Are You at Risk for Osteosarcopenia? How to Know

Are You at Risk for Osteosarcopenia? How to Know
What a mouthful, osteosarcopenia. This condition that refers to bone and muscle losses is relatively new. There is a lack of consensus among researchers on what to call it (sarco-osteopenia, sarco-osteoporosis, osteosarcopenia). No matter what they name it, for you and I this is a topic we need to unpack. 
Before we dive into this week’s episode … a shout out to listener mlg114 who left this comment in iTunes:
“You and Figs might have saved my marriage. My husband and I have been in the “me exercise you not” pattern for a few years! We’ve been hurting each other unintentionally on this very subject! Result has been severe resentment though we’re about to celebrate 25 years married! You have spread your mission of kindness to us successfully! Thank you with all my heart for this valuable, intelligent podcast!”
So thank you to mlg114 this made my day and I shared it with Figs, too.I’d love it if you’d leave a rating in iTunes too. I have been reading these regularly and want to start sharing them with you. I’ll link to iTunes in today’s show notes at flippingfifty.com/osteosarcopenia and to the episode about how to encourage healthy habits without nagging. 
So let’s get into it. I’ve got a lot to cover here. You’ll notice this episode is potentially longer than most. It’s a big topic. There’s a lot of controversy at first glance and that’s resulting in a lot of confusion. I want to clear it all up for you.
Osteosarcopenia is the new term given to the combination of osteopenia/osteoporosis and sarcopenia.
I’ve got to cover some vocabulary first.
Osteoporosis is the low bone mineral density (BMD) that is statistically 2.5 standard deviations from the ideal of a young woman. Meaning, it’s significantly lower than ideal bone density.
Osteopenia is the space between that ideal bone mineral density and 2.5 standard deviations from ideal. You’re not good any longer, you’re not quite bad enough to diagnose as having osteoporosis. But it’s not going in the right direction.
Sarcopenia is pronounced muscle and strength loss. It can be in spite of normal weight or obesity – that when coupled is termed “sarcobesity.” It’s characterized by low grip strength, a poor chair stand test (say you can’t do more than 5 rises from a chair in 15 seconds), low muscle measured by a DXA scan, and low performance of a battery of tests like an up and go test and a timed 400 meter walk, to name a couple. 
The combination of both low bone density and low muscle mass is what I’m referring to today as osteosarcopenia.
This Episode
Non-pharmacological strategies to help prevent, reverse, or treat (by way of exercise and lifestyle habits) to improve both conditions independently and the combined condition osteosarcopenia are the topic for this episode. 
Spoiler alert. This episode is aptly sponsored by STRONGER I, my 12-week strength training program designed for women in perimenopause, menopause, and beyond. It’s based 100% on research featuring women in that group. Such a small percent of programs are made for women, based on research featuring women, that most everything you’ve learned about exercise may be a lie. If it wasn’t about who you were or are at the time you did it, then it wasn’t considering the unique hormones, metabolism, body composition or unique socialization that you as a woman have.
I don’t think for a minute any 60-year-old overweight man would have begun an exercise program based on what worked for 22-year-old female collegiate athletes. Do you? And yet, the equivalent is essentially what’s been going on for decades in fitness for women.
STRONGER I opens four times a year. As I record this my team just let me know it’s open! That means there’s a juicy early bird rate right now. You can learn more about it at flippingfifty.com/getstronger [I’ll share that link in the show notes] If you’re listening to this later – which I know happens – and you’re curious you can get on a notification list to learn when it does open again and have first chance to save a spot if you decide you want it. 
Stopping Bone Losses
Let me start with osteoporosis. For women in post menopause concern about bone density usually heightens. For good reason, once we lose the protective factor that estrogen offers, we lose bone faster – in fact it really accelerates right after menopause. 
Currently losses of .6%, 1.1% and 2.1% per year for the 60-69, 70-79 and over 80 age groups is the level of average bone loss. 
In the first 4-5 years post menopause loss is accelerated to 1.5% per year for spine and 1.1-1.4% for hip.
I want to stop the red flags and alarms going off in your head right now. I want to remind you: that these statistics are looking at a lot of women who Do Not exercise. They may smoke, drink more than a glass of wine a day, eat poorly and never lift weights. This is like “normal range” in labs. It’s COMMON, it may not be you. And no matter what, bone losses are preventable, and to some extent reversible, or there are ways to prevent falls and fractures so bone losses are not devastating.
So if your thoughts are spiraling downward, stop. 
Stopping Muscle Losses
Truthfully, stopping muscle loss is easier or at least has less specific “rules.” To provide adequate stimulus to muscle for lean muscle maintenance or increases, you must reach fatigue. That can be done with heavy load and few repetitions or with a lighter load and more repetitions.
Fatigue, or temporary fatigue, is simply getting to the last repetition that you can do with good form or complete. Within minutes, or actually seconds, you recover and are able to do more if you had to. But without that actual muscle fatigue stimulus of overload for women in perimenopause and beyondcountless studies are coming back saying the positive influences on muscle, strength, fat burning, and metabolism is minimal. 
I Exercise, Is that Enough?
At this point I hope you understand there’s some criteria you have to meet for either bone and or muscle benefit. The effect of exercise on bone loss is controversial. At best, however, every professional not quoting research and testing effects of bone density tends to have anopinion, based on general research collectively done for populations, young and old, men and women. If you are in our Flipping 50 tribe, what I’m about to share is specifically filtered for YOU.
All too often a woman may be told to “exercise” or to “walk” by her physician. She may be told to lift weights but that it doesn’t have to be heavy. I provide research here to explain why that information is or is not on target depending on who you are, what your activity history is.
There is a continuum of exercise with minimal and with optimal benefits. There’s a continuum of sedentary and deconditioned women on one end and athletic women on the other end. Consideration of both continuums has to be examined to arrive at the best option for you. 
Exercise for Osteosarcopenia 
For osteopenia and osteoporosis aerobic and low impact exercise fails to benefit Bone Mineral Density(BMD) in most studies. In a few studies walking limits progressive bone loss. Note that is limits losses, not stops bone losses or increases bone density.
Typical aerobic activity like elliptical trainers, bicycles, rowing machines have little to no positive influence on bone density. There’s a complete lack of heel strike or what’s referred to as Minimal Effective Stress (M.E.S.).  Though there may be some resistance benefit at higher settings as opposed to use of speed for intensity. 
Swimming potentially has a negative effect. It completely removes the effect of gravity. 
With co-existing factors many women have in addition to osteoporosis or sarcopenia, like arthritis, prior joint issues, or lack of cartilage, many older adults naturally (and should) choose water exercise. Choice of swimming for cardio exercise increases the need for resistance training. Surf and turf is a must.
M.E.S. is not even met in repetitive low impact exercise like walking or jogging beyond a certain point of adaptation. Once you’re ambulatory and moving around your body has gained all the benefits it’s going to from that position and stress. More steps do not equate to more stress that the bone will positively respond to.
Jumping rope or other plyometric exercise is most associated with building bone density though it may not be wise in many cases where there is already a low BMD.
Strength is the clear winner for bother bone density and for muscle maintenance.
If You’re Out of Shape vs. Fit
For untrained individuals aerobic activity that is weight bearing in nature, like walking or Zumba, may increase BMD while in already trained individuals who have already attained a baseline of osteogenic activity (bone reformation to avoid getting too technical) these activities neither stimulate more bone density or prevent further losses. 
In other words, once you’ve achieved a minimal level of bone density from an activity, you don’t get more bone benefit from the same level of stimulation. More steps, more miles, more minutes don’t equate to more benefit.
Summarizing A Few Exercise Considerations:
Walking:
The load above gravity is less effective in osteoporosis prevention.
Swimming:
In some cases subjects whose primary mode of exercise is swimming show a 10% greater occurrence of low bone mineral density than those who do land based exercise. Other studies show some minimal support for bone mineral density from swimming and water exercise. This goes back to… are you a beginner who’s been doing very little? Or already active?
Rebounding:
This activity misses the heel strike though there is some muscular force that can increase BMD in those with LBM mass upon initial use. This aerobic activity may be safe for those with high risk of fracture, provided they have good balance (required not necessarily gained from the activity). Can you do more? Can you walk? Can you dance or box with more ground mechanical forces?
Rebounding may make sense. For someone who can’t do higher impact exercise, but higher impact will provide greater benefits for those who are able.
Do you remember Lance Armstrong? It’s rare for a young male, let alone an elite athlete to be diagnosed with osteoporosis. At one point one of the fittest men on earth, from hundreds of hours cycling in an unloaded environment (even with the resistance of uphill climbs) was diagnosed with low bone mineral density. This was before the interference of chemotherapy.
There’s got to be a mechanical stress that is more than usual your stimulation. Once achieved more of the same mechanical stress does not improve bone. A long distance runner for instance, cannot outrun the need for strength training. In fact, because most endurance athletes tend to be lean or smaller in frame, they are likely candidates for low bone density. They’re even more at risk if they have a diet low in absorbable calcium, protein, and otherwise high in nutrient density and also don’t lift weights.
Walking and Running Examples
If you walk 3 miles three times a week and then become a runner you may experience a slight bump in bone density. You leave the ground with running and there’s a greater force to the bones. After that initial change, your bone density won’t further increase.
Running 3 miles 3 days a week then increasing to 3 miles 6 days a week would not make you less likely to lose bone mass. In fact, if you did become leaner, you may accelerate your likelihood of low bone mass. Regular endurance exercise (without strength training) can over time accelerate muscle breakdown called catabolism. The combined loss of muscle and bone loss make a runner just as likely for osteosarcopenia as anyone.
Don’t Throw Out Your Cardio Completely
However controversial, there is some proof that aerobic activity can begin a process of stimulating some enzyme activity within the bone that then makes resistance training more effective. For that to happen the exercise can occur concurrently on same days or on alternate days.
Resistance Exercise for Osteopsarcopenia
The research on aerobic exercise is a little controversial at least before you look at the populations studied. There is no controversy about resistance training’s effects on bone mineral density. There is some confusion however about what qualifies as adequate bone mineral density and I’ll get to that next. Almost all studies point to resistance training – provided it is done with adequate intensity– as providing a protective factor for bone. 
What qualifies as resistance training?
There’s a continuum here too. 
Yoga trainings for registered instructors list bone density as a benefit. I came unglued the day my instructor told the class that in my own 200-hour Yoga Instructor Training. There is evidence yoga helps, again on a continuum.
For someone who has been previously sedentary and deconditioned, there will be bone density benefits from yoga. From couch to mat, I can’t argue that. But we’ve got to keep very clear on the fact that this doesn’t eliminate the need for a progressive resistance training plan. For someone who has been lifting weights regularly or even doing higher impact aerobic activity, there will not be “more” bone benefits from yoga, even “power” yoga.
Resistance exercise for sedentary, weak, or most frail individuals might include water exercise (with adequate intensity), bicycling (again- in high gear simulating uphill climbs) though the benefits will be site specific. That is, if you’re pedaling a bike you’re going to gain the most bone density and muscle benefits in the upper leg and hip. With swimming your gains will be in the arms, upper back, and shoulders, somewhat dependent on your stroke.
Starting and Progressing
You can experience initial bone density benefits from yoga, bands and tubing, pilates reformers, and work your way into free weights and, ultimately, if you have known low bone density, use machine weights. Machine weights make lifting as heavily as you can, safe. I’m a firm believer that every retirement center, assisted living community should provide at the least a leg press, a chest press, and a seat row machine to help load the hip, spine and wrist. 
The recommendations for resistance training for bone density specifically include:
Reaching fatigue at a weight you can lift for 10 or fewer repetitions
Reaching fatigue at a slightly lower weight using power (adding force during the lift)
Not every resistance protocol that supports muscle – (which can prevent sarcopenia) – will help bones and prevent or treat osteoporosis. For muscle-specific benefits you need to reach fatigue and it can be done with lighter weights for more repetitions. That, similar to reasons more running doesn’t result in more bone density, will not be enough stimulus for the bone.
Nutrition for Osteosarcopenia
Low protein is directly correlated with both bone loss and muscle atrophy.
High protein is associated with less muscle loss at a given age and better lower limb performance.
Protein supplementation over 3-24 months corrected sarcopenia. The intervention provided 6-30 gram servings/day combined with resistance training. 
Where older adults need to lose weight, resistance training plus protein intake prevent muscle loss related to calorie restriction.
Bone density is also associated with higher protein intake. Further, hip fractures decreased by 16% in subjects who had high protein intake compared to those with low protein intake.
Lifestyle Choices
Decreasing alcohol intake and managing daily supplements like Calcium(when dietary calcium intake or absorption is less than optimal), Vitamin D, and magnesium may also support bone health. Overall nutrition adequacy is more important than it’s ever been considered before.
In an upcoming podcast I’ll discuss the role of stress and happiness, as they’re associated with bone density.
It’s simple. Strength training is key to aging well, independently, and to metabolism.
Strength training targets bone density and lean muscleboth in a way that aerobic activity does not. That’s not to discount aerobic exercise. It’s important, though in much smaller doses than you’ve ever believed before.
The Bottomline on Osteosarcopenia
“Those with osteosarcopenia have worse prognosis than adults with either osteopenia or sarcopenia alone. Therapeutic strategies that have a dual effect on bone and muscle are critical in the management of osteosarcopenia.”Those therapeutic strategies include:
Adequate protein (6 x 30 gm/day) and calcium intake (1000 day – supplement with 500-600 mg calcium if not consumed though diet)
Maintaining sufficient vitamin D levels (testing regularlyto adjust accordingly)
Regular muscle and bone strengthening exercises (resistance training above all other exercise)
I leave you with this last comment. If you’re not strength training now, start. If you influence and love young women encourage them to get into strength training early in life to prevent bone losses that begin at age 30 otherwise.
If you influence pre-teens or teens encourage participation in sports with higher impact like basketball, soccer, gymnastics, and martial arts. Swimming and biking are wonderful activities but have little influence on bone mineral deposits. Balance them with other activities.

If you want support with the right kind of exercise, the progression and the tips for safe and effective exercise, I’d love to see you in STRONGER I. Click here right now while registration is open. If you’re listening later, click to check whether I’m about to launch a new 12-week series or to get notified when I do.
Resources:
https://www.ncbi.nlm.nih.gov/pubmed/31431811
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6686316/
https://www.ncbi.nlm.nih.gov/pubmed/30471719
https://www.dovepress.com/effects-of-water-based-exercise-on-bone-health-of-middle-aged-and-olde-peer-reviewed-fulltext-article-OAJSM 
You Still Got It, Girl! The After 50 Fitness Formula for Women
Hot, Not Bothered: 99 Daily Flips for Slimmer, Trimmer, Fitter Faster So that You Can Master Metabolism Before, During, and (Long) After Menopause
Please leave a rating in iTunes! It really helps! 
Visit Flipping 50 on iTunes
Click listen in iTunes
Click ratings and reviews
Leave your 5 star rating (seriously I’d love it, but your authentic comments are what I need to grow and give you more of what you want and less of what you can leave!)
Know how much I appreciate you doing this!