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 Trombley PT, DPT

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,

Andrea Trombley PT, DPT

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 Trombley PT, DPT

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

Build Bone with Mineral Water and Eating for Exercise Motivation

Are you ready for another cutting-edge aging update? I stay on top of the current research so you don't have to.

This week, let's talk a bit more about hydration. Last week, I shared this study,  which pointed out the importance of staying hydrated to combat chronic disease and premature aging. The conclusion: 

Stay well hydrated.

What if you could better hydrate AND work on your bone health, specifically calcium absorption, as well? Mineral water may be what you need.

According to this study, mineral water had calcium absorption equal to milk and a calcium supplement in healthy test subjects. That's right, drinking mineral water produced the same increase in blood calcium levels as taking a supplement or drinking milk. 

What I found interesting about the study was the Vitamin D levels. Before the study was performed, all participants were given a Vitamin D supplement for 4 weeks to make sure calcium was absorbed. All the participants had adequate Vitamin D levels on the day of the experiment.

Takeaway: Mineral water may be a good way to get more Calcium and stay more hydrated. And without adequate Vitamin D, it won't be absorbed - get those Vitamin D levels checked and supplement if needed.

Now on to the motivation to exercise. Maybe what you eat has more impact than you thought.

This study just came out in Dec. 2022, in the journal Nature. The authors found a gut-brain connection in mice that seemed to help motivate some mice, labeled the active mice, to run and run, while other mice, labeled the lazy mice, did not. When the running mice were given antibiotics that changed their gut microbiome, the running mice became lazy mice. When the lazy mice were given gut microbiomes from the active mice, they became active. Crazy cool. It may be that the antibiotics destroyed some of the dopamine receptors that helped with that exercise high. Restoring the microbiome then increased the exercise pleasure.

Takeaway: Get your healthy gut microbiome in order. This can be done with foods like yogurt, probiotics, Kefir, Kombucha, and fermented foods such as sauerkraut, and pickles.

Thanks for being here,

Andrea Trombley PT, DPT

References:

Dmitrieva, N. I., Gagarin, A., Liu, D., Wu, C. O., & Boehm, M. (2023). Middle-age high normal serum sodium as a risk factor for accelerated biological aging, chronic diseases, and premature mortality. EBioMedicine, 87, 104404. https://doi.org/10.1016/j.ebiom.2022.104404

Dohnalová, L., Lundgren, P., Carty, J. R. E., Goldstein, N., Wenski, S. L., Nanudorn, P., Thiengmag, S., Huang, K. P., Litichevskiy, L., Descamps, H. C., Chellappa, K., Glassman, A., Kessler, S., Kim, J., Cox, T. O., Dmitrieva-Posocco, O., Wong, A. C., Allman, E. L., Ghosh, S., Sharma, N., … Thaiss, C. A. (2022). A microbiome-dependent gut-brain pathway regulates motivation for exercise. Nature, 612(7941), 739–747. https://doi.org/10.1038/s41586-022-05525-z

Greupner, T., Schneider, I., & Hahn, A. (2017). Calcium Bioavailability from Mineral Waters with Different Mineralization in Comparison to Milk and a Supplement. Journal of the American College of Nutrition, 36(5), 386–390. https://doi.org/10.1080/07315724.2017.1299651