Training for Bone Health: Osteoporosis/ Osteopenia Management and Prevention

A number of clients I work with want to improve and/or protect their bone health, wrestling with osteoporosis or osteopenia, or just wanting to avoid bone loss as they age. I've been thinking about these topics a lot recently, and this article is my deep dive into optimizing bone health through training and nutrition. For further information, check out the references, or consult a physician, personal trainer, dietician, or other health care professional.

What makes bones healthy?

• Bone mineral density (BMD): the mineral content (especially calcium) present in the bones; healthy bones have sufficient bone mineral density to support the body in the activities of daily living.

• Bone strength (and geometry): size, shape, and structure of the bones and how these and other factors allow bones to undergo various forces; healthy bones are strong enough to absorb and withstand forces introduced to it in the activities of daily living.

• Peak bone mass is typically achieved by mid-20s, so it is important to engage in resistance and impact training, in addition to well-rounded nutrition habits, early on to build a good foundation for bone health. The more bone density and strength that is built in adolescence, the easier these are to maintain in adulthood.

• Even after peak bone mass is reached, bones can be kept healthy by maintaining their strength and density through targeted exercise, nutrition, and support from health and medical professionals.

• When bone density and strength diminish to the point of osteoporosis (severe bone density loss, which largely increases risk of fractures) or osteopenia (bone density loss that is less severe than osteoporosis but carries a risk of fracture and of evolving into osteoporosis), measures can still be taken to maintain bone density and strength and to prevent fracturing and further loss of bone mass.

• These measures include exercise and nutrition, and help from a medical professional (talking to a personal trainer doesn't hurt either!).

What kinds of exercise support bone health?

• Building muscle helps with bone density maintenance and, in some cases, remodeling (the process in which old bone cells are cleared through osteoclasts and new bone cells are laid down through osteoclasts). Bones structurally support the muscles, but stimulating muscle growth stimulates the bones as well, allowing them to stay healthy. Exercise that builds muscle supports bone health.

• Resistance training (which exceeds the typical force encountered in daily activities and follows the principles of progressive overload) is the most effective modality of exercise for building and maintaining muscle, and thus for building and maintaining bone density and strength.

• Impact based cardiovascular training can also help with muscle and bone health to a certain extent. Resistance training includes a cardiovascular component and can provide low, high, and odd impact, which makes it the number one bone health training modality, but cardio and sport-specific training have their own unique benefits and are a great supplement (what I mean to say is definitely resistance train, but do any of these other modalities if you enjoy them).

• High impact cardio includes jumping and runnning.

• Low impact cardio includes walking, stair-climbing, and jogging.

• Odd impact cardio includes agility training and aerobic training that involes level changing and mixed planes of motion.

• Very low impact training such as swimming, biking, and water aerobics have limited impact and thus limited benefit for muscle and bone development, but are still great ways to train cardio and can lead to some degree of muscle growth when trained progressively and consistently.

Which muscle groups are most important to train for bone health?

• The thoracic vertebrae (upper back), femoral neck (hips), wrists, and in some cases lumar vertebrae (lower back/sacrum area) are most effected by osteoporosis. It is important to work on reistance exercises that address these parts of the body, such as squats, lunges, pushing patterns, pulling patterns, and hip hinge patterns.

• Exercises that train the core (abdominals, glutes, gait stabilizers, etc.) and balance are also important for fall prevention/safe falling and protecting the back.

• Closed-chain exercises (exercises where distal extremities—such as hand or feet—are fixed in place against a surface—such as the floor or a machine platform) are also beneficial for bone health because they produce multi-directional force.

• Jumping can benefit bone maintenance and growth, but when oteoporosis or osteopenia are present, risk of falling when jumping needs to be introduced and risk of fracture assessed. The same goes for exercises that involve bending and rotating the spine.

• A coach can be helpful for establishing proper form and exercise selection.

How can nutrition and diet support bone health?

• Calcium, vitamin D, protein, and potassium are the most important nutrients for supporting bone health.

• Calcium is best absorbed in the body when consumed through dairy products, especially in the presence of Vitamin D, which is often found in dairy products. For vegans and those who abstain from dairy, calcium can also be consumed through vegetables, soy, and supplementation.

• Vitamin D is more of a hormone than a vitamin, and it is what allows calcium to be absorbed and utilized in the body. Vitamin D is primarily obtained through sunlight exposure (try 10-15 minutes outside per day without sunscreen to allow sun exposure but not sunburn) but can also be obtained through diet by eating fortified dairy products, egg yolks, fatty fish, and fortified orange juice. Supplementation is also an option, as many people are deficient in Vitamin D, despite sunlight exposure and consuming Vitamin-D containing foods.

• Protein supports muscle growth and thus supports bone health. When engaging in trainining geared toward muscle building, consuming 1g of protein per pound of body weight or desired body weight can be a good target to aim for, or starting with 1-4 servings of a protein rich food per meal. Complete proteins contain all the essential protein building blocks (called amino acids) for servicing muscle protein synthesis, and include meat, fish, dairy, soy, pistachios, hemp, and plant-based pairings, such as rice and beans, wheat and nuts, and lentils and grains.

• Low potassium levels are sometimes associated with osteoporosis, so maintaining sufficient potassium levels (especially as it and other electorlytes are lost through sweat, which will almost certainly happen when undergoing an exercise routine) is important. Potassium rich foods include apples, apricots, bananas, beet greens, blueberries, carrots, potatoes, spinach,  tomatoes, and some electrolyte beverages.

Conclusion

• Bone health is a life-long process primarily fueled by exercise and nutrition.

• Do the resistance training.

• Also engage in cardiovascular training if you enjoy it, it's your sport, it helps you achieve other goals, and includes the appropriate amount of impact for your fitness level and bone mass status.

• Eat calcium, vitamin D, protein, and potassium, and go outside.

• Talk to a doctor, get blood work done, get bone health assessed, and consider a DEXA scan (shows bone mineral density and body composition).

• Hire a training and/or nutrition coach to help you with program design, progressive overload, proper form, nutrition planning too, accountability, and/or moral support.

• Make a well-informed plan and stick to it. You got this! Let's go bones!!!

References

Baggerly, C. A., Cuomo, R. E., French, C. B., Garland, C. F., Gorham, E. D., Grant, W. B.,…Wunsch, A. (2015). Sunlight and

Vitamin D: Necessary for Public Health. Journal of the American College of Nutrition, 34(4), 359–365

Bracko, M. (n.d.).Osteoporosis, The Silent Thief—Prevention for Female Clients. (NASM Course Video)

Durstine, J. L., Moore, G. E., Painter, P., & Roberts, S., (2009). ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities. Champain, IL: Human Kinetics.

Eisz A., & Gladwin, L. (n.d.). Osteoporosis: What You Should Know. (NASM Course Article)

Fang, H., Deng, Z., Liu, J., Chen, S., Deng, Z., & Li, W. (2022). The Mechanism of Bone Remodeling After Bone Aging. Clinical interventions in aging, 17, 405–415. https://doi.org/10.2147/CIA.S349604

Hong, A. R., & Kim, S. W. (2018). Effects of Resistance Exercise on Bone Health. Endocrinology and metabolism (Seoul, Korea), 33(4), 435–444. https://doi.org/10.3803/EnM.2018.33.4.435

Kraemer, W.J., & Ratamess, N.A. (2004). Progression and Resistance Training.President’s Council on Physical Fitness and Sports Research Digest. https://www.dnbm.univr.it/documenti/OccorrenzaIns/matdid/matdid546948.pdf

Martin, M. (2024, October 4). Jump Training for Osteoporosis: Does It Increase Bone Mineral Density? MelioGuide. https://melioguide.com/weight-bearing/jump-training-osteoporosis/

National Academies of Science, Engineering, and Medicine. (1997). Dietary Reference Intakes for Calcium, Phosphorous, magnesium, Vitamin D, and Fluoride. Washington, DC: The National Academies Press.

National Academy of Science Medicine Certified Personal Training and Certified Nutrition Coach Courses.