Why Active Women Still Get Low Bone Density
Why Active Women Still Get Low Bone Density, and What Helps
Written by Mish Wright – Head of Graduate Education
Here's a story I hear a lot when I'm out teaching fitness professionals about menopause.
A woman has trained hard for years. She eats well. She does everything she was told to do. Then she reaches menopause and finds out she has osteopenia or osteoporosis.
Dr Ruth White lived that story, and she joined me on the Women's Fitness Education podcast to talk about it. Ruth has been a physiotherapist for nearly 40 years. She completed a Master's in pain, then a PhD in behaviour change, and she now applies all of it to bone health. Here's what stood out for me.
A text message that changed the plan
Ruth had her first DEXA scan at 57, after someone suggested she go and have one. Her GP told her by text that she had osteoporosis and osteopenia. She nearly fell off her chair. She'd had an active working life, she'd been to the gym and she'd eaten well. How could this happen to her?
That question sent her in a new direction, and it's the reason so many women in our industry will recognise themselves in her story.
Osteopenia and osteoporosis in plain language
Both mean low bone density. We reach peak bone density quite early, certainly by our 30s, and it's hard to get a higher peak than that. A good peak gives you plenty of bone in the bank for the rest of your life. Hormones change, some bone naturally comes away, and you still have enough to keep you going.
A diagnosis of osteopenia or osteoporosis means your peak was probably never as high as it ought to have been. Osteopenia sits a bit below where bone density should be. Osteoporosis sits a lot below. Ruth's point is that the label matters less than knowing whether you have low bone density at all, and knowing early. As she put it, it's hard work building bone at 57.
When should you have a DEXA scan?
Ruth explained that in Australia a DEXA scan is routinely offered at 70. Before that, you'll usually pay around $100 unless you already have a diagnosis of osteoporosis. She went through menopause at 49 and a scan wasn't on her doctor's radar, and even as a pain physio she hadn't thought to ask for one.
The guidelines don't say this, and Ruth is clear that it's her personal opinion, but she thinks if you're old enough to have a breast scan, you're old enough to have a bone scan. She also thinks a baseline scan is worth it if you've ever had a stress fracture, even at 25, 35 or 45, or if your mother, sister or aunt has had low bone density. A DEXA scan uses about the same radiation as a flight to New Zealand, and an early baseline gives you years to do something about the result.
A DEXA number is useful, and it isn't the whole picture
DEXA is still the gold standard, and it's where most of the research has been done. Ruth also explained where its limits sit.
Density and quality are different things. Ruth's mum had good density scores shortly before a hip replacement, because arthritic spurs were adding to the picture. The bone tissue itself had started to collapse.
Scoliosis can change what a scan picks up, because you lie a little differently and the machine can miss bone.
If you have repeat scans, use the same place, the same technician and the same machine so you're comparing apples with apples.
Ultrasound bone quality scans are starting to gain traction around the world, although Ruth said they aren't yet available in New South Wales. She flew to Melbourne to have one.
Body composition scans like Evolt are a snapshot of things like body fat. Ruth had one done at her gym, and it didn't pick up her low bone density.
Why do active women still end up with low bone density?
Ruth looked back on her own history with honesty. She trained for ultra trail events, she now thinks she wasn't eating enough protein or calcium for a long time. She grew up as a teenager in the 70s, when women were encouraged to be thin, to have fruit for lunch and to feel proud of getting by on fewer calories. She also wasn't lifting big, heavy weights, because that wasn't part of the culture. And in her last ten to fifteen years as a pain physio, she was sitting a lot more.
Her message is simple. You can't build or keep bone without substantial amounts of protein across the day.
This is exactly what I see with fitness professionals who reach menopause and get a surprise. Diet culture is real, and the fuelling gaps of earlier decades can show up on a scan.
Meet Clive, Cilla and Bella
Ruth explains bone biology using three characters, and I love them.
Clive the Cleaver is the osteoclast. He chips away at old bone all day, and he gets busier and faster as our hormones change.
Cilla is the osteocyte. She sits inside the bone waiting to feel stress, like a heavy lift, a hard sit to stand or a challenging kettlebell.
Bella is the osteoblast, and she's the star of the show. When Cilla signals strain, Bella builds bone.
After perimenopause and menopause, Bella is a lot harder to call out. She's in the easy chair with her tiara on. Cilla will call her, but only for load that's genuinely challenging, which rules out the namby-pamby weights.
The good news is that the research Ruth pointed to used two hard half-hour sessions a week, appropriately challenging, safe and properly checked, and found bone can grow even after menopause. That's a very different message from the one Ruth trained on in the 80s, when women with osteoporosis were wrapped in cotton wool and taught to avoid falls. Falls prevention still matters. Ruth has taken a few cracking falls on her osteoporotic arms without breaking anything, and she puts that down to the quality of her bone.
Where does she start with every single client, even the ones deadlifting big weights? Sit to stand. Can she stand up without using her hands? Is it challenging? Then progress slowly, because tissues adapt more slowly after perimenopause.
Ruth also spoke about loading the arms. She's worked for four years on planks, wall push-ups and push-ups off her knees, and she's levelled out the bone loss in her arms. Her hips and lumbar spine responded much faster. Different parts of the skeleton behave differently, and the arms take patience.
Information doesn't change behaviour
One of my favourite lines from the whole conversation: information is to behaviour change as spaghetti is to a brick.
Women can find information anywhere. What they need is help changing what they do. Ruth uses the COM-B model, developed by Professor Susan Michie in the UK. B is behaviour, and it needs three things in place: capability, opportunity and motivation. If one is missing, the behaviour doesn't happen. Ruth describes it as a maths equation.
Capability covers physical capability (can she do the movement?) and psychological capability (does she feel safe and confident enough to try?). Many women are frightened they're fragile and will break. Their world shrinks. Ruth encourages trainers to know their professional limits, because some women need a psychologist or psychiatrist on the team.
Opportunity covers time, money and life circumstances. A cancer diagnosis, homelessness or a hard season at home can all push bone health down the list. Ruth's advice is to ask the question: is this a good time for you? Group training often costs less and adds a social connection that can make all the difference.
Motivation covers habit and reflective motivation. Some clients haven't built the habit yet and are still thinking it over. Ruth asks, are we going to do it today or tomorrow? If the answer is no, you don't need to work harder than the person in front of you. Leave the door open.
Ruth adds one more layer that came from her PhD research: acceptability. Is what you're offering acceptable to this person? Someone who wants a pill and an injection will rarely find a lifestyle-based program acceptable, and knowing that saves everyone time.
What about pelvic floor dysfunction?
I asked Ruth what happens when a woman has pelvic floor dysfunction, which is very common, and the plan involves impact and ground reaction forces. Her answer was to screen for it, and to learn how. It doesn't mean no. However, it needs to be done sensitively, not announced in front of a group. Women may need to work on their pelvic floor first so they're comfortable with impact, and there can be other reasons impact isn't appropriate for someone with low bone density. It's different for everyone.
Key takeaways for fitness professionals
Consider a baseline bone scan earlier than the routine schedule if you have risk factors.
Bones respond to challenging load. Two good sessions a week can build bone after menopause.
Start where your client is, and check sit to stand every time.
Fear is a capability issue. Know your limits and refer when needed.
Ask about opportunity before you assume a client is unmotivated.
Screen for pelvic floor dysfunction before adding impact.
Listen to the full episode and find Ruth
Listen to the full conversation on the Women's Fitness Education podcast: Behaviour Change and Bone Health with Dr. Ruth White.
Website: buildbehavioursbuildbones.com.au
Instagram: @behaviourandbones
This post is general information and isn't medical advice. If you're concerned about your bone health, talk to your GP.
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