A comprehensive review of the essential ingredients for bone health and osteoporosis was recently published in the Open Orthopaedics Journal. The same article also provides a review of the availability of these essential nutrients in the average North American diet.

The review confirms many of the things published on this blog as they relate to diet and bone health and osteoporosis. It also offers some surprising findings regarding nutrients that are not well known but are important to building strong bones. In many cases, the average North American diet is deficient in these less well-known nutrients as well as being deficient in the more commonly known nutrients.

Essential Nutrients for Bone Health and Osteoporosis

The article also provides a comprehensive list of these essential nutrients, recommended dietary allowance and median intake (by a North American) for each nutrient. The authors provide their own suggested supplementation level for each nutrient – although they do not provide an explanation as to how they arrive at the specific amounts.

Finally, the authors provide a detailed table identifying each of the essential nutrients, popular dietary sources for each nutrient, and the content for each nutrient by source.

Access to the Article

Access to the full article is open and available. The review was prepared by several writers.  One of the authors is Dr. Charles T. Price – an orthopaedic surgeon who practices in Florida. As well as being a practicing physician, Dr. Price is a co-founder of the Institute for Better Bone Health – a supplier of bone health supplements.

In the tables that accompany the article the authors provide the dietary sources for each of the nutrients. However, the authors state “supplementation of the average American diet is recommended for vitamin D, calcium, magnesium, silicon, vitamin K and boron.”

Keep in mind that your diet is probably not average and your needs will probably differ from the norm. Also, calcium supplementation has been linked with some health risks (as noted below).

I encourage you to read the article in detail. It is quite thorough and informative. However, keep in mind that the comparisons that the authors make are to the average North American. Your specific nutrient levels probably differ and you should consult with a health professional knowledgeable in nutrition if you want to know your specific needs.

The Role of Exercise in Bone Health

The authors point out that exercise plays a key role in the development of strong bones as well as being essential to general good health. They further point out that the average North American does not do enough exercise to benefit bone health and recommend an increase in the overall activity and exercise level of most people.

I would also suggest that the recommended increase in exercise activity level include bone-building activities such as weight bearing exercises and strength training.

Vitamin D and Calcium

Vitamin D and calcium are two of the better known essential nutrients for osteoporosis. The review states that both Vitamin D and calcium levels in the average North American diet are inadequate.

Kent MacLeod, Clinical Pharmacist at NutriChem Compounding Pharmacy and Clinic, states in his interview, Too Much Calcium and Too Little Vitamin D,  that most of the clients he sees are taking in too much calcium – probably because there is such awareness of the nutrient and people have been overcompensating with supplements. On the other hand, he finds that most clients that visit his clinic a quite Vitamin D deficient.

The recommended vitamin D levels provided by the authors seem low. I am not sure where they are getting this data. Perhaps they live in southern climates and are influenced by the local sunny climate? They also do not take into account age considerations when recommending the Vitamin D levels.

The amount of Vitamin D recommendations varies dramatically from country to country. For example, the levels suggested by Osteoporosis Canada are much higher than suggested by the authors:

Osteoporosis Canada’s new guidelines (July 2010) recommend daily supplements of 400 to 1000 IU for adults under age 50 without osteoporosis or conditions affecting vitamin D absorption. For adults over 50, supplements of between 800 and 2000 IU are recommended. For people who need added supplementation to reach optimal vitamin D levels, doses up to the current “tolerable upper intake level” (2000 IU) are safely taken without medical supervision. Doses above that require medical supervision. A daily supplement of 800 IU should be regarded as a minimum dose for all adults with osteoporosis.

The authors are cautious about calcium supplementation since “very high levels of calcium supplementation have been associated with increased risks of myocardial infarction.”

Magnesium, Silicon, Vitamin K and Boron

While Vitamin D and calcium are well known to physicians as key nutrients for bone health and osteoporosis, other essential nutrients such as magnesium, silicon, vitamin K and boron are less well known and are often overlooked.

The median intake of each of these nutrients in the average North American diet is below the recommended dietary allowance.

Zinc, Manganese and Copper

The authors identify zinc, manganese and copper as essential nutrients but state that “these nutrients are usually consumed in amounts that meet or exceed the recommended dietary allowance”.

Omega 3

Interestingly, the authors do not mention or discuss the role of Omega-3. Recent research is showing that Omega 3 supplementation coupled with an osteoporosis exercise program yields better Bone Mineral Density or bone mass.

My Recommendation

Remember that these are guidelines and your specific needs will probably vary from the average North American profile. You are encouraged to consult with a health professional trained in the area of nutrition.

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Women and Men: Exercise for Better Bones Program

An osteoporosis exercise program that strengthens bone, reduces fracture risk, improves balance and builds confidence.

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On May 9, 2012 the U.S Food and Drug Administration (FDA) published (in the online version of The New England Journal of Medicine) an analysis it has completed on the long-term use of bisphosphonates in post-menopausal women.

According to the FDA, while bisphosphonate therapy has demonstrated “efficacy in preventing fractures in registration trials lasting 3 to 4 years … data on safety have raised concern regarding the optimal duration of use for achieving and maintaining protection against fractures”.

These safety concerns include increased risk of femoral shaft fractures, esophageal cancer and osteonecrosis of the jaw.

The Findings and Recommendation

The findings of this analysis were presented to a joint meeting of two FDA committees (the Advisory Committee for Reproductive Health Drugs and the Drug Safety and Risk Management Committee). The committees jointly decided that the data from the analysis “did not support a regulatory restriction on the duration of drug use”.

However, the joint committees did recommend that the labeling on bisphosphonate drugs be updated. Bisphophonate drugs now contain an “Important Limitation of Use” definition that states:

The optimal duration of use has not been determined. All patients on bisphosphonate therapy should have the need for continued therapy re-evaluated on a periodic basis.

What is the FDA Saying?

While this recommendation can appear to fall short in terms of specifics what you, as a patient of bisphosphonates, should be doing, it probably reflects the fact that the study data reviewed by the FDA was, at times, inconsistent and incomplete.

In addition, the behaviour of bisphosphonate is quite complex and can vary from person to person and from brand to brand. Since bisphosphonates are absorbed into the bone during the treatment phase, they can persist there for years – even after cessation of treatment. Further, there have been no long terms studies of the effects of bisphosphonates after cessation.

Basically, the FDA researchers state that more work and study has to be done and that individuals should consult, on a regular basis, with their health provider on what is right for them.

This regular evaluation should include an individual assessment of the risks and benefits of bisphosphonate therapy and patient preference. A good source for your health provider to use in evaluating your fracture risk is the online FRAX tool developed by the World Health Organization and the International Osteoporosis Foundation.

Clearly, the FDA and researchers are grappling with this complex issue. As someone with low bone density or osteoporosis, you want clear and easy to follow guidance on one question: Should I take a bisphosphonate?

 Clearer Guidance, Please

The New England Journal of Medicine published another article to accompany the FDA review. This article was written by a group of physicians at a number of medical institutes across the United States.

In the article, the physicians review the data and shed more light on the results. They state the following:

• Vertebral Fractures (i.e., fractures of the spine): Although evidence is limited regarding the risk of fracture with the continuation of bisphosphonate therapy beyond 3 to 5 years, data from randomized controlled trials generally suggest that the risk of vertebral fracture is reduced.
• Nonvertebral Fractures (i.e., fractures of the wrist, ribs, hip, etc): The consistent evidence of a statistically significant reduction in nonvertebral fractures with the continuation of bisphosphonates is lacking.

Further, this team provides the following guidance regarding continued use of bisphosphonates – with the caveat that these recommendations could change as more research is published.

• Patients with low bone mineral density at the femoral neck (T score below −2.5) after 3 to 5 years of treatment are at the highest risk for vertebral fractures and therefore appear to benefit most from continuation of bisphosphonates.
• Patients with an existing vertebral fracture who have a somewhat higher (although not higher than −2.0) T score for bone mineral density may also benefit from continued therapy.
• Patients with a femoral neck T score above −2.0 have a low risk of vertebral fracture and are unlikely to benefit from continued treatment.

As you can see, these physicians recommend that patients with osteoporosis and a high fracture risk should continue bisphosphonate therapy. Those with low or moderate risk of fracture will probably not see material benefit from continued use of this therapy.

What I Recommend

Since each individual’s medical profile is unique, I strongly encourage you to discuss this issue with your physician. Hopefully, articles like this one make you a more informed patient.

As a general rule, if you are at a high risk of fracture, continued use of bisphosphonates is probably the prudent path.

If you are at low or moderate risk of fracture, you need to weigh the risks associated with long term use of this drug (as defined earlier in this article) and the research that is showing that there is no evidence that bisphoshonates cause a significant reduction in nonvertebral fractures.

And, of course, a well designed osteoporosis exercise program is something that everyone should be following.

Conclusion

Expect to hear more about this debate in the coming years as researchers spend more resources examining the long term effects of this drug. Clearly, people within the FDA and researchers in the field have concerns with the continued long term use of this drug and its effectiveness when it comes to reducing fracture risk. The problem today is that there is not enough data to provide definitive guidance or change the FDA’s regulatory position with regard to this drug.

FDA Review in More Detail

The FDA article goes into a lot of detail as to what the study involved. For those of you not interested in reviewing the article but still interested in the mechanics of the study, here is a brief summary.

The FDA examined the long term effects of three bisphosphonates: Fosamax, Reclast and Actonel. One study group took the bisphosphonate and the other took a placebo. The FDA studied the effect of the various bisphosphonates on changes in the bone density in the femoral neck and the lumbar spine. They also looked the effect on vertebral fractures.

The FDA found that continued use of bisphosphonate therapy beyond five years lead to “maintenance of bone mineral density in the femoral neck and further increases in bone mineral density at the lumbar spine”.

However, the FDA review found that the “data raise[s] the question of whether continued bisphosphonate therapy imparts additional fracture-prevention benefit, relative to cessation of therapy after 5 years.” It was this finding that caused the FDA to issue the label change mentioned above.

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Women and Men: Exercise for Better Bones Program

Osteoporosis exercise program that strengthens bone, reduces fracture risk, improves balance and builds confidence.

MelioGuide Exercise for Better Bones Program for Women and Men

Weight bearing exercises are essential to building healthy bone. But how do you select the weight bearing activity that will both challenge and stimulate your bones while, at the same time, be kind to your joints?

What if you have a specific condition or a knee surgery that you feel limits your ability to do certain activities?

Weight Bearing Activities After Knee Surgery

I recently had a client visit me who was a very active runner. But arthroscopic knee surgery caused her to back off from her running and take on swimming and biking – activities she felt were easier on her joints.

MelioGuide Weight Bearing Exercises

Clients who follow the MelioGuide Exercise for Better Bones program are assigned weight bearing activities based on their fracture risk assessment and current activity level.

The Role of Physical Therapy

I encourage Physical Therapists who treat clients after their knee surgery to take into account the bone and skeletal health of their client. You may be hesitant to give them an activity that could overwhelm their joint. But, over time, you should have a plan to introduce weight bearing activities that are appropriate for them and stimulate bone development.

MedBridge recently introduced a course on the dissection of the knee. The course was developed and delivered by Dr. Robert LaPrade, M.D., PhD – a complex knee surgeon and sports medicine specialist at the Steadman Clinic in Vail Colorado.

If you want a better understanding of the knee or you treat clients who have had surgery of the knee, this is an excellent course to add to your continuing education.

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Learn the Prevention, Treatment and Management of Osteoporosis.

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Women and Men: Exercise for Better Bones Program

Osteoporosis exercise program that strengthens bone, reduces fracture risk, improves balance and builds confidence.

MelioGuide Exercise for Better Bones Program for Women and Men

Video and Transcript

Transcript – Scroll Bar is on the Right Hand Side

What effect does exercise have on bone mass in older adults? A recent systematic review demonstrates that the effect is very beneficial, that older adults need to keep active in their advanced years to build bone mass, and that two main categories of exercise are essential (1). The two categories are weight bearing exercises and strength training.

A systematic review is a research study that involves a review of a large body of research articles and studies on a specific topic and draws appropriate conclusions.

This review supports the MelioGuide Exercise for Better Bones program.

Bone Mass and Exercise

Weight Bearing and Cardiovascular Exercise

The review concluded that comfortable walking is not enough to stimulate bone mass. However, when we increase the pace (i.e., running, climbing or brisk movement) or make it multi-component (i.e, nordic walking), the benefit is noticeable. Depending on activity level, the increase in bone mass ranged from 1% to 6%.

What is even more significant was that when the review compared the active people with the control group (of inactive people) the differences were significant. The people in the control group (who were inactive) lost bone mass of up to 5%. Over time this difference between the groups demonstrates that cardiovascular weight bearing exercises are extremely beneficial – in fact, they are essential.

Strength Training

The review demonstrated that strength training allowed people to build bone mass not only at the hip but also at the spine. Further, like the experience with people who did weight bearing exercises, the benefits to people who did strength training compared to those who did none was significant. People who followed a strength training program improved bone mass. Those that did not, lost bone mass.

Benefit of Balance

The review also showed that weight bearing and strength training carried over to improved balance – a key part of fall prevention and fracture risk reduction.

Bone Loss Over Time – Use it Or Lose It

The review showed that both women and men lose bone mass (at different rates and at different times) if they are inactive. It also showed that both sexes can gain bone mass – even in their 60s and 70s.

The message is clear. Be active as early as you can. Stay active. Incorporate both strength training and weight bearing into your exercise program.

References

1. Effects of training on bone mass in older adults: a systematic review. Gomez-Cabello, et al. Sports Medicine. April, 2012.

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Women and Men: Exercise for Better Bones Program

Osteoporosis exercise program that strengthens bone, reduces fracture risk, improves balance and builds confidence.

MelioGuide Exercise for Better Bones Program for Women and Men

Video and Transcript

Transcript – Scroll Bar is on the Right Hand Side

Yin yoga is a style of yoga that claims to targets the connective tissue – specifically the ligaments and tendons in the joints and spine. The poses involve static holds lasting up to three minutes or longer. According to its followers it has many benefits including the elimination of energy blockages and enhancement of circulation.

I decided I would give Yin yoga a try and see if it is safe for someone with low bone density, osteopenia or osteoporosis.

Many of the Yin yoga poses encourage flexion – something that should be avoided by someone with low bone density, osteopenia or osteoporosis. I recommend that you make sure that your teacher understands how to modify the poses so that flexion comes from the hip and not the spine. Or, to be completely safe, I suggest you avoid this type of yoga altogether and find an alternative.

Yoga Spinal Flexion Poses

A recent case study report by Dr Sinaki at the Mayo Clinic’s Department of Physical Medicine and Rehabilitation identifies many of the problems associated with yoga spinal flexion positions and their affect on people with osteopenia or osteoporosis.

In the report, three patients had osteopenia (low bone mass), were in good health and pain free. They embarked on a yoga exercise program to improve their musculoskeletal health. Unfortunately, the yoga flexion exercises the patients followed brought on pain and fractures. The author concludes that while exercise has been proven to be beneficial to bone health, “some yoga positions can contribute to extreme strain on spines with bone loss.” The concern is even greater among individuals with osteoporosis.

Yoga for Better Bones

Many of these concerns were raised in my book, Yoga for Better Bones. The book recommends modifications to popular yoga poses and identifies a number of poses that should be avoided altogether by people with osteoporosis, osteopenia or low bone density.

As I have mentioned in earlier articles, yoga has many benefits and when practiced safely it can bring great joy.

I find that most people do not have the body awareness required to make sure that they avoid getting into a flexed position. As a result, I always encourage my clients with osteoporosis to search out a teacher who knows how to modify poses to make them safe and pain free.

Health Professionals: Building Better Bones Online Course

Learn the Prevention, Treatment and Management of Osteoporosis.

MelioGuide Building Better Bone Online Course for Health Professionals

Women and Men: Exercise for Better Bones Program

Osteoporosis exercise program that strengthens bone, reduces fracture risk, improves balance and builds confidence.

MelioGuide Exercise for Better Bones Program for Women and Men

Video and Transcript

Transcript – Scroll Bar is on the Right Hand Side

A number of my clients at Function to Fitness Physiotherapy ask me how exercise builds bone. As many of you already know, I am a big proponent of exercise. It helps you build bone, build muscle and leads to a better quality of life.

A good osteoporosis exercise program will include both a cardiovascular program (that incorporates appropriate weight bearing activities) and a strength training program. These two classes have been shown to be very effective when it comes to building bone.

Why Weight Bearing is Important

Your osteoporosis program should include cardiovascular activities that are appropriate to your fracture risk level. You want to make sure that the activity level you choose corresponds to your fracture risk level. This is why we require MelioGuide Exercise for Better Bones clients to complete our online assessment before a program is assigned.

Weight bearing is a component of cardiovascular exercises. The weight bearing activity generated through the exercises cause vibrations that stimulate your bone. The bone building process kicks in because you are telling your bone that it needs to learn how to handle the load.

The Role of Strength Training

Strength training is important. It builds muscle and makes you stronger.

The process of strength training also stimulates the bone. When you strength train, muscles are pulled in different directions. This pulling process, in turn, pulls on the bones attached to those muscles and stimulates them (in much the same way as they are stimulated by weight bearing activities.)

The key thing you want to do in your osteoporosis exercise program is target as many muscles (and bones) as possible when you strength train.

Other Benefits

Even if you are taking osteoporosis medications, you should follow an osteoporosis exercise program with weight bearing and strength training activities.

And there are other significant benefits:

• You can reduce your risk of falls (with improved balance and strength).
• Improved quality of life because you can participate in many activities.
• Pain management.
• You will feel stronger.
• Improved heart health.

Conclusion and Recommendations

Exercise does build bone. But you need to make sure that your program is comprehensive and includes cardiovascular activities and strength training. The MelioGuide Exercise for Better Bones Program is an online source for people who do not have (or cannot afford) direct access to a trained professional.

If you prefer to work directly with a trained professional, I encourage you to look at our online directory of health professionals who have completed our Building Better Bones training course.

Health Professionals: Building Better Bones Online Course

Learn the Prevention, Treatment and Management of Osteoporosis.

MelioGuide Building Better Bone Online Course for Health Professionals

Women and Men: Exercise for Better Bones Program

Osteoporosis exercise program that strengthens bone, reduces fracture risk, improves balance and builds confidence.

MelioGuide Exercise for Better Bones Program for Women and Men

Video and Transcript

Transcript – Scroll Bar is on the Right Hand Side

Clients who visit me at Function to Fitness Physiotherapy (my Physiotherapy studio in Ottawa) or who subscribe to this blog frequently ask for my opinion on exercise equipment – particularly as it relates to their osteoporosis exercise program or their fitness goals.

In the past, I have written several blog articles and prepared videos on various types of exercise equipment:

• Nordic walking accessories
• Weighted vests
• Physio balls
• Hip protectors for Osteoporosis
• Whole body vibration platforms (Juvent and Power Plate)
• The Total Gym

A New Type of Pedometer?

I was recently asked to a review a new product by Tractivity – a company based in Vancouver. My initial response was that it was just another pedometer. But this product does more than your basic pedometer.  Tractivity – as the name implies – tracks your activity.

Sensor and Lace Holders

I am not into gizmos and the latest cool device (I leave that to my 16 year old son). However, I do get excited about a product that can motivate my clients to stick with an exercise program. Because Tractivity is easy to use and provides feedback, I think it is a great solution for clients that need motivation to get them out and walking.

It combines the following elements together to offer a very complete solution:

• The sensor technology (the step counter) you typically see in a pedometer
• Wireless connectivity (via a USB stick you put in your computer)
• A personal web page that tracks your activity

Benefits of Walking

I have spoken about the benefits of walking as an exercise to you before. In an earlier blog I spoke specifically about walking (and nordic walking) as an effective osteoporosis exercise.

Many clients find it difficult to motivate themselves to walk (or in some cases do many of their exercises) on a regular basis. I have found measurable progress is a strong motivator for my clients.   Clients who can see and/or feel their progress are encouraged to continue their exercise program.

Tractivity does that  – and does it very well. In fact, I would consider that to be one of the key advantages of a product like Tractivity. It allows you to easily track and record your walking activity – and it does a great job presenting your progress to you.

What is Tractivity?

There are two product bundle options for Tractivity. The Essential Bundle includes:

• The Tractivity sensor – the pedometer or step counter component
• Wireless stick  – for connectivity to your computer and upload of your walking activity into your Tractivity hosted web page
• Laceholder – to attach the sensor (or pedometer or stepcounter) to your shoe or boot

Premium Bundle

The Premium Bundle option includes all of the items in the Essential Bundle plus a pair of insoles (with a cavity for the Tractivity pedometer/sensor) and a measuring tape to record changes in your girth.

Your walking activity is automatically uploaded into your Tractivity web page when you wirelessly connect the sensor/pedometer piece to the USB stick. Record girth changes are optional and done manually.

My Recommendation

If you need that extra motivation to start a walking program (or keep one going), then I suggest you give Tractivity a try. Even if you are already on a regular program, Tractivity  adds a new dimension. Its great to see how it all adds up in the run of a week!

To Learn More

You can learn more about Tractivity at their website or you can visit them at their Facebook page.

Full Disclosure

MelioGuide does not have a commercial relationship with Tractivity and does not receive any compensation of any kind from Tractivity.

Health Professionals: Building Better Bones Online Course

Learn the Prevention, Treatment and Management of Osteoporosis.

MelioGuide Building Better Bone Online Course for Health Professionals

Women and Men: Exercise for Better Bones Program

Osteoporosis exercise program that strengthens bone, reduces fracture risk, improves balance and builds confidence.

MelioGuide Exercise for Better Bones Program for Women and Men

Yes, we know.  Calcium equals bone health.  Kudos to the dairy industry for making the two synonymous.  And while it’s not necessarily a bad thing to think of calcium – or even dairy – when we think bone, calcium certainly isn’t the end of the story.  Indeed, if we stop there, we’re in big trouble.

A rich body of research shows that calcium is just one small piece of the bone health puzzle.  And, guess what? We can even get that calcium from non-dairy sources.  So, in today’s article, let’s explore all the dietary factors associated with bone health.

The Life Cycle of Bone

While it may seem like bones are more static than the other tissues in our bodies, they’re simply not.  Bones experience a high rate of turnover, just like our skin cells, muscle cells, and more.  To this end, bones are continually breaking down and building up.  And this is necessary for bone repair and for safeguarding blood mineral levels.

Until about the age of 20 we have the opportunity to build our bone “retirement fund”.  Small deposits can be made when we have the appropriate food/nutrients coming in.  The right amounts of stress – think exercise – can also make a huge difference over time.

However, starting around the age of 40, bone withdrawals start to exceed bone deposits.  If bone deposits early in life were sparse (e.g., poor nutrition and no exercise), the bone bank account runs dry rather quickly, leading to weakness and pathology.

After the age of 50, 1 in 2 women (and 1 in 4 men) will experience a fracture related to weak bones.  And that’s a shame because many of these are preventable with the right intake of food and drink – and appropriate exercise.  To this end, let’s discuss the critical nutritional factors related to strong bones.

Dietary Minerals and Bone Health

If there isn’t enough calcium coming into the body, bone is broken down to restore levels in the blood.  This helps to maintain whole body calcium homeostasis, making bone an important storage site for mobilizable calcium.

Unfortunately, consuming a lot of dietary calcium doesn’t automatically lead to stronger bones.  What really matters is how much of that calcium gets absorbed.

In the United States and Canada, calcium requirements are 1,200 mg/day for adults.  And this recommendation is a result of the standard American diet’s effect on calcium absorption and retention – it tends to reduce both.  Individuals requirement for calcium, of course, can vary greatly with some data indicating as little as 415 mg per day and some indicating as much as 1,740 mg/day, depending on the overall diet.

Here’s an interesting fact.  In many other countries where average daily calcium intake is lower (e.g., Japan, India, Peru), the incidence of bone fractures is also quite low.  How can this be?  Well, because a high intake of dietary calcium might not be all that important for bone health. Especially calcium in supplemental form.

Sure, there’s some research to suggest calcium is important.  But for every study that says it is, another says it isn’t.  One reason the data may be mixed – with supplementation in particular – is that in those who are deficient, calcium supplements may reduce bone turnoverand fracture.  However, if someone’s dietary intake is adequate, the supplements will have no impact on bone health.

But there is some bad news for those supplementing excessively. Too much dietary calcium can decrease phosphorus, iron and zinc absorption, and lead to calcium plaques on blood vessels, triggering cardiovascular problems.

Magnesium is another important mineral that contributes to the bone matrix.  And potassium promotes calcium retention.  Plus, both minerals support an alkaline environment in the body, essential for good bone health.  When potassium and magnesium intake are low, and sodium intake is high – as is common in the standard American diet – bone development can be impaired as excessive dietary sodium can increase urinary calcium losses.

Another mineral important here is phosphorus.  Balancing phosphorus with calcium intake is necessary for bone mineralization (more information on this below).

Dietary Vitamins and Bone Health

One of the most important vitamins related to bone health is vitamin D.  Without enough active vitamin D in the body, dietary calcium cannot be absorbed and bone renewal is halted.  Since there’s very little vitamin D in our food supply, it’s important to get vitamin D in supplemental form, or from the sun.  For more information on vitamin D, click here.

In addition, the following vitamins play an important role in bone health:

• Vitamin A deficiency or excess can cause bone abnormalities.
• An adequate intake of B vitamins can help offset elevated levels of homocysteine in the blood, helping to preserve bone.
• Vitamin B12, vitamin C and vitamin E can stimulate bone building cells, inhibit bone breakdown, and reduce oxidative stress.
• Vitamin K may help to slow age related bone loss and works in collaboration with vitamin D.

Eating Patterns and Bone Health

While we often spend most of our time discussing individual nutrients, when looking at the research, overall eating patterns actually predict bone health far better than individual nutrients.  That’s why consuming whole foods – and enjoying the rich bounty of vitamins and minerals present within – is a better strategy than loading up on supplements.

Of course, fruits and vegetables are rich in nutrients and compounds that protect bone.  So diets emphasizing them seem to be bone building.  On the other hand, diets emphasizing processed foods, sugars and animal proteins (which can displace plant foods if we’re not careful) seem to be less protective of bones.

It’s important to note here that we’re not suggesting supplements are useless in helping with bone health.  Rather, we’re suggesting that you look to whole foods first.  Then, if deficiencies persist, a supplement might be warranted.  For more on vitamin and mineral supplements, click here.

Dairy Intake and Bone Health

The Dairy Council has convinced millions that consuming additional dairy is essential for bone health.  However, the research paints a different picture.  Diets emphasizing dairy don’t necessarily optimize bone health.  In many parts of the world dairy is a negligible part of the diet, and yet bone problems associated with lack of calcium are rare.  So other factors are at play.

This quote sums up the research quite well:

Scant evidence supports nutrition guidelines focused specifically on increasing milk or other dairy product intake for promoting child and adolescent bone mineralization. (Lanou 2006)

Again, we’re not suggesting dairy is bad.  Instead, we’re just pointing out that the food most promoted for bone health isn’t necessary the strongest choice.  Indeed, with less dairy in the diet, there’s more room for bone building vegetables and fruits, especially calcium-rich choices like dark leafy greens, beans, nuts, and seeds.

Here’s a list of the top plant-based, non-dairy sources of calcium:

• Tofu 350 mg per ½ cup
• Tapioca 300 mg per ½ cup
• Chia seeds 300 mg per 1.5 ounces
• Fortified non-dairy milk 300 mg per 1 cup
• Collard greens 210 mg per ½ cup
• Kale 205 mg per ½ cup
• Bok Choy 190 mg per ½ cup
• Figs 135 mg per 5 figs
• White Beans 120 mg per ½ cup
• Turnip Greens 104 mg per ½ cup
• Spinach 99 mg per ½ cup
• Almonds 93 mg per ¼ cup
• Sesame Seeds 51 mg per 1 tablespoon

In the end, the research is clear.  The foods most correlated with bone health are plant-based foods; namely calcium-rich veggies and fruits.  Dairy falls lower down the list.  For more about dairy and milk, click here.

Protein Intake and Bone Health

In the past, there was some debate as to whether a higher intake of protein could negatively impact bone health.  But this idea has been thoroughly debunked.  Indeed, consuming up to 1.6 g/kg of protein per day (2x the current recommendation) can help:

• Increase calcium absorption
• Increase IGF-1 (a compound that stimulates bone deposition)
• Decrease parathyroid hormone (low protein intake can lead to secondary hyperparathyroidism)

All three of these lead to stronger bones.  That’s why a higher protein diet is likely best for bone health.  But keep in mind that consuming mostly animal protein in the diet can lead to higher calcium losses.  That’s why a key to balancing out higher animal protein intakes is to make sure that plenty of whole vegetables and fruits are included in the diet.  Again, these are rich in bone building and alkalizing nutrients.

A quick note on soy: soy-based foods are a dense source of protein and tend to have a positive impact on bone.  This might be due to the impact of soy isoflavones on estrogen receptors.  However, because of the potentially negative impact of soy on the other systems of the body, we recommend it only make up a very small percentage of the diet.  For more about soy, click here.

Dietary Alkalinity and Bone Health

The overall acidity (or alkalinity) of the diet can play a large role in bone health as well.  Interestingly, grains – as well as foods high in protein and phosphorus – present themselves as acidic once digested and absorbed.  On the other hand, foods high in potassium, calcium and magnesium present themselves as alkaline once digested and absorbed.

If the diet is out of balance, and too many acidic foods (think meat, fish, most grains and cheeses) dominate at the expense of alkaline foods (think vegetables and fruits), low-grade acidosis can develop in the body.  And this metabolic situation can cause calcium to be leached from bones to help neutralize the pH of body fluids.  Fortunately, this situation is easily corrected by increasing the intake of alkaline food and drink, with vegetables and fruits being the best options.

Also remember, while our ability to buffer a net acid load with calcium from bone is frowned upon for longevity and health, during times of starvation and/or high meat intake at the exclusion of plant foods, this ability gave us a survival advantage.  For more about dietary acid and alkaline balance, click here.

Beverage Consumption and Bone Health

We often hear that soft drinks – even diet soft drinks – are bad for bone health.  This is because they often contain phosphoric acid.  Especially cola.  Lots of phosphorus coming in the body can bind calcium (leaving less for bones), stimulate parathyroid hormone, and diminish active vitamin D formation.

And speaking of beverages, alcoholism is associated with poor bone health (for the exact reasons you are probably thinking of).  High alcohol intake can displace nutrient rich food intake, interfere with nutrient absorption, increase parathyroid hormone, and can skew reproductive hormones in the body.

Conversely, moderate alcohol consumption might be bone protective.  Why?  Well, beer and wine contain silicone, a compound that can help bone.  And since moderate alcohol intake may slightly increase estrogen levels in the body, this can help to preserve bone as well.  For more about alcohol intake, click here.

Recommendations for Bone Health

In the end, as you’ve probably considered so far, eating to improve bone health also promotes general health.  According to the research, the best practices include:

• Focus on overall dietary quality more than any one single food or beverage.
• Eat nutrient rich whole foods, including plenty of vegetables and fruits – at least 5 servings per day.  One serving is about the size of your fist.
• Eat plenty of foods rich in calcium, magnesium, potassium, and B vitamins.
• Consider getting blood levels of vitamin D tested and using a supplement if needed.
• Eat enough protein to assist in bone building, which happens to be the same dose required muscle building – for men this means about 2 palm-sized portions per meal and for women this means about 1 palm-sized portion per meal.
• Consider a vitamin B12 supplement if needs aren’t being met from the diet.
• If one’s diet is built around animal proteins, grains and/or processed foods, consider a calcium supplement as well.

For Extra Credit

Looking for more interesting facts about how diet and lifestyle impact bone health?  Check these out:

• Performing regular physical activity with impact is the soundest method of preserving bone health.  Still, masters level athletes experience bone loss, so other factors are at play.
• The hormone estrogen tends to increase bone formation.
• Smoking damages bones.
• Visceral fat (around your organs) seems to have a more negative influence on bone, whereas subcutaneous fat (just under your skin) seems to have a protective effect.
• The supplement creatine may increase bone formation via increases in osteoblast activity and decreases in osteoclast activity.
• While all fruits and vegetables appear to improve bone health, prunes appear to have a bonus effect.  Eating 10 prunes per day has been shown to inhibit bone breakdown.
• The hormone leptin tends to have a positive influence on bone.
• Per calorie, kale has more calcium than milk.  And it might be absorbed better as well.
• Bone contains 99% of the body’s calcium.
• Bone contains 60% of the body’s magnesium.
• The recommended calcium intake per day in Japan for adults is 600 mg/day.

About The Authors

Dr. John Berardi received his PhD in exercise physiology and nutrient biochemistry at the University of Western Ontario, Canada.  He’s currently an Adjunct Professor at Eastern Michigan University and the University of Texas.  For the last 4 years, Dr. Berardi has acted as the director of the world’s largest body transformation project, a one-of-a- kind lifestyle-coaching program that’s produced more weight loss than all seasons of The Biggest Loser combined.  Dr. Berardi is currently the Chief Science Officer of Precision Nutrition, offering life-changing, research-driven nutrition coaching for everyone.

Ryan D. Andrews is a registered dietitian and strength and conditioning specialist who completed his education in exercise and nutrition at the University of Northern Colorado, Kent State University, and Johns Hopkins Medicine. He’s written dozens of research articles on nutrition, exercise, and health, authored Drop The Fat Act & Live Lean, and coauthored The Essentials of Sport and Exercise Nutrition Certification Manual. Ryan is currently a coach with Precision Nutrition, offering life-changing, research-driven nutrition coaching for everyone.

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References

• Gunter KB, et al.  Physical activity in childhood may be the key to optimizing lifespan skeletal health.  Exerc Sport Sci Rev 2012;40:13-21.
• Ahmadieh H & Arabi A.  Vitamins and bone health: beyond calcium and vitamin D.  Nutrition Reviews 2011;69:584-598.
• Candow DG & Chilibeck PD.  Potential of creatine supplementation for improving aging bone health.  J Nutr Health Aging 2010;14:149-153.
• Soleymani T, et al.  Obesity, bariatric surgery, and bone.  Curr Opin Rheumatol 2011;23:396-405.
• Cao JJ & Nielsen FH.  Acid diet (high-meat protein) effects on calcium metabolism and one health.  Curr Opin Clin Nutr Metab Care 2010;13:698-702.
• Jesudason D & Clifton P.  The interaction between dietary protein and bone health.  J Bone Miner Metab 2011;29:1-14.
• Feskanich D, et al. Calcium, vitamin D, milk consumption, and hip fractures: a prospective study among postmenopausal women.  Am J Clin Nutr 2003;77:504-511.
• Feskanich D, et al.  Milk, dietary calcium, and bone fractures in women: a 12-year prospective study.  Am J Public Health 1997;87:992-997.
• Heaney RP & Layman DK.  Amount and type of protein influences bone health.  Am J Clin Nutr 2008;87:1567S-1570S.
• Tucker KL.  Osteoporosis prevention and nutrition.  Curr Osteo Reports 2009;7:111-117.
• Heaney RP & Weaver CM.  Calcium absorption from kale.  Am J Clin Nutr 1990;51:656-657.
• Zhang Q, et al. The association between dietary protein intake and bone mass accretion in pubertal girls with low calcium intakes. Br J Nutr 2010;103:714-723.
• Appleby P, et al.  Comparative fracture risk in vegetarians and nonvegetarians in EPIC-Oxford.  Eur J Clin Nutr 2007;61:14001406.
• Thorpe DL, et al.  Effects of meat consumption and vegetarian diet on risk of wrist fracture over 25 years in a cohort of peri- and post menopausal women.  Public Health Nutr 2008;11:565-572.
• Weaver CM & Plawecki KL.  Dietary calcium: adequacy of a vegetarian diet.  Am J Clin Nutr 1994;59(5 Suppl):1238S-1241S.
• Hunt CD & Johnson LK.  Calcium requirements: new estimations for men and women by cross-sectional statistical analyses of calcium balance data from metabolic studies.  2007;86:1054-1063.
• Cumming RG & Klineberg RJ. Case-control study of risk factors for hip fractures in the elderly. Am J Epidemiol 1994;139:493-505.
• Huang Z, Himes JH, McGovern PG. Nutrition and subsequent hip fracture risk among a national cohort of white women. Am J Epidemiol 1996;144:124-34.
• Cummings SR, et al. Risk factors for hip fracture in white women. N Engl J Med 1995;332:767-73.
• Tucker KL, et al.  Potassium, magnesium, and fruit and vegetable intakes are associated with greater bone mineral density in elderly men and women.  Am J Clin Nutr 1999;69:727-736.
• Macdonald HM, et al.  Low dietary potassium intakes and high dietary estimates of net endogenous acid production are associated with low bone mineral density in premenopausal women and increased markers of bone resorption in postmenopausal women. Am J Clin Nutr 2005;81:923-933.
• Macdonald HM, et al.  Effect of potassium citrate supplementation or increased fruit and vegetable intake on bone metabolism in healthy postmenopausal women: a randomized controlled trial. Am J Clin Nutr 2008;88:465-474.
• Macdonald HM.  Alcohol and recommendations for bone health: should we still exercise caution?  Am J Clin Nutr 2009;89:999-1000.
• Hooshmand S, et al.  Comparative effects of dried plum and dried apple on bone in postmenopausal women.  Br J Nutr 2011;106:923-930.
• Nieves JW & Lindsay R.  Calcium and fracture risk.  Am J Clin Nutr 2007;86:1579-1580.
• Emo Peters BS & Martini LA.  Nutritional aspects of the prevention and treatment of osteoporosis.  Arq Bras Endocrinol Metab 2010;54:179-185.
• Calcium and Milk: What’s best for your bones and health?  The Nutrition Source.  Havard School of Public Health.  http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/calcium-full-story/index.html
• Darling AL, et al. Dietary protein and bone health: a systematic review and meta-analysis. Am J Clin Nutr 2009;90:1674-92.
• Bischoff-Ferrari HA, et al.  Calcium intake and hip fracture risk in men and women: a metaanalysis of prospective cohort studies and randomized controlled trials.  Am J Clin Nutr 2007;86:1780-1790.
• Seeman E.  Evidence that calcium supplements reduce fracture risk is lacking.  Clin J Am Soc Nephrol 2010;5:S3-S11.
• Ho-Pham LT, et al.  Veganism, bone mineral density, and body composition: a study in Buddhist nuns.  Osteoporos Int 2009;20:2087-2093.
• Barzel US & Massey LK.  Excess dietary protein can adversely affect bone.  J Nutr 1998;128:1051-1053.
• Ma DF, et al.  Soy isoflavone intake increases bone mineral density in the spine of menopausal women: meta-analysis of randomized controlled trials.  Clin Nutr 2008;27:57-64.
• Ma DF, et al.  Soy isoflavone intake inhibits bone resorption and stimulates bone formation in menopausal women: meta-analysis of randomized controlled trials.  Eur J Clin Nutr 2008;62:155-161.
• Messina M, et al.  Skeletal benefits of soy isoflavones: a review of the clinical trial and epidemiological data.  Curr Opin Clin Nutr Metab Care 2004;7:649-658.
• Ronis MJ, et al.  Effects of nutrition and alcohol consumption on bone loss.  Curr Osteoporos Rep 2011;9:53-59.
• Castelo-Branco C & Cancelo Hidalgo MJ.  Isoflavones: effects on bone health.  Climacteric 2011;14:204-211.
• Bliuc D, et al.  Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women.  JAMA 2008;301:513-521.
• Lanou AJ. Bone health in children. BMJ. 2006;333:763-764.
• Warensjo E, et al. Dietary calcium intake and risk of fracture and osteoporosis: prospective longitudinal cohort study. BMJ. 2011;342:d1473.

Physical Therapists are experts in physical activity prescription and management among a variety of patient populations.  Many examples of the roles Physical Therapists play exist in a number of patient conditions.

• Physical activity recommendations are emerging for populations of people with spinal cord injury and arthritis.
• The Canadian Pediatric Society offers physical activity recommendations for children with juvenile idiopathic arthritis, hemophilia, asthma and cystic fibrosis.
• Physical Therapy plays a major role in the management and treatment of osteoporosis, osteopenia and low bone density.

However, no guidelines or recommendations exist for children and adolescents with eating disorders and our understanding of negative exercise behaviours is limited. The Physical Therapy profession can play a significant role in the management of eating disorders through exercise prescription.

Prevalence of Eating Disorders

Eating disorders are more prevalent than most people (and health professionals) think:

• Five percent of women in Canada have experienced an eating disorder before reaching adulthood (Eating Disorders in Adolescents:  Position Paper of the Society For Adolescent Medicine, 2003)
• Thirty to eighty percent of eating disorder patients with anorexia nervosa and bulimia nervosa engage in unhealthy exercise, referred to as excessive exercise or compulsive exercise.  (Shroff, 2006 & Davis, 1997)
• Negative exercise behaviours and cognitions often precede the onset of an eating disorder.  As well, excessive exercise in eating disorders, is a predictor of poor outcome, relapse (Strober, 1997) and longer inpatient treatment. (Solenberger, 2001)

Eating Disorders Defined

An eating disorder is a medical condition diagnosed by the criteria in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition (DSM-IV).

• Anorexia nervosa is characterized by weight loss or failure to gain weight during a period of growth, leading to a weight that is less than 85% of that expected for height and age, an intense fear of gaining weight, a distorted body image and loss of at least 3 consecutive menstrual cycles.
• The core features of bulimia nervosa are binge eating and purging.  Compensatory behaviours occur after a binge, such as vomiting, laxative or diet medication use, fasting or excessive exercise.

Management of Physical Activity and Eating Disorders

The current management of physical activity in eating disorder patients varies enormously. (Davies, 2007)  Traditionally, patients have been put on bed rest to reduce caloric expenditure.   However, the management of physical activity in eating disorders is changing with the following evidence:

• A literature review of the effects of exercise interventions in patients with eating disorders reported that patients with eating disorders can safely engage in exercise programs during treatment. (Hausenblas, 2007)
• Supervised exercise prescription in eating disorders has been shown in the literature to not adversely affect weight gain or the return of menstruation.
• The evidence indicates there is increased treatment compliance, improved therapeutic relationship, decreased food preoccupation, decreased bulimic symptoms and decreased negative exercise behaviours with supervised exercise.
• As well,  eating disorder patients considered “improving body experience” as a core element of their treatment (Vanderlinden, 2007).

Role of Physical Therapy in Treating Eating Disorders

As a Physical Therapist in the Eating Disorders Program at the McMaster Children’s Hospital in Hamilton, Ontario, Canada,  I assess and manage the physical activity of inpatients with anorexia nervosa and bulimia nervosa.   While developing the role of the Physical Therapist in eating disorders, I created physical activity guidelines for children and adolescents with anorexia nervosa and bulimia nervosa. These guidelines act as a tool to help clinically guide my management of their physical activity.

I primarily work with the inpatient population who are admitted for medical stabilization, weight restoration or symptom interruption.  The following criteria direct the level and type of physical activity I recommend:

• vital sign instability,
• low percentage of ideal body weight,
• severity of negative exercise behaviours (The Compulsive Exercise Test, H. Goodwin, in press),
• low bone mineral density/fracture risk
• menstrual dysfunction.

Most Physical Therapy interventions target patients classified as severe or moderate according to this criteria.

Treating Patients with Severe Eating Disorder

Patients with a severe eating disorder would be expected to rest and reduce activity.  Physical activity is individually prescribed and supervised.  It is at a low intensity and is of short duration, and includes; lying, sitting or 4 point; range of motion, stretching exercises and yoga poses.  (See images).

Treating Patients with Moderate Eating Disorder

Patients with a moderate eating disorder  are progressed to standing range of motion, stretching exercises and yoga poses.  Education and activity planning for low bone mineral density/fracture risk is ongoing, as an increase in bone mineral density has an average delay of 21 months from weight restoration.

Impact physical activities (i.e. gymnastics, jumping) and moderate intensity resistance training are contraindicated.  (From Physical Activity and Bone Heath, Position Stand of the American College of Sports Medicine)

Also important to note is that there appears to be no benefit of exercise on bone mineral density, if a patient has amenorrhea or loss of menses  (Academy of Eating Disorders, Catherine Gordon, and Philip Mehler, 2009)  Most patients resume menses within 6 months when they reach 90% of their ideal body weight.   Aerobic exercise can be resumed at 90% ideal body weight; however, a longer weight stabilization period improves outcomes.

Compulsive Exercise Test Important to Understanding Behaviour

Understanding a person’s exercise behaviours is important in the management of their physical activity.  The Compulsive Exercise Test provides an assessment of five core features of compulsive exercise.

1. The avoidance of affective withdrawal symptoms and guilt if unable to exercise , therefore making up for missed exercise or exercising despite illness or injury.
2. Exercise for weight and shape reasons.
3. Exercise for mood improvement, an increased positive affect or decreased negative affect.
4. Lack of exercise enjoyment.   Exercise is viewed as a chore to be completed from which the exerciser derives little or no enjoyment.
5. Exercise rigidity.  When exercise is practiced according to a strict schedule.  (Goodwin, in press)

Eating disorders have the highest mortality rate of any mental disorder (Crow, 2009).  Earlier identification and intervention is associated with improved outcomes and better long term prognosis.

Identifying Clients with Eating Disorders

How can we identify those people at risk for eating disorders earlier?  Athletes are distributed along a spectrum between health and disease.  (Nattiv, 2007)  For most female athletes, participation in sports is a positive experience, providing improved physical fitness, enhanced self-esteem, and better physical and mental health; however, studies have reported disordered eating in up to 62% of female athletes.

Disordered eating is not the same as an eating disorder.  Disordered eating includes a wide range of abnormal eating behaviours, such as those seen in anorexia and bulimia, chronic restrained eating or compulsive eating.  Disordered eating also has negative effects on overall health.   Symptoms of low energy availability (with or without an eating disorder), loss of menstrual cycles and low bone mass, alone or in combination, pose significant health risks to physically active girls.

Loss of menstruation is not a normal response to training.  It is a clear indication that health is being compromised.  The prevalence of loss of menstrual cycles is much greater in the athletic population (3-66%) than in the general female population (2-4%).

Peak bone mass is largely established by the end of adolescence, loss of menstrual cycles can lead to bone loss which increases fracture risk and may not be reversible.  Adolescence marks the period of greatest risk for onset of eating disorders.

While, all female athletes are at risk, sports with an aesthetic component such as ballet, figure skating, and gymnastics, endurance sports, such as running or those sports tied to a weight class, such as rowing or wrestling, are believed to have a greater eating disorder risk among athletes.

Prevention of eating disorders and recognition of eating disorder risk should be a priority of those who work with athletes.  The Joint Position Paper on Nutrition and Athletic Performance for the Dieticians of Canada, the American College of Sports Medicine and American Dietetic Association encourages those who work with female athletes to monitor changes in exercise performance and energy level, normal menstrual function, stress fractures, recurrent injury or illness, and general overall well-being.

The Coaching Association of Canada recommends that screening for eating disorders should occur at a pre-participation exam or annual health exam.

As well, recommendations from a study on the use of the pre-participation exam in Canadian Interuniversity Sport to screen for the Female Athlete Triad (the name for the triad of medical disorders including, low energy availability, menstrual dysfunction and low bone mass) reported that better efforts needed to made to increase awareness of the triad and its risks among female athletes.

About the Author

Lisa Scott

Lisa Scott is a Physiotherapist at the Adolescent Medicine and Eating Disorders Program at McMaster Children’s Hospital in Hamilton, Ontario. Lisa completed her Bachelor of Science (Physical Therapy) at the University of Toronto in 1997 and her Bachelor of Education at Brock University in Hamilton in 2001. She has been employed as a physiotherapist at McMaster Hospital since 2000.

This article was originally published in the Ontario Physiotherapy Association’s journal, Physiotherapy Today as part of the Innovation in Practice program.

For more references and correspondence you can contact Lisa via email.

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Osteoporosis exercise program that strengthens bone, reduces fracture risk, improves balance and builds confidence.

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References

1. Shroff, H., et al.  Features Associated with Excessive Exercise in Women with Eating Disorders.  International Journal of Eating Disorders, 2006
2. Davis, C. et al.  The Prevalence of High-Level Exercise in the Eating Disorders:  Etiological Implications.  Comprehensive Psychiatry, 1997
3. Davies, S.  et al.  The Inpatient Management of Physical Activity in Young People with Anorexia Nervosa, European Eating Disorders Review, 2007
4. Strober, M.  The Long-term course of Severe Anorexia Nervosa in adolescents:  Survival analysis of recovery, relapse and outcome predictors over 10-15 years in a Prospective Study.  International Journal of Eating Disorders, 1997
5. Solenberger, S. Exercise and eating disorders: A 3-year inpatient hospital records analysis.  Eating Behaviours, 2001
6. Vanderlinden, J . et al. Which Elements in the Treatment of Eating Disorders Are Necessary ‘Ingredients’ in the Recovery Process?-A Comparison between the Patient’s and Therapist’s View, European Eating Disorders Review, 2007
7. Hausenblas, H. et al.  Can Exercise Treat Eating Disorders?  Exercise and Sports Science Review, 2008
8. Goodwin, H. et al. Psychometric Evaluation of the Compulsive Exercise Test (CET) in an Adolescent Population:  Links with Eating Psychopathology, European Eating Disorders Review, in press.
9. Crow, S.J., Peterson, C.B., Swanson, S.A., Raymond, N.C., Specker, S., Eckert, E.D., Mitchell, J.E. (2009)  Increased mortality in bulimia nervosa and other eating disorders.  American Journal of Psychiatry 166, 1342-1346.
10. Nattiv, A., M. Manore, F. Sanborn, J. Sundgot-Borgen, M. Warren, American College of Sports Medicine Position Stand on The Female Athlete Triad, Medicine and Science in Sports and Exercise, 2007
11. American College of Sports Medicine Position Stand on Physical Activity and Bone Health
12. Eating Disorders in Adolescents:  Position Paper of the Society For Adolescent Medicine, 2003
13. Beals, Katherine and Nanna Meyer,  Female Athlete Triad Update, Clinics in Sports Medicine, 2007
14. Academy of Eating Disorders, Catherine Gordon, and Philip Mehler, 2009
15. Rumball, J. et al. Use of the Preparticipation Physical Examination Form to Screen for the Female Athlete Triad in Canadian Interuniversity Sport Universities, Clinical Journal of Sport Medicine, 2005
16. Eating Disorders-Signs, Screening, Confronting, Coaching Association of Canada, 2010
17. Joint Position Paper on Nutrition and Athletic Performance, the Dieticians of Canada, the American College of Sports Medicine and American Dietetic Association

I will be hosting a special two hour Yoga for Better Bones workshop on April 15, Sunday at Kalyana Yoga in Ottawa. If you are in town, I hope that you can come.

This will be a hands-on and practical workshop on how to practice your routine if you have osteoporosis, osteopenia or low bone density. We will go through what is happening to your bones as you age, cover suggested modifications to poses and identify poses you should avoid.

Yoga Practitioners and Teachers

If you practice yoga and are concerned about the health of your bones, you should attend this workshop. If you are a teacher and instruct students with osteopoenia or osteoporosis, you should also attend.

This workshop is designed for both teachers and practitioners. I will make sure that this will be a learning experience no matter your level.

If you are a health professional with an interest in yoga and how it applies to you clients, I also encourage you to attend. I think that you will learn new things that you can bring to your clients. Please keep in mind that the format is designed to be practical so we are going to be covering quite a few poses. Expect a busy session!

Yoga for Better Bones

My new book, Yoga for Better Bones, will be available on sale at a special price during the session.

Registration Details

The event will take place from 1:00 PM to 3:00 PM on Sunday, April 15, 2012. Kalyana Yoga will be the host and is handling the registration. Please contact Kalyana to book your place.

I have prepared a brochure on the workshop.

The price for the workshop will be $30 + HST.

Hope to see you there.

Health Professionals: Building Better Bones Online Course

Learn the Prevention, Treatment and Management of Osteoporosis.

MelioGuide Building Better Bone Online Course for Health Professionals

Women and Men: Exercise for Better Bones Program

Osteoporosis exercise program that strengthens bone, reduces fracture risk, improves balance and builds confidence.

MelioGuide Exercise for Better Bones Program for Women and Men