Osteoporosis & Nutrition: What Really Builds Strong Bones? With Sandra Iuliano, Senior Research Fellow

Season 3 Episode 13 · July 2026 · 65 min

Listen to the full Spotify episode here

Did you know you can reduce hip fractures by 46% and falls by 11%  by simply adding more milk, yogurt and cheese to the daily menu. That's exactly what happened in Associate Professor Sandra Iuliano's landmark two-year trial across 60 aged care homes, at a cost of just 66 cents per person per day. It's a result that challenges how complicated we've made nutrition and bone health, and a reminder that the most powerful interventions are often the most straightforward. In this episode, I sit down with Sandra Iuliano to talk about what actually drives bone loss, which nutrients matter most, why falls are just as critical as bone density, and the everyday changes that can protect your skeleton at every age.

ABOUT SANDRA IULIANO

Associate Professor Sandra Iuliano is a Senior Research Fellow and internationally recognised expert in bone health and nutrition, based at the University of Melbourne. Her research spans the full lifespan — from children and adolescent athletes through to aged care — and her landmark nutrition trial in older adults demonstrated that simple dietary changes could reduce fractures by a third. You can find Sandra via the University of Melbourne website here.

WHAT YOU'LL LEARN IN THIS EPISODE

• Bone health starts in childhood — and peaks matter. The bone mass you accumulate during puberty is like money in the bank. The higher your peak, the more reserves you have to draw on across your lifetime. Adolescent girls skipping dairy to avoid weight gain are missing the most critical window.
• You can reduce fractures significantly through food alone. Sandra's research showed that simply increasing dairy intake to 3.5 serves per day in aged care residents reduced fractures by 33%, hip fractures by 46%, and falls by 11% — at 66 cents per person per day.
• Calcium is non-negotiable, but vitamin D is the key that unlocks it. Without enough vitamin D, you can't absorb calcium properly. Australians are often deficient, especially in winter or if they consistently cover up or use sunscreen. A supplement of 400–1,000 IU is a reasonable option if sun exposure is low.
• Falls cause most fractures — so strength and balance matter as much as bone density. In Sandra's trial, all but one fracture resulted from a fall. Practices like Tai Chi, single-leg balance exercises, and stepping up and down stairs directly reduce fracture risk.
• Impact exercise is what drives bone adaptation — and you don't need much. Walking, jogging, stepping up and down stairs — even 50 impacts in a session is enough to stimulate bone. Step UP for muscles, step DOWN for bone. Running is beneficial as long as you maintain a healthy weight and (for women) a regular menstrual cycle.
• Protein needs increase with age, and most older adults aren't meeting them. Australian guidelines recommend about 1g per kilogram of body weight per day; international guidelines now suggest 1.2–1.5g/kg. Aim for roughly 30g of protein per meal, spread across the day — your body can only metabolise about that much at once.
• Vegans face a higher fracture risk than vegetarians or omnivores. The key gaps are calcium and iron. Non-dairy milks vary widely in protein content, so label reading is essential. Combining plant protein sources and choosing fortified products helps close the gap.
• Dietary pattern matters more than any single supplement. A diet that includes fruit, vegetables, whole grains, dairy, and protein from eggs, fish, and poultry is consistently associated with lower fracture risk across cultures. Highly processed foods — even vegan ones — are linked to higher fracture risk.

FROM THE EPISODE

"If you don't fall, you don't fracture. All but one of the fractures in our trial happened from a fall — just one." — Sandra Iuliano

"Nutrition provides the material, and exercise provides the stimulus. You need both — it's like a chemical equation." — Sandra Iuliano

FREQUENTLY ASKED QUESTIONS

What is the difference between osteoporosis and osteopenia? Both refer to lower-than-average bone density, measured on a spectrum. Osteopenia sits in the middle of the distribution, and osteoporosis at the lower end. Importantly, bone density scans can be misleading — a naturally small person may register as osteoporotic simply because there's less bone for the scan to measure, not because the bone structure itself is poor. Fracture risk depends on bone density, bone structure, fall risk, and other factors combined.

How much calcium do I actually need for bone health? Before menopause, the recommendation is around 1,000mg per day, achievable with three serves of dairy. After menopause, that rises to 1,300mg — closer to four serves per day. One serve is a glass of milk, 200g of yogurt, or roughly 40g (two slices) of cheese. Spreading those serves across the day is more effective than having them all at once.

Should I take calcium or vitamin D supplements for my bones? Food first, always — dairy foods provide calcium along with protein and other nutrients a tablet doesn't deliver. Vitamin D supplements (400–1,000 IU/day) are worth considering if you have limited sun exposure, cover up outdoors, or live in a cooler climate with short winter days. Mega-dosing fat-soluble vitamins like D can cause toxicity, so stick to recommended doses unless directed otherwise by a doctor.

Does running help or hurt bone density? Running is beneficial for bones because it's a weight-bearing, impact activity — and more impact means more bone stimulus. The risk comes when runners become too lean and lose their menstrual cycle. Loss of oestrogen is effectively putting a young woman into early menopause, which accelerates bone loss. Casual runners who maintain a healthy weight and regular cycle are doing their bones a favour.

What exercises are best for preventing falls and fractures? Strength training and balance work are the two pillars. Tai Chi has strong evidence behind it for improving balance and reducing falls. In everyday life, stepping up and down stairs counts — step up for muscle, step down for bone. You don't need a marathon's worth of impact; around 50 impacts in a session is enough to stimulate bone adaptation.

Can I still improve my bone health after menopause? Yes — it is never too late. While menopause does cause accelerated bone loss (due to the drop in oestrogen), you can slow that loss significantly with resistance exercise, adequate calcium and protein, vitamin D, limiting alcohol, and not smoking. The goal isn't to reverse what's happened; it's to lose bone as slowly as possible for as long as possible.

Is dairy necessary for bone health, or can I get enough calcium from plant foods? Dairy is the most efficient and well-researched source of calcium, but it's not the only one. Fortified plant milks, firm tofu, and green leafy vegetables all contribute. The challenge for vegans is getting enough calcium and protein consistently — non-dairy milks vary considerably in protein content, and some have very little. Reading labels and combining varied plant protein sources is essential. Data does show vegans have a higher fracture risk than vegetarians and omnivores.

How does alcohol affect bone density? Alcohol is a problem in excess for several reasons: it displaces food and nutrients from the diet, dehydrates the body, and increases urinary calcium loss. The Australian guideline of no more than two standard drinks per day — with two alcohol-free days per week — is relevant here. It's also worth noting that a standard drink is smaller than most people assume: a can of beer is closer to 1.6 standard drinks.

FULL EPISODE TRANSCRIPT

Lightly edited for readability

Louise: Hi. Today I'm joined by Associate Professor Sandra Iuliano, Senior Research Fellow and expert in bone health and nutrition. In this episode we explore the role of nutrition in osteoporosis and osteopenia — from calcium and vitamin D to protein, caffeine, alcohol and more — as well as the critical role of falls and fracture prevention. So if you're looking for clear, evidence-based insights into what really supports bone health, this conversation is for you. Sandra, thank you so much for making yourself available today. Can you give us a clear picture of what's actually happening in the body with osteoporosis and osteopenia?

Sandra: If you imagine, we've got a distribution of people. You'll always have some people that have a smaller skeleton and they'll be considered osteoporotic. You've got the majority of people in the middle that are normal and osteopenic, and then you've got a group at the top who just have really good, strong bones. So you've always got that distribution. When we do a bone density test, if a person's small, it's going to say that they're osteoporotic, because the beam is going through a smaller bone. Versus a big person has a bigger bone — the beam takes longer to go through, so they're automatically going to be seen as having okay bone. But it's not just the density; it's actually the structure of the bone as well. So we are starting to look at other ways of predicting people who may fracture, because you can have a small person who — because they're little — are considered osteopenic or osteoporotic, but they're not actually osteoporotic. Where you can have a large person that's got quite poor bone structure, and yes, they are osteoporotic. So it's the measurement itself that can be a little bit misleading.

Louise: It's really tricky. I'm quite a small person and I'm just terrified about my bones. I had a DEXA scan a couple of years ago — they're okay, not osteopenia or osteoporosis or anything like that — but my sister's got osteopenia, she's only five years older than me, and my mum's got osteoporosis. And being so small and also being a dancer... I was quite athletic as a young person, but then there was all that dieting that goes on when you're a dancer as well. You just think, how are my bones going?

Sandra: The other thing that's really important to know is that you inherit your bones, just like everything. There's family history of cardiovascular disease and high cholesterol — we inherit our bones. They've done studies looking at mothers and daughters, and if your mum has low bone density at the spine, the daughters are likely to be low at the spine. But it's very site-specific. So you can have normal at the hip and low at the spine, or the other way around, and it tracks through the family. But what you said about exercise is a major part. Even though you're small and on the lower end, that's not to say "just give up now, your bones are useless." We make the best of what we've got. Exercise and nutrition — that lifestyle contribution is making the best of what you have. You'll never be at the top of the tree with bone density because you're not six foot tall. But it's about making the best of what you've got.

Louise: I saw something on Facebook the other day — a woman said she did bodybuilding, she ate a lot of protein and lifted heavy weights, but she actually had low bone density. Is that because she didn't eat enough? Or could she have not had enough calcium? Can that happen with too much exercise?

Sandra: It's hard to say without knowing what she was before she started bodybuilding. Was she already low? The good thing with weight bearing — the exercises she's doing with weights — is that loading bones actually helps them stay strong, to a degree. Because if you load a bone, the bone has to adapt to that loading. So she could have been low beforehand. Lots of things can happen when people body build. If they're competing and very low in body fat, and she's menstruating, you can lose your menstrual cycle because you're too lean. And as soon as you lose your menstrual cycle because you're lean, the oestrogen is gone and you start to lose bone.

Louise: Because the whole process — why do we take calcium out of our bones? If we're not consuming enough calcium, what do we need it for?

Sandra: We need a really stable level of calcium in the blood — it's very tightly regulated. If it's too high there are issues. If it's too low, there are issues. So if I'm not eating it from food, our bones are basically a storage cabinet. If I'm not getting enough from food, it triggers hormones to go, "No, we need to keep that level" — and it takes it from the bone. We're in a constant state of flux. We take it out of the bone if our calcium levels start to drop in the blood. If we're eating it, we'll put some back in. If it's going to get too high, we urinate it out. The body is regulating it constantly. And so it's like a storage cabinet — when women have babies, we can use the calcium from bone to help create the baby's skeleton. When we're breastfeeding, it's a reserve. It's basically a calcium reservoir that we can put in and take out. But if we're taking out and taking out and taking out and not putting enough back in — if our diet's not good — then you'll start to find your bone density goes down.

Louise: Should we be having more calcium when we're pregnant?

Sandra: Your needs do go up. If you look at the requirements, as a child it's pretty stable. We hit puberty and it goes up to 1,300 milligrams, then comes back down when we're an adult, because we're in a sort of steady state — a bit in, a bit out. It goes up during pregnancy, and then after menopause it goes up again and stays elevated. I haven't studied pregnancy specifically, but we've followed women before and after pregnancy and through lactation, and there is data showing bone density does go down during that period — and then we recover it to a degree. I always talk about bone like a piece of Swiss cheese with holes in it. We dig holes and we refill. Menopause is one where we dig more holes. If you've got a piece of Swiss cheese with three holes and you scan it, that's the density. If you take that same piece and make 30 holes, there's less bone there — density's lower. And breastfeeding, yes — the bone is the reserve of calcium for the milk, so you want to make sure you're getting enough so it's not just being taken from your bones.

Louise: How early should we be thinking about bone health? Is it only a post-menopause issue?

Sandra: Way back. As a child, we accrue bone — about 100 grams a year — it just goes up. Then we hit puberty and we accrue a lot of bone during that huge growth spurt. That's a time when girls may think, "Oh, I'm getting fat, I won't have dairy because it's fattening." So the very time they need it most, they're not consuming enough. If you imagine your peak bone mass like money in the bank — if you start off with more, you have more to draw on. Exercise is really important as well because we can actually change the shape of the bone with exercise, especially during growth. Then when you get to adulthood, we need to maintain what we've got. If we have poor diet and no exercise, we're not going to maintain it as well. And then menopause is that huge drop-off. But again, it's not a death sentence. We ask, what do we do to make the bone as strong as it can be, and keep our muscles strong so we stay functional?

Louise: What about running? Does it actually help to build bone because of the impact, or is it not as good because you're using so much energy?

Sandra: It's all about impact. If I walk, there's a certain amount. If I walk fast, there's a bit more. If I jog, there's a bit more still. If I sprint, even more. So it is good. The issue people sometimes raise — that runners have less bone density — comes back to the point I made before. If they're too lean and they lose their menstrual cycle, it's the loss of oestrogen that's the problem. That's like putting that young athlete into menopause. If you're a casual runner, as long as you don't get too lean and too light, it's actually good because it's impact. And often I say, if you go for a walk and you pass some steps, step up, step down. If you step down, it's more impact. And always: go up for the muscle, down for the bone.

Louise: And muscles pulling on the bone — does that help increase bone density too?

Sandra: To a degree, yes. But it's the actual impact that's the primary driver. There's been some great work done with tennis players. They used to play very one-sided, so one arm got all the impact from hitting the ball. Rafael Nadal — his playing arm is huge, and the other is small. A colleague of mine did her PhD looking at that. We compared the bones of the playing arm and the non-playing arm. Controlling for genetics, diet, everything — the playing arm had either a wider bone or a thicker bone. The bone itself adjusted. If you do it through puberty, while you're still growing, you have the capacity to change the shape of the bone, the thickness, where the bone is, the distribution. But once you've achieved your peak bone mass and consolidated — that's it. I can't change it. Which is why childhood and puberty are so massively important.

Louise: If you could simplify bone health nutrition into a few key pillars, what would they be?

Sandra: Obviously calcium is important. The work I did with older adults — all we did was provide milk, yogurt, and cheese, which are high in protein and calcium — and we reduced fractures. The thing with food is there are lots of different nutrients we still don't fully understand. Having a tablet, you're not getting all the other things in the food. If I take a calcium tablet, I'm not getting the protein, I'm not getting all the other vitamins and minerals. So calcium is important — before menopause, it's about three serves of dairy per day: a glass of milk, 40 grams of cheese, and a 200g tub of yogurt. Vitamin D is important because if you don't have vitamin D, you can't absorb the calcium. Even though we're in the land of plenty in terms of sunshine, people put sunblock on straight away, or don't go outdoors. So if you're not getting enough sunlight, a vitamin D supplement is the other option.

When we look at the diet overall — and they've done a lot of work on this across different cultures, in Asia, Europe, the Americas, here — the diets associated with lower fracture risk all contain fruit and vegetables, usually whole grains, fermented milk and dairy, and protein from eggs, poultry, and fish. And on the other side, the diets associated with higher fracture risk are high in processed foods, high sugar, and high fat. So it comes back to eating from the core food groups — grains, fruit, vegetables, dairy, and protein from fish, poultry, eggs, and legumes.

Louise: And red meat?

Sandra: We don't know enough, because often in studies they lump red meat and processed meat together. Processed meat is very different — it's high in fat, high in salt. No one's completely separated the two, so we don't know specifically about red meat. But the food group as a whole — which includes legumes, eggs, fish, and chicken — is associated with lower fracture risk.

Louise: What if you're vegan and don't eat meat or dairy? Can you get adequate calcium and protein?

Sandra: Vegans need to be careful. They need to combine their plant sources to get all the protein they need. If you're young and active, you can eat enough food to get the variety. It's older people who may not be able to eat enough volume to cover everything. Most non-dairy beverages — oat milk, rice milk — have calcium added, but they're not all the same. Some have quite low protein. So if you're consuming one of those milks thinking you're also getting lots of protein, you may not be. Read your label.

Louise: What about skim milk — does it still have enough calcium and protein?

Sandra: All that happens with skim milk is you take the fat off the top. The protein's still there. In actual fact, the nutrient content is slightly higher because you've taken out the fat. The only thing you lose when you remove the fat are the fat-soluble vitamins — but dairy isn't the main source of those anyway, so it's not critical. So with skim milk, you're getting lots of protein, lots of calcium, and all the other nutrients — just without the fat.

Louise: Are we overly focused on calcium? Is that still justified?

Sandra: It's still the primary mineral in bone. There's no substitution — we can't replace it with another mineral. Our blood levels need to stay very stable. Our skeleton evolved to be a calcium reservoir. So yes, the focus on calcium is still warranted. Vitamin D is critical to absorb it. If you're getting a lot of calcium and minimal vitamin D, there is some passive absorption that occurs, so it's not catastrophic — but ideally you have both.

Louise: And if you don't have enough vitamin D?

Sandra: We're starting to see rickets in children again in Australia. A mother deficient in vitamin D has a child who's deficient at birth. When they stand up, you see their legs bow — the bones are soft because there's no mineral in them. Joseph Pilates, the founder of Pilates, had rickets. What he did was go outside and exercise in his undies in the sunshine. He got his vitamin D, he was into exercise — and that's not a bad approach. As a child, you can see his legs were a little bowed as an adult because if the deficiency continues through puberty, the bow can become permanent.

Louise: What about sun through a window?

Sandra: The window blocks the UVB — the rays you need to produce vitamin D. It might be warm, but you're not producing vitamin D. It's a really fine line, which is why it's hard to give a universal recommendation. In Northern Queensland in summer, two minutes is all you need. In Melbourne in winter, it's longer — but not as long as you might think. They suggest about 15% of your body surface exposed — roll your sleeves up, expose your lower legs — and go out around the middle of the day. Just having lunch outside can help. Your face: put sunblock on. But expose your arms and legs for a short period before you do.

Sandra: We also bank it a little. In summer, our vitamin D levels go up and we draw on stored vitamin D in our fat tissue over winter. So there is a natural ebb and flow. But you can't have ten minutes in the sun and then go three years without sun. I did work with Antarctic expeditioners — from about April through October, they can produce no vitamin D at all, and they're covered and it's dark. We looked at what happened to their bones. They did lose bone. Within four months, they were deficient.

Louise: What role does overall dietary pattern play versus single nutrients?

Sandra: Our bone turns over all the time, and there are lots of nutrients involved in the metabolic processes — magnesium, zinc, vitamin K, and others. Calcium is the main one, but those others are important too. Vitamin K, for example, is in green leafy vegetables. The pattern of eating means I'm getting everything I need across all those nutrients. With vitamin K specifically — the data shows supplementation didn't reduce fractures. But eating about a cup of spinach worth of green leafy veg gives you what you need. And our gut flora also produces some vitamin K itself. If you're eating poorly, lots of alcohol, and antibiotics are killing off your gut flora — then maybe a supplement is warranted. But if you're eating well, including green leafy vegetables, you probably don't need the supplement.

Louise: Can we over-supplement? Is there a risk of too much calcium or vitamin D?

Sandra: With vitamin D, when we produce it in our skin ourselves, we have a natural shutoff valve. Once we've produced enough, we just stop. With supplements, it's usually people megadosing who end up with levels that are too high and potentially toxic. Your water-soluble vitamins — B group, vitamin C — we urinate those out. But fat-soluble vitamins you can accumulate. It's usually either a metabolic issue or megadosing that causes problems. Your average multivitamin won't do it. But people sometimes take several different supplements on top of each other. Generally, if taken as prescribed, they're okay. But if you're getting everything from your diet, supplements aren't really needed.

Louise: How important is protein for bone health, especially in aging women?

Sandra: Our protein needs go up as we get older because our body doesn't respond as well. We need to maintain muscle — that's where most of our metabolism is happening. Our strength means we can stay functional: go shopping, carry bags, play with grandkids, all of those things. When we're younger, we need about 0.8 grams per kilogram of body weight. When we get older, the Australian recommendation is about 1 gram per kilogram. Internationally, they're now saying even more — 1.2 to 1.5. So if you're a 60-kilogram person, that's about 72–90 grams a day.

Louise: What if you're a larger person — do you still need the same amount?

Sandra: There are a lot of diets around — high protein, low protein, high carb, low carb — and I think everyone just gets confused. The main thing is that if you're eating high fat, high simple carbohydrate diets, you're taking in a lot of energy that's nutrient-poor. There's a theory that we eat to meet our protein needs — so if we're eating high fat, high carb and not enough protein, we just keep eating until we hit that protein threshold. That's one theory about overeating. About 30% of our energy comes from fat and about 20% from protein — so we've got it a little out of whack with a lot of modern diets.

Louise: Does salt impact calcium loss and bone density?

Sandra: In excess, yes — because when you have a lot of salt, part of the metabolic process in the kidney results in calcium being excreted along with it. We already have high salt intake because of processed foods. Bread is probably one of the biggest sources of salt. Canned beans, soups — all have salt added. We don't really need to be salting things at home because it's already heavily salted. Salt is an acquired taste, and you can wean yourself off it. I've found that when I've cut back on salt, I notice if foods are too salty.

Louise: Should we be limiting coffee for bones?

Sandra: It would have to be quite excessive. If you're having a cup or two a day, I don't think it's going to have much impact. It's when you're up into ten cups of coffee and Diet Pepsi and Diet Coke and so on that it gets excessive. Interestingly, green tea has antioxidants — there are other good things in it. And if you have a latte, you're getting your coffee and your calcium and your protein all together.

Louise: What about Ozempic? Can people who lose weight very quickly on it become deficient in calcium?

Sandra: There would be some concern around fat-soluble vitamins in particular. Ideally, it's done under medical supervision — they should be monitoring supplementation for exactly that reason. If people are self-medicating, they need to be careful. It's life-changing and can be the difference between life and death for some people, and it's very effective. But it hasn't been around long enough to fully understand all the nutritional effects. Under proper supervision — ideally with an obesity specialist or endocrinologist, and possibly a dietitian as well — they'll be looking after nutrient intake. You can't just take the drug and keep eating fast food. You'll lose weight, but you're not getting the nutrients.

Louise: What does a bone-friendly day of eating actually look like?

Sandra: For the protein, it's about 30 grams per meal. And for women in menopause and beyond, four serves of dairy. So for example, you get up in the morning and have your porridge with milk. Bulk it up — add some muesli, some other grains, have fun with it. Milk in the porridge is your first serve. At lunch, if you've got a sandwich or salad, make sure there's cheese in it — there's your second. Mid-afternoon, your cappuccino or hot chocolate — there's your third. And after dinner, some yogurt and fruit. That's four serves of dairy spread across the day and it wasn't too hard. I've also heard it said that 75% of soups, salads, and desserts in aged care had no protein or next to no protein. But you can make a panna cotta, a cheesecake with yogurt and condensed milk — that's a whole serve of dairy in one piece. Lots of ways to do it.

Louise: We've made eating seem so complicated.

Sandra: There are too many diets, too many fads, and too much information. And influencers — we know that on TikTok, about 4% of nutrition information is actually accurate. Just because someone is branded an influencer, they can change people's thinking. But the science keeps showing us: go back to your food groups, eat a variety, and the rest largely takes care of itself.

Louise: Are there common dietary mistakes you see women making when trying to protect their bones?

Sandra: With supplements — if they're not in excess, they might be expensive but they're not really harmful. Vitamin D is probably the main one worth considering if you're not going out in the sun. If you've got fair skin that burns quickly, sun exposure is almost not an option, so a supplement makes sense. Just the basic dose — usually 400 to 1,000 IU — is fine. It's when it gets up to and above 4,000 IU that you want medical guidance.

Louise: If we go to Queensland for a week of sun, does that last us through a Melbourne winter?

Sandra: We do bank it a little. In summer, our levels go up and we draw on stored vitamin D over winter. But you can't have ten minutes of sun and then go three years without. There is a natural ebb and flow — we all go down a little in winter because we're covered up more. But a week in Queensland, come back, and then we're into spring in a couple of months and getting incidental sun again — it can work.

Louise: What about astronauts? Do they lose bone density from lack of gravity — and vitamin D too?

Sandra: You're absolutely right. When they go to outer space, they can lose up to 16% of their bone density in weight-bearing areas. They do about two hours of exercise a day to try and keep their bones — and there's lots of research on it. They do running and weights, and it's almost like a reverse bungee cord, because they've got to be impacting on the treadmill and not floating away. And going to Mars — I don't know if our skeleton would last that long without doing something to maintain it, because of the lack of gravity. Not just bones either — metabolically, everything gets pushed around because of the lack of gravity.

Louise: You were recognised with an award in 2025. Congratulations. Can you share a little about the work that led to that?

Sandra: I was very honoured. The work I did was in aged care — with our oldest adults. What we found was that their protein intake is low, their calcium intake is low, and their fracture risk is really high. So over a two-year trial across 60 aged care homes, we provided more milk, yogurt, and cheese to 30 of the homes — no rules, whatever combination they wanted. The other 30 had their normal diets. About 7,000 residents in total. They comfortably had three and a half serves of dairy a day, and we reduced fractures by 33%, hip fractures by 46%, and falls by 11%. When we did bone density analysis on some of them, they were maintained — no detectable loss. The control group, those that didn't have the extra dairy, were losing about 2% bone density per year, which is about normal. And it cost 66 cents per person per day.

Louise: Did they know they were in the study?

Sandra: Yes and no. If you're having porridge every morning and I put skim milk powder in it and you can't taste it, you really don't know. Or all of a sudden your salad has cheese in it, or there's a cheese sauce on your vegetables, or we make a tuna bake. We did it across the whole menu. And we'd make a cheesecake with yogurt and condensed milk — a whole serve of dairy in one piece. We asked them what they wanted. They wanted milkshakes. We gave them milkshakes. For people in their eighties and nineties, food memories are really important. Having cheese, having a milkshake — it brings back beautiful memories for them.

Louise: We often focus on bone density, but how important are falls in the fracture equation?

Sandra: In our trial, all but one of the fractures happened from a fall — just one exception. So if you don't fall, you don't fracture. It can happen — very old people sometimes fracture just getting up out of a chair — but it's not common. Most fractures come from a fall. The other exception is vertebral fractures, the fractures of the spine. Some people develop that kyphosis — the widow's hump, as they used to call it — where the vertebrae slowly compress. If there's more than a 20% loss of height in a vertebra, it's considered a crush fracture. Continuous postural pressure on the front of the vertebrae over time contributes. These are very painful, and people often don't realise that back pain in older age can be vertebral crush fractures.

Louise: What increases someone's risk of hip fracture beyond just bone density?

Sandra: The biggest factor is age. The older you are, the greater the incidence. Interestingly, taller people fracture more — because they're coming from a greater height when they fall. And people who carry more body fat tend to fracture less, because they're better padded on impact. So there are these catch-22 situations. Bone density matters, but so does the angle of the impact. If you fall sideways and land on your shoulder, it's likely to break because that's not how you'd normally move.

Louise: From your perspective, what are the most effective strategies to reduce falls?

Sandra: Balance is a key one. We don't test our balance much in daily life — just standing there on two legs. Going up on one leg and doing things like Tai Chi, which has been demonstrated to help with mobility and balance. Then strength — getting into the gym and doing strength work to keep the muscles strong and functioning. It's about function. It's not about running a marathon. It's about being able to do activities of daily life. Being able to step over something in your way without losing your balance. Some people, if something's in the way and they need to step over it, they lose their balance and fall. So it's about how to be functional.

Louise: Hip fractures can be life-changing. Can you talk about the real impact they have?

Sandra: They're disastrous. Hip fractures occur later in life, and we know that with older adults, maybe half can pass away within six months. That's disastrous. And for those who survive, if they don't recover well, they lose their mobility, they lose their independence. A lot of them end up in aged care. Surgeries are a bit quicker and better now, but it can still be completely life-changing.

Louise: What do most people misunderstand about fracture risk?

Sandra: It's a combination of everything — vitamin D level, dietary intake, exercise, bone density, family history. You minimise risk across all of those. And anyone, if the impact is greater than what they're accustomed to, can fracture — regardless of bone density. If I fell down the stairs, I'd probably break a bone, even though I'm active, because the impact is just that much higher than what I'm used to. And the angle of impact matters too. If I fell sideways and landed on my shoulder — that's not how you'd normally move, so it's likely to break.

Louise: How do nutrition and exercise work together for bone health?

Sandra: Nutrition provides the material, and exercise provides the stimulus. My PhD was in children, and we did calcium and exercise — high impact exercise, step aerobics and skipping. What we found was that the effect of calcium showed in the arms, and the effect of the exercise showed in the lower leg. But we saw a combined effect at the hip — greater than either alone. So it's like a chemical equation. You've got the material and the stimulus and together they produce something better than either on its own.

Louise: What would you say to women who exercise but don't think about their nutrition?

Sandra: Both are really important. One is the material and one is the stimulus. Make sure you're having 1,300 milligrams of calcium per day if you're postmenopausal. That's the recommended intake.

Louise: Myth-busting: "I drink milk so my bones are fine."

Sandra: To a degree — true. Because the calcium's in the milk. But it depends how much milk. If you drink two cups of tea with a dash of milk, there's not enough milk in it. It's four serves of dairy a day. If you're drinking two glasses of milk a day plus some cheese and some yogurt, you're doing it.

Louise: What about "thin women are at higher risk"?

Sandra: It kind of is true, because they've got smaller bones. But it's not a death sentence. And remember — taller people fracture more too. It's proportional to your height in its own way.

Louise: "It's too late to improve bone health after menopause" — myth or true?

Sandra: Never too late. You can either lose bone really quickly by smoking, drinking, not exercising, and eating badly — or you can lose it really slowly by exercising, eating well, and not smoking. Imagine you start off with a high peak and you're losing it. I can lose it quickly and by age 70 I'm osteoporotic. Or I can lose it really slowly and not reach that critical risk point until I'm 110. The idea is to lose it as slowly as you possibly can.

Louise: What's emerging in bone health research that really excites you?

Sandra: Drug-wise, they're looking at anabolic drugs that can actually build bone back up. Previously, people would be given regular medication, still fracture, fail on it, and then be given the anabolic drug — but by that stage it was nearly too late. Now they're starting to use it earlier. But you generally have to have had a fragility fracture, or be at very high risk, to be eligible for those medications. There are a lot of changes happening with drug treatments.

Louise: Are there outdated recommendations we're still holding onto?

Sandra: One interesting one is that they're updating dietary guidelines at the moment, and a lot of overseas guidelines have moved to plant-based eating. Canada, for example, has a plate model — half the plate is fruit and vegetables, a quarter grains, and a quarter protein foods. But it doesn't tell you how much you need, or which protein food. If I eat red meat all day and no dairy, my iron is fine but my calcium is low. Our current Australian guidelines keep the food groups separate, and I hope we keep it like that — especially for older adults. Because the whole reason we have dietary guidelines is that if you follow them, you get all the nutrients you need. And the evidence on dairy changes too. Full-fat dairy was demonised — people thought it would raise cholesterol — and now we're realising it doesn't. Things come in waves as we learn more.

Louise: If you could give one piece of advice to women in midlife about protecting their bones?

Sandra: Weight-bearing exercise. Stay active. Make sure your diet is good — limited alcohol, and if you smoke, try to stop. And make sure you're getting enough calcium. If you're going to be vegan, read your labels — make sure there's calcium in what you're buying.

Louise: And what's one small change that could make a big difference over time?

Sandra: For someone who doesn't exercise at all, getting up and moving is a great start. Even just a walk. And as I mentioned — when you pass some steps, step up and step down. With bone, the beauty is it doesn't take a lot of impact. You don't need to run a marathon. Maybe 50 impacts in a session is enough. Do your walk, do 10 steps up and down, go to the next set of steps, do 10 more. That's probably enough for your bones. And stronger muscles mean you're less likely to fall and less likely to break a bone if you do.

Louise: Thank you so much, Sandra. If people want to get in contact with you, what's the best way to find you?

Sandra: They can go to the University of Melbourne website and look me up there.

LINKS & RESOURCES

• University of Melbourne — Sandra Iuliano's profile
• Sandra's study: Provision of High Protein Foods Slows the Age-Related Decline in Nutritional Status in Aged Care Residents: A Cluster-Randomised Controlled Trial
• DEXA scan (Dual-energy X-ray absorptiometry): https://www.radiologyinfo.org/en/info/dexa
• Healthy Bones Australia: https://healthybonesaustralia.org.au/
• Vitamin D and sun exposure guidance — Cancer Council Australia: https://www.cancer.org.au/cancer-information/causes-and-prevention/sun-safety/vitamin-d
• Taube Pilates: https://www.taubepilates.com/

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