosis, you shouldn't bend or twist or lift more than 10 pounds in people who had high risk. That's a disincentive to physical activity participation because now you're creating fear. This idea that you can have people who have expertise like a physical therapist and exercise physiologist, even your local yoga instructor that knows the basics of what osteoporosis is and what movements might be risky. And in the case of the physios and exercise physiologists, more advanced knowledge around assessment and exercise prescription specific to osteoporosis, you can then have that confidence. The physician can have that confidence or a nurse practitioner whomever can have that confidence that they're referring to someone who has some based background knowledge and then the patient can have that confidence that the person understands their risk and can design a program that's appropriate for them or adapt their yoga class or whatever it is for them. So bone fit arose where osteoporosis Canada saw this need to kind of have to train people, provide continuing education for exercise professionals so that they understood what osteoporosis was and could and it's a mechanism for mobilizing the research into the real world. What are the the riskiest things that that someone should not do when it comes to exercise? All of that depends on the continuum of risk, right? So the things that are risky are things that are going to make you fall, right? And things that are going to apply, for example, loads to the spine, like that will compress the spine or apply torsional or twisting forces on someone who has like, veritable fracture history or anyone. Well, people have low bone strength. So again, it's how big is the applied load, how low is the bone density? So in someone who is really, really low bone density in the spine, bending over to Thai shoes may compress the spine enough to cause a fracture, right? So this is where like, you know, you can say like there's lots of things that are risky like in everyday life, not just exercise. So it's about thinking about the things that are going to increase your risk of falls because that's one way of applying loads, it's falling and the other is like loads to the spine or loads to the bone, like compression or twisting. So you have to think about what are that you have to break down the things that you're doing and figure, you know, where are those things? So I had someone message me, 60 something year old is an aerialist, like one of those people who does the routines in the ribbons, you know, and is a coach. She teaches people how to do this. So she is expert level, right? And she was diagnosed with osteoporosis and asked her doctors like, do I have to quit? And like, is it too risky? Like what? And the doctors like, I don't know, ask a physical therapist, went to a physical therapist, the physical, said, therapist said, I don't know, Google it. So again, a bone fit trained person would have some basic knowledge that might be able to think about that. There's no randomized trials that are randomizing people to aerialist activities and no aerialist activities and seeing if people could fracture. So we don't have an evidence based to answer to this question. So this is where when I talked about the layers of evidence, you have to think you have to break this down and go, okay, what are the risky parts of being an aerialist, right? Falling and movements that are really bendy twisty that cause compressive retortional loads to the spine. So my response to her is a number one, I'm not healthcare professional, nor am I your healthcare professional. So I'm not giving you medical advice, but I can break this down from a general perspective that you can discuss this with your physical therapist. And my, I said this, there's two things you need to think about. So if you are expert level aerialist, like your risk of falls is probably pretty low, right? You have to accept the risk that if you fall, you're more likely to fracture than someone who doesn't have low bone density. But if you think, if you're willing to accept that risk because you think your risk of falls is low, then we're not worried about that. So that one's gone, right? Again, the spine loading, it's not just about like how twisty it is, but how fast you're twisting all this stuff. So break down your aerialist practice. Where are the pieces where you're going to be applying those types of loads to the spine? And maybe you modify those movements or you don't do those movements. Or again, you accept the risk that if you do these things, you may fracture a bone in your spine, but understanding it's about a discussion with that person and what their risk is. So I can't give you these exercises are going to cause fractures and these don't because A, they depend on the person, they depend the way they do them. They depend on their tolerance. Like someone who on one day is able to do a deadlift may not get enough sleep and they may fatigue easier and then their muscles can't support their spine and then that day they fracture. So there's a lot of variables that influence injury risk and there's no black and white here. It's about A, understanding what your personal risk is and your abilities are working within your abilities, but just enough that you're challenging yourself, but also doing what you can to reduce the risk, but also accepting that inherently, And living, there's risk. - You find that people like that lady in that example, and cyclists often like upper body, or maybe even people that do yoga, just people in general that are active throughout their life, but perhaps not doing resistance training, and loading the skeleton, who are diagnosed with osteophenia, or osteoporosis are quite surprised by that, given how active they are. - Yes, frequently. There is that, I'm healthy, like I walk every day, I eat healthy, why is this happening to me, right? And you can still resistance train and do all the right things, and it can still happen. So again, you have to accept that, it's not like there's a magic way to reverse it, and if there was, everyone would be doing it. How do you feel about activities like yoga, or swimming, or cycling, in terms of, in this conversation around bone health? - I think that many people choose to do activities in their daily life, or leisure, that they do for many different reasons. So they do it because they get mental health benefits, they get physical health benefits. They do cycle with a group, and it's social for them. They garden because they like pretty flowers. There's lots of reasons why people to choose to do things, and I think that we need to encourage people to do the things they want to do if they can be done safely, or if they can be modified for safety. So I think, number one, people want to cycle, 'cause they enjoy cycling, awesome. I think if a person is diagnosed with osteoporosis and they're concerned about that, and they want to do something about it, my kind of take on that is, absolutely do those activities you want to do, but don't do them instead of balance and functional training and strength training, because those are the things probably where we have the highest evidence that it's gonna potentially help you when it comes to fracture risk. So can you fit in the other stuff? And again, that also then may modify your risk in the other places. So for example, if someone asked me, Physio asked me, I have a client who wants to know if she can still go trail running because she has osteoporosis. And so again, break it down. The trail running may increase the risk of falls 'cause she's gonna trip over stuff. So she has to accept that risk, right? Like I've tripped trail running lots of times, right? 'Cause there's sticks and whatever. And then is she on medication? Is she doing the strength and the balance training? So balance training might help her have better reactive balance so she's not tripping, right? Is she doing all these things? Is she getting adequate calories and calcium in D? Is she addressing the modifiable risk factors? Because you don't wanna be all like, yeah, running's fine. And negate all these opportunities to address modifiable risk factors. And if someone has very poor balance and has very low bone mass, then yeah, I might go, you know what, that might be risky for you. Especially if you're not taking medication, not eating properly, not doing these other things, right? So it's not as simple as it's risky for everyone or not risky for everyone. I don't know if that makes sense. But when it comes to balance training, it's something like yoga, which seems to challenge balance. I know it challenges my balance when I'm doing the warrior one and warrior two and reversing the warrior and all that. Good stuff. But a vinyasa flow style yoga training, like if you're doing that a few times a week, is that a replacement for the type of specific balance training we were talking about before? - So there's different ways to answer that question. So the first is, is there evidence from randomized trials that yoga can prevent falls? And the answer is no. So the evidence that exists either says, there's no effect or says it's actually not effective and can potentially increase risk. So there was actually, I haven't read it yet, but because it just came out a few months ago, but there was a study that looked at an aangar style practice and actually found that the risk of falls was higher in the yoga group, right? - And that's taking, that's taking people with low bone mineral density. - No, it would have been like older adults or people at risk of falls. - Got you. - Because again, they're looking for fall events, not fractures in this instance. So they didn't, I don't think they measured fractures on outcome or they didn't show a significant effect if they did. And I'm basing this on reading the abstract 'cause I have not read the full paper yet. But, so I would say like if we, asking if there's evidence that yoga can prevent falls, I would say no, there isn't. And you would have to do exercises that actually target aspects of balance because that's what's been studied and that's where we have the evidence. Is there evidence that yoga might improve balance? There is some evidence 'cause there have been some studies that looked at balance as a surrogate outcome for falls. And there is, it can potentially improve physical functioning and balance. And yeah, I think, you know, there are gonna be yoga postures that do target some of those aspects of balance like anticipatory control, dynamic stability, et cetera. But there's also the kind of way it's delivered in that it's often delivered in a class. There's not individualization per se or a consideration of individual risk and how you might modify the posture. Some yoga instructors do that and do it very well, but not all do. And I would say it's a bit more inconsistent in terms of the way, I mean, you've probably been to a variety of different yoga classes and they're all taught differently. And so where people might run into problems is if they have a yoga instructor that's not tailoring it or doesn't know their risk, your risk or doesn't know how to adapt it for people at risk of falls and fractures. And there, and you have someone who's higher risk and they fall over and fracture. So I've heard of people fracturing a hip in a yoga class because they fell during a balanced posture. That risk could be for all types of exercise, but in this case, because some of the poses are quite challenging, you can see how that can happen. So I'm not saying don't do yoga, I'm just saying be aware of the risks and benefits. And yes, it possibly could improve your balance, but it has to be, you have to do it within your limits of ability. - I mentioned earlier that part of the reason you set up a bone fit was-- - I didn't set it up just as there. - Sorry, I suppose it's Canada. - I'll say it's a prosa in Canada. So your research or work help inform the program? - Yeah, I'm occasionally consulted on it. And so Judy LePride was very much a leader working with osteoporosis Canada. And she's a physio who is a prof in U of T. And she developed bone fit in consultation with a number of people myself included. And it has evolved it over time in consultation with a bunch of people myself included. And so it's this workshop and so she developed it. But osteoporosis Canada kind of delivers it and she would be sort of the lead person involved in the content creation, but informed by me. - And the idea there is to give practitioners the knowledge so that they can safely work with individuals who are at risk of falls and fractures and get them doing exercise, which is going to be meaningful as opposed to previously where a lot of practitioners were just time able, don't do anything 'cause they're scared. This scared of another fracture or an injury or a fall. The thing that I'm kind of grappling with here is I can understand why practitioners are scared because when it comes to kind of getting the adaptations, you kind of balance training or resistance training, you have to take people almost to the edge. - And people will hurt themselves. And so I think a lot of it is having a conversation about risk and understanding that there is that risk there. That's the nature of exercise interventions or even any kind of physio, right? You often going to even physical therapy for a problem, they're kind of trying to figure out what's wrong and then trying things to see if they can help and sometimes it helps and sometimes it doesn't, right? Sometimes you can hurt yourself, right? There was a case study of a person who had osteoporosis related to cancer, so it was a secondary osteoporosis and physio was doing an arranging motion exercise for extra graffiti for shoulder. Like these things happen, not just in exercise, but even just other types of physio practice. - But overall, like the type of program that we're talking about, if done appropriately, meeting the person with or at, there's a net positive. - You would think so, yeah. So in general, when we look at the adverse event reporting across exercise interventions, serious adverse events are infrequent, not zero, but infrequent and the most common minor adverse events are muscle soreness and musculoskeletal injury. But those also happen, so again, informed consent, right? So you may be at increased risk of repetitive strain injury and other types of injuries, we'll do our best to try to reduce that risk. And then, yeah, there is a possibility you could fall or fracture doing this. So you do have to have those conversations. - You mentioned earlier that it's not clear if resistance training is superior to impact training or vice versa, the kind of independent effect that these have. So if you can, probably best to do both, at least for now. And we've gone through a resistance training. Can we just spend a moment on impact training a little bit more? And how would we approach that in terms of meeting someone with where they're currently at? Yeah, and I just want to, before I get to that, I want to say like, going back to the multiple lines of evidence, we have animal research that says there's certain types of exercise that are effective, and high magnitude loads is one of those things, or rate of strain of loading, or multi-directional loads, or, you know, dynamics, so that's that. And then you have like, you can look at observational studies, and look at the types of sports that people play, and like gymnasts, and people of high force, loading, or fast movements in multiple directions, tend to have higher bone mass. Then we go to the clinical, it's just as we narrow down to clinical trials, specifically in people with osteoporosis, that's where it gets tricky, because we have fewer studies. But yes, in general, probably the combined, because we don't have enough information to separate it. So you asked me if people wanted to approach an impact training program, so I would say they would start with, it depends where they are starting from. So if this is a person who's already strength training, it's a different answer than if they're not. But I would say like, starting with lower impact activities, and making sure they have a good foundation of strength training, one so that their joints and muscles and tendons are used to that level of impact, those that level of forces. And then it becomes a progressive overload exercise. So now, okay, I want them the muscles and tendons to be able to experience lately higher forces, so I can do higher loads, or I actually like the idea of higher velocity movements, because if you think about impact a lot of the times, it's like, okay, I'm hopping from side to side, this is a fast movement. So I won't, specificity, right, of training, I want to get our muscles and tendons used to those fast movements. So can I, you know, do my sit to stand a little faster, or, you know, that sort of thing? So kind of get people conditioned to moving a little bit more quickly. And that also will challenge, make sure that they have the balance to move quickly, because what you don't want is, okay, let's do agility drills, jumping side to side to work on impact, and then they don't have the agility to do that, and they fall, or you don't want that either. So you have to think about all these aspects that you have to train, right? So I think about, okay, start with foundation of strength training, foundation of, you know, low impact, aerobic physical activity. So I have the aerobic conditioning, I have the strength to do it. Then I'm going to move a little faster, right? And I get my body used to moving more quickly, or doing more unusual movements. So maybe I do my resistance training with different types of movements, when my body gets used to that. I'm just thinking of an example, like, you know, - would popping be an impact? - Yes. Yeah. So then I would say, once you get to that foundation, then I would go to, okay, now we're going to make the impact a little higher. So maybe I'm going to do some heel drops, some hopping, some lateral side to side kind of hopping, movements in different directions. So think about the direction of movement and the speed of the movement and the impact. - We're jumping, hopping off of the box. - Yeah. So that's even higher impact. So I would start with the hopping first, maybe two legged hops, then one legged hops, side to side hops. Then you can slowly increase the impact by either jumping higher or jumping off a surface. So you have this sort of, you apply this principles of specificity in terms of the types of loads, right? Multi-directional velocity of movement, force, the amount of force applied to bone, and you create that continuum. You start with lower ones and progress along that continuum of ability. And some people may never get to jumping off a box. They may have to stop at heel drops because they have phlantrofacillitis, or they have arthritis, or some other problem. And that's where they stop. - And when you say velocity, essentially you're talking about the speed, at which someone's doing that movement. - Of the movement. - Yeah. Is that like an important factor when it comes to falls? - I think so. I think that like in order to be able to react to a sudden perturbation, you need to be able to move quickly. And I think one of the challenges that we are, we are muscle fibers change such that we're not able to generate high force movements, but also quick movements, or our neuromuscular function changes, right? So there's lots of things that happen with aging. And if you can try to continue to challenge those systems, you can hopefully try to maintain that level of ability to move quickly as well as to move with high forces and high impact in all of the things, right? - From a safety point of view, I think the old adage is very slow and controlled. What I'm hearing is still do it safely, but modify the tempo a bit. - And again, it also depends on the person, right? So there's some people where that may not be realistic, because I'm a little bit worried about, like if I've got someone with multiple vertebral fractures, I'm maybe not progressing towards jumping off a box with that person, and I may focus more on the fall prevention on, you know, stabilizing the spine by working the muscles, the back extensor muscles, abdominals, that sort of thing, and preserving function. But yeah, like in someone who, you know, I, osteopenia really has motivated to try to improve their bone density, wants to progress towards this jumping off a box situation. You want to make sure that they have that capacity to move quickly, to react, to handle higher force loads and higher velocity, because you're, if you're jumping down, you have to be able to absorb that impact, you have to have the conditioning to do that, right? - What would you say to someone who maybe has had a vertebral fracture or hip fracture, they, for good reason, have some anxiety related to this conversation, but they do not have access to a practitioner that's been through bone fit, and they're apprehensive around kind of doing this themselves. Are there any racelaces that you know about online or apps, or like something that people can freely access? - We actually created some just handouts for patients on recovery after spine fracture. They're freely available. Right now, they're on the fragility fracture network website, they're available in English and French, and we actually are doing a study right now looking at the feasibility of a virtual rehab intervention for people with spine fractures, because we think that there's a need, there's, there's not really good kind of rehab care pathways, like there are certainly many physios who deliver excellent rehab after spine fracture, I'm not saying that they don't, but I think there's no like kind of standard approach to it or no kind of accepted, this is how we should do it. And increasingly, AI is being used to, you know, scan CT scans to pick up vertebral fractures so that we can better diagnose people. So there's going to be more and more people being diagnosed, but we don't know what to do with them. So we actually are testing the feasibility of a virtual intervention where we kind of address pain management, because that's a number one concern for many people, spine safe movement strategies, so how to get back to moving safely, and then nutrition and exercise, and how to start an exercise program. And I think that what I'd like to see is, you know, can we have some evidence-based programs that can then trickle down through workshops like BoneFit, but also can we then develop resources for patients who have issues related to access to support those types of programs? So I think that's what we need. I think there's probably bits and pieces of information out there, but there's not a lot specific to spine fracture recovery. We'll put a link to that in the show notes. I think in one of your papers you also mentioned an app called Clock. Clock yourself. Clock yourself. Yeah, that was developed by a physical therapist named Meg Lowry, who's amazing. And it's essentially, you envision that there's a clock on the floor, and you're standing in the middle of it, and it'll kind of say random numbers, and you have to step to the numbers. So it'll be like two, eight, and you can set it at different speeds and different durations. And then there'll be different levels. So it'll be one that'll say, like, bicep curl three. So you're doing like two tasks at once. There'll be like aerobic versions where you, like, it'll incorporate other movements. There's one that has a cognitive challenge. So it'll say February and you have to step to two. So it's mostly balance-based? Mace, it's mostly balance-based. Cool. Yeah. But it's like four dollars on the app store. And it's just a way to kind of incorporate balance training without thinking into your day, right? Okay. So we'll make sure both of those are in the show notes. What do we need to think about here with regards to how nutrition is supporting this exercise? There's a couple things I want to address. So the first is that we want to make sure that we're not unnecessarily losing bone because we're trying to constantly lose weight. So women often are bombarded with images that cause them to hate their bodies and they want to be very skinny. I'm over-generalizing by the way. But like, there's this pressure to like, and then you have body changes that occur as you get older. And then you might try to like lose weight for health reasons or for body image reasons. And they don't maybe realize the consequences of that. That if you're constantly on a diet or you're constantly restricting your calories and you're losing weight, you may be also losing bone, right? So we may need to rethink our weight and health goals and instead eat to fuel the activity that we do and the goals that we have. So if we want to build muscle, we need to eat adequate calories and protein. right? And we need to eat adequate calcium and vitamin D to support bone health. So rather than kind of this loss, I want to lose both mass, I want to gain strength and to do that I need to eat these things, right? And inevitably, if you do strength training and eat healthy and get enough protein, it tends to result in a healthier body composition and it's better anyway, right? So take it enough protein to kind of quantify that. Are we talking like at least that 1.2 grams per kilogram? Yeah, everyone has different numbers. So definitely, I think there's evidence to suggest that especially in older adults or middle aged older adults or people who are very physically active, they probably need more than the RDA or the like point eight grams. Yeah, point eight grams for kilogram body weight. And but I think that you know, some people advocate 1.2 to 1.6 grams per kilogram body weight depending on your activity level and your individual circumstance. But you know, doing the math on that. So we actually, we have like a Bones Lab YouTube channel and we did a little video series called the protein primer. It's like five quick animated videos that talk about protein intake. And one of them is how to calculate how much you need. And yeah, saying you should at minimum get the RDA, but really if you're more physically active, 1.2 to 1.5 grams per kilogram body weight. And the thing that can make that difficult is changes to satiety. So appetite and often, you know, a pretty high percentage of people over 70 and not meeting the even the RDA. This is where, you know, someone in healthcare or even a physiotherapy pick it up, like the idea of doing a malnutrition screen and identifying people who are at risk of not getting enough calories, protein, other nutrients, and then referring them to whatever resources are available. So sometimes that means dietitian, but even just like food access supports, right? So maybe there are, maybe they don't have the money to pay a tie addition or the access to it, but maybe there's like, you know, food delivery supports available through some sort of community support services or encouraging communal dining kind of programming or other things where people can get access to to higher quality food. Sometimes a lot of it is people live alone and they don't want to make a whole meal. So they, you know, eat whatever is there, right? And people are more likely to eat well when they eat with other people. So how can we put the supports in place around a person to make sure that they're eating well? And it's not always just about like them not calculating the math on the protein, right? There's many issues. There's swallowing difficulties, right? You have to address that to get people to eat properly or make sure that they have the right texture foods to get an adequate protein. Will you ever come across this idea that protein causes calcium to be leached from bones? Yeah, but I think that it also increases calcium absorption. So to be honest, it's, I'm not a dietician and that's not really my area. So I don't read in that area extensively. But my understanding was that that like I don't know necessarily that it's a cause of long standing bone loss. Yeah, I think, I think, I mean, I raise it because I think it was one of those kind of weird claims that came, came to the 90s and it's been thoroughly, you know, put to bed, but it still persists a little bit out there. And I just say it just in case, someone's listening to a thing a bit worried about increasing my protein because it's going to have a negative effect on my bone. Yeah, I mean, there was a study that showed that people who had higher protein intakes were less likely to fracture a hip. So I'll stick with that one. Yeah. Me too. From a micro nutrient perspective, do you have any specific views on nutrients of focus that people should keep an eye on? There's a lot of talk about magnesium and vitamin K. And I think that certainly you want to make sure you get enough of those things. And people who are eating like a well balanced diet with a variety of foods probably do get enough of those things. But if, for example, they don't eat a lot of leafy greens and they're not getting vitamin K or they're not having a lot of food sources of magnesium, then that's where they might need supplementation. And really a conversation with their physician or a dietitian around like what is their diet and should they take a supplement or do they take a multivitamin and hope for the best. But I don't think there's enough evidence to say conclusively that people who have low bone mass need to take supplemental magnesium or vitamin K. I wouldn't say that. And in fact, the osteoporosis Canada guidelines do not recommend those supplements. What do the guidelines say about calcium and vitamin D? You want to get the recommended daily allowance of those nutrients and ideally get them through food. There is some research that shows that too much supplemental calcium can have adverse effects. So ideally get your calcium, meet the RDA through diet. But if you cannot, then consider a supplement. But the calcium supplements, like they definitely not more than 500 milligrams at a time. Now also depends where you live. So in Canada, many Canadians don't get enough vitamin D through sun exposure because we don't get a ton of it between October and March. And the sun is that the sun's not high enough in the sky to make vitamin D through skin. You're often wearing lots of clothing, so you're covered. So health Canada actually recommends that many Canadians take a supplement of at least 400 international units of vitamin D. But that may vary depending on where you live in your sun exposure. And some people might need more. So I'm a person who tends low. So I've had hyperparathyroidism because of suboptimal vitamin D levels just happen to have it measured once and realized. And so I now take more vitamin D than that just because it's what I need. So some people are at risk and need higher levels of vitamin D. And again, that's a conversation with a physician about their risk. You mentioned getting enough calories is important. And right now there's a big conversation around JLP1 agonist. And of course there is a very high incidence of obesity. Do you have any concerns about JLP1 agonist or is this conversation about exercise just even more critical in this moment? So when people started having bariatric surgeries to lose weight, there's a various different types of surgeries you can have. There was evidence that they were losing bone when they were losing weight. And also some of the surgeries affected the parts of the digestive system that are involved in calcium metabolism without also effect bone. So I think you're going to see similar things here where you now have effects on gastric motility. You have effects on weight loss which is going to cause bone loss because you're losing weight. And you're eating less food that contains calcium and magnesium. Exactly. So I think you're going to see similar things where you're going to have bone loss. And I guess the question is what bone mass are they starting with? And does it place people at risk sooner? For some people maybe they have enough people in mass that they can handle the bone loss they experience. It doesn't put them at an increased risk. And other people it might put them at an increased risk or maybe it puts them at an increased risk 20 years later. Right. So I do think it's going to be a potential. I think it is a potential cause of bone loss and could increase the risk of fractures later on. I don't know that exercise can prevent that bone loss from happening. I think there's some evidence to suggest it might prevent some of it from happening but not all of it. And that evidence is inconsistent. So there have been some studies where they've done diet interventions and people who are like older adults who are overweight. And they've shown that resistance training may prevent some of the loss of lean mass and bone mass law in people who are on a weight loss program. I don't know if that's true for those drugs. And also I've seen studies that have done a similar thing and not and shown that it doesn't prevent. So I guess what I'm saying is the findings are heterogeneous. They're not consistent. So I just I don't think we can rely on exercise for preventing that muscle and bone loss. And the other thing is we're talking about people who have struggled with weight loss. So that's assuming that you can get them to commit to the type of exercise that you want to do them to do to prevent that loss from happening in addition to the weight loss drug. The question of adherence. Is it possible that because of the high of BMI they do start with a higher bone mineral density? Yeah. Yeah. Yeah. It's just that I also see like I think that there are some people who are starting the drug who are not necessarily clinically obese, but they're using it for weight loss purposes too, right? So they may already have a skeleton that is lower in bone mineral density to be honest. Yeah. So I think there's going to be a variety of or variability in the starting levels of bone mass. And so you're just kind of playing with I'm going to lose weight and you may lose some bone and you have to be able to accept that risk. And as long as that conversation is happening. Are they screening people where before someone starts a J.O.P. when I going to say look at bone mineral density? Not likely. I don't know for sure, but it's not likely. Unless maybe they have risk factors. I don't know actually. Where to from here for you? What are the questions that you're most interested in answering with the future studies that you can. So many. So we just finished. We're just closing two clinical trials right now. So one is the one I mentioned looking at the feasibility of a virtual rehab intervention for people with spine fractures. So that trial is gonna be done in March. So just we we had four different centers. So British Columbia like a UBC McGill U of T McMaster and our site Waterloo was the lead but we didn't actually recruit people at our site long story. But so we looked at the feasibility of recruitment because it's a really tough group to recruit people with spine fractures because they don't really have a home in the sense that they don't all go to the same place like some people are diagnosed in primary care sometimes in emerge sometimes in by a specialist so it's they're kind of hard to find. Is that usually a thoracic fracture or it could be lumbar? Both. The most common sight is like T-78 and then like T-1112L1 kind of area for one because that's the site of the max chifotic curve and then the other likely and I'm just guessing but like the other is kind of where you transition from like chifotic to lumbar and also you're more mobile in that area you don't need ribs so like lots of reasons why probably. Just made me think about my posture and do a bit of farm rolling when I get it. Totally totally. So what's I saying? So Viva trial that's the virtual rehab trial that's gonna be done in March and then I'm hoping that we'll then apply for funds to do a larger trial so this is kind of the long-term vision. We also finished a trial called fortify bones which was three arms so one group got like low intensity home exercise and then the other two got a resistance training program because what we wanted to know is does resistance training increase bone mineral density like no impact training just resistance training and then so one group was moderate intensity and one was high intensity and so the idea is that what we'll do is we'll pull the two resistance training groups and we'll say does resistance training increase bone mineral density compared to the low intensity home exercise and then we will also look at whether intensity influences. How do you define high and moderate intensity? So the high intensity was like in like a 6RM target and the moderate intensity was a 10RM target so repetitions maximum so like a weight you can lift 10 times versus a weight you can only lift six times essentially. Yeah yeah. Interesting but yeah. What's your hypothesis? I think I hypothesize that resistance training is effective. I'm not entirely convinced that we'll see a difference based on intensity. And what was the outcome again? Lumbar spine bone mineral density is the primary outcome but we will look at hip bone density, we'll look at trabecular bone score, we'll look at bone structures, we'll do some hip structural analysis, we're in like a body composition, physical functioning, quality of life, bunch of things. Now that you mentioned bone structure, this gets me interested. I know that you are across the research that Darren Candell and his colleagues are doing on creatine. Yeah. And I think off-air at the start of this conversation you mentioned that was a new creatine study. Yeah it was just published and they didn't actually show an effect of the creatine on bone mineral density so I think their hypothesis was they would see it. I think they saw some changes in some of the structural outcomes but they were quite small. So and again the more things you test, it's like the more times you throw the fishing rod in the more likely you're going to catch a fish right to the more thing variables you test the more likely you're going to see something significant just by chance. So they did see some changes in some of the structural variables but not the bone density which were the primary outcome. So how do you think about creatine? So what I think about creatine is that that it might help you train a little bit harder and it may help you build muscle if you are training. I think creatine like you know it's essentially like you're creating an environment that is optimizing your muscles for adaptation but you have to train pretty hard to see an effect over and above just training by itself. So like many people are new to training or not training that hard so they're not going to see this incremental huge benefit from creatine because they're not. The efforts not already there. The efforts not over there or their window for seeing a change with strength training alone is huge because they're not training that hard. So I think it's better to place more emphasis on a high quality resistance training program and then if like if you want this like possible added benefit you might see because you have to pay for creatine you have to take it all the time right so I don't know. If you're taking crazy and then training it like a five out of ten effect yeah that's not going to solve the problem. No, no, you're going to see the benefit if you're training like hard and close to fatigue and you know so you have to be have that established first have the like and and probably like if you're training twice a week with a full body program for 30 minutes like the added advantage of creatine is probably not that great. I think you have to train pretty hard to see that huge added advantage and train at that level of effort and I think for most people bigger bang for your buck to focus on high quality training then trying to get the benefits out of the supplement that's my personal opinion but yeah people who are training pretty hard want that potential added benefit they might see improvements in muscle or improvements in strength or what they can push if they're taking creatine but I don't know that the evidence is there necessarily for huge bone adaptations based on that trial. That brings us back to I think one of the biggest takeaways from this conversation which is trying to understand how much effort you're putting into your exercise is is really important here and is like really the key whether you're lifting a heavyweight or a lightweight. What is that perceived exertion? How do you how do you kind of communicate that or explain that to someone? I'll usually say you want to start with an exercise that you can do six to ten times with good form and you run a really work on your form. The quality of the movement is really important and ideally you get some coaching on that but the idea of kind of working on like don't worry too much about what you're lifting it's more about pick the exercise that you can do six to ten times and work on the movement pattern and get that down pat then you want to start to progress the load right and or the difficulty level doesn't necessarily have to be load but pick a difficulty level and again depending on your goals but I lean towards a smaller rep range because a) I find higher reps really boring and also in people who are novices and don't know what they're capable of like I think that if you kind of push them towards a higher difficulty level lower reps and get them to really focus on form you're less likely to get injured fatigued all those things and they're probably going to work a little harder because you're like oh you can do ten we can increase it right so I would say pick a difficulty level that you can do six to ten reps you know six to twelve doesn't really matter that much the idea is that you can pick a difficulty level you can do that many and you can't do that many more so I I use the repetitions and reserve idea so like at the end of the set how many more do you feel like you can do if you if it's more than two it's too easy for you so if you decide you want to do 15 reps that's fine but pick it pick it as you know two repetitions and reserve now if your goal is getting stronger or you really want to hit that moderate or high intensity because you want to hit bone density and that's probably where we think it might work then yeah your reps need to be a bit lower so the higher intensity is like closer to six the moderate intensity closer to ten I don't get to hung up on those numbers to be honest with you for me it's more about effort is are you are you working at an effort effort level where you are within one or two reps in reserve one or two reps left in the tank that's where we want to be and good quality movement like your form is good nice and controlled so I will I will talk about speed of movement so we want I like to encourage people to use like two-second concentric and I up to three four-second eccentric so that they're concentrating on the movement and moving slowly especially if people are new and they have osteoporosis I want to make sure they're doing it slow and controlled so that they're in control they're not going through it really quickly and they have good form right so so for me the the quality of the movement the speed of the movement and is it hard enough that you've only got one or two left in the tank that's where we want to be right and then yeah if you really want to get nitpicky and your goal is strength you want to be on the lower reps maybe if you want to build bigger muscles you might be want to be higher volume so that's a combination of load and reps and sets but I don't get that nitpicky because I just want people to train more to be honest with you what's possible here if if someone implements this is there a particular patient subject story that comes to mind about someone who's implemented these things and had really good results yeah like you know like I said that woman that I told you about where she couldn't get out of a chair and now she's godless squatting 30 pounds we had another person in one of our studies started had rheumatoid arthritis and started lifting and she said I'm not in pain anymore right that was an great outcome for her, right? Regardless of her bone density, she thought that was fantastic. People just saying that they find it easier to lift their groceries, right? Look, we've had people say that, right? They feel better. The big thing is we've had quite a few people in the most recent study who, when we ask them like about their exercise, they've continued to do it after finishing the study. So they train with us for a year in this particular study and they're doing it one year later still. And so that's a great success story for me, the fact that they've built that confidence and self-efficacy around strength training and they're still doing it. That for me is the biggest takeaway, like 'cause that will hopefully result in maintained muscle strength and physical functioning and other outcomes and hopefully maintain their bone density too. Is that what keeps you engaged in this science and passionate about your work? - Yeah, I really think it's important to do our best to conduct the best quality science that we can with the money and resources we have. And sometimes we can't do the ideal study. So one of the money and can't convince the government to give us the money or the study's too complicated to do. So let's do the best quality science we can't have and make sure we temper our expectations and our conclusions so that we're not overselling the results, right? And we see that a lot in research. Unfortunately, where people are like overinterpreting what the science says. And then also have efforts to communicate that science and try to influence policy and practice. So we've worked with us to versus Canada to develop tools for patients, the basic education, consult it on bone fit so that, and again, I didn't develop bone fit, just I talked to them sometimes about the guidelines and that sort of thing. But make sure that we're implementing it and then do studies to look at implementation, right? So we did a study where we worked with partner organizations like the YMCA to see can we deliver like a strength training workshop at the Y, where people can learn how to strength train. Because that's the kind of models that I think make it accessible to people because the YMCA has a sliding scale for income in terms of joining as a membership, right? So now you can reduce some of these barriers. It's a more kind of, people kind of, it's part of their community. They may be more accessible than a gym where they feel intimidated because it's all young people lifting heavy and they feel nervous about strength training, right? So we have to think about what are the barriers to access and then design our communication strategies, our intervention strategies around those barriers. And so that's where it becomes less important about the reps you're doing and just like how do I get people to do these types of things? And I think like one story I'll share is that this became very apparent to me when I was early career because I was invited, you know, as a researcher to give talks in the community to patient groups, right? And so I would go and I would have all these slides about clinical trials and bone physiology and all these things that academics care about and present my research. And then they would pepper me with questions. Like is it safe for me to lift my grandchild? Should I do sit-ups? You know, can I do yoga safely? Is it going to improve my bone density? And I start to realize like the types of things that we study in our research are not necessarily aligned with what patients care about and what questions they have. And so we need to make sure that in our approach to communicating research or designing research, we need to actually think about what's important to patients, what outcomes are important to them. What is the intervention that I've designed aligned with something I can actually implement in the real world? Because if it's not, who cares if it's effective? Because if it's not going to be implemented, except by the most high-income people who can afford a personal trainer, what's the point? Right? So you have to think about how do you design research that's actually considers patient outcomes and how we can actually get it into practice. So I think it's really important to me to kind of do that work as well. Beautiful. Well, thank you so much for coming and hanging out with me today. This was really fun. Yeah, it was awesome. I've learned so much and we're all really grateful for all the work you're doing and contribution to this area of science. Where can we send people if they want to follow your work and future studies that you publish? Yeah, so we have like a little newsletter that we send out to people who want to know what's going on in our research and events and stuff like that. And so they can just email [email protected] and we have a YouTube channel. We occasionally post videos there and that's BonesLab at YouTube. And we have a Facebook group also so people who use Facebook, we post some stuff there, events, information and that's UW BonesLab. And then I have an Instagram, people can, well, I occasionally post stuff there. Although sometimes I also post my baking and family trips too. Okay, well, people can check out your baking and all the new science. We'll put the links to all that in the show notes. Thank you so much. Thanks for having me. It was really fun. There you have it, friends. I hope you enjoyed this episode. If you did and want to stay up to date with future episodes, be sure to hit that subscribe button on YouTube and follow on Apple or Spotify. Finally, thank you for showing up and the effort that you're making to take control of your health. I look forward to hanging out with you again in the next episode.