Strategies for Preventing Bone Loss
Help your clients grow and retain the strongest bones.
As a fitness pro, you can’t fix the genetic and environmental contributors to bone loss, but you can encourage physical activity and proper nutrition, both of which improve bone health. Therefore, prioritize knowing the basics of bone loss and development, and helping your clients grow and retain the strongest bones possible with these training strategies.
Bone Loss Basics
- Calcium, vitamin D, dairy and physical activity are critical to preserving and building bone mass.
- Bone mass peaks in the early 20s.
- BMD = bone mineral density (measured in T-score, a negative number because it quantifies bone loss).
- Osteopenia is the onset of bone loss (T-score -1 to -2.5).
- Osteoporosis is the most serious bone loss (T-score below -2.5).
- Walking has limited effect on bone health.
- Progressive resistance training helps to maintain and improve BMD.
- High-impact activities help the most with bone growth.
- Posture and balance training are essential to fall prevention.
- Heavy resistance training is safe and improves bone, function and stature.
- Women over 50 have the highest risk of osteoporosis and fractures.
Activities for Bone Loss
Walking is often the top recommendation for osteoporosis, even though a plethora of studies have shown it has only a limited effect on bone (McMillan et al. 2017; Karaguzel & Holick 2010; Watson et al. 2015). If combined with impact and resistance training, however, walking can help maintain BMD in the hip region and in the lumbar and sacral spine (Karaguzel & Holick 2010). In people over 65, increasing daily steps by 25% has been associated with an increase in hip BMD (McMillan et al. 2017).
Progressive Resistance Training (PRT)
PRT is the most widely researched method for preserving BMD and preventing bone loss. It has proved to be the most effective way to increase BMD in women and older adults and to maintain BMD in men (McMillan et al. 2017). Resistance training also improves muscle mass and strength (Karaguzel & Holick 2010), both of which are crucial to osteogenesis (bone formation) as well as fall prevention, which becomes a more pronounced risk in older adults.
Emphasize exercises that target posture muscles, such as back and spinal extensors, and that increase strength in functional movements, such as stair climbing or box squats. Greater back extensor strength has been associated with lower risk of vertebral fracture and thoracic kyphosis, which correlate with balance impairment (IOF 2017; Giangregorio et al. 2014).
Activities that produce a weighted impact on the skeleton are especially osteogenic. The most osteogenic activities induce high-magnitude strains in bone at a high rate (Watson et al. 2015). Brief, high-impact exercises such as hopping, skipping and jumping can increase BMD, muscle strength and power (McMillan et al. 2017). Adding unilateral and multiplanar components—such as single-leg hopping or side, front and back hops—can improve balance and proprioception, two key factors in fall prevention.
High-Intensity Progressive Resistance Training (HiPRT)
HiPRT combines heavy resistance training with high-impact activities. This type of training has proved to be effective for postmenopausal women with low to very low bone mass (Watson et al. 2015). The combination of progressively increasing weight in resistance exercises while boosting impact loading in high-intensity exercises can enhance bone mass, physical function and posture while decreasing the risk of osteoporotic fracture (Watson et al. 2015). Postural improvement is noticeable with a reduction in thoracic kyphosis.
Posture and Balance Training
Staying upright and standing without falling are crucial everyday skills we often take for granted because they happen automatically (Lacour, Bernard-Demanze & Dumitrescu 2008). The posture-control system depends on multiple inputs—visual, vestibular, proprioceptive somatosensory and tactile somatosensory—and these can become compromised as we age (Chiba et al. 2016; Lacour, Bernard-Demanze & Dumitrescu 2008). As dynamic and static postural tasks become much more challenging, it gets more difficult to perform a cognitive task at the same time, and the body prioritizes posture control over cognitive-task performance to avoid falling. This is known as the “posture first” principle (Lacour, Bernard-Demanze & Dumitrescu 2008). Being aware of posture-first principles can help you design programs for older adults or other clients with posture and balance impairments.
Emphasize exercises that incorporate two tasks, such as walking and talking, or that challenge the exerciser to close the eyes (visual), use a tilting platform (proprioceptive) or use a foam mat (tactile).
See also: Having the Bone Health Talk With Clients
Bone Loss in Women
Fitness professionals have to be aware of just how great the osteoporotic fracture risk is for women. Worldwide, osteoporosis affects 200 million women, and the lifetime risk of a hip fracture is 1 in 6, compared with 1 in 9 for breast cancer (IOF 2017).
The risk for postmenopausal women is even higher. Most fractures occur in postmenopausal women, and the lifetime fracture risk for a 50-year-old woman with osteoporosis is as high as 60% (IOF 2017; Karaguzel & Holick 2010). To frame it another way: A woman’s risk of hip fracture is equal to her combined risks of breast, uterine and ovarian cancer (NOF 2016).
When working with clients who have had a previous fracture, it is important to know that 1 in 5 women with a vertebral fracture will experience a second one within 1 year (Karaguzel & Holick 2010). Thus, program development should prioritize avoiding the second fracture.
Most fitness pros have female clients, and some even specialize in working with postmenopausal clients. Thus, staying aware of the increased fracture risk puts you in a good position, not only to educate clients about the risk, but also to provide them with workouts that prioritize bone health as well as muscle mass.
Exercises for Clients with Osteoporosis and Bone Loss
When working with any clients diagnosed with osteoporosis, you want to maximize the benefit, but you must also take care to avoid unnecessary risk. If mobility and posture are altered after a vertebral fracture, pay close attention to correct lifting technique and avoid pitfalls such as loading the spine in a flexed posture. For example, since exercise machines often require twisting and forward bending, you may need to avoid using them with clients who have osteoporosis (Giangregorio et al. 2014). Also, tailor the intensity and type of exercise to minimize chronic pain—a condition that is common in clients with a previous osteoporotic fracture.
Include all major muscle groups at least twice a week.
- Include 2 sets per exercise, 8–12 reps per set.
- Avoid exercise machines.
- Use slow and controlled movements.
Aim for 15–20 minutes daily to accumulate at least 2 hours a week.
- Include three-dimensional exercises such as tai chi.
- Encourage lifestyle-integrated exercises:
- tandem stance while washing dishes
- closing eyes while doing static tasks
Do not use this to the exclusion of resistance or balance training. Aim for 150–300 minutes per week of moderate-intensity exercise or 75–150 minutes of vigorous exercise.
- Include exercises with dynamic, high-force movements (jumping, skipping).
- With clients at high risk of vertebral fracture, do not do vigorous exercise or dynamic, high-force exercises.
Source: Giangregorio et al. 2014.
See also: Bone Health: A Primer
Chiba, R., et al. 2016. Human upright posture control models based on multisensory inputs; in fast and slow dynamics. Neuroscience Research, 104, 96–104.
Giangregorio, L.M., et al. 2014. Too fit to fracture: Exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. Osteoporosis International, 25 (3), 821–35.
IOF (International Osteoporosis Foundation). 2017. Facts and statistics. Accessed Mar. 3, 2018: iofbonehealth.org/facts-statistics.
Karaguzel, G., & Holick, M.F. 2010. Diagnosis and treatment of osteopenia. Reviews in Endocrine and Metabolic Disorders, 11 (4), 237–51.
Lacour, M., Bernard-Demanze, L., & Dumitrescu, M. 2008. Posture control, aging, and attention resources: Models and posture-analysis methods. Neurophysiologie Clinique, 38 (6), 411–21.
McMillan, L.B., et al. 2017. Prescribing physical activity for the prevention and treatment of osteoporosis in older adults. Healthcare, 5 (4), e85.
NOF (National Osteoporosis Foundation). 2016. Accessed Mar. 19, 2018: nof.org.
Watson, S.L., et al. 2015. Heavy resistance training is safe and improves bone, function, and stature in postmenopausal women with low to very low bone mass: Novel early findings from the LIFTMOR trial. Osteoporosis International, 26 (12), 2889–94.