Once you hit midlife, you’re told to lift heavy weights and work your bones hard to prevent fractures. But a new method has come along to revolutionize osteoporosis prevention—all in 10 minutes a week. Tony Edwards investigates
Last March, two astronauts were rescued from the International Space Station (ISS), having been trapped there due to a technical fault. Originally scheduled to spend a mere eight days in space, the pair had been stuck orbiting the Earth in zero gravity for over eight months.
After they successfully splashed down in the ocean, they might have been expected to leap for joy when ferried back to terra firma. But no. They were immediately placed on gurneys and wheeled off to a medical ward.
Why? Although it’s fun to experience, prolonged weightlessness is dangerous to the human body. NASA doctors couldn’t risk letting the astronauts stand upright without thoroughly checking out their bones beforehand.
In fact, perhaps the most surprising discovery about the medical effects of space travel is that the body needs gravity to maintain its skeleton.
Bone health is usually measured as bone mineral density (BMD), and tests on astronauts routinely show that weightless living reduces BMD by up to 2 percent a month, mainly in the spine, hip and thigh bones. At that rate of loss, bones soon become brittle and vulnerable to fractures.
Bone is made up of a hard outer casing supported by an inner network of spongy bone, which is filled with a softer pulp of bone cells. The inside of a bone is popularly called marrow but is technically known as trabecular bone.
There’s a constant interchange between the inner and outer bone layers—used-up bone cells are absorbed into the trabecular area, which in turn creates fresh bone material. To trigger this process, however, bones need to be put under stress, either by supporting muscular movement or by being subjected to the force of gravity.
As it’s impractical to simulate gravity in space, the ISS has on-board exercise machines. Astronauts are required to spend as much as two hours a day working out on them. Their primary workout involves exerting whole-body strength against a set of pistons; they also use a suitably tethered treadmill and bicycle machine.
As a backup, astronauts must take a small cocktail of anti-osteoporosis pills, mainly a Big Pharma drug called Fosamax but also calcium and vitamin D supplements. Nevertheless, almost all astronauts return to earth with varying degrees of osteoporosis—hence the hurry to wheel them off to a medical center as soon as they land.
But what about us earthlings? The people at highest risk of osteoporosis are cancer patients undergoing chemotherapy.
No surprise there. After all, chemo is designed to destroy rapidly dividing cells, and bones contain a vibrant cell-division factory. Other cancer drug culprits are aromatase inhibitors (for breast cancer) and androgen deprivation therapy (for prostate cancer).
However, by far the most common cause of osteoporosis is Father Time. As we age, our sex hormones begin to ebb away, with catastrophic consequences for the skeleton. Indeed, the iconographic picture of old age is a figure shuffling along with the aid of a stick, hunched low as if burdened by rounded shoulders.
That’s osteoporosis writ large—testament to the spine having been shrunk by the inexorable loss of bone mineral density as the years go by. In fact, after menopause, women can lose up to 2 percent of their BMD every year, slightly more than men over age 50 lose.
It’s a degenerative process that has no obvious symptoms . . . until it’s too late. Often, someone first realizes they’ve got osteoporosis when they fall. A tumble that would have been brushed off at age 30 can crack a bone in the wrist, hip or spine 20 years later, leading to pain, immobility and hospitalization.
The toll in death and disability is horrifying. After age 50, almost one in two women and one in five men will sustain a bone fracture during their remaining lifetimes.
Many of these fractures are severe enough to dramatically affect quality of life—25 percent of hip fractures result in premature death. That’s why osteoporosis has been called “the silent killer.”
Of those who survive, roughly half will be permanently unable to walk without assistance. Astonishingly, in women, the overall incidence of fractures is greater than that of breast cancer, heart attack and stroke combined.
And yet, for such a devastating disease, osteoporosis gets very little coverage in the press. Perhaps that’s because it also gets very little attention from medicine itself. That’s not just because geriatrics itself is a Cinderella branch of medicine but also because preventing osteoporosis is fairly unexciting.
After all, there are very few prescription drugs for weak bones, and they haven’t changed in decades. The main ones are called bisphosphonates, which decrease the rate of cell turnover within the bone, in theory prolonging the life of the external bone structure.
The best-known brand name is Fosamax (alendronate), the drug given to astronauts. However, in older people, it has been linked to toxic side effects, not least a paradoxical increase in the risk of fractures with long-term use. Another drug, denosumab (brand names Prolia and Xgeva), appears to be more effective, but again there’s the paradox of a raised fracture risk if you stop taking it.
Ramping up your sex hormones seems to work better than taking either of these drugs. For women, the loss of estrogen after menopause can be artificially reversed by hormone replacement therapy (HRT).
There was a huge hoopla when HRT was introduced in the 1960s, but since then it’s been linked to an increased risk of heart disease and breast cancer. As a result, women have largely been discouraged from taking it for osteoporosis.
Medicine’s answer? Change HRT’s name and rebrand it.
HRT has now morphed into MHT, “menopausal hormone therapy,” but it’s essentially the same thing—an artificial estrogen booster. Modern formulations also carry much the same set of risks as before, such as breast cancer and blood clots. As a result, physicians are warned to weigh the osteoporosis benefits of MHT (a modest 20–40 percent lower fracture risk) against its not-so-modest side effects.1
Although one way to reduce MHT’s toxicity is transdermal administration (a patch) rather than a pill,2 the most effective nontoxic remedies come from a branch of medicine that hospital doctors often shun: micronutrients and diet (see boelow).
For example, ingesting 1,600 mg of freeze-dried kefir (fermented milk powder) daily has been found to partially reverse osteoporosis,3 an outcome considered well nigh impossible within conventional pharmacology. Simple Lactobacillus probiotics are almost equally effective.4
Surprisingly, the lycopene in cooked tomatoes also appears to be of benefit.5 Even more astonishing, so does wine.
A US study has found that a third of a bottle of wine a day significantly improves BMD in postmenopausal women.6 Indeed, in Romania, researchers have noted that any amount of wine drinking halves the risk of fractures in both sexes.7
The most common prevention strategies are various types of exercise regimes. Because muscles are attached to bones, any extra activity during exercise adds to the gravitational force on the bones exerted during simple everyday living. This higher force signals the body to make the bones stronger.
Interestingly, the most effective exercise regimes involve high-impact movements, such as running, jumping and combat sports—activities that place sudden loads on the skeleton. The supportive evidence comes from experiments on laboratory rats showing that bone loading increases BMD.8
So far, so good. But studies assessing the value of exercise have been limited; some surprisingly show little or no subsequent reduction in the risk of fractures. This has led to the development of exercise regimes specifically exploiting bone-loading techniques. There are three main contenders.
High-impact and resistance exercises. A regime developed in Erlangen, Germany, in 1998 is both complex and highly intensive: two one-hour gym workouts and two half-hour home sessions per week. The gym workouts combine high-impact aerobic dance, multilateral jumping, high-intensity resistance training and weight training. After all that, if you’ve got any energy left to spare, the two home workouts are mainly rope-skipping.
Impressive, grueling stuff, but does it work? Well, yes and no.
A 16-year study of more than 100 early-postmenopausal women found the exercisers had half the number of fractures that were occurring in a matched control group. Strangely, though, the exercisers still lost some BMD, suggesting it’s difficult to arrest the decline through exercise alone.9
LIFTMOR. Another regime is LIFTMOR, a handy acronym for Lifting Intervention for Training Muscle and Osteoporosis Rehabilitation. As the name implies, it involves a lot of lifting, much of it very heavy.
There are three basic exercises: deadlift, back squat (both using a weighted barbell) and overhead press. The last is the most unusual: It involves jumping as high as possible, grabbing an overhead bar and then letting go, “landing as heavily as comfortably possible,” say the instructions.
Although LIFTMOR’s target customers are mainly older women, a surprising number manage to complete the exercises—some lift barbells weighing as much as 165 lb (75 kg). A few have complained of bone damage, however.
Does it work? An eight-month study of postmenopausal women found that two 30-minute exercise sessions per week had measurable benefits, such as slight gains in height. They also saw a 3 percent increase in BMD, but only in the lower spine.10 A bigger study of middle-aged Australian men was more promising; it showed up to a 4 percent improvement in overall BMD.11
Isometric axial loading. The third anti-osteoporosis technique, isometric axial loading (IAL), is diametrically different. Rather than lifting weights or performing jumps, patients exert all their strength against a static device, which records the amount of force exerted. It involves almost zero physical movement, simply maximum muscular exertion.
There are four static machines, each one designed to strengthen a particular part of the skeleton:
Astonishingly, the procedure involves no repetitions (as in conventional exercise), simply four separate muscular strength challenges, each one lasting about five seconds. So the therapy is done and dusted within 10 minutes.
How often must you do it ? No more than once a week, “to allow bone growth to occur between sessions,” say IAL’s proponents.
It sounds too good to be true, but there is some sound science behind it. This method was discovered 15 years ago in pioneering work by Professor Jon Tobias and Dr Kevin Deere at Bristol University’s Musculosketal Research Unit.
They knew that for bone growth to occur, bones must be forcefully compressed with an impact, but no one had yet put a figure on exactly how much load is needed. The pair decided to find out.
To do so, they recruited a large group of adolescents and put them through a series of graded impact tests. Using measures based on the load exerted by gravity, they found the minimum load required to trigger bone growth in the hip (the most important area) is 4.2 times the force of gravity.12
Later experiments found different bone growth thresholds for other parts of the body. This gave IAL the science it needed, enabling it to set the target muscular output for each patient based on their body weight.
For example, once the patient has exerted a force above 4.2 times their weight during the hip exercise, they are assumed to have kick-started a bone “growth trigger” in the area of the body under test. Mimicking a slow-motion impact, the patient needs to maintain the trigger point for only a few seconds.
There are two companies offering similar machines: bioDensity® and OsteoStrong®. Note the trademark registrations, indicating that these are competing enterprises; both are US-based, with franchise outlets internationally.
But, again, does IAL actually work?
The Australian LIFTMOR study I mentioned earlier found that men using the bioDensity machine improved their BMD more than a control group of inactive men, but this method was somewhat less effective than the LIFTMOR exercise regime.
OsteoStrong has undergone about half a dozen tests, all of which have reported some benefit. However, these studies have been variously criticized for being too small or inadequately randomized or for connections to the equipment manufacturer.
Sweden’s prestigious Karolinska Institute recently completed the first independent, properly conducted trial. The (as yet unpublished) study recruited nearly 200 healthy postmenopausal women who were osteoporosis-free at the start of the trial.
They were then randomly split into two groups: one received OsteoStrong therapy weekly, and the other was assigned an exercise regime involving two multitasked one-hour gym sessions per week. After nine months, the women’s bone health was assessed. Remarkably, there was not much difference between the two groups, say the researchers in a preprint report.
“We saw no statistically significant differences between the two groups regarding [bone strength], BMD and bone markers at follow-up,” they write. “However, we did observe improvements within the groups. In the OsteoStrong training, we saw a 2.9 percent increase in bone quality, and in the [exercise group], we saw an 0.8 percent increase in BMD in the lumbar spine.”13
However, the really important overall finding was that all the women had managed to avoid the bone degeneration expected to occur in such a high-risk population over the course of nearly a year. “In both groups, the BMD in the lumbar spine and hips remained unchanged,” say the researchers. “This is a good thing as a decrease in BMD is normally seen over time.”
So here’s the question: Rather than togging yourself up in gym gear for two hours of sweaty exercise a week, could osteoporosis prevention be as simple as spending a mere 10 minutes in your everyday clothes, pitting your strength against static machines?
Unlikely as it sounds, the prospect looks feasible—although these are early days, of course. The proof of the pudding will be in long-term studies to see whether IAL actually reduces the risk of fractures. If it does, osteoporosis prevention will have been truly revolutionized.
OsteoStrong (osteostrong.me) is a set of machines called the Spectrum System, one machine for each movement. It has about 200 centers in North America, five in Scandinavia and one in southeast England.
bioDensity (biodensity.com) consists of a single machine used to complete four exercises. The company has about 70 centers in North America, five in the UK, three in continental Europe and one in Dubai.
LIFTMOR has no specific centers, but the technique is generally available in specialist fitness gyms.
People in these groups are the most likely to suffer from weakened bones, in order from the highest risk to the lowest.
Source: Royal Osteoporosis Society
The least accurate of the options listed here, this test uses ultrasound to measure bone density in the heel of the foot. That’s where bone growth is most likely to take place (due to the mechanical effects of walking), so it’s believed to be a proxy measure for the rest of the body.
But the evidence says it is not. Thus its ability to predict fracture risk is relatively poor.1
The most common test, this one employs dual-energy x-ray absorptiometry (DEXA) to measure bone density. Although it’s often considered the gold-standard BMD assessor, it has significant drawbacks.
For example, its two-dimensional imaging can’t analyze structural aspects of bone, such as mechanical and elastic properties, which are important predictors of fracture risk. So it’s not very good at spotting potential osteoporosis victims.2
Also, the equipment emits x-rays, so it’s used mainly to confirm an osteoporosis diagnosis, not for routine mass screening. And finally, there are questions about its accuracy in women at the high and low ends of height and weight ranges because it doesn’t account for bone size, which is closely linked to bone strength, and because fat distribution affects the path of the x-rays through the bone.3
Due to the shortcomings of the methods above, osteoporosis specialists are increasingly turning to three-dimensional imaging. These scan types include quantitative computed tomography (QCT), peripheral QCT (pQCT), high‐resolution pQCT (HR‐pQCT), and magnetic resonance imaging (MRI).
CT scans deliver low doses of x-rays similar to those from a DEXA scan, 1–15 microsieverts (μSv), and about the same as normal background radiation (7–10 μSv). MRI uses no radiation.
A cheaper, more portable technology is radiofrequency echographic multi spectrometry (REMS), marketed as Echolight®. Some studies show it’s more accurate than DEXA, particularly for assessing bone fragility and risk of fracture.4 It also doesn’t rely on radiation, which makes it safer to use more often.
As well, artificial intelligence is increasingly being touted as the solution to frequent inaccurate diagnoses, whatever the technology.
Supplements
Calcium 1–2 g/day
Vitamin D 800 IU/day
Vitamin B9 (folate) up to 0.5 g/day
Vitamin C 1–5 g/day
Magnesium up to 1.8 g/day
Zinc over 15 mg/day
Diet
Among the medical papers on wine and osteoporosis, almost all show a favorable connection between the two.1 The startling fact is that wine drinkers tend to have better BMD, and hence less osteoporosis, than non-drinkers. The question is why.
The obvious place to look is at wine’s constituents, particularly the ingredients other than its alcohol content. Polyphenols are the hundreds of trace chemicals produced by the vine to protect its fruit from disease and the sun’s ultraviolent rays. They give wine its color, and the good news is that they promote not only grape health but human health, too.
They behave as antioxidants, repairing the damage caused by free radicals, which the cells generate by simply being alive and using oxygen. A dramatic laboratory assay 25 years ago found a single medium-sized glass of red wine contains “antioxidant activities” equivalent to those in four apples, three glasses of blackcurrant juice, or five portions of aubergine (eggplant) or onion.2
Other laboratories have examined polyphenols’ direct effects on bone itself. Test tube experiments show that they accelerate healthy natural bone turnover.3 Similarly, feeding red wine polyphenols to female rats whose ovaries had been removed strengthened their bones within just six months, making them seriously fracture-resistant.4
So we have solid laboratory evidence that wine polyphenols have favorable effects on osteoporosis. But there’s another reason wine is such a tonic for bones: It’s not just the polyphenols but the alcohol itself.
Astonishingly, even a regular shot or two of whiskey or gin has been found to increase BMD, according to a meta-analysis comparing 300,000 vulnerable drinkers and non-drinkers. It reported that “consumption of up to two standard drinks of alcohol per day was correlated with higher lumbar and femur neck BMD values, while up to one standard drink of alcohol was correlated with higher hip BMD.”5
Drinking more than that is bad news, however—mainly because getting tipsy makes one vulnerable to falls and fractures.
But what if you don’t like alcohol or wine? There are other sources of polyphenols, of course. Olive oil, for example, is packed with them, and science says it will increase your BMD. Choose top-notch extra virgin olive oil and consume a couple ounces of it every day.6
Less onerous and far cheaper are tea and coffee. They’re full of polyphenols, but for unknown reasons, they don’t have a strong effect. You’ve got to drink a few cups of each every day to get any benefit.7 One factor could be consuming them alongside a protein, such as by adding milk, which some studies show improves polyphenol absorption.8
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