Bone Health Overview

When I started looking for information about bone density, the amount of information available about osteoporosis was a bit overwhelming.  Especially since I was interested in learning how to avoid osteoporosis, not what to do after being diagnosed with osteoporosis.  Below are a couple overviews that were helpful.

A Visual Guide to Osteoporosis - A WebMD slideshow that provides a quick introduction to bone health and osteoporosis.

Osteoporosis - In-Depth Report, in NY Times Health Guide

The NY Times overview covers everything but it's pretty dense reading.  There are references from 2007-2009 and links for assorted websites, including National Osteoporosis Foundation.

A key point made is that testing is important.  The recommendations (below) are standard.  However, getting a baseline sooner is worth considering.  Meaning for women, can be useful to have a bone density test well before menopause.  For all humans, bone loss begins at some point after age 40.  Better to know earlier which areas (hips, spine, arms, legs) are weak.  My family physician suggested that I get tested when I was over 55 but not yet 60.  We learned that while my hip bones are strong, the bone mineral density of my spine is low enough to be considered osteopenia.

Because osteoporosis can occur with few symptoms, testing is important. Bone density testing is recommended for:

• All women over age 65
• Postmenopausal women under age 65 with one or more risk factors for osteoporosis
• All men over age 70
• Men ages 50 - 70 with one or more risk factors for osteoporosis
• Any man or woman over age 50 who has suffered a fracture

EFOPS, 16 year study concludes exercise helpful for bones of older women

One of the most interesting studies to finish in the last couple years is the Erlangen Fitness and Osteoporosis Prevention Study (EFOPS), which ended in 2014 after 16 years.  The study was based in Erlangen-Nuremberg, Germany and run by Wolfgang Kemmler, Ph.D., and his colleagues at the Institute of Medical Physics, University of Erlangen.  Before EFOPS, very few studies followed subjects for more than two years.  The study design was set up to allow post-menopausal women who met the study criteria to choose whether to be in the exercise group (EG) or the control group (CG).  The goal was to have enough women at the end of 16 years to allow for valid statistical comparisons between the groups.  BMD and other assessments were made every four years (4-, 8-, 12-, and 16-year follow-up).  The key measurements were bone mineral density (BMD) for the lumbar spine (LS) and femoral neck (FN).  It was clear by the first interim report after 4 years that exercise was associated with increased BMD, while the CG BMD decreased.  The exercises evolved as the study progressed.  By 2014, there were 105 women remaining in the study (EG: n = 59 vs. CG: n = 46).  The overall conclusion based on the 16-year analysis was that older adults would benefit from doing exercises regularly that could stimulate bone growth as well as help prevent fractures due to falls.

If you are interested in learning more about EFOPS, read on.  The most complete report online is #3.

1) The Erlangen Fitness Osteoporosis Prevention Study: a controlled exercise trial in early postmenopausal women with low bone density-first-year results

INTERVENTION: Fourteen months of exercise training, with 2 joint sessions and 2 additional home training sessions. Exercise and control groups were supplemented individually with calcium and cholecalciferol up to 1500mg of calcium and 500IU of vitamin D per day.

RESULTS: Bone density increased significantly at the lumbar spine for the exercise group (1.3%, P<.001) and decreased in the control group (-1.2%, P<.01). Differences at the total hip (-0.3%, not significant vs -0.8%, P<.05) and the femoral neck (-0.8%, P<.05 vs -1.8%, P<.001) were nonsignificant. Changes in isometric maximum strength were significant for each region (grip strength, trunk flexors and extensors, hip flexors, leg adductors and abductors, arm flexors and extensors) in the exercise group (11%-39%) compared with nonrelevant changes (-1.1% to 3.9%) in the control group. Between-group differences were significant (P<.01-.001) for all strength parameters. VO2max increased significantly by 11% (P<.001) in the exercise group but decreased in the control group by 4% (P<.05) while showing significant between-group differences.

Arch Phys Med Rehabil. 2003 May; 84(5):673-82
http://www.ncbi.nlm.nih.gov/pubmed/12736880

2) Exercise and fractures in postmenopausal women. Final results of the controlled Erlangen Fitness and Osteoporosis Prevention Study (EFOPS)

ABSTRACT: The EFOPS trial clearly established the positive effect of long-term exercise on clinical low-trauma fractures in postmenopausal women at risk. Bearing in mind that the complex anti-fracture exercise protocols also affect a large variety of diseases of increased age, we strongly encourage older adults to perform multipurpose exercise programs.

RESULTS: In 2014, 105 subjects (EG: n = 59 vs. CG: n = 46) representing 1680 participant-years were included in the 16-year follow-up analysis. Risk ratio in the EG for overall low-trauma fractures was 0.51 (95 % confidence interval (95 % CI) 0.23 to 0.97, p = .046), rate ratio was 0.42 (95 % CI 0.20 to 0.86, p = .018). Based on comparable baseline values, lumbar spine (MV -1.5 %, 95 % CI -0.1 to -2.8 vs. -5.8 %, -3.3 to -7.2 %) and femoral neck (-6.5 %, -5.2 to -7.7 vs. -9.6 %, -8.2 to 11.1 %) BMD decreased in both groups; however, the reduction was more pronounced in the CG (p ≤ .001).

Osteoporos Int. 2015 Oct;26(10):2491-9. doi: 10.1007/s00198-015-3165-3. Epub 2015 May 12.
http://www.ncbi.nlm.nih.gov/pubmed/25963237

3) Long-Term Exercise and Bone Mineral Density Changes in Postmenopausal Women—Are There Periods of Reduced Effectiveness?

ABSTRACT
The exercise protocol initially focused on a high-intensity strategy that addressed bone but increasingly shifted to a more comprehensive intervention. LS-BMD differences between the EG and CG continuously increased (year 4: 2.4% (95%- Confidence Interval 1.0% to 3.8%), year 8: 3.1% (1.6% to 4.7%), year 12: 3.9% (1.9% to 5.8), year 16: 4.5% (2.5% to 6.6%). Correspondingly, rising differences for FN-BMD (0.9% (–0.2% to 2.1%) versus 1.9% (0.4% to 3.3%) versus 2.0% (0.5% to 3.8%) versus 3.0% (1.0% to 5.0%)) were observed. However, in contrast to our hypothesis, group differences within the four 4-year periods were not consistently significant (LS, p = 0.001 to 0.097; FN, p = 0.026 to 0.673); further, BMD kinetics among the groups varied between LS and FN. Of particular importance, significant differences (p ≤ 0.030) for both regions were still found in the final period. We conclude that exercise—even when adapted for subjects' decreasing bone, health, and fitness status—is consistently effective in favorably affecting BMD in (initially) early-postmenopausal osteopenic women without any leveling-off effect after 16 years of exercise.

Journal of Bone and Mineral Research, Vol. 1, No. 1, Jan 2016
http://onlinelibrary.wiley.com/doi/10.1002/jbmr.2608/full - online Sept 2015

Research on effectiveness of weight and resistance training for building bone

Research related to bone density is being done not only by physicians, but also people working in the nutrition and fitness fields.  The study populations are usually restricted to one of three groups: pre-menopausal women, post-menopausal women, and men.  Many studies support the idea that weight and resistance training (high load, low reps) can make a difference in as little as six months.  Even if there is not clear improvement, the treatment group is more likely to hold steady instead of losing bone density during the study period.  Most studies last less than two years.  Below are a few examples.

Effects or high-intensity resistance and bone mineral density and muscle strength or 40-50-year-old women
Journal of Sports Medicine and Physical Fitness, 1997, Vol. 37, Num. 4, pp. 246-251.  Authors at UNC-Chapel Hill in the Dept. of Physical Education, Radiology, and Nutrition

Systematic strength training as a model of therapeutic intervention. A controlled trial in postmenopausal women with osteopenia
Am J Phys Med Rehabil., 1996, Jan-Feb;75(1):21-8.  Authors at the Department of Sports and Performance Medicine/Internal Medicine IV, University of Vienna, Austria.

Effectiveness of resistance training or jumping-exercise to increase bone mineral density in men with low bone mass: A 12-month randomized, clinical trial
The Bone Journal, Oct 2015, Vol. 79, pp. 203-212.  Authors at Univ. of Missouri in the Dept. of Nutrition and Exercise Physiology.

Bone building for the spine using weight exercises

Strengthening the spine using weight exercises is not that difficult.  However, it's important to use the correct form as well as the correct weight.  The idea is to develop form using a lighter weight but need to work up to a heavy weight in order to encourage bone growth.  The general guideline is to work up to a weight that allows 5-8 reps.  Doing heavy weight exercises 2-3 times a week has been shown to be enough to encourage bone growth over 6-12 months.

1) Weight lifting to prevent osteoporosis, 6 min
Importance of stacking the skeleton

2) Osteoporosis Exercises for Spine Strength and Posture - Australia, 9 min

Working on the middle of the back

Building bone at any age is possible

The best time to work at building bone is before age 40 or so.  However, for those over 50 it's not too late.  Even those who have been diagnosed with osteopenia or osteoporosis can improve their bone mineral density in 1-2 years.  Just as there are many reasons for bone loss, there are also many approaches to building bone.  Nutrition, medication, supplements, exercise all can play a role.

The website Osteopenia3 is a good place to start learning about both the causes for bone loss and potential ways to increase bone density.  The objective is help someone learn enough to figure out what can help for their individual situation.

Osteopenia and Osteoporsis Treatments and Cures

The creator is a retired professor, Kate Lindemann, who learned she had a bone loss problem after breaking a wrist a while back.  She writes in clear language and provides plenty of references for more information.  Clearly Prof. Lindemann's research proved useful in helping her to build bone.  Her bone density score at age 74 was +3.5, far exceeding the normal value for a woman much younger.

Examples of studies that show weight/resistance training increases bone density

The research findings related to weight training or resistance exercises has clearly changed in the last 25 years.  By the mid-1990s, there were many studies undertaken.  In the last 10-15 years, many more studies on post-menopausal women or older men were done.  It's pretty clear that improving bone density with appropriate exercises is not only possible, the change can happen in relatively short amounts of time, meaning less than a year.  Here are a few examples.

A Huffington Post article in 2011 titled Women, Weights and Osteoporosis referenced three studies from 2000, 2003, 2007.  The author was a fitness professional wrote about the concept that weight training helps if the weight involved is relatively heavy.  Meaning more than 10 pounds, which she said was the average weight of a handbag.

The study reported in 2007 in Osteoporosis Intl. involved about 70 young women in the U.S. who did resistance training for five months, split between concentric and eccentric isokinetic exercises.  The exercises were high-intensity and slow-velocity.  The non-dominant side was the control that was compared to the dominant side.  The results showed clear improvement in bone mineral density (BMD) for hip and arm.

A similar study done in Australia was reported in 1996 in the Journal of Bone and Mineral Research that involved 56 post menopausal women who did either strength or endurance training on one side for a year.  For strength training, the women did 3 sets of 8 reps at a high load on one.  Endurance training was 3 sets of 20 reps, presumably at a lower weight than for strength.  Which side was used for strength vs. endurance was chosen at random.  The conclusion was:

"Postmenopausal bone mass can be significantly increased by a strength regimen that uses high-load low repetitions but not by an endurance regimen that uses low-load high repetitions.  We conclude that the peak load is more important than the number of loading cycles in increasing bone mass in early postmenopausal women."

A small study done in Norway reported in January 2013 in the Journal of Strength and Conditioning involved 16 post menopausal women who were diagnosed with osteoporosis.  Eight women did short but intensive squat workouts on a weight machine three times a week for 12 weeks.  They were compared to eight controls.  The idea was that if a woman could do more than 5 reps, then the weight was increased.  The goal was to warm up and then do 4 sets of 3-5 reps with 85-90 percent of the maximum weight possible for 1 rep.  Even with only one exercise and a relatively short period, BMD increased significantly in the exercise group.

Procrastinators Fitness Guide: 5 exercises to start ski conditioning

Fall colors are past peak in the high country of the NY Adirondacks.  There is snow in the high mountains of the Rockies.  Snow guns are running in Colorado, Vermont, and elsewhere.  Are you feeling ready for ski season?  There is still time to get into better shape.  But how to start?

The SkiNet Procrastinators Fitness Guide (link below) covers 5 exercises that can be done at home or in the gym.  Includes lunges, calf raises, hamstring lift.  Doing all the exercises could be a bit intense for someone who hasn't done any ski conditioning before.  In that case, take a look any way and decide on a few goals to work towards.

Procrastinator's Fitness Guide

The objective is to do some deliberate ski conditioning three times a week for 6-12 weeks.  Remember that ski conditioning is not just a matter of strength.  Improving balance and flexibility can make skiing easier and more fun.