Wellness Industry vs My PubMed Access: We Are Doing The Bone Dance

This article will radicalize you to care about your skeleton. Yes.

First off: I know. THIS IS BORING. WHO CARES.

That is what I, too, once thought at the beginning of medical school, at the beginning of residency, etc up until about two years ago, when I started experience mild low back pain, and ended up in physical therapy to help with the ongoing bother of it. This opened a sort of Pandora’s Box for me, and in combination with my clinical work in eating disorders, general distaste for the Wellness Industry, and deeply feminist orientation, I have begun to care with great vigor about my (and, dear reader, your) bones. Today’s Wellness vs Pubmed will battle it out over what we can do with exercise now and later to help prevent being brittle when we would love to be spry in our 60s and beyond (and possibly before that).

As always, this is not medical, clinical, or personalized advice. I am not speaking in any way as an expert, and I am not an endocrinologist, so buyer beware of information. I write this column to offer a way of looking through the actual research together, and coming to nuanced, more usable points of understanding than magazines or companies selling you things do. Alright, onward!

Point 1: Why Care?

Everyone always says people should have to work in food or retail at some point in their lives so as to build empathy and understanding (and not be an asshat to servers for the rest of their lives). I think people would also generally benefit from working with sick people for 6 months of their life, and this would give the benefit of understanding what illness, aging, and mortality are actually like. Bones began to matter to me not just in medical school, but when a family member of mine was diagnosed with a neurologic cancer, and suddenly his physical function and day to day strength was much changed. Part of one thing that protected him was his history of running and three times a week lifting weights at home.

Muscle mass and bone reserve may be a nice thing to have day to day when you’re overall healthy, but they become a full-on necessity and life saver as you age or encounter very serious illness. The reserve—of muscle, of bone, and of cardiovascular health—matter both for treatments and ability to recover to your prior functioning level when going through acute changes in health, or changes over the lifespan.

One of the ways bone health is emphasized in medical school training is through understanding the importance of increased mortality after someone suffers from a hip fracture, which happens due to weakened bones combined with decreased balance (ie lower threshold for bones to break, and higher frequency of situations that may result in force upon the hip to break). 12 Month mortality seems to increase somewhere between 20-30% after hip fracture¹, with a substantial portion of folks who do well with treatment still not returning to prior functioning. Keeping our bones strong as well as our muscle and balance strong as preventative healthcare especially with longer lifespans is important—but often, we aren’t marketed it in this way.

Point 2: Fine, I care now. Not saying I’ll do anything about it, but if I did, what’s good advice on this?

Great! This question splits a few different ways, but we will focus on two questions regarding exercise. Many things impact the bone, including autoimmune illness or treatment, oncologic illness, malnutrition, GI conditions, vitamin deficiencies, etc. We will not get into these here, and as always speak to your clinician and professionals if you have questions or concerns on your overall approach to bone health.

The two questions regarding exercise, then, become:

1. Is there guidance on exercise for kids vs young / middle adulthood that can help future us out?

2. Is there a difference between exercise type and impact on bone strength, structure, and subsequent outcomes?

Point 3: What is preventative health for our bones?

In childhood—the time when the most bone building and forming happens—advice from pediatrics is ensuring wholesome, vitamin-containing nutrition, usual screening for hormonal or metabolic conditions, and exercise.² By 18 years old, approximately 90% of peak bone mass has already been accrued. Per this 2014 article from the American Academy of Pediatrics, “For most children and adolescents, walking, jogging, jumping, and dancing activities are better for bone health than are swimming or bicycle riding” due to the fact that body-weight bearing activities with impact offer better stimulus than those without impact (ie the smooth pursuits of swimming and biking)³. Moving more throughout childhood, with some special attention to differences in pre-puberty and during puberty seems indicated. These benefits also seem to last into adulthood and onward.

In adulthood, the recommendations related to exercise get a bit less clear-cut, but trends have been emerging over the last decade. It is known that more daily movement overall (not just in exercise, but in walking, grocery shopping, acts of daily living, etc) appears to be correlated to better bone health.⁴ When it comes to type of exercise difference, this position statement from the National Osteoporosis Foundation in 2016 explains:

“Bone is most responsive to physical activities that are dynamic, moderate to high in load magnitude, short in load duration, odd or nonrepetitive in load direction, and applied quickly… On the other hand, due to desensitization of the osteocytes, static loads and repetitive low magnitude loads are not osteogenic [my note: bone-building]”.

In adulthood, in particular beyond the early 20s, the question of bone health becomes one of maintenance rather than aiming at baseline improvement. Our current understanding of bone loss and osteoporosis emergence seems to be a slow and then more increased decline, especially post-menopause for women. Exercise that helps maintain muscle mass (which facilitates bone strength and maintenance in its action at the bone), exerts tolerable impact, and helps with balance are all key to preventative approaches via exercise for bone health and reduced risk of future fractures. Of those three, balance is the least important as a prevention method compared to building muscle and impact at the bone.⁵ Balance in addition to muscle and impact becomes more important in later decades of life when, for many reasons related to comorbid health concerns common to later years, balance worsens.

Due to the lack of impact for most forms of pilates, yoga, and barre (unless there is jumping or fast force, which some specialized forms can possibly include), there is not a major bone protective benefit compared to day to day living. Additionally, given that for a majority of these method muscle failure is not reached due to loads being too small (ie, though the muscle may burn, you are not struggling to lift the weight, or can do 30+ reps), muscle is also not increased after the first few months of this type of exercise.

Point 4: But I like (xyz) and I don’t like this form of exercise

I get this. I feel this. I also did not want to know this information at first. This is where imagination and taking the urgency out can help us.

This information does NOT mean you need to suddenly change your fitness routine, or that low-impact or low weight workouts should have no place in your routine, or that community, group class, or all movement is good movement should not still be your foundation. I think that SHOULD be the foundation. This information is for future you, and to help debunk and declutter the many things the wellness industry INSISTS each season you must now do. I love Pilates and still work that and yoga in once or twice throughout the week, and they do help with balance which is needed now and forever as well.

This is information for you to have to help you make choices, not to make a choice for you. This information is to help you have more knowledge and choice in how you pick or don’t pick your exercise. Maybe this information just is good to have right now, and a year from now when your friend wants to go to an intro to progressive weights class, you decide to check it out together. Maybe you ask your pilates instructor if there is a way to get closer to failure in less reps for certain exercises, especially in areas where you would like to get stronger. Maybe this means that instead of thinking that a dance class or running workout is bad for your joints, you remember it can, at the right intensity, be something quite good for your bones.

This type of exercise doesn’t need to look like going to a big box gym, doing barbell or crossfit workouts, or giving up the mindful listening skill that low-impact exercise classes are often so good at teaching us. As you all know, I do Evlo (not-sponsored…I wish), which is by 3 physical therapists who also used to teach barre and Pilates. I light a candle, unroll my pink and green yoga mat, and use heavy dumbbells during sunrise in a corner of my apartment for my lifting. There are ways to take this information and personalize it, and that can be a joy to a lifetime of tending to movement and your well-being.

In the comments, let me know what other questions you have, and I’ll answer or point to more expert resources. There is soooo much more that could be said on this, but I am already way past most people’s attention spans.

To your good health and good science,

xx Margaret of Bad Art Every Day

1. O'Neill TW, Roy DK. How many people develop fractures with what outcome? Best Pract Res Clin Rheumatol. 2005 Dec;19(6):879-95. doi: 10.1016/j.berh.2005.06.003. PMID: 16301185.

2. Neville H. Golden, Steven A. Abrams, COMMITTEE ON NUTRITION, Stephen R. Daniels, Steven A. Abrams, Mark R. Corkins, Sarah D. de Ferranti, Neville H. Golden, Sheela N. Magge, Sarah Jane Schwarzenberg; Optimizing Bone Health in Children and Adolescents. Pediatrics October 2014; 134 (4): e1229–e1243. 10.1542/peds.2014-2173

3. Neville H. Golden, Steven A. Abrams, COMMITTEE ON NUTRITION, Stephen R. Daniels, Steven A. Abrams, Mark R. Corkins, Sarah D. de Ferranti, Neville H. Golden, Sheela N. Magge, Sarah Jane Schwarzenberg; Optimizing Bone Health in Children and Adolescents. Pediatrics October 2014; 134 (4): e1229–e1243. 10.1542/peds.2014-2173

4. Weaver CM, Gordon CM, Janz KF, Kalkwarf HJ, Lappe JM, Lewis R, O'Karma M, Wallace TC, Zemel BS. The National Osteoporosis Foundation's position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations. Osteoporos Int. 2016 Apr;27(4):1281-1386. doi: 10.1007/s00198-015-3440-3. Epub 2016 Feb 8. Erratum in: Osteoporos Int. 2016 Apr;27(4):1387. doi: 10.1007/s00198-016-3551-5. PMID: 26856587; PMCID: PMC4791473.

5. Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, Nieman DC, Swain DP; American College of Sports Medicine. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011 Jul;43(7):1334-59. doi: 10.1249/MSS.0b013e318213fefb. PMID: 21694556.