Role of Exercise in Post-menopausal Women

Bego Tokic

HSC 4730

Public Health Research

Dr. Barnes

April 19th, 2021

 Abstract

Osteoporosis is a chronic skeletal disease in which bone tissue is catabolized faster than it

is anabolized due to factors such as calcium and/or vitamin D deficiencies, loss of estrogen, or a

habitual sedentary lifestyle. The most affected population for this disease is Post-menopausal

women. Menopause is the natural decline in reproductive hormones for women when they reach

the age of 40-50. Implications of the loss of bone mass density can cause serious injuries such as

fractures or displacement of the skeletal frame. Weight-bearing and strength-training exercises

are considered as treatments for this illness; maintaining or improving the bone mass density is

the overall goal. The positive benefits of varying types of exercises on post-menopausal women

with osteoporosis will be discussed. Defining the right exercise program and frequency needed to

create the ultimate progressive treatment against osteoporosis for postmenopausal women will

establish the remediation of an illness that affects every 1 out of 2 women.

 Background

The skeletal system of the human body is the frame for action and the shield. Muscles

connect onto the bones and pull them in certain directions. Bones such as ribs and the skull,

protect vital orangs from exterior damage. The shape and place of the bone give its purpose and

function to the body.

Osteoporosis is a degenerative bone disease that affects men and women especially after

the age of 30. Bones are comprised of cells that are constantly building (osteoblasts) and

destroying (osteoclasts) themselves. Naturally, bones use calcium to strengthen the bone and

vitamin D to absorb the calcium. Bones are living organisms and react to their environment.

Supplied with blood and nerves, bones are signaled to either increase growth or decrease. As a

human progressively gets older, the bones receive signals to increase reabsorption of the bone.

Other factors such as being sedentary, smoking, and taking certain medications can deteriorate

the bone much quicker. A major factor for bone deterioration is being a woman, especially

Caucasian. Women lose bone density much faster than men, especially after menopause. Post-

menopausal women are at extreme risk for developing osteoporosis due to hormonal changes.

The hormone that creates the damaging effect is estrogen (Amgen). Estrogen is a vital inhibitor

for a gene called Rank Ligand (Bell, 2003). Rank Ligand is a major component of the resorption

of bone (Blair et al. 2006). When inhibited, bone loss is set to a minimum, when uninhibited, the

bone loss is much greater. After menopause, the production of estrogen is severely lowered,

causing osteoclasts to be more active, breaking down bone much quicker. Osteoclasts break

down the bones at a continuous gradual rate. The weakening of the bone causes susceptibility to

fractures and deformities of the skeleton. The main affected areas are the hip, spine, upper legs,

and wrists. The illness usually goes undetected until a fracture occurs. The fracture occurs due to
the osteoclasts tearing away the inner structures of the bone creating pores. The unstable bone

can no longer endure everyday forces as it could before, once acted upon with a slightly stronger

force a fracture will occur. The bone can become so weakened that a sneeze is forceful enough to

fracture a bone. As a result, of this chronic illness, a treatment for women is crucial. Varying

forms of treatment are available to assist the disease from progressing. Hormonal therapy is

available to prevent the increasing loss of bone, however, the side effects are more damaging.

Influencing a new diet is possible, a very green, vitamin D, protein, and calcium-rich diet is

beneficial (emedicinehealth). Also, a new lifestyle change of programmed exercise is extremely

beneficial overall.

There are four types of exercise, the one that is most crucial for osteoporosis treatment is

strengthening (health.harvard). Strength exercises include weight-bearing exercises which can be

further divided into isometric or isotonic exercises. Weight-bearing exercises use gravity as a

means of resistance for bones and muscles. Common forms are walking, running, or stair

climbing. These exercises can be done anyway and are very important for the overall health of

bones and muscles. Force acted upon bones is crucial for the stimulation of osteoblasts to rebuild

bone tissue. Bones as living tissue react upon their changing environment. Signals from

osteocytes are sent to osteoblasts notifying their environment has a changing degree of stress and

bone integrity needs to be increased. A continuous degree of impactful stress onto the bones will

cause a net gain or even out of bone tissue from the degenerative actions of osteoporosis.

Weight-bearing exercises create this net gain from consistent stress. From person to person with

osteoporosis, the exercise program needed to maintain or improve bone mass density varies.

Incorporation of a mixed set of isotonic and isometric exercises is the best route. Isotonic

exercises are moving flexions and extensions of muscles with a weight. These improve the
strength of the muscle and site bone strength. Muscle contractions pull bone to move, thus

causing stress onto the site where the tendon connects. Bones become denser near tendon and

joint attachments (theconversation). Isometric exercises are the static contractions of a muscle

without movement of the joint. These improve the strength of the muscle in one specific area

(Mayoclinic). These are very helpful for people that have had an injury or are prone to injury

with exercise. Including isometric exercises at the beginning of an exercise program for

postmenopausal women with osteoporosis will help strengthen the muscles of groups before

heavier weights and stress are introduced. This will reduce the risk of injury and increase the

density of the bone much safer and quicker. The balance of isometric and isotonic exercises

causes a significant increase in bone mass density. Osteoporotic women need exercise to stay

healthy from their illness. Constant stimulation is needed, 30 minutes of walking 5 times a week

is a minimum requirement to maintain bone density. Subsequently, walking is not enough to

prevent the effects of bone loss through aging, thus exercise must be incorporated into the

lifestyle to deter the deterioration of aging (Heathline) and osteoporosis on bone.

Osteoporosis affects women all over the world, especially after menopause. Creating an

effective treatment that can help hundreds of millions of women at once would be an everlasting

positive outcome. The purpose of the study is to discover what type of exercises and how often

they should be done for how long to unlock the best program to increase bone density and

prevent injuries in osteoporotic postmenopausal women. Inquire about the effects of exercise on

the hip, spine, and leg bone densities. Creating a treatment and potential preventative measure to

osteoporosis for women. If the treatment can be implemented and be proved to show signs of

progression, advocating for exercise to women before they reach menopause age could deter the

effects of osteoporosis from developing sooner.

 Study Design

Millions of women are diagnosed with osteoporosis, however, 1 out of 3 are diagnosed.

This leaves 2 out of 3 women unaware of their condition. Public awareness for women needs to

increase throughout the world as the average lifespan increase. The older humans can live the

more dire chronic illnesses become. Osteoporosis is highlighted as having a severely high

physical and financial burden on women. A fracture can cost up to $30,000 in hospital bills, thus

showing a motive to immediately find an effective remedy that will get rid of this potential

burden for about 25% of the global population. Many studies have been conducted on geriatric

patients using exercise and discovering the benefits of exercise, my approach will be similar

regarding the beneficial aspect, however, I want to find the best application of exercise to induce

the most beneficial results in bone density. This project aims to find the right exercise program

for osteoporotic women in which their illness is negated by the benefits of exercise and shows

improvement than previous data. To figure out the benefits, a recording of the bone mass density

is needed before and after the program, including the degradation with age and the disease itself,

subtracted from the gain from the stimulation of exercise, once completed.

Through conducting a cross-sectional study, we will gather quantitative data about the

osteoporotic women’s bone density before and after the program, their exercise level, BMI, and

improvement in quality of life. A survey will be conducted before and after the exam with

varying questions. The questions will focus on the previous history of physical activity, family

history of osteoporosis, and menopause. Questions will include participants' age, age when they
experienced menopause, age of being diagnosed with osteoporosis, and any prior injuries during

the interval time. Study participants' identities will be anonymous to protect them; they will be

given a random identification number that will allow easier data progression collection.

Participants will be asked for their address and phone number and kept securely in a locked

database, encrypted for maximum protection. The use of the phone number is to keep up to date

with the participants via phone and make sure they are going through the program effectively.

The address is used for the possible geographical significance of injuries and regional data, to see

if certain regions’ populations of women are susceptible to osteoporosis. The intended sample

size is 450 postmenopausal women with osteoporosis in Florida. Participants must be diagnosed

with osteoporosis, a woman, and postmenopausal, age minimum will be 65 to a maximum of 80.

We will recruit 30 people per age, thus having an even number of participants per year. A 10-

month fitness program will be conducted for every participant. The design of this will proceed as

such: The participants will start on March 1st until December 31st. They will be provided a

precisely constructed fitness program that changes and increases in intensity as the year

progresses. This is to ensure consistent new applied force onto the bones so there is no tolerance.

The beginning month will be simple isometric exercises meant to establish muscle and bone

knowledge; most of the participants will be very new to exercise and need a grasp of the new

lifestyle change before they can conduct serious exercises. The beginning month will consist of

at least 3 days a week of 30 minutes of walking with 3 days a week of 1-hour isometric

exercises. The second month will include a mix of isometric and isotonic exercises and increase

to 4 days a week of 30 minutes of walking. The third month to the end will be strictly isotonic

exercises increasing to 5 days a week of 30 minutes of walking and 4 days a week of 1-hour

exercise. After every 2 months, a bone mass density test will be conducted on each participant to
graph out the progression. A post-program survey will be conducted with a few varying

questions to update any change of opinions.

A pilot study was conducted in which 28 participants completed a mock survey. The

survey was conducted using Google Forms and data analyzed through Google Sheets. 17 (65%)

of the participants took between 0-5 years after experiencing menopause to be diagnosed with

osteoporosis. This information can be used as a preventative measure for women to begin to

investigate their bone health as soon as they experience menopause. The data shows the

deterioration of bone after menopause is drastic and needs to be combatted with exercise. 11

(39%) of the participants experienced menopause between the ages of 46-53. Most of the

participants (67%) had experienced a fracture. Also, 21 (75%) had some type of direct family

history of osteoporosis.

From the pilot study including current age would be necessary as it was indeterminable to

know from the questions. The pilot study data showed 21 (75%) conducted moderate-intensity

exercise between the ages of 16-25, however, osteoporosis still occurred, furthermore, this could

be interpreted that although participating in exercise while you are younger is important

continuing it is vital to prevent the disease. Consistent exercise is needed especially after

menopause.

The main method of these participants receiving this program and survey is through

phone and email. The survey will be sent through Google Forms to their email where the data

will be collected digitally. The participants will receive the program in the very beginning

completed scheduled out to be accomplishable with relative ease, it is up to them to complete it

legitimately. They will fill out their checklist in the forms with the program that way we can

observe when they complete the exercises. An incentive we established to increase the likelihood
of completion is starting every participant with $100 in their ‘account’, every month they do not

complete all the exercises they lose $10 from the account. Once the 10-month program is over

they may acquire the money via a check to their address.

Recruiting 450 participants might be an expected issue especially getting willing and

consistent ones who will continue the program throughout the whole way. Participation might

also drop throughout the program due to inactivity or personal reasons by the individual. That

way every 2 weeks we will send a mass email motivating them, send them helpful videos on how

to do the exercises, and call them once every 2 weeks to make sure they are doing well.

Outcomes I expect to see is an increase in bone mass density in all the participants and an

increase in quality of life through exercise.

Study Dissemination

The findings will have to be anonymous, and identities withheld, however, the statistics

of the bone mass density of the participants will be published in various health journals such as

American Journal of Public Health, American Journal of Preventive Medicine, CDC Public

Health Law News, and CDC Public Health Law News. Prestigious journal articles would be

recommended to publish this article in. CDC website would be an incredible source to spread the

knowledge of the potential findings that exercise can treat this chronic disease. Many doctors

jump to prescribe medications for chronic illnesses to people however if people saw many

established publications of this information that exercise was one of the best medications,

doctors would no longer force medication on people if it were not the most efficient treatment.

The finding of this program is expected to prove a major notion of exercise is the best medicine

for the body, based on the nature of a human we are in need of exercise, we cannot support a
sedentary lifestyle. Many issues can be fixed with exercise and this program will prove to many

people that medication cannot solve everything.

 Pre-Program Survey

1. What is your age?

2. Do you have any family history with Osteoporosis? Yes or No or Unsure

3. If Yes, list the immediate family below, up until great-grandparents.

a. Brother

b. Sister

c. Mom

d. Dad

e. Grandparent

f. Great grandparent

4. At what age did you experience Menopause?

5. At what age were you diagnosed with Osteoporosis?

6. Do you participate in moderate-intensity exercises (at least 150 minutes per week)

currently? Yes or No or Unsure

7. Since being diagnosed with osteoporosis…

a. Have you fallen due to it? Yes or No or Unsure

b. Have you fractured a bone due to it? Yes or No or Unsure

c. Have you fractured a bone due to a fall? Yes or No or Unsure

8. (Circle One) Osteoporosis have decreased my quality of living.

Strongly Disagree Disagree Neutral Agree Strongly

Agree

9. How many minutes a week do you exercise?

10. Which do you feel is more important when it comes to osteoporosis prevention? (select

one)

Diet or Exercise or Both or Other______

11. Do believe you can exercise for 10 months consistently? Yes or No or Unsure

12. On a scale of 1-5 how important is exercising regularly to you? (1 being not important at

all to 5 being very important)  (circle one)

1 2 3 4 5

Post-Program Survey

1. What was the most challenging aspect of the Program? _______

2. Would you recommend this to anyone? Yes or No

3. Did your quality of life improve, stay the same, or decrease? ______

4. Do you feel healthier? Yes or No or Unsure

5. Do you feel stronger? Yes or No or Unsure

6. Will you continue exercising? Yes or No or Unsure

7. Should people exercise more often?

8. Were there any negative effects on you? ______

 Budget Item Total Cost

Compensation $100 x 450 = $45,000

DEXA Scan (choosingwisely) $125 x 450 = $50,000

Journal Publication Fees $5,000

Total $100,000

Budget and Timeline for 1 year

 Project Timeline

Year 1

Activity Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Recruit

Participants

Sending Pre-

Program

Surveys to

Participants

Receive Pre-

Program Survey

Responses

Exercise

Program

Sending Post-

Program

Surveys to

Participants

Receive Post-

Program Survey

Responses
 References

Alex Ireland Postdoctoral Researcher in Neuromuscular and Skeletal Physiology. (2021, March
12). What exercise does to your bones. https://theconversation.com/what-exercise-does-to-
your-bones-57524.

Bell, N. H. (2003, April). Rank ligand and the regulation of skeletal remodeling.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC152945/.

CR;, B. J. M. Z. Y. D. (n.d.). Rank ligand. https://pubmed.ncbi.nlm.nih.gov/17174136/.

Edward R. Laskowski, M. D. (2020, March 21). Are isometric exercises good for strength
training? https://www.mayoclinic.org/healthy-lifestyle/fitness/expert-answers/isometric-
exercises/faq-20058186.

Foundation, A. B. I. M. (2019, May 2). Bone-Density tests: Choosing Wisely.

https://www.choosingwisely.org/patient-resources/bone-density-tests/.

Medical information and health advice you can trust. (n.d.). https://www.healthline.com/.

Postmenopausal osteoporosis. (2012). https://www.youtube.com/watch?v=c5tc01WFYks.

Publishing, H. H. (n.d.). The 4 most important types of exercise.

https://www.health.harvard.edu/exercise-and-fitness/the-4-most-important-types-of-
exercise.

William C. Shiel Jr., M. D. (2020, June 8). What causes bone loss? Symptoms & treatments for
density loss. https://www.emedicinehealth.com/what_is_bone_loss/article_em.htm.