Physical activity and

osteoporosis

Prof. Daniel Courteix, Université Blaise Pascal

Clermont Ferrand France

Laboratoire de biologie
intégrative
du tissu osseux de St Etienne

Background
Bone health in an aging population means
simply the ability to engage in routine everyday
activities without suffering “low trauma”
fractures.

Fractures in the elderly have many contributing

causes. Amongst them, osteoporosis
represents a major concern in Europe and in
the world

1
Osteoporosis
A silent disease
metabolic disorder
age related reduction in bone mass and
strength
spine
fracture femoral neck
wrist

A major medical problem

One third among post menopausal
women affected
200 millions people worldwide suffer
from osteoporosis
This number is growing as the
population ages

WHO definition

Osteoporosis is a disease of the bones

characterized by a decrease in bone mass and
structural deterioration of bone tissue, leading
to bone fragility and increased susceptibility to
fractures

2
 Postmenopausal and senile (age-related)
osteoporosis compared: Epidemiological factors

Postmenopausal Age-related
(Type I) (Type II)

Age (years) 55-75 >70(F); >80 (M)

Sex ratio (F/M) 6:1 2:1

Vertebral Fracture
Chronic Rachialgy
Mechanical cause
Static diseases of column.
body height decrease, kyphotic attitude

3
Clinical Presentations of Osteoporosis
Spinal deformity may result after repeated compression fractures

Detection
Bone Density Tests:
 Can detect osteoporosis before a fracture
occurs.
 Predicts your chances of fracturing in the
future.
 Determines your rate of bone loss and
monitors the effects of treatment.

4
 Femme 1,71m, 57 kg,
30 ans

Femme 1,71m, 57 kg,

30 ans

Prevention
 Peak of bone mass
Building strong bones in childhood and adolescence is the
best defense.
 Nutrition
A balanced diet rich in calcium, protein and Vitamin D

 A healthy lifestyle
No smoking or excessive alcohol intake
No sedentarity

5
 Prevention
 Peak of bone mass
Building strong bones in childhood and adolescence is the
best defense.
 Nutrition
A balanced diet rich in calcium, protein and Vitamin D

 A healthy lifestyle
No smoking or excessive alcohol intake
No sedentarity

Peak bone mass

The Peak Bone Mass is the amount of bone

tissue present at the end of the skeletal
maturation
Bone mass accumulation can virtually be
completed before the end of the second
decade in Caucasian females

Evolution de la masse osseuse au cours de la vie

et ses déterminants

HORMONES
?
OSTEOPOROSIS
menopause
?
growth
NUTRITION +
PHYSICAL ACTIVITY

GENES
Peak of acquisition
11 – 17 (depending on sex)

6
 Determinant of peak bone mass
Mechanical
Genetic loading
factors (exercise)
Adolescent peak bone
mass

Nutritional Other factors

(smoking,
factors medical
(calcium, vit D3 …) Hormonal treatment)
milieu
(Bailey DA)

Bone gain and growth

The main period for bone accretion is
the peripubertal age, i.e. between
 11 and 14 years in females
 13 to 17 in males
(Cooper et al., 1995, Theintz et al., 1992).

Lumbar spine BMD gain during

adolescence
0.12 Females
D L2-L4 BMD (g.cm-2.yr-1)

Males
0.1

0.08

0.06

0.04

0.02

0
9-10

10-11

11-12

12-13

13-14

14-15

15-16

16-17

17-18

18-20

Age range

Theintz et al., 1992

7
 Bone gain during adolescence

During puberty, the marked

increased in both standing height
(PHV) and bone mass appear to be
dissociated in time, the former
occurring earlier than the latter.

Such a dissociation
between the rates of
statural growth and
mineral mass accrual
could define a
transient state of
relatively low bone
mass and contribute
to the higher
incidence of fracture
known to occur at the
age when this
dissociation is
maximal

BAILEY et al., 1999

Increase in BMD during years of

maximal bone mass gain
0.14 Females : 11-14 yrs Males : 13-17 yrs

0.12
D BMD (g.cm2.yr-1)

0.1

0.08 Females
Males
0.06

0.04

0.02

0
Lumbar spine Femoral neck Femoral shaft

Theintz et al., 1992

8
 BMD changes after maximal bone
mass gain
0.06
p < 0.05
0.05

0.04
D BMD (g.cm2.yr-1)

p < 0.05
0.03

0.02 NS NS Females
0.01 Males

-0.01 NS

NS
-0.02
Lumbar spine Femoral neck Femoral shaft

Theintz et al., 1992

Relationship between spinal and femoral

BMD gain and years after menarche
**

0.10
Lumbar spine
* **

0.08 Femoral neck

* **

Femoral shaft
* **
D BMD (g.cm2.yr-1)

0.06
*

0.04

0.02

0.00

-0.02
Pubertal stage P5a P5b P5c P5d
Yrs after menarche < 1 1-2 2-4 >4

* p< 0.05; * * p < 0.01; * * * p < 0.001 Theintz et al., 1992

Prevention
 Peak of bone mass
Building strong bones in childhood and adolescence is the
best defense.
 Nutrition
A balanced diet rich in calcium, protein and Vitamin D

 A healthy lifestyle
No smoking or excessive alcohol intake
No sedentarity

9
 Nutrition
Vitamine D
Calcium
Protéines

Calcium is the hard, dense material which forms

bone.

Calcium deficiency is actually a sort of generic term

which represents only one of the possible causes for
metabolic bone disease.

Complex Interaction between Calcium intake and Vit. D:

 In case of calcium deficiency a supplementation can
be effective
 If enough calcium intake, a supplementation needs
Vit. D or physical activity
 Level of Vit. D controls PTH activity

Recent analyze: 9-10 mg / kg BW / D (GRIO, 2008)

10
Bone density gain after a 1-year of calcium placebo
supplementation in children (double blind)

D. Courteix et al., Int J Sports Med. 2005 Jun;26(5):332-8

Microarchitecture change in after 6-months of calcium placebo

treatment and physical activity intervention in female children
Δ Hmean P < 0.05

0.12

0.1

0.08

0.06

0.04

0.02

0
Sp+Ca+ Sp-Ca+ Sp+Ca- Sp-Ca-

Ianc, Courteix et al, Int Journal Sport Nutrition and Exercise Metabolism, 2006

Protein intake
Protein is important to the integrity of bone.
 Protein restriction has been shown to reduce growth
hormone.
 Low protein and low albumin are strongly and
independently associated with functional outcome after
hip fracture.
 Short-term studies have suggested that intakes of low
protein can cause a reduction of intestinal calcium
absorption resulting in secondary hyperparathyroidism.
 Higher protein status has been associated with shorter
hospital stays, reduced mortality, reduced rate of
complications after a hip fracture.

11
Influence of protein intake on the impact of increased
physical activity on BMC in prepubertal boys

Chevalley et al., JBMR 2008

Prevention
 Peak of bone mass
Building strong bones in childhood and adolescence is the
best defense.
 Nutrition
A balanced diet rich in calcium, protein and Vitamin D

 A healthy lifestyle
No smoking or excessive alcohol intake
No sedentarity

Bone health
Healthy bone maturation needs a gravitational
environment (Bourrin et al., 1995)
Young athletes have been found to have higher
BMD when compared with nonathlete age matched
controls.
Physical inactivity due to bed rest and space flight
results in rapid declines in BMD
BMD loss up to 1 % per week

12
 Bone response to
mechanical loading
(exercise)

Bone strength

Bone
Bone mineral
content
+ architecture
Bone Strength

Wolff’s law (1892)

Bone structure could adapt in
response to changing Mechanical
Environment

The general form of bone being

given, alterations to the internal
architecture and external form
occur as a consequence of
primary changes in mechanical
stressors.

13
 Wolff’s law

Mechanical strains and bone

mineral density
Mechanical strains are known to increase the
bone mineral density (BMD). They affect
bone metabolism, especially skeletal
remodelling (cellular mechanisms of bone
formation or resorption) :
• stimulation of osteoblast activity

in response to an increased strain

Trabecular BMD in the os calcis in women

aged 20-25 years categorized according to
self-reported childhood physical activity
250
240
230 n=24
BMD (g.cm2)

220
210
200
190 n=30 n=35
n=12
180
170
160
150

Low activity Avg activity Active Very active

Childhood activity levels
McCulloch et al., 1990

14
 Type of exercise

Bone mineral density comparisons between

Impact Load and Active Load children
p<0.01
0.8

0.75
BMD (gHA.cm2)

Impact load
0.7
Active load

0.65

0.6
Lumbar spine Femoral neck

Grimston et al., 1993

Bone Density of Female Runners, Swimmers,

and Weight Lifters in 3 Locations
% of Sedentary Control Value

16

12
Spine
8 Radius
Femur
4

0
Runners Swimmers Weight Lifters

15
 ORGANISATION OF PHYSICAL FACTORS
High Low

Frequency

Magnitude

Number of
cycles

BMD in gymnasts (red) and in swimmers

(blue) expressed as percentage of controls
BMD (% controls)
40 ***

35

30

25
*** ***
20 **
*
15

10
NS
5

0 Controls
-5

-10

Whole Mid-radius Distal Lumbar Femoral Ward's

body radius spine neck triangle

* p< 0.05; * * p < 0.01; * * * p < 0.001 Courteix et al., Osteoporos Int 1998

Z-scores of whole body, lumbar spine, femoral neck, and

total hip BMD: comparisons between female swimmers
(black bars) and soccer players (grey bars)

Ferry, Courteix et al. Bone Miner Metab (2011) 29:342–351

16
Proximal femur in female swimmer (SWIM) and
soccer (SOC) Ferry, Courteix et al. Bone Miner Metab (2011)

Swimming and bone

“Unloading’’ environment of the swimming pool
may exert a deleterious action on bone

Swimming training has no effect on bone quantitative

parameters, mainly because of its hypogravity
environment. Furthermore, these results reveal the
deleterious effect of an intensive swimming practice
on some of the bone geometric parameters and
therefore on bone strength.

Load Impact

Gymnastics
Weight lifting
Volley ball
Bodybuilding Benefits
Tennis, squash
Throwing ....
....

Velocity Hypogravity

Long distance running Swimming

Cycling ....

17
 BMD comparisons at the lumbar
spine
Judo (n=9) Controls Hand Ball (n=7)
French team (n=26) 1st national division
(mean – SD) (mean SD) (mean – SD)
Age 21.9 ns 23.8 ns 23.9
2.8 4 5.1
Height (cm) 166.5 ns 164.7 ns 169.8
7.7 6 5.6
Weight (kg) 69.4 ns 59.5 ns 65.7
15.4 8.8 4.7
BMI 24.8 ns 21.9 ns 22.8
3.6 3.2 1.5
BMD L2-L4 1.419 p<0.001 1.152 p<0.001 1.378
0.081 0.149 0.097
T-score 2.085 p<0.001 -0.061 p<0.001 1.707
0.7 1.25 0.8

During 12 months, total body, spine, and leg areal bone density
increased 30 85% more rapidly in active prepubertal gymnasts
than in bone age-matched prepubertal controls.

Bass S, et al. JBMR, 1998

(Emma M Clark, et al, JBMR 2006, in 6213

children aged 9.9 years)

18
 Playing-to-nonplaying arm difference in the BMC
of the humeral shaft according to the starting age
of playing relative to the age at menarche
30 S S
S
25
BMC difference (%)

20

15
S
10

0
> 5 yrs. 3-5 yrs. 0-2 yrs. 1-5 yrs. 6-15 yrs > 15 yrs.

Before Menarche After Menarche Controls

Kannus et al, 1995

Persistence of bone mass gain is linked to the

started age of practice
Humeral shaft
30 21.6 ±7 1993
BMC difference (%)

25 1998
20 39.4 ±10
15
10 28.6 ±10
5
0
Young Starters Old Starters Controls
10.5 yrs 20.4 yrs Kontulainen 2001

ZANKER CL, et al . Osteoporos Int 2004

An elevated bone mass in female former gymnasts was retained during

early adulthood, in spite of a cessation of training for up to12 years
Kudlac et al, Calcif Tissue Int 2004
Gymnasts continue to have greater BMD despite their decreased exercise

19
 Conclusion
The most compelling evidence for a
beneficial effect of exercise on bone
mineral density is during growth
Weight-bearing exercise during
childhood is advocated as one strategy to
increase bone mass and reduce the onset
and severity of age related osteoporosis

Conclusion (cont.)
The most effective strategy against osteoporosis
is to exercise the body in order :
 to maximize peak skeletal development
at maturity
 to maintain skeletal integrity throughout
the lifespan

In older adult
The sensitivity of bone tissue to mechanical constraints
decrease with ageing. Moreover, the lack of estrogens
results in an augmentation of the bone response threshold
to constraints (Zaman G, et al, JBMR 2006).
When ageing the preservation of bone mass by exercise
needs a higher mechanical stimulus (Cussler et al. 2003),
for example in menopausal women (Bassey et al. JBMR
1998)
High level of constraints Frailty bone tissue

Increased risk of traumatic fractures

20
 Physical activity and osteoporosis
in menopause

"There is no evidence that resistance- or endurance-

type physical activity can reduce the accelerated
rate of bone loss in postmenopausal women in the
absence of estrogen replacement therapy...."

US Surgeon General's Report (1996)

Which way ?

GOOD LIFE for seniors ! ! !

21
 Local ,regulation of bone
remodeling:

Role of physical activity on osteocyte

Bone tissue cells

Mesenchymal refers to
cells which were deep
within the embryo during
early development; some
of them remain in the
bone marrow but do not
form blood cells.
The hematopoietic cells
form the liquid part of
the bone marrow, and
some of them circulate
with the blood.

Regulation of bone formation by

osteocyte
The recent identification of sclerostin as a molecule
preferentially secreted by osteocytes that appears to be
regulated by bone’s mechanical environment has attracted
considerable interest.
The mechanism by which mechanical strain could exert
its effect through sclerostin is envisaged to be by
inhibition of the Wnt-signaling pathway. Exposure to
mechanical strain, by suppressing sclerostin production,
would increase the osteogenic effect of the Wnt pathway.
(Ominsky MS et Paszty C, ASBMR 2006)

22
 Ominsky MS et Paszty C, ASBMR 2006

Relationship between mechanical loading-related changes in

osteocyte sclerostin expression and magnitudes of local strain
engendered vs. subsequent changes in bone mass in trabecular
bone

Moustafa et al. Osteoporos Int 2011

23