• dr puisan

"I want strong bones!" - Part 2

Diet is a huge part of osteoporosis prevention but that is only one part of a big puzzle.

The other huge chunk of preventive measure is physical activity (ie exercise), more specifically weight bearing exercises.

What exactly are weight bearing exercises?

Well, an easy way to understand this is ANY exercise that involves you carrying your own load (or even additional load) over a certain distance, without any mechanical aid or devices. Examples will be lifting weights, running, stair climbing, hiking and even walking.

If you are an avid cyclist or seasoned swimmer and you do not find your preferred activity listed above as weight bearing exercises, please do not feel offended. Various researches out there have proven many times over that weight-bearing activities trumps non-weight bearing activities (cycling, swimming etc) when it comes to bone density.

In fact, to give a clear distinction between the activities and how it affects your bone mass, let’s refer to a study done by Rector et al., (2009) that looked into the bone density differences between men who did (1) resistance training – ie lifting weights, (2) running and (3) cycling.

The idea is to distinguish whether higher loading onto bones (resistance training > running > cycling) will make it stronger and denser. Of course the authors of this paper concluded that the participants who strength train had the densest bones followed by the running group and lastly the cycling group.

“But cycling up hill is tough….surely that is adequate weight bearing!”

I understand your frustration and I occasionally have the same thought as I attempt to power up (albeit rather slowly) another ridiculously steep inclined hill. However do bear in mind that your entire body weight is seated on a saddle while your legs bear down to pedal, where pedalling is made easier with the changing of the appropriate gearings. There is no impact to the bones (esp your hips and your spine) when you pedal…unlike walking and running.

It does not mean that cycling is a bad form of exercise. In fact it is a great form of exercise to improve cardiovascular fitness but when viewed from the aspect of improving bone density and prevention of osteopenia/osteoporosis, then cycling just does not do the job. If cycling is your only ‘true love’ in terms of physical activities, then I’d advice to add on 2 to 3 days of resistance training. Not only will that improve bone density, but it also reduces the risk of cycling-related musculoskeletal injuries.

“But doc, this study you mentioned focuses on young men only. Isn’t osteoporosis a menopausal women’s disease?”

I’m glad you brought this up. Because osteoporosis is NOT only a menopausal women’s disease (as discussed in Part 1 of this series).

Also, I have more research that looked into menopausal women such as the LIFTMOR study (Watson et al., 2017). This study looked at 101 post menopausal women with low bone density and how different types of exercises affect their bone mass. Half the women participants underwent heavy resistance training where they were trained to lift up to 85% of their 1RM (repetition max – the most amount of weight you can lift for 1 repetition) for deadlift, back squats and overhead press. The other half did lower intensity body weight exercises such as lunges, calf raises, shrugs and some stretching. I’d like to point out that both groups would definitely have improvement in bone mass at the end of the intervention. And it shouldn’t surprise you that the improvement in bone density is more significant in the group of ladies who lifted heavy, as there is more loading onto the musculoskeletal system (ie bones).

“But doc, I’m worried about lifting weights even though I’m still young. Wouldn’t it make me huge and bulky?”

If I was given a dollar for every time I hear this response, I’d be able to retire right now with an insanely enormous figure in my bank account.

No. It would not make you huge and/or bulky. It takes quite a while (and a whole lot of effort in terms of training, nutrition, supplements and “supplements”) to build enough muscles to give Dwayne ‘The Rock’ Johnson a run for his money.

In fact for those entrenched in the endurance paradigm, the only method to reduce the risk of sporting injuries (ranging from ITB syndrome, plantar fasciitis to rotator cuff tendinopathies) is consistent resistance training.

Also those who fear “getting huge and bulky”, if by some luck you won the genetic lottery that builds muscles easily, you get huge and bulky when you do not watch what you eat. Resistance training does not give you a free pass to eat more than usual. In fact, if you want to look lean, mean and sculpted, you’d need to lose the subcutaneous body fat lying over those muscles you have worked hard to build.

“But doc, wouldn’t lifting weights be dangerous for older people?”

It would be if they accidentally drop the dumb bell onto their feet causing bruising and maybe a black toe (or worse…a fractured bone due to their osteoporosis).

But in all seriousness, why would lifting weights be dangerous for older people? Because you start off lifting at what you are able to lift and progress upwards!

Remember the LIFTMOR study and how the older ladies lifted 85% of their 1RM? If at the very start, someone could only lift 1kg for only 1 rep then that would be his or her 1RM. 85% of 1kg is only 850g. Which means they start lifting 850g for a certain number of sets and reps and as it gets easier (it eventually always will), then the weight will be increase as they go along. This is called progressive overload. And that is how we (our bodies) become stronger.

It does not mean lifting their entire body weight in load on their very first training session.

Unfortunately people always have that misconception when it comes to resistance training.

Strength and resistance training has repeatedly been shown to reduce morbidity (getting sick and ill) and mortality (dying) rates (Morales et al., 2018), plus it improves independence (older patients that are stronger and more mobile depend on others less) and reduce the risk of falls which may cause fractures. All of these can be avoided by changing our perception and adopting regular resistance training.

“Ok ok you’ve got a point. So tell me what I need to do?”

In Malaysia at this point in time, most doctors refer to the Clinical Practice Guidelines (CPG) for Osteoporosis (downloadable online) but we unfortunately do not have our own exercise guidelines for osteoporosis prevention. The CPG only states that physical activities and exercise is one of the preventive measures that should be looked into but no detailed guidelines laid down.

Therefore, we shall look at what other countries are recommending.

Cauley et al., (2019) looked at several exercise guidelines from countries such as Canada, UK and Australia. As expected there are variance in each guidelines but there are 2 things in common through out all those guidelines, which are:

- weight bearing exercises such as walking, hiking, climbing stairs, jumping and jogging, moderate intensity, most days of the week (ie 4-7 days), totaling to 150 minutes or more per week. This is exactly like the ACSM Exercise Guidelines for general health as well.

- 2-3 times per week of progressive resistance training (increasing load over time), 2-3 sets of 8-12 repetition maximums.

These guidelines are doable for most people and thus, a very good place to start at.cul

Take home points of this article are:

1. Weight bearing exercises are key in osteoporosis prevention (together with a good diet).

2. Resistance training is necessary and reduces all cause mortality rates.

3. Cycling and swimming are not enough

3. People need to stop proclaiming that resistance training is dangerous for elderly population.

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