Last updated: 01-Jul-19
By Karina Teahan
What is osteoporosis?
Bone is a dynamic, living tissue in which two things are constantly happening: bone formation and bone reabsorption. Osteoporosis occurs when there is an imbalance between the two. It affects the skeleton and means that weaker bones predispose you to an increased risk of fracture.
It is often referred to as the silent disease as you feel no pain unless you sustain a fracture. The World Health Organisation (WHO) operational definition of the disease is based on a DEXA scan* scoring of your Bone Mineral Density (BMD) in comparison to the average for a young adult Caucasian woman. You can check that out here.
You suffer from osteoporosis most commonly in the back and hips.
Incidence of Osteoporosis:
The chances of suffering from osteoporosis are relatively high – more so for women! In Ireland and the UK, one in five men and one in three women over 50 years old will experience a fragility fracture due to osteoporosis. In Australia two-thirds of over 50 years old have a low bone mass (30% of whom are male & 70% female).
Risk Factors for Osteoporosis:
The causes of Osteoporosis depend on a number of factors and for some it is inevitable as 60-80% of our peak bone mass is predetermined by our genetics.
There are also other things that can make you more predisposed. These include:
- Rheumatoid arthritis.
- Certain medications: corticosteroid use (> 3 months), PPIs (proton pump inhibitors-used as a long acting reduction of stomach acid production), certain sedatives, methotrexate, antacids, lithium, antipsychotics.
- Malabsorption (Coeliac disease).
- Endocrine disorders.
- COPD (respiratory disease).
- Multiple Sclerosis.
- Liver or kidney disease.
Whereas you may not be able to prevent or change the above there are other factors that you CAN change. These include:
- Alcohol: Consuming greater than, or equal to, 4 units/day will affect your bones and is considered high risk.
- Physical inactivity: reduced muscle strength, impaired balance or gait, increased risk of falls.
- Smoking: destructive to bone and the risk increases with age.
- Low BMI/excessive weight loss.
- Poor nutrition.
Osteoporosis in Athletes
Although sport and exercise provide overwhelmingly positive benefits, there are certain situations in which our bone health does suffer in the pursuit of the best physique or performance. Osteoporosis in athletes is associated with the age when training started, duration, intensity and volume of training, the type of sport as well as any of the risk factors listed above.
The highest Bone Mineral Content (BMC) and Bone Mineral Density (BMD) (both of which are good things for preventing osteoporosis) are found in strength and power trained athletes. There is a higher incidence of low BMD in non-weight bearing sports or sports with weight categories such as light weight rowing, swimming, diving, road cycling and long distance running.
In a bone health study on elite Norwegian endurance cyclists and middle to long distance runners it was found that the road cyclists had lower BMD than the distance runners in spite of performing lower limb heavy resistance training (3). Road cyclists are found to have lower BMD than mountain bikers.
Low body mass and low energy availability is commonly seen in endurance athletes. This is called Relative Energy Deficiency in Sport (RED-S) and it is a condition that can affect athletes of any age and sex. RED-S occurs when an imbalance in energy intake and energy output has detrimental effects on bone health, hormones (menstrual function in women and lower testosterone in men), metabolic rate, immune function, cardiovascular health and psychological health.
So, keep that nutrition HIGH and RELEVANT. The level of cortisol in our bodies is also increased by intense exercise and in over-trained athletes. Long term elevated levels of Cortisol affect calcium and bone metabolism resulting in Osteoporosis (4).
What Exercises are best to Prevent Osteoporosis or Maintain Optimal Bone Health?
Exercises that are considered to be bone building are those that are dynamic and load bearing. The evidence (1, 2) suggests that loading must be:
- Dynamic not static.
Relatively few reps with heavy weights are required. Short bursts with intermittent rest is often better than the same load all at once as bones become desensitised to customary patterns such as running, so we must consider more novel movements and directions.
Athletes involved in high or unusual impact weight bearing sports with rapid rates of loading such as gymnastics, volleyball, basketball, football, power lifting, tennis and squash have superior bone mass to the previously mentioned road cyclists, swimmers & distance runners.
The aim of exercise management is to optimise bone health and this is achieved through:
- Exercise training involving hopping/jumping; and/or
- Progressive Resistance Training (PRT). The best result is when the resistance (weight) is progressively increased over time, the magnitude of the load is high (80-85% 1 Rep Max: 1 repetition), training is performed at least twice per week and large muscles across the spine & hip are targeted.
Older athletes or those with severe arthritis or other associated conditions may not be able to do these kind of programmes and Tai Chi or the OTAGO home exercise program may play a positive role instead. However due to the nature of the RunUltra community – that is fit, long distance, endurance athletes, I am going to cite the exercise goals and prescription guidelines from Exercise & Sports Science Australia (#1) for:
- Low risk individuals/normal BMD T-score above -1.0
- Moderate risk individuals/T-score between -1.0 and -2.5
The goal is to preserve or improve bone mass and strength, but also to improve muscle strength, power and balance. It may take some time to progress to the high intensity PRT if you haven’t done it in the past.
Another really interesting study called the LIFTMOR trial (2) studied postmenopausal women who are a very high risk group. What it showed was how incredibly effective this kind of strength and weight training can be for all over health.
The training comprised of 8 months of twice-weekly 30-minute supervised high intensity PRT versus a low intensity home based exercise program of the same duration and dose. The PRT group improved in all domains of: height, femoral neck & lumbar spine BMD, lean muscle mass, back extensor strength and physical function. They had reduced curvature of the spine and improved overall stature.
The exercises described were:
- Deadlift 5 reps x 5 sets @ 80-85% 1RM
- Squats 5 reps x 5 sets @ 80-85% 1RM
- Over-head press 5 reps x 5 sets @ 80-85% 1RM
- Jumping chin ups with drop landing: 5 reps x 5 sets: this can be progresses by pulling yourself higher and gradually landing with stiffer legs to increase the loading.
The warm up consisted of 2 sets of 5 rep deadlifts at 50-70% 1RM. For many this may not be realistic and does need it be supervised to perform the exercises correctly but the evidence suggests it works. Many of us will be quite confident at exercises 1 and 2 but 3 and 4 may offer a novel challenge.
The message is clear: avoid the risk factors that you can and start combining your training with body weight exercises or get down the gym and do some lifting.
*DEXA Scan: Dual Energy X-ray Absorptiometry scan provides a direct measurement of bone density. The dose of radiation used is extremely low. The scan is fast, accurate & painless and takes just 10-15 minutes.
** I have not discussed medications or diet with regards to Osteoporosis in this article as this would be under the expertise of a doctor or clinical dietician.
- Beck RB, Daly RM, Fiatarone Singh MA, Taaffe DR. Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of Osteoporosis. Journal of Science and Medicine in Sport 20(2017) 438-445
- Watson SL, Weeks BK, Weis LJ, Horan SA, Beck BR. 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 LIFTMOR trial. Osteoporosis Int (2015) 26: 2889-2894
- Anderson OK, Clarsen B, Garthe I, MØrland M, Stensrud T. Bone health in elite Norwegian endurance cyclists and runners: a cross-sectional study. BMJ Open Sport Exerc Med 2018;4e000449