Zone Training for Stronger Bones after Menopause

What is Zone training?

If you haven't heard of it before, fear not! I am going to give you an overview here and give you a few thoughts on where you might want to focus your training. When you are exercising to improve your osteoporosis and osteopenia bone scores, it is important to have as much good information as possible about appropriate training.

There are five zones of training. Zone 2 seems to be making the social media circuit these days, so let’s delve into it for a moment.

When I talk about training in Zone 2, I am referring to working at 60-70% of your max heart rate. It means you can easily talk to your friend as you walk, and you can sustain this exercise for quite some time.

Here is a good video from Dr. Andrew Huberman, a tenured professor of neurobiology and ophthalmology at Stanford University School of Medicine.

​How & Why to Get Weekly "Zone 2" Cardio Workouts | Dr. Andrew Huberman​

While I think he makes some great points, let's check in with a WOMAN physiologist, Dr, Stacy Sims. She recently wrote a​ very scientific blog about women and Zone 2​ (November 2023).

She counters that Zone 2 training is better for men than women, and women need to add high-intensity interval training (HIIT) or sprint interval training (SIT). As Dr. Stacy Sims sums it up:

"because females have better mitochondria respiration and mitochondria density than men, men need to do the long slow aerobic work to be more like women (go figure…!). By peppering your long slow work with specific high-intensity work, you will improve your mitochondria capacity and anaerobic capacity by the nature of the high-intensity work."

Take home message:

Zone 2 is a good place to exercise, but as a post-menopausal woman, be sure to add some higher-intensity work as well. Women are not the same as men, and to get the most from your workouts, you need to get in more power and speed work. Aim for high-intensity intervals lasting less than 30 seconds, and do it at least 2 times a week.

I wish I could give you exact time frames to do this work, but this has not been studied enough at this time.In general, you could try 5-10 seconds of higher-intensity work (think of pedaling harder on a stationary bike) followed by 45-60 seconds of recovery for 10 minutes. Of course, get clearance from your primary care provider for higher-intensity exercise, and if you are on heart medication, make sure you know how it works with exercise.

If you need guidance and like to work out at home, consider joining my next Strong Women, Strong Bones jumpstart. We cover all the basics of exercise recommendations and have fun while doing it.

Stay strong, be informed,

Andrea

References

Dupuit, M., Maillard, F., Pereira, B., Marquezi, M. L., Lancha, A. H., Jr, & Boisseau, N. (2020). Effect of high intensity interval training on body composition in women before and after menopause: a meta-analysis. Experimental physiology, 105(9), 1470–1490. https://doi.org/10.1113/EP088654

Dupuit, M., Rance, M., Morel, C., Bouillon, P., Pereira, B., Bonnet, A., Maillard, F., Duclos, M., & Boisseau, N. (2020). Moderate-Intensity Continuous Training or High-Intensity Interval Training with or without Resistance Training for Altering Body Composition in Postmenopausal Women. Medicine and science in sports and exercise, 52(3), 736–745. https://doi.org/10.1249/MSS.0000000000002162

Sims, Stacy. Blog - What Women Need to Do Instead of Zone 2. Nov. 11, 2023 https://www.drstacysims.com/blog/what-women-need-to-do-instead-of-zone-2

Sims, Stacy. Blog - What Women Need to Know About Zone 2 Training. Oct. 23, 2023.https://www.drstacysims.com/blog/what-women-need-to-know-about-zone-2-training

Does Acupuncture Help Combat Bone Loss?

Getting a diagnosis of either osteopenia or osteoporosis can be very distressing. You want to do all you can to regain the bone you have lost and prevent further deterioration. While making sure you have adequate protein, Vitamin D, and calcium, sometimes more off-beat interventions show up as possible bone fighters as well.

I was recently asked, “Does acupuncture help combat bone loss?”

I honestly hadn't spent much time looking into it. At first, I couldn't imagine how acupuncture could help with bone. While it is well known that acupuncture can be useful for pain relief in cancer patients, people with TMJ, and low back pain, as well as helping people with insomnia and lowering blood pressure, I hadn't heard anything about it being used to treat osteopenia or osteoporosis.

With every question I get, the first thing I do is search PUBMED for quality articles. I usually look for articles published in the past 5-8 years. With this search, I have to say, there was not much there.

The most recent meta-analysis was done in 2022, Acupuncture for Osteoporosis: a Review of Its Clinical and Preclinical Studies. The authors reviewed over 100 articles published since 2000. They concluded that there is a lack of high-quality evidence for the treatment of osteoporosis with acupuncture. That said, there are a few promising studies, including those that use electro-acupuncture.

In 2023, the Effect of laser acupuncture on pain and density of bone in osteoporotic postmenopausal women: a randomized controlled trial, was published in the journal Menopause. For this study, 68 post-menopausal women between 50-60 years of age, with osteoporosis and wrist pain were treated with Vitamin D, calcium, and fluoride daily for 12 weeks. Half of the women also received laser acupuncture to the lower abdomen, back and legs for 20 minutes, 3 times a week, over 12 weeks.

Both groups showed significant improvement in their forearm t-score at the conclusion of the study. The Laser acupuncture group did a bit better. The authors stated that the exact mechanism of action promoting bone health is not known. There wasn't any long-term follow-up, and since both groups improved, the addition of Vitamin D, calcium and fluoride probably had some effect. Further investigation is needed to make actual recommendations.

It is interesting to see that the authors only reported the forearm bone density, and not the spine or femur. If they were using DEXA scans, it seems this information should have been available.

Takeaway:​
If you want to spend 20 minutes, 3 times a week doing something for bone loss, a proven intervention is resistance exercise. While acupuncture has some interesting promise, the strong evidence we need for you is not here yet.

Of course, if acupuncture is something you are already doing, you can keep going and you may be getting a small bone benefit. But at this time, I would not call it a first-line defense.

Here are three exercises I would recommend spending your 20 minutes doing each week to promote bone preservation and building:

#1: Exercise One: Biceps Curl​

#2: Exercise Two: Bent Elbow Fly​

#3: Exercise Three: Goblet Squat / Sit to Stand at a Chair​
​

That's it. I love your questions.

As always, my references are listed below.
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I hope you found this helpful.

Andrea

References:

Hassan, E. S., Maged, A. M., Kotb, A., Fouad, M., El-Nassery, N., & Kamal, W. M. (2023). Effect of laser acupuncture on pain and density of bone in osteoporotic postmenopausal women: a randomized controlled trial. Menopause (New York, N.Y.), 30(5), 545–550. https://doi.org/10.1097/GME.0000000000002166

Tian, Y., Wang, L., Xu, T., Li, R., Zhu, R., Chen, B., Zhang, H., Xia, B., Che, Y., Zhao, D., & Zhang, D. (2022). Acupuncture for Osteoporosis: a Review of Its Clinical and Preclinical Studies. Journal of acupuncture and meridian studies, 15(5), 281–299. https://doi.org/10.51507/j.jams.2022.15.5.281

Zhang, J., Zhou, X., Jiang, H., Zhu, W., Chi, H., Jiang, L., Zhang, S., Yang, J., Deng, S., Li, B., Zhuo, B., Zhang, M., Cao, B., & Meng, Z. (2024). Acupuncture for insomnia symptoms in hypertensive patients: a systematic review and meta-analysis. Frontiers in neurology, 15, 1329132. https://doi.org/10.3389/fneur.2024.1329132

Build Arm Bone Strength: Two Essential Exercises for Strong Shoulders

I was recently asked about how to strengthen the bones of the arm with weight training, to prevent fractures when falling. I am always eager to share ways to increase bone density in the wrist area as well as the shoulder girdle. To be able to lift, carry, push, and pull - these are the things we need to be able to do for independent living - as well as for fun.

I picked these two shoulder strengtheners that can be done back to back to strengthen your shoulders protect your rotator cuff. This will ultimately help keep you from fracturing your wrist or upper arm bone (the humerus) when you fall.💪

The first exercise is the front raise.

Keep your weight light, as you don't want to lift too far out in front of your body with a straight arm and strain your neck. Your shoulders might be stronger than your neck muscles, so give your neck a few weeks to adjust to this new exercise.

The second exercise is the lateral raise.

Again, I am doing this with a straight arm, so I am going to keep the weight a bit lighter. This can be a progression from the​ bent elbow fly,​ which is done with your elbow bent to 90 degrees.

✅ Click on the picture to see the video.👇

Who can benefit from this?

If you have shoulder pain when you lift your arm higher than your shoulder level, you can do this to help stabilize your rotator cuff.

If you have arthritis in your shoulder, you can do this to take the pressure off the joint and enhance muscle control.

If you have had neck issues, this will strengthen the muscles that hold your head up (but keep the weight really light at first).

It is also really good for your core stabilization. As you go back and forth between the two exercises and slowly increase your weight (over time), your core gets activated to hold you in place.

I hope all is going well with your exercise routine.

If you are interested in doing your weight training more consistently and with a group of supportive women, consider joining the next Strong Women, Strong Bones jumpstart.

To your strong body and healthy shoulders,

Andrea

Gut Health and Osteoporosis❤️

Let's talk about how your gut 🦠 health and bone health💪are connected.

You already know that what you eat directly affects your bone health. Eating enough protein, and getting sufficient Vitamin D, as well as calcium are the foundations of good bone health.

But what happens with your healthy diet once it enters your digestive tract? Does your gut health matter?

In a nutshell, YES!

We are truly at the beginning stages of knowing exactly what a healthy gut looks like, and how to restore it if there are problems. But, if osteoporosis is a metabolic disorder, we need to look at our gut health.

Anatomy First: Your small and large intestines are responsible for the majority of your nutrient absorption. Your small intestine begins at the end of your stomach. Your food travels about 18 feet through your small intestine before continuing to your large intestine. As you can imagine, most digestion occurs along this 18-foot path. Some digestion occurs in the large intestine before the remainder of the waste moves out through the rectum.

Inside the lining of the small intestine is a rich and diverse microbiome. Over 1000 species of bacteria, viruses, and fungi live in your gut and assist with digestion and absorption of nutrients and minerals, biosynthesis of vitamins and amino acids, and carbohydrate fermentation (Conway, Duggal, 2021).

It is thought that by the age of 3, most of us have established our gut microbiome. But some factors can change its makeup, including the use of antibiotics, alcohol, medications, and exercise.

Do people with osteoporosis have something happening that interferes with the absorption of nutrients and disrupts their gut health?

The gut-bone axis. In 2022, He and Chen published a review in Osteoporosis International titled: The potential mechanism of the microbiota‑gut‑bone axis in osteoporosis: a review. The authors did a thorough investigation of the relationship between gut health and bone health. They found that prebiotics, probiotics, and traditional Chinese medicine have promising, but not yet proven, positive effects on gut health. Almost all studies connecting gut health and bone loss have been done on mice and rats, and the findings are at the cellular level.

Clinical trials with post-menopausal women who take specific pre or probiotics have not been done, and therefore specific recommendations about what to take, how to take it, and when, cannot be made.

In 2024, Zhang et. al. released a paper titled: Diets intervene osteoporosis via gut-bone axis. The authors of this paper analyzed different diets, such as a vegan diet, Mediterranean diet, Ketogenic, traditional Western, and others to see if there were differences in regards to osteoporosis. Like the other study, while there are strong indicators that diet and your gut affect your bone status, there are not enough studies to make anything but broad generalizations.

What are the broad generalizations?

✅ Diets are hard to evaluate long-term because people change their diets over time
✅ Inflammation, brought on by a poor diet, stress, medications, or lack of exercise, affects bone-building
✅ Osteoclasts and osteoblast activity may be affected by the gut microbiome, and therefore future interventions can be targeted to the gut.
✅ Exercise does alter the gut microbiome, potentially lowering inflammation, by increasing blood circulation, similar to how it helps with your heart health while potentially increasing bone strength
✅ A Mediterranean or anti-inflammatory diet is probably best. Food diversity, including fruits, vegetables, beans, fish, nuts, seeds, fermented foods, low sugar, minimally processed food, as well as limited alcohol will help your gut stay healthy

What about probiotics and prebiotics?

We do not have any specific, evidence-based, recommendations on what to take or how much to take. This remains an unregulated industry. Taking a pre- or probiotic by mouth means it has to pass through your stomach, which is acidic. It is thought that most of these supplements are deactivated by the acid in the stomach and do not make it to the gut. A probiotic would need to be able to withstand a pH of 2 to make it out of the stomach.

What makes it through to the gut? FOOD!!
​Fermented foods, such as pickles, sauerkraut, kimchi, and yogurt. Others include tempeh, Kombucha, aged cheese, fermented cottage cheese, and miso.

🦠That's it. As always, my references are listed below.
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I hope you found this helpful.
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Here is to your healthy gut,

Andrea

References:

Conway, J., & A Duggal, N. (2021). Ageing of the gut microbiome: Potential influences on immune senescence and inflammageing. Ageing research reviews, 68, 101323. https://doi.org/10.1016/j.arr.2021.101323

He, Y., & Chen, Y. (2022). The potential mechanism of the microbiota-gut-bone axis in osteoporosis: a review. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, 33(12), 2495–2506. https://doi.org/10.1007/s00198-022-06557-x

Koga Y. Microbiota in the stomach and application of probiotics to gastroduodenal diseases. World J Gastroenterol. 2022 Dec 21;28(47):6702-6715. doi: 10.3748/wjg.v28.i47.6702. PMID: 36620346; PMCID: PMC9813937.

Zhang YW, Cao MM, Li YJ, Chen XX, Yu Q, Rui YF. A narrative review of the moderating effects and repercussion of exercise intervention on osteoporosis: ingenious involvement of gut microbiota and its metabolites. J Transl Med. 2022 Oct 27;20(1):490. doi: 10.1186/s12967-022-03700-4. PMID: 36303163; PMCID: PMC9615371.

Zhang, Y. W., Song, P. R., Wang, S. C., Liu, H., Shi, Z. M., & Su, J. C. (2024). Diets intervene osteoporosis via gut-bone axis. Gut microbes, 16(1), 2295432. https://doi.org/10.1080/19490976.2023.2295432

The information provided is for general educational purposes only and is not intended to serve as medical or physical therapy advice to any individual. Please consult with your physician before starting any new exercise program. Any exercise has the potential to cause injury or physical problems.

PPI's, Acid Reflux, Osteoporosis and Osteopenia

Let's talk about acid reflux. This is a very real and uncomfortable problem for many adults. Medications called proton pump inhibitors (PPIs) are widely prescribed to treat acid reflux. You may recognize the brand names of Prilosec, Prevacid, Omeprazole, or Nexium.

But are these medications hurting your bone health?

In 2019, a review of studies over the previous 5 years looked into the link between long-term PPI use and fracture risk. Three studies, in particular, focused on post-menopausal women, and in each of the studies, the risk of fracture in this population was increased. Reasons for the possible effect include the possibility of PPIs interfering with mineral absorption or osteoblast and osteoclast bone balance. The review concluded that people who take PPIs should have their bone health monitored regularly.
​
In 2022, Park et al. compiled retrospective data to evaluate the effect of long-term PPI use, osteoporosis, and fracture. The population of adults over 50 who took PPIs for more than 180 days, were noted to have a significant association with osteoporosis, but their results looking at hip fractures were inconsistent.

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Also in 2022, a retrospective case-control study by Patel et. al. came out with findings that contradicted these other studies. The authors found a decreased risk of fracture in women aged 50-65 who were taking PPIs. While it is always good to question results and move science along, this study had some serious limitations. The biggest limitation, stated by the authors, was the distribution of women who were taking PPIs: "Only 18.9% were identified to have been on chronic PPI as opposed to about 81.1% not on PPI therapy."
​
​Takeaway: Take this article with a grain of salt. Let's wait for a good randomized controlled study to come out before we throw out the previous findings.

In December 2023, the Use of Proton Pump Inhibitors and Risk of Fracture in Adults: A Review of Literature was published. The authors of this study concluded that although observational studies show a relationship between long-term PPI use and bone fracture, the only group that showed a significant risk of fracture were women over 60 with a prior history of fracture.

What about your Trabecular Bone Score (TBS)?

In 2019, Shin and colleagues found that women between the ages of 40-89 who had used PPIs had a lower TBS than women who had not used them in the past.

​
​Big takeaways -
If you have been taking PPIs for a long time (greater than 180 days), you should be aware of the potential for your bone health to be affected.

You may need to advocate for more frequent DEXA scans and see if you can get a trabecular bone score with your DEXA scans, especially if you have already fractured.

The research is still in progress for how PPIs affect bone health in post-menopausal women.

I will continue to watch the research and hope to see more quality studies on this come out in the near future.

✅ That's it. As always, my references are listed below.
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I hope you found this helpful.
​
In health,
​
Andrea Trombley PT, DPT
​
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​References​
Park, D. H., Seo, S. I., Lee, K. J., Kim, J., Kim, Y., Seo, W. W., Lee, H. S., Shin, W. G., & Yoo, J. J. (2022). Long-term proton pump inhibitor use and risk of osteoporosis and hip fractures: A nationwide population-based and multicenter cohort study using a common data model. Journal of gastroenterology and hepatology, 37(8), 1534–1543. https://doi.org/10.1111/jgh.15879
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Patel N, Fayed M, Faldu P, Maroun W, Chandarana J. Chronic Proton-Pump Inhibitor Therapy and Fracture Risk in Women Aged Between 50 and 65 years: A Retrospective Case-Control Study. Cureus. 2022 Aug 26;14(8):e28429. doi: 10.7759/cureus.28429. PMID: 36176864; PMCID: PMC9512296.

Paudel, Y., Najam, B., Desai, H. N., Illango, J., Seffah, K. D., Kumar, M., Naveen, N., Pachchipulusu, V. K., & Penumetcha, S. S. (2023). Use of Proton Pump Inhibitors and Risk of Fracture in Adults: A Review of Literature. Cureus, 15(12), e49872. https://doi.org/10.7759/cureus.49872
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Thong BKS, Ima-Nirwana S, Chin KY. Proton Pump Inhibitors and Fracture Risk: A Review of Current Evidence and Mechanisms Involved. Int J Environ Res Public Health. 2019 May 5;16(9):1571. doi: 10.3390/ijerph16091571. PMID: 31060319; PMCID: PMC6540255.

Shin, Y. H., Gong, H. S., & Baek, G. H. (2019). Lower Trabecular Bone Score is Associated With the Use of Proton Pump Inhibitors. Journal of clinical densitometry : the official journal of the International Society for Clinical Densitometry, 22(2), 236–242. https://doi.org/10.1016/j.jocd.2018.06.008
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Weighted Vest for Osteoporosis and Osteopenia: Pros and Cons

If you have osteoporosis or osteopenia, you may have wondered about wearing a weighted vest when you walk or exercise. This question comes up frequently. Many of us enjoy walking as our primary exercise and we want to know if there is a way to keep doing it AND counter osteoporosis or osteopenia.

"How can I make walking a better exercise for building bone?"

Weighted vests are an option. But they aren't for all of us, and adding a vest still won't make walking the only exercise you need to do.

Here are my thoughts on weighted vests:

PROS:
​👍Potential to increase bone density: Adding weight above your hips and spine can help stimulate bone growth and improve bone density, which is crucial for managing osteopenia and osteoporosis.

👍Enhanced strength and stability: Wearing a weighted vest while walking can intensify your workout by challenging your core muscles, leg muscles and cardiovascular system. Over time, this can lead to improved strength and endurance, helping you better manage daily activities and reduce your risk of falls.

👍Convenient and Adjustable: Weighted vests are easy to incorporate into your walking routine. They come in various weights and designs, allowing you to adjust the intensity of your workouts based on your fitness level and comfort. You can add weight or make the vest lighter, depending on your goals for the day.

CONS:

👎Potential Strain on Joints: Wearing a weighted vest while walking can put additional strain on your joints, particularly the knees and lower back. It's essential to listen to your body and avoid increasing the weight in a vest too fast, or wearing it for too long.

👎Balance and Stability Challenges: The added weight from a vest can affect your balance and stability, especially if you're already prone to balance issues. It's important to start with lighter weights in the vest and gradually increase the load as your strength and stability improve.

My Recommendations:

👉Look for vests specifically made for women. Many vests are designed for men who wear them for weight training. These vests won't fit well and tend to be bulky.

👉Look for vests designed for walking or running. These are going to be more comfortable. They may have added reflective features as well, to keep you safe out on the road.

👉Try it before you buy it - if possible. A comfortable vest is one you will wear. If you live in a larger city, head to your local running store and see if they have a few to try on. If you order online, make sure you can return it.

Can I just wear my backpack?

​
👉Vests are better than wearing a backpack🎒. Backpacks, especially those without a hip strap, cause your posture to become rounded forward. This is not the posture you want to promote. A weighted vest will distribute some weight in the front of your body, and some in the back. Your posture will be less flexed forward and more balanced.

Added note: I do not wear a weighted vest when I walk. I do wear a backpack with a hip strap when I hike. I like my Quest backpack with a Camelback because I carry quite a bit of water with me. I also have snacks, a first aid kit, clothes layers and collapsable hiking poles.

I hope this answers some of your questions about weighted vests. As always, my references are listed below. The research is a little older. If anything new comes out, I will be sure to update you. Please note that the research article by Shaw, 1998, included wearing a weighted vest and doing resistance exercises, they didn't just walk.

👉Thanks for sticking around and staying strong on this journey with me,

Andrea

References:

Shaw, J. M., & Snow, C. M. (1998). Weighted vest exercise improves indices of fall risk in older women. The journals of gerontology. Series A, Biological sciences and medical sciences, 53(1), M53–M58. https://doi.org/10.1093/gerona/53a.1.m53

Snow, C. M., Shaw, J. M., Winters, K. M., & Witzke, K. A. (2000). Long-term exercise using weighted vests prevents hip bone loss in postmenopausal women. The Journals of Gerontology. Series A, Biological sciences and medical sciences, 55(9), M489–M491. https://doi.org/10.1093/gerona/55.9.m489

Vitamin C for Osteopenia or Osteoporosis Fractures?

I love it when I get questions from all of you. This helps me keep this blog relevant.

This week, I was asked about the value of taking high doses of Vitamin C after a fracture (for instance, after a broken wrist).

Is it helpful? Is it necessary?

First, you should know if you are actually at risk for Vitamin C insufficiency.

According to Crook et al. (2021), about 41% of the U.S. population has Vitamin C insufficiency. In their analysis, they found that the groups with the highest risk of insufficiency were males, adults aged 20–59, Black and Mexican Americans, smokers, individuals with increased BMI, middle and high poverty levels, and those with food insecurity. Women over 60 were actually the least likely to have insufficiency.

But what if you have osteoporosis or osteopenia? Should this diagnosis change your Vitamin C intake?

Brzezińska et al. asked this very question in 2020. Their paper was titled "Role of Vitamin C in Osteoporosis Development and Treatment-A Literature Review". The scientists reviewed 66 studies published between 2000-2020. They concluded that a balanced, well-rounded diet was the most appropriate way to achieve bone health, while the role of high-dose supplements was not established. Future studies may help us understand supplements better.

The balanced, well-rounded diet was further confirmed by a study by Zeng and colleagues (2020) in their paper titled "Can Dietary Intake of Vitamin C-Oriented Foods Reduce the Risk of Osteoporosis, Fracture, and BMD Loss? This group dug into the connection between vitamin C-rich foods and bone health by looking at 13 studies. They concluded that people who regularly consumed vitamin C-oriented foods had a reduced risk of osteoporosis and fractures.

Important Note - these studies suggest that dietary intake is the best solution, not supplements.

How Can You Boost Your Vitamin C Intake?

Here are some easy tips to make sure you're getting your daily dose of this bone-loving vitamin:

• Fruit: Start your day with a delicious fruit that includes vitamin C- like oranges, kiwis, cantaloupe, or strawberries.

• Veggie Power: Make veggies like broccoli, Brussels sprouts, red or green peppers, and kale a regular part of your meals.

A Little Sunshine ☀️ on Your Plate: Think of vitamin C as a little sunshine on your plate. It not only helps your bones but also boosts your overall well-being. Plus, it's an easy and tasty addition to your meals. The more color on your plate, the better - eat the rainbow.

What if you have a fracture? Should you increase your Vitamin C to assist with healing?

Yes, if your PCP recommends it. According to a 2022 Systematic Review by Barrios-Garay, "vitamin C seems to accelerate bone regeneration without adverse events". They do not have specific recommendations on the dose. This is something you should discuss with your PCP if/when you fracture.

Go out and enjoy those vitamin C-rich foods and let the goodness soak into your bones. I think organic, locally-grown fruits and vegetables are your best bet. Cancel the supplements and spend your money on the best quality food you can afford.

If you have any specific questions or topics you'd like me to cover in future blog posts, please feel free to reach out.

Andrea

References

Barrios-Garay K, Toledano-Serrabona J, Gay-Escoda C, Sánchez-Garcés MÁ. Clinical effect of vitamin C supplementation on bone healing: A systematic review. Med Oral Patol Oral Cir Bucal. 2022 May 1;27(3):e205-e215. doi: 10.4317/medoral.24944. PMID: 35368012; PMCID: PMC9054165.

Brzezińska, O., Łukasik, Z., Makowska, J., & Walczak, K. (2020). Role of Vitamin C in Osteoporosis Development and Treatment-A Literature Review. Nutrients, 12(8), 2394. https://doi.org/10.3390/nu12082394

Crook, J., Horgas, A., Yoon, S. J., Grundmann, O., & Johnson-Mallard, V. (2021). Insufficient Vitamin C Levels among Adults in the United States: Results from the NHANES Surveys, 2003-2006. Nutrients, 13(11), 3910. https://doi.org/10.3390/nu13113910

Zeng LF, Luo MH, Liang GH, Yang WY, Xiao X, Wei X, Yu J, Guo D, Chen HY, Pan JK, Huang HT, Liu Q, Guan ZT, Han YH, Zhao D, Zhao JL, Hou SR, Wu M, Lin JT, Li JH, Liang WX, Ou AH, Wang Q, Li ZP, Liu J. Can Dietary Intake of Vitamin C-Oriented Foods Reduce the Risk of Osteoporosis, Fracture, and BMD Loss? Systematic Review With Meta-Analyses of Recent Studies. Front Endocrinol (Lausanne). 2020 Feb 3;10:844. doi: 10.3389/fendo.2019.00844. PMID: 32117042; PMCID: PMC7008177.

Pelvic Tilts & Pelvic Clocks - The Basis for Lifting Heavier with Osteoporosis and Osteopenia

You have likely heard by now that you need to start lifting weights if you have osteopenia or osteoporosis.

But, before you start loading your spine and doing much lifting, you need to figure out how to activate the smaller muscles that make up your core. These muscles include the abdominal obliques and transverse abdominus on the front of your body, and the multifidus, erector spinae, and quadratus lumborum toward the back. There are more, but I won't go into that much detail.

The muscles I listed above play a big role in supporting your spine and keeping you upright. After an injury, these muscles don't always work the way they did before the injury. If you have ever been to physical therapy, you might be familiar with at least one of these exercises. We often show you the pelvic tilt as your first exercise to get these muscles fired up and doing their job again.

✅ You can click on the video to get a full description of how to do both a pelvic tilt and the pelvic clock

These two exercises can be done on the floor or in your bed. A small pillow or blanket can go under your head for comfort.

If you feel like you are using your leg muscles, or tightening up your buttocks, try and relax them.

And breathe!

I really like doing both the pelvic tilt and pelvic clock after I have been sitting for a long time, like a long car ride or trip on an airplane. They also feel good if my back is cranky.

Lifting weights and working on your balance are key to staying active with bone loss. The pelvic tilt and pelvic clock are basic exercises I go back to time and again to help me progress with my heavier weights and challenge my balance.

Give them a try and let me know what you think.

Before I go, ⭐ I want to remind you about my Strong Women, Strong Bones 4-Week Jumpstart. I offer it four times a year, click here to see when the next one is offered.

Andrea

What Is A Trabecular Bone Score?

Today I want to talk briefly about your Trabecular Bone Score (TBS).

You probably already know that your DXA scan and the resulting T score don't give you the full picture of your bone health. It is a score of bone density and doesn't give you a lot of information about your fragility.

The next step in figuring out your risk of fracture is your Trabecular Bone Score.

Anatomy first. You have two types of bone, cortical and trabecular.

Cortical bone is the hard, outer part of your bone, it is dense and compact.

Trabecular bone is the inner bone. It is honeycomb-like, and filled with marrow and fat.

The TBS is calculated from the lumbar spine image in your DXA scan. It is important to note that not all DXA scans can give you the TBS value, as it is computed from a specific software program your imaging center has to have.

Getting a TBS can add to the bone health picture by helping to predict your risk of bone fracture. It takes information about the number and spacing characteristics of the trabecular bone and gives you a score.

While a high TBS number indicates strong inner bone, a low TBS number is related to an increased risk of fracture. This is valuable because the DXA scan alone may indicate very mild osteopenia or normal bone mass while the inner bone may be more fragile.

Having two scores (the TBS and the DXA) will give you a better picture of what is happening with both the cortical and trabecular bone. You can then add your medical history to the puzzle to help you determine how to proceed with getting stronger bones and eventually reducing your risk of fracture.

I hope this is helpful. As always, my references are listed below. You can read more in-depth if that is your thing - I gave you an overview here today.

Get active today!

Andrea

Reference:​
Harvey, N. C., Glüer, C. C., Binkley, N., McCloskey, E. V., Brandi, M. L., Cooper, C., Kendler, D., Lamy, O., Laslop, A., Camargos, B. M., Reginster, J. Y., Rizzoli, R., & Kanis, J. A. (2015). Trabecular bone score (TBS) as a new complementary approach for osteoporosis evaluation in clinical practice. Bone, 78, 216–224. https://doi.org/10.1016/j.bone.2015.05.016

Sangondimath, G., Sen, R. K., & T, F. R. (2023). DEXA and Imaging in Osteoporosis. Indian journal of orthopaedics, 57(Suppl 1), 82–93. https://doi.org/10.1007/s43465-023-01059-2

Can I Build Bone with Exercise?

I want to start 2024 by addressing the most frequent question I get about osteopenia and osteoporosis:

Single leg lunge with added bone strengthening by adding Dumbbells at shoulder level

Can I build bone with exercise?

There are so many factors that go into your bone health.

One of the first things to consider is how strong your bones got before you turned 25. I have heard osteoporosis referred to as a young person's disease that shows up decades later.

If you had access to good food and participated in sports, your bones had a good chance of getting to peak density. You started in a good place.

Unfortunately, many women did not maximize their bone in their early years and are paying the price now.

But that doesn't mean you can't make gains now if your bone is loaded correctly and your diet includes the building blocks of bone.

Why doesn't everyone in the medical community know this and recommend weight training?

The truth is that very few studies have been published that focus on strength training for women with bone loss. Osteopenia and osteoporosis research is still in its infancy.

When the science isn't there, conflicting and confusing information comes out. Some women have been told not to lift anything, to avoid activities that put them at any risk of falling, and to be sedentary.

This is the opposite of what the research says is needed to build bone and keep it strong.

Here is the latest study "The effects of high velocity resistance training on bone mineral density in older adults: A systematic review" published on Dec. 7th, 2023. I think it represents the future of osteoporosis and osteopenia management.

This study pushes the boundaries of what exercise for older adults looks like. High-velocity resistance training? Wow, that is a step in the right direction about how to approach bone loss.

No more kid gloves, let's work those muscles and bones!

The authors found that bone mineral density improved in the spine, the femoral neck, and the total hip with high-velocity resistance training. This is a different type of exercise than resistance training. The weights tend to be bigger, and more explosive or faster movements are encouraged. It was a systematic review, so the protocols were varied.

I love how this study supports a higher level of training and suggests we can be more aggressive with the treatment of bone density issues.

I think we will continue to see more studies like this. And with the research, the specific exercise protocols will be published, and we will have more options for women beyond just recommending medication.

Quick summary:

If you want more gains in your bone strength, you need to gain muscle strength and to do this, you need to overload the muscle.

You need twice-a-week strength training and you need to keep it up long-term (6 months plus).

You will lose your gains after six months if you stop completely.

An initial higher-intensity program can help you make gains, but you need to keep a moderate program going long-term to keep your benefit.

OK, that's it. If you would like to start an exercise program you can do at home - be sure to join my next Strong Women, Strong Bones program. In four weeks, you will learn how to lift weights even if you have never touched a weight before. We also work on safe yoga poses, balance challenges and nutrition. I hope you join me.

Andrea

Reference:​
Haque, I., Schlacht, T. Z., & Skelton, D. A. (2023). The effects of high velocity resistance training on bone mineral density in older adults: A systematic review. Bone, 179, 116986. Advance online publication. https://doi.org/10.1016/j.bone.2023.116986

Collagen for Stronger Bones? Is Collagen Vegan?

Can collagen be vegan?

It is a good question to ask because the information out there is confusing.

Bone broth is a good source of collagen.

First, we should know why we would want collagen at all.

Collagen has shown to be a promising supplement for those with osteoporosis and osteopenia.

Let's look at two studies.

This study, ​Specific Collagen Peptides Improve Bone Mineral Density and Bone Markers in Postmenopausal Women - A Randomized Controlled Study​, came out in 2018. The researchers studied 131 post-menopausal women with low bone mineral density (BMD) at either their femoral neck (the hip) or in the spine. Half of the women dissolved 5g of collagen peptides in water before breakfast for 12 months, and the control group got a placebo to dissolve in water before breakfast. At 12 months, repeat DEXA scans found that the collagen supplement group had increased their BMD by almost 3.0% in the spine and 6.7% in the femoral neck. For the control group, BMD decreased by −1.3% for the spine and −1.0% in the femoral neck.

In 2020, the ​Effect of calcium and vitamin D supplementation with and without collagen peptides on bone turnover in postmenopausal women with osteopenia​ was published. The study was done with two groups of postmenopausal women with osteopenia (mean age 62 for both groups). Group A took a collagen peptide (Fortibone), Vitamin D, and Calcium for 3 months, while Group B took just Vitamin D and Calcium. After 3 months, the women in Group A, with the collagen peptide, showed bone marker changes that Group B did not. The authors concluded that adding collagen peptides along with Vitamin D and Calcium may have slowed down the bone turnover rate.

I do want to note that the studies were at least partially funded by companies that sell collagen. That said, the studies do appear to be legitimately peer-reviewed, and the scientists declared they had no conflict of interest. But it is always good to check these things when looking at results. Collagen is not a new product and has been extensively studied by the beauty industry for its skin benefits. It is interesting to see how one product can affect multiple body systems, something we should always consider when ingesting any supplement.

So what is collagen? Collagen is a structural protein. It is frequently referred to as the “glue” in your body.

It is found in muscle, bone, tendons, ligaments, and skin. It helps hold your cells together.

Your fascia is made of collagen, which is essential for your connective tissue health.

It is made of molecules called amino acids.

We need 20 amino acids in our diet, but some of the important ones for building protein include:

Glycine, Proline, and Hydroxyproline.

amino acids build peptides. Many peptides combine to build complete proteins.

These amino acids combine to make up peptides, and when there are hundreds of amino acids linked together, they build collagen proteins.

Collagen is found abundantly in animal products.

Meat - beef, chicken Bone broth - bones boiled, collagen released Fish with bones (sardines) Shellfish - Oysters - Shrimp Egg whites

Your diet needs to include all the nutrients you need to make collagen.

And supplements might help you get all of the collagen you need as you get older.

But what if you are vegan? Can you get a vegan collagen supplement?

No. Collagen is derived from animals. There isn’t any true collagen supplement that is vegan. But, there are vegan collagen boosters or promoters. These supplements may help you make your own collagen.

Read the label on your "Vegan Collagen" and make sure your supplement has the following:

✅Vitamin C
✅Amino acids
✅Zinc
✅Copper
✅Probiotics and Prebiotics

Many products on the market use clever wording to make it seem like you are getting vegan collagen. But if you look closely at the labels, you will see the amino acids listed, but not collagen.

Collagen should be listed by type and source. For instance, you may see Type II collagen from chicken, or Type I from bovine or marine sources.

If you would like to know even more about the different types of collagen and how to pick out collagen for yourself, I have a recorded collagen masterclass available, ​Collagen: What's All The Hype? Should you be supplementing with collagen?​ It is about 37 minutes long and I go through all the details of what collagen is, why you might want to take it, and how to read a label. This class was presented to my Strong Women, Strong Bones members in October 2022.

It is not easy figuring out fact from fiction with the clever marketing out there. I hope this helps clear up the confusion. I made a short video of myself and my collagen routine you can​ see here on YouTube.​

Here are a few brands I have tried (no affiliate links, just me sharing the info).
Maxi-life 7000 from Country Life.
Sparkle Skin Boost Plus with Verisol.
Ancient Nutrition Multi Collagen Protein.
Momentous Collagen Peptides Powder (this is the one I am currently using)

✅Stay informed and stay strong, and learn more about collagen and staying strong by joining my Strong Women, Strong Bones program. I look forward to learning with you,

Andrea

References:

Argyrou, C., Karlafti, E., Lampropoulou-Adamidou, K., Tournis, S., Makris, K., Trovas, G., Dontas, I., & Triantafyllopoulos, I. K. (2020). Effect of calcium and vitamin D supplementation with and without collagen peptides on bone turnover in postmenopausal women with osteopenia. Journal of musculoskeletal & neuronal interactions, 20(1), 12–17.

König, D., Oesser, S., Scharla, S., Zdzieblik, D., & Gollhofer, A. (2018). Specific Collagen Peptides Improve Bone Mineral Density and Bone Markers in Postmenopausal Women-A Randomized Controlled Study. Nutrients, 10(1), 97. https://doi.org/10.3390/nu10010097

Lampropoulou-Adamidou, K., Karlafti, E., Argyrou, C., Makris, K., Trovas, G., Dontas, I. A., Tournis, S., & Triantafyllopoulos, I. K. (2022). Effect of Calcium and Vitamin D Supplementation With and Without Collagen Peptides on Volumetric and Areal Bone Mineral Density, Bone Geometry and Bone Turnover in Postmenopausal Women With Osteopenia. Journal of clinical densitometry: the official journal of the International Society for Clinical Densit

Will Prunes help me build stronger bones?

Eating prunes can help you get the nutrients you need to keep your bones strong

Have you heard that prunes are good to eat to prevent osteopenia or osteoporosis?

It's true.

​ The Prune Study, published in 2022, found prunes to be effective in preserving bone density. The study was conducted over 12 months, and the postmenopausal women ate 50g or 100g of prunes daily. That is roughly 6 prunes to get to 50g. The 100g prune group lost many participants, suggesting eating that many prunes isn't feasible.

Women who consumed 50g of prunes had a decreased risk of fracture compared to the control group at one year. While the control group lost 1.1% of bone mass, the 50g prune group maintained their bone density.

I will be honest, I tend to eat 2 prunes a day, fewer than the amount recommended by the authors of the study. But I am also weight training and I haven't had a fracture. This seems like an easy addition to what I am already doing.

You can decide what feels right for your body and your bone situation.

Be sure to check with your primary care physician and/or pharmacist if you are taking medications that may interact with this many prunes. While they are a good source of Vitamin K and good for bone health, foods high in Vitamin K, such as broccoli, cabbage, chard, kale, and prunes, may counteract the effects of blood thinners.

Takehome tips:​
Eat a wide variety of foods
Get enough protein in your meal to help feel full and build muscle
Drink plenty of water to stay hydrated, especially when you are working out and lifting weights
Food before Pharmacy - get your nutrition from your food rather than supplements whenever possible.

✅Enjoy your food, nourish your body,

Andrea

References:

Damani, J. J., Oh, E. S., De Souza, M. J., Strock, N. C., Williams, N. I., Nakatsu, C. H., Lee, H., Weaver, C., & Rogers, C. J. (2023). Prune Consumption Attenuates Proinflammatory Cytokine Secretion and Alters Monocyte Activation in Postmenopausal Women: Secondary Outcome Analysis of a 12-Mo Randomized Controlled Trial: The Prune Study. The Journal of nutrition, S0022-3166(23)72732-6. Advance online publication. https://doi.org/10.1016/j.tjnut.2023.11.014

De Souza, M. J., Strock, N. C. A., Williams, N. I., Lee, H., Koltun, K. J., Rogers, C., Ferruzzi, M. G., Nakatsu, C. H., & Weaver, C. (2022). Prunes preserve hip bone mineral density in a 12-month randomized controlled trial in postmenopausal women: the Prune Study. The American journal of clinical nutrition, 116(4), 897–910. https://doi.org/10.1093/ajcn/nqac189

Whole Body Vibration or Heel Drop for Osteoporosis and Osteopenia?

Your time is precious, how should you spend it? You want to address your osteopenia or osteoporosis and prevent further bone loss, but how?

Let's talk about Whole Body Vibration (WBV) as a way to increase bone density.

I get asked about WBV fairly often. When you first find out that your bone density is not what you thought it was, it is normal to want to do everything you can to improve it. Maybe WBV is the thing you should be doing.

What does the most recent research tell us about whole-body vibration?

In January 2023, The journal, Osteoporosis International released Effectiveness of whole-body vibration on bone mineral density in postmenopausal women: a systematic review and meta-analysis of randomized controlled trials and meta-analysis with some interesting findings.

After evaluating 21 studies, it was concluded that WBV at a high frequency (30 Hz), low magnitude (0.3g), and high cumulative dose (>7000 minutes) is effective at increasing bone density at the lumbar spine. This is a lot of time on a vibration plate. You would need to be on the vibration plate for about 20 minutes a day for over a year to get this benefit. And, because the benefits were mostly seen with high-frequency settings, this type of protocol is not safe for those who are at a high risk of fracture.

​What does this mean?

When we look at the benefits of WBV compared to a regular exercise program, there is no difference; meaning they both help.

At this time, we don't know if the benefits of WBV last. A few more drawbacks to WBV include access, most people do not have a WBV plate, and the expense of buying one that has these specific parameters and will last over 7000 minutes is not cheap. There is also some conflicting information about whether you should stand on the plate with flexed knees or not. For anyone with knee arthritis, this may be difficult to do.

Another systematic review released in July 2023, Impacts of Whole-Body Vibration on Muscle Strength, Power, and Endurance in Older Adults: A Systematic Review and Meta-Analysis, found that lower body strength improved with WBV. Most of the included studies were of low quality, and they concluded that there was no difference between WBV and other types of exercise.

We do know that regular resistance and cardiovascular exercise have many benefits beyond bone and lower body strengthening that WBV doesn't have. This includes improvement in:
👉heart disease risk,
👉improving depression,
👉helping with weight management
👉decreased hot flashes.

This means exercise, including weight training, resistance training, and cardio workouts is a much better use of your time and money.

Takeaway: Spend your 20 minutes a day doing resistance exercise, rather than standing on a vibration plate. Spend your money on an exercise class or coach rather than buying a vibration plate.

To go along with exercises that benefit your bones, see my Exercise Tip heel drops and foot stomping. The way to increase bone density comes down to anatomy. Bone is stimulated to form in relation to the forces put through it, particularly compression. What better way to compress bone than stomping around or doing heel drops? Of course, if you have an active fracture, don't do these exercises.

What do you think?

If you need help getting started with a consistent exercise routine, I am here to help. Join my waitlist and be the first to get the details of my upcoming Strong Women, Strong Bones 4-week Jumpstart program.

I look forward to helping you build bone and healthy habits,

Andrea​
​

Reference:​
de Oliveira, R. D. J., de Oliveira, R. G., de Oliveira, L. C., Santos-Filho, S. D., Sá-Caputo, D. C., & Bernardo-Filho, M. (2023). Effectiveness of whole-body vibration on bone mineral density in postmenopausal women: a systematic review and meta-analysis of randomized controlled trials. Osteoporosis International: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, 34(1), 29–52. https://doi.org/10.1007/s00198-022-06556-y

Gonçalves de Oliveira R, Coutinho HMEL, Martins MNM, Bernardo-Filho M, de Sá-Caputo DDC, Campos de Oliveira L, Taiar R. Impacts of Whole-Body Vibration on Muscle Strength, Power, and Endurance in Older Adults: A Systematic Review and Meta-Analysis. J Clin Med. 2023 Jul 3;12(13):4467. doi: 10.3390/jcm12134467. PMID: 37445502; PMCID: PMC10342949.

Weight Training for Stronger Bones After 50

What is the best way to combat bone loss and prevent future fractures?

Weight Training. 💪💪💪

Osteoporosis and osteopenia are a reality for many women over 50. The loss of estrogen during our menopause transition is the problem. Our osteoclasts and osteoblasts, the cells that break down and rebuild bone, get out of balance.

The osteoclasts, the cells that break down bone, outnumber the bone-building osteoblasts, and we end up with a net loss of bone.

It's not fair, I agree. But that doesn't mean we are without tools to get ourselves back to a good place.

Lifting weights (resistance training) is the best way to fight back against bone loss. But we don't have specific exercise protocols to follow yet. We can't say exactly what amount you should do, how much you should lift, or how often.

One reason we don't have specific protocols is that we don't know exactly what it is about weight training that helps our bones.

But the research is coming. And with it, we will have a better understanding of what happens at the cellular level and eventually, this should result in more specific weight training recommendations.

👉 This pilot study, Anti-osteoporosis mechanism of resistance exercise in ovariectomized rats based on transcriptome analysis published in Frontiers in Endocrinology investigated what effect exercise had on the bone of post-menopausal rats. The rats were divided into three groups. Two groups had their ovaries removed (the post-menopausal rats) and the third group (the sham group) did not.

The exercise group of rats underwent a 5-day-a-week program that included climbing a ladder, as well as pulling steel balls with increasing amounts of weight. 🐀

The control group did not exercise nor did the sham operation group.

The results showed that the rats who did the resistance training decreased their body weight compared to the other group, and had less bone loss. The sham group did not lose bone.

While the exact mechanism of how exercise helped keep the bone, the researchers confirmed that resistance exercise had an inhibitory effect on osteoclast activity. Osteoclasts break down or reabsorb bone, so if exercise can halt that, bone loss will be reduced.

This was a pilot study and opens the door for further investigation into how exercise changes bone at the cellular level. It's very exciting!

That is it for today. Stick around and I will continue to follow the research and give you recommendations as they come out.

✅ Let's keep exercising and preventing fractures,

Andrea

Reference

Wang, Q., Weng, H., Xu, Y., Ye, H., Liang, Y., Wang, L., Zhang, Y., Gao, Y., Wang, J., Xu, Y., Sun, Z., & Xu, G. (2023). Anti-osteoporosis mechanism of resistance exercise in ovariectomized rats based on transcriptome analysis: a pilot study. Frontiers in endocrinology, 14, 1162415. https://doi.org/10.3389/fendo.2023.1162415​

Bone Strength, Vitamin D and Muscle Strength - All Connected!

The research on osteoporosis and osteopenia is hard to find, but there are indications that it is being studied more and more. And now the connection between bone loss and muscle loss is also getting attention.

I came across this brand-new study and wanted to share it.

​The association of vitamin D with bone microarchitecture, muscle strength, and mobility performance in older women in long-term care.

It was published in the journal Bone in November, 2023.

I have written about Vitamin D before. You probably all know that I have low Vitamin D levels which were discovered with a blood test. My primary symptom was bone pain when I went to bed at night - not a symptom any of us want.

I was lucky to have a great physician who caught this, but unfortunately, after 2 years of increasing my Vitamin D and sunlight, my levels were still low. I now take prescription strength Vitamin D and will have my levels checked again next summer.

Back to the study.

The study was designed to see if there was a connection between three variables:
1. ​Vitamin D levels​
​2. Bone status using Trabecular Bone Score (TBS),
​3. Muscle strength using gait speed and grip strength

The Trabecular Bone Score is a way to evaluate bone microarchitecture indirectly and may help predict fragility fractures. It is a score taken from the lumbar spine DEXA (dual-energy X-ray absorptiometry) image. It is an advancement in DEXA technology but not all machines are capable of calculating this score.

The TBS is produced from a scanned image. The trabecular bone number, separation, and connectivity density are scored. A high TBS represents a strong, fracture-resistant microarchitecture, while a low TBS reflects weak, fracture-prone microarchitecture. It cannot be used accurately if you have had a lumbar fracture, or have a BMI above 37. It is not a stand-alone test, it is used to complement the original DEXA.

In the study, a connection was made between low Vitamin D levels, lower-quality bone, and lower strength. The study was relatively small, and the authors note that other factors could be at play.

I am sure there will be studies that go into this in-depth in the near future.

Takeaways​
* Vitamin D levels are easy to evaluate with your next blood work - go ahead and ask to have them checked.
* Keeping your muscles strong will improve your grip strength and gait speed, and will reduce your fall risk
* You may have a TBS on your next DEXA report, let's see how this helps us figure out our risk of fracture.

I hope this was helpful. I thought you might still have questions about the TBS, so I wrote more about it here: What Is A Trabecular Bone Score?

✅ Stay strong and retire active,

Andrea

References:

Haeri NS, Perera S, Greenspan SL. The association of vitamin D with bone microarchitecture, muscle strength, and mobility performance in older women in long-term care. Bone. 2023 Nov;176:116867. doi: 10.1016/j.bone.2023.116867. Epub 2023 Aug 5. PMID: 37544395; PMCID: PMC10528338.​

Rajan, R., Cherian, K. E., Kapoor, N., & Paul, T. V. (2020). Trabecular Bone Score-An Emerging Tool in the Management of Osteoporosis. Indian journal of endocrinology and metabolism, 24(3), 237–243. https://doi.org/10.4103/ijem.IJEM_147_20​

Osteoporosis Exercise Guidelines⭐

I you are a woman over 50 with osteoporosis, or osteopenia or are at risk, you probably have questions about the best exercises you should do to stay strong for years to come.

I am sending out a big thank you 🙏 to the Canadian Medical Association Journal for publishing these guidelines on osteoporosis management a few weeks ago.

Clinical Practice Guidelines are something astute healthcare providers look forward to in order to stay on top of the most current research. Guidelines like these are compiled by a group of healthcare professionals who go through all of the research and provide best-practice treatment recommendations. This is a time-consuming process, and the results often change what healthcare providers recommend to their patients.

While the guidelines are meant for healthcare providers, I think it is helpful for anyone with bone loss to know what the evidence for intervention supports and what it debunks. The complete document is sort of long, but there are 25 recommendations and 10 good practice statements you can check out.

I am going to highlight a few things I think are worth knowing, but of course, you can read the whole guide here.​

👉Recommendations (Check out tables #2-4 in the guide):

#1: Exercise.

💪 Balance and functional training more than 2 times per week. This includes reaching beyond the comfort zone, increasing repetitions and sets over time, changing the pace, and moving while doing something - all to improve balance and reduce the risk of falls.

#2 Nutrition.

Calcium from food, NOT FROM SUPPLEMENTS. Get 1200mg per day from calcium-rich foods.
​Vitamin D - It is hard to get the recommended dose from food, a supplement of 400 IU/day may be appropriate.
​Other - if you have a healthy diet, they suggest no supplementation of protein, vitamin K, or magnesium to prevent fractures. If you are on medications, consult your physician for your own plan.

#3 Fracture Risk.

Use the FRAX tool to assess risk.
✅Bone Mineral Density testing in postmenopausal females and males who
a. are aged 50–64 years with a previous osteoporosis-related fracture or ≥ 2 clinical risk factors OR
b. are aged ≥ 65 years with 1 clinical risk factor for fracture OR
c. are aged ≥ 70 year

#4 Pharmacological Recommendations​
Before initiating pharmacotherapy, good practice includes assessing for secondary causes of osteoporosis, and for potential limitations when considering specific osteoporosis pharmacotherapy.
Check out the complete table #4 for all recommendations, including specific medications and durations.

I hope you found this helpful.

I think one of the biggest challenges I see when women are first diagnosed with osteoporosis or osteopenia is the immediate desire to load up on supplements. While I understand the desire to take action and make up for something that might be missing in your diet, supplements are more often than not, not absorbed and therefore useless, expensive, and at times, harmful. I recommend supplements ONLY if you have been SPECIFICALLY told to take them by YOUR physician. DO NOT fall for the marketing of unregulated, untested supplements sold online, in health stores, or by personal trainers.

👉There is some specific research for very few supplements that can help with muscle 💪 and bone strength: vitamin D, Collagen, and creatine. Other than that, most vitamins, minerals, and protein should be taken in as food. Spend your money on organic food, exercise programs for women over 50 or exercise equipment - you will get more bang for your buck!

If you do see something that you want to try, please check with your doctor to make sure it isn't going to interact with the medication you are taking.

And remember, bone strength 🦴 is built by using it, not by ingesting the building blocks. Get out there and build bone by lifting weights.

​
Stay strong and retire active.

Reference:

CMAJ 2023 October 10;195:E1333-48. doi: 10.1503/cmaj.221647

Knee Arthritis, Is Exercise Making it Worse?

Once again, I have been scouring the internet for recent research on exercise to see what is hot 🔥 and relevant for those of us over 50, 60, 70, 80, and beyond. This week, let's talk about knee arthritis and ageism.

First, I want to congratulate you for participating in sports in your younger years, this was most likely beneficial to your health today, including your joint health. Unless you were a high-level elite athlete, your risk of developing osteoarthritis is the same as someone who has been sedentary. In this review article from 2016, the authors concluded:

"Moderate daily recreational or sport activities, whatever the type of sport,
are not a consistent risk factor for clinical or radiographic knee/hip OA."

Stop beating yourself up for running, or playing tennis, or whatever your sport was. You were active, and you are better off for it. The authors point out that physical activity helps more than it harms. The good stuff you get from physical activity:

"soft-tissue extensibility, blood flow, and synovial fluid mobility,
normal joint range of motion and ... essential nutrients to the cartilage matrix."

These are all GOOD things!

But some of you may have arthritis nonetheless. What should you do about it now?

In the September 2023 issue of the Journal of Geriatric Physical Therapy, a systematic review and meta-analysis, addressed this question. Should someone continue resistance training or add it in the presence of knee osteoarthritis?

The short answer is YES.

The average age of the subjects in the review was 64.2 years. The resistance training programs varied in length from 4-120 weeks, with a frequency between 2-7 times per week. Because it was a review, there was not a consistent exercise intervention. Some studies used weight machines, others used theraband or ankle weights. All of the studies worked to strengthen the quadriceps and hamstring muscle groups in some way.

The conclusions - Resistance training 2 times per week, above 50% of your one rep max, and consistently done beyond 4 weeks can help knee symptoms, function, and strength.
​
If you have not been strengthening your knees but would like to start, I have these two exercises for you.

The Straight Leg Raise, and the Quad Set. These are particularly helpful to know before any type of surgery, or after surgery, or to stay strong when standing exercises don't feel great. I am particularly fond on the leg press machine if you have access to one.

If your knees are feeling good but you need to be sure to keep your strength, start working on higher-demand exercises like the squat.​

Now I want to touch on the subject of ageism.

Definition from the American Psychological Association: Ageism is defined as discrimination against older people because of negative and inaccurate stereotypes—and it’s so ingrained in our culture that we often don’t even notice.

A recent comment in my Osteoporosis and Osteopenia Exercise group got me thinking about how important it is to keep pushing back on the stereotypes of aging. This sentence from this study in JAMA in 2022, really struck me:

Associating poor health with old age may be the most deeply rooted aging stereotype, despite evidence to the contrary (for example, 82.3% of participants in the current study rated their physical health as good or better).

I want to list a few examples of the questions that were asked in this study to determine if the participants were experiencing everyday ageism (you can read the whole list here):

​
I hear, see or read jokes about old age, aging, or older adults
I hear, see or read things suggesting that older adults and aging are unattractive or undesirable
People insist on helping me with things I can do on my own
People assume I have difficulty hearing or seeing things
Having health problems is a part of getting older

As a physical therapist, I can tell you I have been yelled at and called names many times for pushing older clients too hard by their well-meaning relatives. It started during my very first clinical rotation, right up to today in my Facebook group - MY Facebook group, about exercise! The irony.

Let's end ageism.​

✅ Stay strong and retire active,

Andrea

Addendum: This article by orthopedic surgeon Howard Luks backs up all I said here! Three Words that Cause Harm: "Bone on Bone"

References

Allen, J. O., Solway, E., Kirch, M., Singer, D., Kullgren, J. T., Moïse, V., & Malani, P. N. (2022). Experiences of Everyday Ageism and the Health of Older US Adults. JAMA network open, 5(6), e2217240. https://doi.org/10.1001/jamanetworkopen.2022.17240

Lefèvre-Colau, M. M., Nguyen, C., Haddad, R., Delamarche, P., Paris, G., Palazzo, C., Poiraudeau, S., Rannou, F., & Roren, A. (2016). Is physical activity, practiced as recommended for health benefit, a risk factor for osteoarthritis?. Annals of physical and rehabilitation medicine, 59(3), 196–206. https://doi.org/10.1016/j.rehab.2016.02.007

Wang, Huan PhD1; Ma, Baoan MD1; Wang, Guotuan PhD2; Wang, Pu PhD1; Long, Hua PhD1; Niu, Shun PhD1; Dong, Chuan PhD1; Zhang, Hongtao PhD1; Zhao, Zhen PhD1; Ma, Qiong PhD1; Hsu, Chihw-Wen PhD3,4; Yang, Yong PhD5; Wei, Jianshe PhD2,6. Dose-Response Relationships of Resistance Training in Adults With Knee Osteoarthritis: A Systematic Review and Meta-analysis. Journal of Geriatric Physical Therapy ():10.1519/JPT.0000000000000394, September 29, 2023. | DOI: 10.1519/JPT.0000000000000394

Online Exercise: Effective for improving balance, strength and independence ✅

Once again, I have been scouring the most recent research to see what is hot 🔥 and relevant for those of us over 50, 60, 70, 80, and beyond. This week, I want to share with you the results of a new research paper. The authors delved into the effectiveness of online exercise classes for older adults (that's what I do)!!!

This study: Effectiveness of an online multicomponent physical exercise intervention on the physical performance of community-dwelling older adults: A randomized controlled trial concluded that a consistent online program could be beneficial for improving overall physical performance, balance and decrease functional dependence for older adults. (FYI, the participants were both women and men, age 60 and over).

When I read the list of exercises, it gave me goosebumps!!

​
They practically replicated my Strong Women, Strong Bones program!

Here is a quick summary of what they did:​
1) 10 min warm-up exercises (walking, followed by head, shoulder, and lower limbs movements),
2) 30 min of the general exercises: upper and lower body strength exercises to improve neuromuscular activity, muscle mass, strength, power, and functional capacity,
3) 10 min back to normal exercises consisting of neck flexion movements, shoulder and arm stretches, and limb stretch exercises.

This equates to what I do with my Tuesday and Thursday yoga classes, as well as my Monday and Friday Weights & Core classes.

I was blown away at how similar the exercise program they used was to mine - but I shouldn't be, they are both based on what we know from the research in exercise science and studies with older adults.

Those of you who are already working with me should really celebrate. 🎉
You are doing all the right things, and it is going to pay off.

For those who are new here, I would love for you to join me for a 4-week Strong Women, Strong Bones Jumpstart.

My 4 week intensive eases you into regular exercise in a way that minimizes your chances of getting an overuse injury, teaches you how to lift weights safely, as well as practice yoga in a way you can modify no matter where you take a class.

✅The authors of the research paper stated this:

"The minimum period of the training program should be three months, and it should include endurance, strength, coordination, balance, and flexibility exercises that last 30 to 40 minutes each time."

That might sound difficult, so why not start with just a 4-week commitment?

My program meets 4 mornings a week, and the classes are 35 minutes. Once you complete the 4-week intensive, you can continue with me month-to-month in my membership for as long as you like (hopefully at least an additional 2 months).

Are you ready to commit to your health?

Whether you are about to jump in and join the upcoming cohort, have already worked with me, or are currently working with me in the membership, I am here to cheer you on and do the work with you.

Stay strong and retire active,

Dr. Andrea Trombley PT, DPT

Reference

Edna Mayela VC, Miriam LT, Ana Isabel GG, Oscar RC, Alejandra CA. Effectiveness of an online multicomponent physical exercise intervention on the physical performance of community-dwelling older adults: A randomized controlled trial. Geriatr Nurs. 2023 Sep 14;54:83-93. doi: 10.1016/j.gerinurse.2023.08.018. Epub ahead of print. PMID: 37716123.

Can You Reverse Bone Loss with Supplements? NOPE. Call out the scammers.

Are you ready for some straight talk on supplements and people pushing products that help their bottom line, but not you?

This is all over the online space in regards to osteoporosis and osteopenia, as well as other issues women have around menopause. I see too many women spending money on unsubstantiated supplements.

This week, in my private Facebook group, Osteoporosis & Osteopenia Exercise Support, a sincere member asked about taking salt for bone knitting. This is just one example of how a dietary product gets blown up into an expensive product.

As someone who has spent a good amount of time going over the chemical reactions needed to make bone and understand the ways bone loss occurs, I can state that not once did salt show up as something that women need to purposefully add to their diets.

Someone was actually telling women to be sure to add a very specific type of salt to help "knit" bone.

It sounds sort of fancy and promising.

It makes it sound like it is the magic, missing key to making bone. But if there was indeed one ingredient you all needed to be taking, I would be the first to shout it from the rooftops!

Sidenote: Let's take a moment to say that yes, quality ingredients 🥬sourced from legitimate companies are always important. Micronutrients are essential. But getting them in salt is probably not where I would choose to source micronutrients.

Fact: The number one killer of women is heart disease. That's right, ❤️ Heart Disease is our biggest challenge as women.

Diet is a HUGE part of the healthy heart equation (and bone-building). Limiting salt is something almost all of us need to do. According to the National Cancer Institute, on average, women consume 2895 mg of sodium per day. This level is well above the current FDA recommendations to keep sodium intake below 2300 mg.

If you want to buy better salt, go for it. Head to your local health food market and buy fancy salt. But let's be honest, how much salt do you really add to your food? Do you need a $30 half-pound bag of salt? I have had a small bag of Himalayan salt in my pantry for years. I hardly ever add salt to anything. There is more than enough salt in the food I buy.

I am picking on salt today, but there are many other supplements being promoted online that "reverse osteoporosis".

I have not seen any supplement that you can buy online that reverses osteoporosis. I would be the first one to tell you if such a thing existed.

What should you be looking for to see if the product is legit?💊

Who is selling the supplement? If you see the author of the post promoting their own product, that is a red flag🟥. Same goes for podcasts that are sponsored by a supplement.There are many self-proclaimed "authorities" on bone loss who have no medical training. And now they are selling their unregulated supplement and making claims that are just not true.

Remember, reviews can be made up. Open a new tab and ask a question like "Is taking salt a good way to build bone", or Google the name of the person selling the supplement to see if Wikipedia has some general info.

👉I follow Dr. Jen Gunter, an OB/GYN who is constantly calling out pseudo-scientists online. She recently wrote an extensive piece on the ugly game of supplements that you may enjoy: Supplement Roulette. The Shocking Truth About What's Really in Your Products​

You can also learn how to evaluate claims by learning to use PUBMED.

PUBMED is a great place to check sources. I will get a post ready for you on how to look up quality information next week.

Today, let's quickly review what really reverses osteoporosis and bone loss:

An evidence-based approach to combat bone loss is through regular weight-bearing exercises. Weight-bearing activities like walking, jogging, dancing, and resistance training can significantly improve bone density and strength. These exercises stimulate bone growth and reduce the risk of fractures.

Good nutrition, including adequate levels of protein, Vitamin D, and sufficient calories to build muscle is also needed.

Medications for bone building can be prescribed for those of you who have profound bone loss and have a high risk of fracture. Take your time deciding if these medications are for you. You do not need to decide in a day or even a week after getting an osteoporosis diagnosis. Get second opinions, meet with an endocrinologist, ask questions, and know all about them. Many women have had fantastic results combining medication and exercise.

Don't make your mind up based on scary stories from people you don't know. If you do decide to take medications, do not let anyone make you feel bad. You are in control and only you know what is best for you!

I🌟 find it interesting that so many people are unwilling to take medications prescribed by their own doctors to build bone, yet these same people take unregulated supplements recommended by people on the internet whom they don't know. I can't explain it.

Your health and well-being are of utmost importance to me, and I'm here to provide support and guidance.

Wishing you good health and strength in your journey to manage osteoporosis.

To your health,

References

Carbone L, Johnson KC, Huang Y, Pettinger M, Thomas F, Cauley J, Crandall C, Tinker L, LeBoff MS, Wactawski-Wende J, Bethel M, Li W, Prentice R. Sodium Intake and Osteoporosis. Findings From the Women's Health Initiative. J Clin Endocrinol Metab. 2016 Apr;101(4):1414-21. doi: 10.1210/jc.2015-4017. Epub 2016 Feb 10. PMID: 26863423; PMCID: PMC4880174.

National Cancer Institute. Sources of sodium among the US population, 2005–06 report. Available from: http://riskfactor.cancer.gov/diet/foodsources/sodium/table3a.html.

Zhang S, Huang X, Zhao X, Li B, Cai Y, Liang X, Wan Q. Effect of exercise on bone mineral density among patients with osteoporosis and osteopenia: A systematic review and network meta-analysis. J Clin Nurs. 2022 Aug;31(15-16):2100-2111. doi: 10.1111/jocn.16101. Epub 2021 Nov 1. PMID: 34725872.

Hiking Poles or Nordic Walking, do you know the difference?

Let's talk about hiking poles.

Last weekend, I hiked with a new group of women, ranging in age from mid-20s to mid-70s (I am guessing)....

There were 11 of us. I wasn't too nervous about the ability of the group because in general, anyone who is willing to get up early and meet at 6 a.m. in the dark on a Saturday, probably has a certain level of fitness and ability to hike.

That was absolutely true for this group. We had a great out-and-back hike. 🥾

At the mid-point, when we turned around to head back down the trail, half of the women pulled out their collapsible hiking poles.

Smart women.✨

The terrain here in southern New Mexico can be quite challenging to descend. The small rocks and dry dirt can invite sliding and slipping.

✅Hiking poles can help stabilize the terrain and prevent falls. They also allow you to go a bit faster.

Many of my clients over the years have been resistant to using poles. The age stigma is real.

I am here to say, they can really make a HUGE difference in what you are willing and able to hike.

👉Here are some of the benefits of using hiking poles on uneven terrain:

Improved Balance and Stability: Hiking or trekking poles provide added stability on challenging trails, reducing the risk of falls and injuries.Reduced Impact on Joints: The poles help distribute your body weight, minimizing the impact on your knees, hips, and ankles. Your next-day soreness can be reduced, and you can go further.

Engagement of Upper Body Muscles: Hiking with poles engages your upper body muscles, leading to a more comprehensive and effective workout.

Enhanced Endurance: The support from poles allows you to maintain your pace for longer periods, boosting your endurance and extending your hiking range.

Adjust your poles for the best hike:

Proper Length: Adjust the poles so that your elbows are at a 90-degree angle when your hands are on the grips and the tips are planted on the ground.Terrain-Specific: Shorten the poles for uphill climbs to provide additional support. Lengthen them slightly for downhill sections to reduce impact. Grip and Strap: Hold the grips comfortably with a relaxed grip. The straps should support your wrists but allow easy movement of your hands. Planting Technique: As you walk, plant the poles slightly ahead of you, and push off with your palms to engage your muscles.

Nordic Walking

There is a difference between using poles for hiking versus an exercise called Nordic Walking.

Nordic walking arm motion is similar to Nordic skiing. This exercise does not require you to go out and find a trail, it is a way to add upper-body exercise to your walking program.

You do use poles with Nordic walking. Your arms stay relatively straight, and the pole stays behind you as you reach forward and plant the tip. You generate force by pushing backward on the pole, while the back of the pole stays behind you. The poles are used to push off the ground.

Nordic walking has been ​studied recently​ to see if it helped with bone density at the hip in women over 60. The results were promising. The study only lasted 8 weeks, but even in that short time, bone changes were found.

If you are having a hard time imagining what Nordic Walking is, you can see a great demonstration of what it is ​here.​

I hope you found this helpful.💯

While you can order poles from Amazon, I do recommend heading to your local sports store to try them if at all possible. You want to make sure the grip is comfortable, and that the weight feels good. You should also be able to collapse them (for travel, because I know you have an exciting hiking adventure in your future) and adjust them easily. REI is one place that carries poles, or your local sports store (shop local)!

References

Saller, M., Nagengast, N., Frisch, M., & Fuss, F. K. (2023). A Review of Biomechanical and Physiological Effects of Using Poles in Sports. Bioengineering (Basel, Switzerland), 10(4), 497. https://doi.org/10.3390/bioengineering10040497

Wochna, K., Ogurkowska, M., Leszczyński, P., Stemplewski, R., Huta-Osiecka, A., Błaszczyk, A., Mączyński, J., & Nowak, A. (2022). Nordic walking with an integrated resistance shock absorber affects the femur strength and muscles torques in postmenopausal women. Scientific reports, 12(1), 20089. https://doi.org/10.1038/s41598-022-24131-7