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Table 4 Description of included studies investigating the association between physical activity and osteoporosis employing an observational design

From: Evidence on physical activity and osteoporosis prevention for people aged 65+ years: a systematic review to inform the WHO guidelines on physical activity and sedentary behaviour

Reference
Overall Risk of Bias
Study design Included / Analysed Participants (n, age mean (SD), % women, setting, health status) Exposure Outcomes Results
aFoley 2010
(Tasmania Older
Adult Cohort study)
Overall risk of bias: High [81]
Prospective cohort study
(2.6 years follow-up)
875
Setting: Community, Australia
Health status: Healthy
n= 875 (included)
Age: 62.7 (7.3) (included)
[NB: quartile 1, 2 and 3 are not of interest in this study as mid-point age <65 years]
Female: 49%
Mid-point of age quartile 4:
Age: 74.8
Ambulatory activity (steps per day) was assessed using pedometer for 1 week at both baseline and follow-up and participants were divided in quartiles
Classification: total physical activity
1. Lumbar spine areal BMD
2. Hip areal BMD
Adjusted point estimates (95% CIs)
1. Lumbar spine areal BMD
Not reported for sample >65 years
2. Hip areal BMD at follow-up
Age quartile 4, Female
Q1. 0.434 (0.372 to 0.497)
Q2. 0.441 (0.378 to 0.503)
Q3. 0.446 (0.383 to 0.509)
Q4. 0.466 (0.401 to 0.532)
Age, quartile 4, Male
Q1. 0.554 (0.490 to 0.618)
Q2. 0.566 (0.501 to 0.631)
Q3. 0.572 (0.507 to 0.637)
Q4. 0.584 (0.518 to 0.651)
aMuir 2013
(Canadian multicentre osteoporosis study)
Overall risk of bias: Low [84]
Retrospective (previous 12 months) Setting: Community; Canada
Health status: Mixed (included participants with diagnosis of osteoporosis)
n= 1169
Age: 79.84 (4.43)
Female: 100%
Physical activity was quantified based on the level of activity (moderate or strenuous or vigorous) and the reported frequency and duration of said activity over the course of the previous 12 months.
Classification: total physical activity
1. Lumbar Spine (L1-4) BMD
2. Femoral neck BMD
3. Total hip BMD
4. Ward’s triangle BMD
5. Trochanter BMD
Multiple regression analysis of the relative effects of moderate activity on BMD. Coefficient (95% CI)
1. Lumbar Spine (L1-4) BMD
-0.006 (-0.013 to 0.000)
2. Femoral neck BMD
0.004 (0.000 to 0.008)¥
3. Total hip BMD
0.006 (0.001 to 0.011)¥
4. Ward’s triangle BMD
0.004 (-0.001 to 0.009)
5. Trochanter BMD
0.005 (0.006 to 0.074)¥
aNakamura 2012
(Muramatsu Study)
Overall risk of bias: High [85]
Cohort
(6 years follow-up)
774/382
Setting: Community; Japan
Health status: Healthy
n= 382
Age: 73.3 (3.7)
Female: 100%
Physical activity was assessed via questionnaire based on whether participants regularly engaged in light or moderate physical activity (yes/no) activities:
A. Light physical activity (includes croquet, taking walks and traditional Japanese dancing): yes or no
B. Moderate physical activity (includes farm work and gardening): yes or no
Classification: total physical activity (light and moderate)
1. Forearm BMD p-value association between baseline physical activity levels BMD changes
1. Forearm BMD
A. Light: p=0.5122 or
B. Moderate: p=0.0711
[Quantitative estimates not reported]
aRodriguez-Gomez 2019
(Toledo Study for Healthy Aging)
Overall risk of bias: High [86]
Cohort
(4 years follow-up)
227/192
Setting: Community; United States
Health status: Healthy
n= 192
Age: 80.5 (4.3)
Female: 52.6%
Physical activity was assessed by accelerometry during waking hours for seven consecutive days, except while bathing or swimming activities
A. Sedentary behaviours - mean % of waking hours: 55 (baseline); 59 (follow-up)
B. Light physical activity - mean % of waking hours: 41.9 (baseline); 38.8 (follow-up)
C. Moderate to vigorous physical activity – mean % of waking hours: 3.1 (baseline); 2.2 (follow-up)
Classification: total physical activity
1. Whole body BMC
2. Pelvic BMC
3. Arms (mean) BMC
4. Legs (mean) BMC
5. Lumbar spine (L1-4) BMC
6. Femoral regions BMC (proximal femur – mean, femoral neck, trochanter, ward’s triangle)
7. Whole body BMD
8. Pelvic BMD
9. Arms (mean) BMD10. Legs (mean) BMD
11. Lumbar spine (L1-4) BMD
12. Femoral regions BMD (proximal femur – mean, femoral neck, trochanter, ward’s triangle)
NB: Only significant findings were reported here]
Multiple regression coefficient (y) of change in the composition of movement behaviours and changes in BMC or BMD:
4. Legs (mean) BMC
A. NS
B. NS
C. y=1.767, p= 0.04¥
5. Lumbar spine (L1-4) BMC
A. NS
B. NS
C. y=0.050, p= 0.03¥
10. Legs (mean) BMD
A. NS
B. NS
C. y=0.005, p= 0.04¥
aShephard 2017
(Nakanojo Study)
Overall risk of bias: Low [87]
Cohort
(5 years follow-up)
615/496
Setting: Community; Japan
Health status: Healthy
Men
Age: 71.2 (3.9)
n= 212
Women
Age: 71.3 (4.2)
n= 284
Female: 57.3%
Physical activity was measured using pedometer for 5 years and analysed as daily step count and the daily duration of exercise at an intensity >3 METs
A. Physical activity level Quartile 1
Step count (steps/day) at baseline: 3888 (1117) [men]; 3824 (1298) [women]
Duration of activity > 3 METs (min/day): 4.0 (1.8) [men]; 4.0 (2.4) [women]
B. Physical activity level Quartile 2
Step count (steps/day) at baseline: 5994 (943) [men]; 5931 (924) [women]
Duration of activity > 3 METs (min/day): 10.9 (2.4) [men]; 10.1 (2.3) [women]
C. Physical activity level Quartile 3
Step count (steps/day) at baseline: 7521 (833) [men]; 7626 (691) [women]
Duration of activity > 3 METs (min/day): 19.3 (2.9) [men]; 18.4 (2.6) [women]
D. Physical activity level Quartile 4
Step count (steps/day) at baseline: 10892 (1433) [men]; 10199 (1398) [women]
Duration of activity > 3 METs (min/day): 31.8 (5.6) [men]; 30.3 (4.3) [women]
Classification: total physical activity
1. Osteosonic Index (OSI) from the ultrasonic measurement of the calcaneus (Fracture threshold – yes/no) Multivariate Cox proportional hazard ratio (risk of the OSI falling below the fracture threshold) and 95% CI
Step count (steps/day)
Men
Q1. 2.63 (1.35 to 4.41)¥
Q2. 1.75 (1.03 to 3.95)¥
Q3. 1.01 (0.55 to 3.37)
Q4. 1
Women
Q1. 3.33 (2.10 to 5.21)¥
Q2. 2.51 (1.25 to 4.03)¥
Q3. 1.12 (0.47 to 2.16)
Q4. 1
Duration of activity >3 METs (min/day)
Men
Q1. 2.77 (1.46 to 5.59)¥
Q2. 1.91 (1.02 to 3.99)¥
Q3. 1.00 (0.48 to 2.27)
Q4. 1
Women
Q1. 3.94 (2.35 to 6.73)¥
Q2. 1.87 (1.00 to 3.60)¥
Q3. 0.99 (0.40 to 2.06)
Q4. 1
aSvejme 2014
Overall risk of bias: Low [88]
Cohort
(25 years follow-up)
Setting: Community; Sweden
Health status: Healthy
A. Active women
n= 91
B. Inactive women
n= 21
Age: women recruited at age 48 and followed up for 25 years
Female: 100%
Physical activity measured using questionnaires at four defined time periods: at menopause, 5 and 10 years after menopause, and at age 72.
A. Active women (>30 min/day) – mean (95% CI) number of hours of physical activity per week:
Baseline: 9.0 (7.8 to 10.2)
Average post-menopausal physical activity: 8.7 (7.6 to 9.8)
Physical activity at age 72: 8.2 (6.9 to 9.4)
B. Inactive women (<30 min/day) – mean (95% CI) number of hours of physical activity per week:
Baseline: 3.0 (1.6 to 4.4)
Average post-menopausal physical activity: 2.0 (1.4 to 2.5)
Physical activity at age 72: 1.2 (0.5 to 1.9)
Classification: total physical activity
1. Forearm BMC (mg/cm)
2. Forearm bone mineral apparent density (mg/cm3)
Mean (95% CI) average annual changes
1. Forearm bone mineral content (mg/cm):
A. -1.2 (-1.3 to -1.1)
B. -1.6 (-1.9 to -1.3)
Mean differences
0.4 (0.1 to 0.6)¥
2. Forearm bone mineral apparent density
A. -1.8 (-1.9 to -1.7)
B. -2.0 (-2.2 to -1.7)
aBleicher 2013
(CHAMP study)
Overall risk of bias: Low [80]
Longitudinal cohort study
(2 years follow-up)
1,705/1,122
Setting: Community; Australia
Health status: Healthy
n= 1,122
Age: 76.2 (5.1); range 70-97
Female: 0%
A. Walking for daily exercise was self-reported and measured in kilometres per day
A. Walk daily > 0 to ≤ 1km
B. Walk daily > 1 to ≤ 2 km
C. Walk daily > 2 to ≤ 4 km
D. Walk daily > 4 km
Classification: planned physical activity (exercise)
B. Physical Activity Scale for the Elderly (units)
Classification: total physical activity
1. Total hip BMD
2. Total hip BMC
Multiple regression coefficient (95% CI)
Reference: no walking
Leisure-time walking
1. Total hip BMD
A. 0.09 (-0.18 to 0.36), p=0.5
B. 0.18 (-0.06 to 0.41), p=0.1
C. 0.29 (0.06 to 0.52), p=0.01¥
D. 0.19 (-0.1 to 0.49), p=0.2
2. Hip BMC: NR
Age adjusted annualised percentage change in total hip BMD per unit change
General physical activity
1. Total hip BMD
-0.01 (-0.09 to 0.07)
2. Hip BMC: NR
Greendale 1995
(Rancho Bernardo study)
Overall risk of bias: Low [49]
Retrospective study
1,703
Setting: Community; United States
Health status: Healthy
n= 1,703
Age: 73
Female: 60%
Lifetime leisure physical activity, calculated based on leisure time physical activity (collected retrospectively via questionnaire) for the past year, age 30 years and age 50 years
Exercise level: classified by the highest level of exercise performed for at least 15 minutes per session at least three times per week.
Participants were divided into levels of physical activity according to the tertiles
A. Low
B. Medium
C. High
Classification: planned physical activity (exercise)
1. Total hip BMD
2. Intertrochanter BMD
3. Femoral neck BMD
4. Greater trochanter BMD
5. Lumbar spine (L1-4) BMD
6. Distal radius BMD
7. Midshaft radius BMD
Adjusted mean (p-value for comparison A vs C)
1. Total hip BMD (p=0.002)¥
A. Low: 0.8241
B. Medium: 0.8367
C. High: 0.8507
2. Intertrochanter BMD (p=0.007)¥
A. Low: 0.9631
B. Medium: 0.9769
C. High: 0.9908
3. Femoral neck BMD (p=0.003)¥
A. Low: 0.6597
B. Medium: 0 6716
C. High: 0.6819
4. Greater trochanter BMD (p = 0.0001)¥
A. Low: 0.5969
B. Medium: 0.6093
C. High: 0.6248
5. Lumbar spine (L1-4) BMD
A. Low: 0.9324
B. Medium: 0.9612
C. High: 0.9479
6. Distal radius BMD: NR
7. Midshaft radius BMD: NR
aGudmundsdottir 2010
Overall risk of bias: High [82]
Cohort
(4 years follow-up)
162
Setting: Community; Iceland
Health status: Healthy
A. Physical activity performed ≤ 3 per week
n= 41 (analysed)
B. Physical activity performed > 3 per week
n= 111 (analysed)
Age: 75
Female: 100%
Physical activity was calculated based on number of leisure time walks per week and number of other exercise session per week (self-reported questionnaire)
Results were presented according to number of times of physical activity performed per week
A. ≤ 3 per week
B. > 3 per week
Classification: planned physical activity (exercise)
1. Femoral neck BMD
2. Total trochanter BMD
3. Total hip BMD
Change score; mean % change (SE)
1. Femoral neck
A. -1.3 (1.1)
B. -0.2 (0.9)
β: NR
2. Total trochanter BMD
A. -1.5 (0.8)
B. -1.2 (0.7)
β= 0.22, non-significant p value
3.Total hip BMD
Mean (SE)
A. -1.4 (0.8)
B. -1.1 (0.7)
β= 0.19, non-significant p value
Huddleston 1980
Overall risk of bias: High [51]
Retrospective observational study
35/35
Setting: Community; United States
Health status: Healthy tennis athletes
n= 35
Age: range 70-79
Female: 0%
Lifetime tennis exposure in athletes with tennis experience ranging from 25 to 72 years
Results were presented for:
A. Playing arm
B. Non-playing arm
C. Comparison with data for a “normal male population”
Classification: planned physical activity (sport – tennis)
1. Radius midshaft BMC 1. Radius BMC
4% to 33% greater for the playing arms as compared with the nonplaying arms
The mean difference between the playing arm and nonplaying arm: 13%
Reference data suggest difference between dominant and nondominant
BMC values of 6% to 9%
aKemmler (2016) Bone
(Erlangen Fitness and Osteoporosis
Prevention Study)
Overall risk of bias: High [83, 93]
Retrospective secondary analysis of the intervention group of a quasi-randomised trial (16 years follow-up) Setting: Community; Germany
Health status: Osteopenia
A. Exercise group:
n= 55
Age: 55.1 (3.4)
Female: 100%
Exercise group: Supervised group class (aerobic dance exercise, jumping and resistance exercise) + Home training (rope skipping, isometric and dynamic resistance exercise and stretching/ flexibility exercise) five months after study started; 49 to 50 weeks/year throughout the 16 years
Exercise frequency (ExFreq): session/week/16 years
Classification: planned physical activity (exercise)
1. Lumbar spine BMD
2. Total hip BMD
Linear mixed-effect regression analysis. Marginal effect (95% CI)
1. Lumbar spine BMD: 0.035 (0.024 to 0.045)
2. Total hip BMD: 0.015 (0.005 to 0.026)
Minimum effective dose of exercise (training sessions/week)
1. Lumbar spine: 2.11 (2.06 to 2.12)
2. Total hip BMD: 2.22 (2.00 to 2.78)
Rikkonen 2010
(Kuopio Osteoporosis Risk Factor and Prevention study)
Overall risk of bias: Low [66]
Cohort (15 years follow-up)
8560
Setting: Community; Finland
Health status: Healthy
n= 8560 (analysed)
A. Physical activity quartile I
Age: 52.1 (2.9)
B. Physical activity quartile II
Age: 52.0 (2.9)
C. Physical activity quartile III
Age: 52.2 (2.9)
D. Physical activity quartile IV
Age: 52.3 (2.8)
Female: 100%
Leisure-time physical activity (self-reported) collected at 5 years intervals
A. 15-year average PA, hours/week: 0.35 (0.35)
B. 15-year average PA, hours/week: 1.7 (0.39)
C. 15-year average PA, hours/week: 3.2 (0.54)
D. 15-year average PA, hours/week: 7.0 (2.9)
Classification: leisure-time physical activity (exercise, transportation, sport)
1. Femoral neck BMD
2. Trochanter BMD
3. Ward’s triangle BMD
4. Lumbar spine (L2-4) BMD
Beta ± SE (quartile IV vs inactive)
1. Femoral neck BMD
1.752 ± 0.493
2. Trochanter BMD
1.783 ± 0.581
3. Ward’s triangle BMD
2.412 ± 0.723
4. Lumbar spine (L2-4) BMD
0.040 ± 0.649
All results were significant (except for lumbar spine) and suggest a positive effect of physical activity on BMD.
  1. BMC bone mineral content (g unless specified), BMD bone mineral density (g/cm2). Where studies reported effect estimates with differing degrees of adjustment for confounders in different models, we used the estimate from the most adjusted model
  2. aindicate studies that were found in the updated search
  3. ¥indicates statistically significant between-group difference at p < 0.05.