Osteoporosis

Exercise and Osteoporosis

National Institutes of Health - www.nih.gov and University of Arizona
BEST (Bone Estrogen Strength Training) Study
1. The BEST study was completed on 266 healthy, non-smoking, postmenopausal women.
  1. Women were followed for one year. Bone density was measured at the hip, spine, arm and total body using dual energy x-ray absorptiometry (DXA)
  2. Results from the study showed that weight bearing and resistance exercises over a one-year period, combined with calcium supplementation, significantly improved bone mineral density at skeletal sites at risk for osteoporotic fractures in postmenopausal women.
  3. The study results were reported in the peer-reviewed Osteoporosis International journal, entitled, "Effects of exercise on bone mineral density in calcium-replete postmenopausal women with and without hormone replacement therapy", Volume 14, Number 8 (August, 2003), pp. 637–643, DOI 10.1007/s00198-003-1436-x. available online at http://www.springer.com/medicine/orthopedics/journal/198.
  4. Osteoporosis International is a joint publication of the International Osteoporosis Foundation and the National Osteoporosis Foundation.
2. BEST Study Summary - http://cals.arizona.edu/cpan/best.phtml
  1. U of A BEST Team - www.dswfitness.com/products/index.cfm?action=detail&productID=432 - has links to authors.
  2. Videos of BEST Exercises - www.citracal.com/best
3. Bone Builders - http://ag.arizona.edu/maricopa/fcs/bb - osteoporosis prevention education program
  1. Benefits of Exercise - http://ag.arizona.edu/maricopa/fcs/bb/exercise.html
Centers for Disease Control and Prevention - www.cdc.gov and Tufts University
GrowingStronger - www.cdc.gov/physicalactivity/downloads/growing_stronger.pdf
1. The Growing Stronger program is "a safe, simple, and highly effective exercise program based on the principles of strength training. Studies at laboratories around the world have shown that strength training benefits women and men of all ages and all levels of fitness. According to Physical Activity and Health: A Report of the Surgeon General (1996), experts agree that aerobic activities should be supplemented with strength-developing exercises at least twice per week."
2. To access a copy of the Growing Stronger program, click the above link or on the CDC homepage, click "Healthy Living", then "Physical Activity and Exercise", and under Related Links, "Strength Training for Older Adults".
3. The Growing Stronger program was developed by researchers at Tufts University, and the Centers for Disease Control and Prevention.
4. The program has three parts, with the last two parts using dumbbells and ankle weights.
5. For most exercises, you slowly contract your muscles as you count to 2, pause, then slowly relax muscles as you count to 4. Repeat 10 times for one set. Rest 1 minute, then do a second set of 10. Increase weights to challenge your bones.
6. Exercise 8 (Side Hip Raise) states on page 52 that this exercise "strengthens your hipbones, which are more vulnerable to fracture as you age."
American College of Sports Medicine - www.acsm.org
Position Stand on "Physical Activity and Bone Health", published November 2004,
http://journals.lww.com/acsm-msse/Fulltext/2004/11000/Physical_Activity_and_Bone_Health.24.aspx
To read the position stand, click the above link.
1. The following exercise prescription is recommended to help preserve bone health during adulthood:
  1. Mode: weight-bearing endurance activities (tennis; stair climbing; jogging, at least intermittently during walking), activities that involve jumping (volleyball, basketball), and resistance exercise (weight lifting)
  2. Intensity: moderate to high, in terms of bone-loading forces
  3. Frequency: weight-bearing endurance activities 3-5 times per week; resistance exercise 2-3 times per week
  4. Duration: 30-60 min·per day of a combination of weight-bearing endurance activities, activities that involve jumping, and resistance exercise that targets all major muscle groups.
2. Animal Studies
  1. A few loading cycles (e.g., 36 per day) of relatively high magnitude were necessary to optimize the bone formation response; increasing the number of loading cycles by 10-fold had no additional effect.
  2. Applying a given number of loading cycles in multiple daily sessions is more osteogenic than applying the same number of cycles in a single daily session.
  3. It has been estimated that complete restoration of sensitivity to loading requires a recovery time of 8 hours in rats.
3. Human Studies - in evaluating the osteogenic effects of exercise training programs, the following principles should be noted:
  1. Specificity: Only skeletal sites exposed to a change in daily loading forces undergo adaptation.
  2. Overload: An adaptive response occurs only when the loading stimulus exceeds usual loading conditions; continued adaptation requires a progressively increasing overload.
  3. Reversibility: The benefits of exercise on bone may not persist if the exercise is markedly reduced.
Rusk Institute of Rehabilitation Medicine - rusk.med.nyu.edu
1. Rusk has program for people with osteoporosis to improve posture.
2. Contact: Laurie Kilmartin, DPT, or Ting-Ting Kuo, DPT, phone: 212-263-5601.
American Council on Exercise - www.acefitness.org
1. www.youtube.com/acefitness#play/uploads/7/XymEXUVfaeg - Robyn Stuhr, Executive Vice President
  1. At 0:55 - exercise is site specific when it comes to bone adaptation. Muscle pulls on bony attachments and stimulates the bones to grow in those locations.
  2. At 1:50 - jumping exercises - side-to-side one footed hop, two footed jumps, two footed diagonal jumps, jump off a box.
Memorial Sloan-Kettering - www.mskcc.org/integrativemedicine - Integrative Medicine
1. Strong Bones class - www.mskcc.org/mskcc/html/1988.cfm - taught by Donna Wilson, attended 2009Jul30
Exercises for Osteoporosis, book by Dianne Daniels, published by Hatherleigh Press, Long Island City, NY 11101, ISBN 978-1-57826-273-1, www.hatherleighpress.com.
My Exercise Program - modified from above.

Diet and Osteoporosis

Calcium Fact Sheet - http://ods.od.nih.gov/factsheets/calcium.asp
Recommended Adequate Intake (AI) by the IOM for Calcium - age 51+ - 1200 mg/day
Sources of calcium

Food	Calcium (mg)	% DV*
Yogurt, plain, low fat, 8 oz.	415	42%
Sardines, canned in oil, with bones, 3 oz.	324	32%
Cheddar cheese, 1 ½ oz shredded	306	31%
Milk, non-fat, 8 fl oz.	302	30%
Mozzarella, part skim 1 ½ oz.	275	28%
Salmon, pink, canned, solids with bone, 3 oz.	181	18%
Spinach, cooked, ½ cup	120	12%
Kale, cooked, 1 cup	94	9%
Soy beverage, calcium fortified, 8 fl oz.	80-500	8-50%
Broccoli, raw, ½ cup	21	2%

The percentage of calcium absorbed depends on the total amount of elemental calcium consumed at one time; as the amount increases, the percentage absorption decreases. Absorption is highest in doses ≤500 mg. So, one who takes 1,000 mg/day of calcium from supplements might split the dose and take 500 mg at two separate times during the day.
Some individuals who take calcium supplements might experience gas, bloating, or constipation. Such symptoms can often be resolved by spreading out the calcium dose throughout the day, taking the supplement with meals, or changing the brand of supplement used.
From www.nof.org/prevention/calcium2.htm: substances that interfere with calcium absorption are oxalate, phytate sodium, protein, caffeine.
1. Foods with high amounts of oxalate and phytate reduce the absorption of calcium contained in those foods. Spinach, rhubarb and beet greens are examples of foods that are high in oxalate. While these foods can be an important part of a healthy diet, they are not good sources of calcium.
2. Legumes, such as pinto beans, navy beans and peas, are high in phytate.
3. 100% wheat bran is a food that provides fiber but is also high in phytate. It is the only food that appears to reduce the absorption of calcium in other foods eaten at the same time (for example, eating wheat bran cereal with milk). If you are taking calcium supplements, you may want to take them two or more hours before or after eating any foods with 100% wheat bran.
A diet that is too high in animal protein, sodium, and caffeine can decrease calcium absorption.
If you consume any foods that interfere with calcium absorption, you may want to take your calcium supplements at a different time of day.

Vitamin D Fact Sheet - dietary-supplements.info.nih.gov/factsheets/vitamind.asp
Recommended Dietary Allowances (RDAs) for vitamin D (as of 2011Jan14):
Age 51-70 - 15 mcg (microgram) or equivalently 600 IU (International Units)
Age 71+ - 20 mcg or 800 IU

There is considerable discussion of the serum concentrations of 25(OH)D associated with deficiency (e.g., rickets), adequacy for bone health, and optimal overall health.
Serum 25-Hydroxyvitamin D [25(OH)D] Concentrations and Health

ng/mL**	nmol/L**	Health status
<11	<27.5	Associated with vitamin D deficiency and rickets in infants and young children.
<10-15	<25-37.5	Generally considered inadequate for bone and overall health in healthy individuals.
≥30	≥75	Proposed by some as desirable for overall health and disease prevention, although a recent government-sponsored expert panel concluded that insufficient data are available to support these higher levels.
Consistently >200	Consistently >500	Considered potentially toxic, leading to hypercalcemia and hyperphosphatemia, although human data are limited. In an animal model, concentrations ≤400 ng/mL (≤1,000 nmol/L) demonstrated no toxicity.

Reported in nanograms per milliliter (ng/mL) and nanomoles per liter (nmol/L). 1 ng/mL = 2.5 nmol/L.

Sources of Vitamin D

	IUs per serving*	Percent DV**
Cod liver oil, 1 tablespoon	1,360	340
Salmon, cooked, 3.5 ounces	360	90
Tuna fish, canned in oil, 3 ounces	200	50
Sardines, canned in oil, drained, 1.75 ounces	250	70
Milk, nonfat, reduced fat, and whole, vitamin D-fortified, 1 cup	98	25

Dietary supplements: In supplements and fortified foods, vitamin D is available in two forms, D₂ (ergocalciferol) and D₃ (cholecalciferol). Many supplements are being reformulated to contain vitamin D₃ instead of vitamin D₂. Both forms (as well as vitamin D in foods and from cutaneous synthesis) effectively raise serum 25(OH)D levels.
The authors of a recent evidence-based review of research concluded that supplements of both vitamin D₃ (at 700-800 IU/day) and calcium (500-1,200 mg/day) decreased the risk of falls, fractures, and bone loss in elderly individuals aged 62-85 years.

National Osteoporosis Foundation - back of 2011 Supporter Card
1. Daily Vitamin D Needs - age 50+ - 800-1,000 IU
Vitamin K - is it important? See my Vitamin K webpage.

Research Info about Osteoporosis

Journal of Bone and Joint Surgery - www.ejbjs.org
1. "What's New in Orthopaedic Research" by Suzanne A. Maher, PhD, Chisa Hidaka, MD, Matthew E. Cunningham, MD, PhD and Scott A. Rodeo, MD, all of Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for S.A. Rodeo: RodeoS@hss.edu. 2008;90:1800-1808. doi:10.2106/JBJS.H.00739.
  1. Clinical studies in the area of bone density have shown an important side effect of antiresorptive therapy that should give surgeons pause in prescribing bisphosphonates to certain patients. Several groups, including that of Joseph Lane, MD, and Dean Lorich, MD, at the Hospital for Special Surgery in New York, have reported on the increased prevalence of subtrochanteric fractures in patients taking bisphosphonates for the long-term treatment of osteoporosis. The Hospital for Special Surgery group described nontraumatic, nonpathologic fractures of the femoral shaft with a simple transverse pattern and hypertrophy of the diaphyseal cortex in patients taking Fosamax. On the basis of those studies, the authors recommended that patients who have sustained a fracture should stop taking Fosamax and that patients receiving long-term treatment should be carefully monitored.
New England Journal of Medicine - http://content.nejm.org
1. http://content.nejm.org/cgi/content/full/359/3/316 - More on Atypical Fractures of the Femoral Diaphysis - 2008July17
2. http://content.nejm.org/cgi/content/full/358/12/1304 - Atypical Fractures of the Femoral Diaphysis in Postmenopausal Women Taking Alendronate - 2008March20
FDA - www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/
DrugSafetyInformationforHeathcareProfessionals/ucm070303.htm - recent issue of The New England Journal of Medicine raised question about association of atrial fibrillation with bisphosphonates.
Current Concepts in Osteoporosis - http://cme.medscape.com/viewarticle/555822 by Stuart A. Weinerman, MD, published 2007May22.
1. Slide 4: NOF Patient of the Year 1995 - age 50 vs. 75.
2. Slide 26: So, at a minimum, you want to be shooting for 30 ng/ml for optimal vitamin D levels, and that is based on bone. We do not yet know the optimal vitamin D levels for the other potential benefits of vitamin D.
Management and Treatment of Osteoporosis - http://cme.medscape.com/viewarticle/555823 by Ellen H. Miller, MD, published 2007May22.
1. Slide 6: All of our patients with osteoporosis should be advised to take 1,200 to 1,500 mg of calcium daily and 800 to 1,000 units of vitamin D.
2. This may seem like a high dose; however, we may safely use up to 2,000 units daily, and toxicity is rare unless chronic doses exceed 10,000 units daily.
A Call to Action - http://cme.medscape.com/viewarticle/540179 - by Joseph M. Grisanti, MD, published 2006July11.
1. Slide 45: If you are trying to predict greatest risk for hip fracture, you should look at the femoral neck measurement and the trochanteric measurement. Because that is where the fractures occur.
2. But if you are trying to assess somebody's response to treatment, you should look at how the total hip has changed over time, because it is an average of the femoral neck, the trochanteric region, and the intertrochanteric region, and you gain precision and accuracy by looking at an average measurement.

Information from MayoClinic.com

Definition - www.mayoclinic.com/health/osteoporosis/DS00128
RiskFactors - www.mayoclinic.com/health/osteoporosis/DS00128/DSECTION=risk-factors
1. Any weight-bearing exercise is beneficial, but jumping and hopping seem particularly helpful for creating healthy bones.
Prevention - www.mayoclinic.com/health/osteoporosis/DS00128/DSECTION=prevention
1. All men and women older than 65 should aim for 1,500 mg of elemental calcium and at least 800 IU of vitamin D daily.
2. Getting enough vitamin D is important. Not only does vitamin D improve bone health by helping calcium absorption, but it also may improve muscle strength. Scientists are continuing to study vitamin D to determine the optimal daily dose, but it's safe to take up to 2,000 IU a day.
3. Sometimes calcium supplements can cause constipation. If this is a problem, drink more water and try a fiber supplement.
4. Swimming, cycling and elliptical trainers can provide a good cardiovascular workout, but because they're low impact, they're not as helpful for improving bone health as weight-bearing exercises.

General Information about Osteoporosis

Organizations Devoted to Osteoporosis

Search Engine Directories for Osteoporosis

Helpful Info

Tufts School of Nutrition - http://nutrition.tufts.edu
Center for Physical Activity and Nutrition - http://jhcpan.nutrition.tufts.edu
http://www.jwatch.org/cgi/collection/osteoporosis-bone-disease - journal watch for current info
http://dermatology.jwatch.org/cgi/content/full/2009/522/1 - vitamin D deficiency
Osteo Education - www.osteoed.org - University of Washington, School of Medicine
http://osteoporosis.creighton.edu/
Piezoelectric Effect - Repeated stress, such as weight-bearing exercise or bone healing, results in the bone thickening at the points of maximum stress (Wolff's law). It has been hypothesized that this is a result of bone's piezoelectric properties, which cause bone to generate small electrical potentials under stress.
Netter, Frank H. (1987). Musculoskeletal system: anatomy, physiology, and metabolic disorders. New Jersey, Summit: Ciba-Geigy Corporation. ISBN 0914168886, p. 187-189.
NOFExchange - exchanges.webmd.com/osteoporosis-exchange - moderated by NOF experts
Osteopenia3 - www.osteopenia3.com - independent site created by Kate Lindemann, Ph.D.
OrthopedicScience - www.orthopedicscience.com - at NShore LIJ. www.orthopaedicassociatesmanhasset.com
TreatMySpineFracture - www.treatmyspinefracture.com - Orthovita

Questions

Exercises for neck, ankles
Vitamin K - is it important? See my Vitamin K webpage.

(This page was last edited on January 15, 2011 .)