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Mediterranean Diet Combined with Physical Activity Mitigate Bone Density Decline in Older, At-Risk Women, New Analysis Finds
Following a Mediterranean-style diet and a prescribed regimen of physical activity was significantly protective of BMD, particularly at the lumbar level, over 3 years.
A weight-loss lifestyle intervention combining an energy-reduced Mediterranean diet with increased physical activity protected against age-related bone mineral density (BMD) decline in older women with metabolic syndrome, according to a prespecified secondary analysis of the PREDIMED-Plus randomized clinical trial published in JAMA Network Open.
The 3-year study found that women who followed an energy-reduced Mediterranean diet while reaching guideline-recommended weekly physical activity targets showed significant benefits in lumbar spine BMD compared to women who received only conventional Mediterranean diet recommendations. This protective effect was not observed in men, suggesting a potential sex-specific response to the intervention.
“To our knowledge, our study is the first to report a mitigated BMD decline among older women following an energy-reduced healthy diet, increasing physical activity, and receiving behavioral modification,” the researchers, led by Jordi Salas-Salvadó, MD, PhD, Distinguished professor of nutrition and bromatology and an ICREA-Academia researcher at the Rovira i Virgili University, wrote. The findings, they continued, support the multipronged approach “for older women at risk of bone disturbances as a feasible strategy to preserve the effects of possible concomitant weight loss on age-related decreases in BMD.”
The study included 924 older adults (mean age 65.1 years; 454 women and 470 men) with metabolic syndrome and overweight or obesity who were part of the larger PREDIMED-Plus trial and had access to dual-energy x-ray absorptiometry (DXA) measurements at 4 Spanish centers. The analysis was conducted from September 1 to October 30, 2024.
Participants were randomly assigned to either an intervention group that followed an energy-reduced Mediterranean diet with physical activity promotion (n=460) or a control group that received advice to follow an *ad libitum* Mediterranean diet without specific physical activity recommendations (n=464).
Researchers measured BMD (total femur, lumbar spine (L1-L4), and femoral trochanter) and total BMC using DXA at baseline and at 1 and 3 years of follow-up. T scores from BMD variables were determined, and osteopenia or osteoporosis status was defined as low BMD.
FINDINGS
After 3 years, the intervention group showed a significant protective effect on lumbar spine (L1-L4) BMD compared to the control group (between-group differences, -0.1 [95% CI, -0.8 to 0.8] g/cm² after 1 year and 0.9 [95% CI, 0.1-1.8] g/cm² after 3 years; overall P =.05). This beneficial effect was particularly pronounced in women (between-group differences, -0.1 [95% CI, -1.3 to 1.1] g/cm² after 1 year and 1.8 [95% CI, 0.6-2.9] g/cm² after 3 years; overall P =.005) but was not observed in men.
Total body weight decreased by 3.0% over three years in the intervention group compared with 0.7% in the control group, with overall 3-year differences in changes in total body weight between groups being significant (between-group difference, –2.2 kg [95% CI, –2.7 to –1.6 kg]; overall P <.001).
In intention-to-treat analyses, additional beneficial effects were observed in women for total femur BMD (between-group differences, -0.6 [95% CI, -1.9 to 0.7] g/cm² after 1 year and 1.0 [95% CI, -0.3 to 2.3] g/cm² after 3 years; overall P =.05) and femoral trochanter BMD (between-group differences, -0.5 [95% CI, -1.8 to 0.9] g/cm² after 1 year and 1.4 [95% CI, 0.1-2.8] g/cm² after 3 years; overall P =.01). However, no significant intervention effect was found on total bone mineral content (BMC) or low BMD prevalence.
Contrast with Look AHEAD Study
The authors note that these findings contrast with previous research, including the Look AHEAD trial, the largest long-term study to date focused on effects of hypocaloric weight loss and increased physical activity on BMD. In Look AHEAD, conducted among adults with type 2 diabetes (T2D), investigators reported greater bone loss in intervention group participants compared with control group. Salas-Salvadó et al point to important differences between the studies, including the presence of T2D. They suggest, too, that the Mediterranean diet's nutrient profile and the nature of the physical activity component may have contributed to the protective effect observed in this study.
The intervention group was prescribed a Mediterranean diet with a 30% energy reduction and counseled to gradually increase physical activity to meet World Health Organization recommendations of 150 minutes of moderate to vigorous physical activity per week. Participants were encouraged to walk for at least 45 minutes daily, 6 days per week, and to engage in strength, flexibility, and balance exercises 3 days per week, along with resistance training 2 days per week.
The researchers acknowledge several limitations, including that the study was based on a subsample of the PREDIMED-Plus trial participants who agreed to DXA measurements, potential limited generalizability to populations other than those studied, some loss to follow-up resulting in missing DXA data, and the absence of femoral neck BMD data. Additionally, the PREDIMED-Plus trial was not originally designed to evaluate bone-related variables as primary outcomes.
Despite these limitations, the authors conclude that their findings have significant public health implications “given the high prevalence of osteoporotic fractures in aged populations with excess weight, especially women.” They call for weight loss lifestyle interventions with longer follow-up to confirm their results with respect to bone health.
