More than 10 million Americans aged 50 and older live with osteoporosis, a bone condition characterized by diminished bone mass and disrupted microarchitecture. Notably, women face a fourfold higher risk than men. This condition renders bones fragile and susceptible to fractures, although many people are unaware that they have it, as it is generally diagnosed via a bone mineral density (BMD) scan. Osteoporosis is typically diagnosed when an individual’s BMD falls 2.5 standard deviations or more below the average density of young adults, posing an elevated fracture risk, particularly in the hip, spine and wrist.

The structural weakening and heightened fracture risk associated with low BMD and microarchitectural deterioration underscore the critical health concerns of those who have, or are at risk for, osteoporosis. Hip, spine and wrist fractures, in particular, carry significant public health implications, particularly for older adults. Among these, hip fractures stand out as particularly devastating due to their strong association with severe disability and increased mortality.

As a health and exercise professional, understanding the distinctive exercise needs of individuals with osteoporosis is essential. This article outlines strategies for designing programs that will enable your clients who have osteoporosis to perform exercise safely and effectively.

Lifestyle Behaviors and Risk Factors Related to Osteoporosis

Osteopenia is defined as bone density between 1.0 and 2.5 standard deviations below the mean. In simpler terms, it means a person’s bone density is lower than what is considered normal, but not yet at the level seen in osteoporosis. An estimated 43 million Americans have osteopenia, which means they are at increased risk for developing osteoporosis during their lifetime. Moreover, people with osteopenia are at a greater risk for fracture and further bone deterioration, advancing to osteoporosis.

During the early growth years, the rate of bone formation is typically greater than the rate of bone resorption, resulting in an overall gain in bone mineral. However, this “remodeling” balance is disrupted as people age and the amount of bone formation no longer keeps pace with the amount of bone being resorbed. Various risk factors can contribute to bone loss. Some of which are nonmodifiable, while others are modifiable. Nonmodifiable risk factors include genetics, being female, being Caucasian or Asian, and being post-menopause. Near or at the onset of menopause, there is a decline in estrogen, and bone loss accelerates from the typical 0.5 to 1% to 2 to 6.5% per year. A range of modifiable risk factors and lifestyle behavior choices, including being physically active, consuming adequate calcium and vitamin D, limiting alcohol intake and avoiding smoking, influence 20 to 40% of adult peak bone mass.

Nutrition

Calcium and vitamin D are the two most important nutrients related to bone health. Lifelong adequate calcium intake is necessary for attaining peak BMD and maintaining bone health. The skeleton contains nearly all of the body’s calcium stores. When a person’s dietary intake of calcium is inadequate, bone tissue is resorbed from the skeleton to maintain blood calcium at a constant level. Vitamin D plays a major role in calcium absorption, bone health, muscle performance, balance and risk of falling. Clinicians recommend consuming a diet with adequate amounts of calcium (1,000 mg/day for men aged 50 to 70 years and 1,200 mg/day for women aged 51 and older and men aged 71 and older). For vitamin D, the recommended intake is 800 to 1,000 IU/day, including supplements if necessary for clients aged 50 and older. Encourage clients who have osteoporosis to meet with a registered dietitian or other qualified healthcare professional for recommendations on vitamin and mineral supplementation and appropriate diets.

Alcohol Intake

Drinking alcohol in excessive amounts is detrimental to bone health. Moderate alcohol intake has no known negative effect on bone and may be associated with slightly higher bone density and lower risk of fracture in postmenopausal women. However, consuming more than two alcoholic drinks per day for women or three drinks a day for men is associated with impaired bone health, increased risk of falling and potential alcoholism.

Age and Osteoporosis

Osteoporosis is the most common bone disease, affecting one in three women and one in five men over the age of 50 worldwide. With a rapidly aging population, in the United States and elsewhere, the prevalence of osteoporosis has increased and will continue to increase markedly into the future. If you are a health and exercise professional who works with middle-age to older adults, it is essential that you understand the effects of aging on bone health.

Although it is inevitable that physiological function will decline with age, the rate and magnitude of change is dependent on a complex interaction of genetics, individual health, the presence of disease or injury, and exercise history. Safe and effective exercise programming for older adults requires an understanding of the effects of aging on physiological function at rest and throughout the exercise intensity spectrum. A list of key physiological aspects of aging is presented in Table 1. Being aware of the physiological aspects of aging for your clients with osteoporosis will help you and your clients work together to establish realistic program goals.

*adapted from American College of Sports Medicine, 2021

Exercise Programming for Clients Who Have Osteoporosis

Exercise is important for both the prevention and treatment of osteoporosis. The primary goal is to prevent the loss of bone mineral and to decrease the risk of falls and fractures. While there is currently no single, optimal strategy for preserving bone health, it is known that physical stress influences the strength of bone. Mechanical stress applied to bone results in a minor change in the shape or structure of bone tissue, which stimulates bone formation and associated gains in bone mass and strength. Compelling evidence suggests that regular physical activity can increase BMD and lower the risk of falls and fractures.

There are currently no established guidelines on contraindications for exercise for people with osteoporosis. However, the following exercise considerations are helpful for individuals who have, or are at risk for, osteoporosis:

• Avoid excessive bending, twisting or compression of the spine. These types of activities may increase the risk of spine fracture. However, trunk extension and abdominal stabilization exercises may be beneficial.
• Engage in weight-bearing aerobic activity (e.g., walking, jogging and stair stepping) and high-velocity resistance training. Exercises that involve high-impact loading or explosive movements should be avoided. Clients who have osteoporosis can safely perform a variety of aerobic physical activities and muscular training. However, the intensity of the exercise sessions should initially be moderate and progressively increase based on the individual’s capability and proper alignment and form are more important than intensity.
• Incorporate activities that promote balance. Focus on exercises that improve strength in the muscles of the trunk, hips and lower extremities, as these are important in balance.
• Avoid movements or environments that could lead to a fall. Quick, jarring movements or exercise on slick surfaces or around tripping hazards should be avoided to minimize the risk of a fall or fracture.

Follow the exercise guidelines presented in Table 2 for cardiorespiratory and muscular training when designing programs for clients who have osteoporosis.

Reduce Fall Risk With Balance Training

Individuals who have osteoporosis have weak bones, which increases their risk for fractures that can lead to serious health problems and premature mortality. Women with a hip fracture, for example, are four times more likely to experience another fracture, and about one in two women and one in four men over the age of 50 will break a bone due to osteoporosis, and falls are the most common cause. Falls are responsible for more than 90% of all hip fractures, and the incidence of hip fractures increases exponentially with age due to a loss of bone density and muscular strength, as well as poor balance.

Given the increased incidence of falls and subsequent hip fractures, regular balance programming should be a priority for clients who have osteoporosis to reduce their risk of falls and fractures. The aim of a balance-training program is to improve gait and balance deficits and reduce the fear of falling to increase self-confidence and physical activity. The ability to divide attention between a proprioceptive and a cognitive task is known as dual tasking, which is common in everyday life. Balance-training programs for older adult clients should focus on functional and progressive tasks of daily living. Some examples of different training programs include dual- and multitask exercises related to falling, such as spelling words while doing balance exercises, and standing core exercises. You can learn more about balance programing in this previous CERTIFIED article.

Summary

Working with clients who have specific health challenges such as osteoporosis can be extremely gratifying. Regular physical activity and other healthy lifestyle behaviors have been shown to lessen the progression from osteopenia to osteoporosis, help reduce the risk of falls and fractures, and improve overall health and well-being. To learn more about this disease and how to work with individuals who have osteoporosis, please check out these respected resources:

• American Bone Health
• Bone Health and Osteoporosis Foundation
• International Osteoporosis Foundation

Expand Your Knowledge

ACE Senior Fitness Specialist Program

The growing population of older adults is seeking to gain strength and vitality while warding off inactivity-related disease and cognitive decline—and you can help them achieve their goals. The NEW and IMPROVED ACE Senior Fitness Specialist Program will teach you how to safely and effectively help senior clients maintain vibrancy through health and fitness. You’ll discover a holistic approach to both body and brain health, combining rapport-building, behavior change, exercise programming, nutrition and cognitive health. Most older adults are impacted by some type of age-related chronic illness, injury or cognitive decline, so this specialized expertise will help increase your value and client pool.

Buff Bones^® Instructor Training

The Buff Bones^® Instructor Training course features a comprehensive movement system for bone and joint health, combining research-based techniques with innovative exercises. Taught by renowned movement educator and creator of the Buff Bones® system, Rebekah Rotstein, the course provides dynamic and accessible workout options that are adaptable to varying levels of ability and safe for those with osteoporosis and other comorbidities, like stenosis and osteoarthritis.

Simply Fit Senior

Based on the research series “ACE Health and Wellness Reports,” this practical course outlines the role that physical activity plays in delaying age-related declines in functional ability as well as in the prevention and management of chronic health conditions common to older adults, such as osteoporosis, arthritis, depression, and cardiovascular disease and its risk factors. You’ll learn how to plan, prepare, implement and make modifications to older clients’ exercise and wellness programs to meet their individual needs and goals so that they can achieve and maintain vibrancy, vitality and vigor as they age.