Recommendations on exercise and nutrition for fall and fracture prevention in postmenopausal females and males aged 50 years and older*
| Recommendations | Strength of recommendation and certainty of evidence† |
|---|---|
| 1. Exercise‡ | |
| 1.1. We recommend balance and functional training ≥ twice weekly to reduce the risk of falls. Remark: Increase difficulty, pace, frequency, volume (sets, reps) or resistance over time. Balance exercises challenge aspects of balance, such as:
| Strong recommendation; moderate-certainty evidence |
| 1.2. We suggest progressive resistance training ≥ twice weekly, including exercises targeting abdominal and back extensor muscles. Remark: Resistance training involves exercises in which major muscle groups (e.g., upper and lower extremities, chest, shoulders, back) work against resistance (e.g., squats, lunges and push-ups). Increase volume (e.g., sets, reps, weight), frequency or difficulty to achieve progressive overload. Many resistance-training exercises would be considered functional exercises. | Conditional recommendation; low-certainty evidence |
| 1.3. We suggest that people who want to participate in other activities (e.g., walking, impact exercise, yoga, Pilates) for enjoyment or other benefits be encouraged to do them, if they can be done safely or modified for safety. Other activities should be encouraged in addition to, but not instead of, balance, functional and resistance training. Remark: Encourage a variety of types and intensities of physical activity in accordance with the Canadian 24-Hour Movement Guidelines (https://csepguidelines.ca), such as getting ≥ 150 min of moderate to vigorous physical activity per week, but prioritize balance, functional and resistance training. If participating in impact exercise, progress to moderate-impact (e.g., running, racquet sports, skipping) or high-impact (e.g., drop or high vertical jumps) exercise only if appropriate for fracture risk or physical fitness level; safety or efficacy of impact exercise is uncertain in people at high fracture risk (e.g., history of spine fracture or 10-yr fracture risk for major osteoporotic fracture of ≥ 20% calculated by FRAX or CAROC fracture risk assessment tools). | Conditional recommendation; very low-certainty evidence |
| 1.4. Activities that involve rapid, repetitive, sustained, weighted or end range-of-motion twisting or flexion of the spine may need to be modified, especially in people at high risk of fracture. | Good practice statement |
| 1.5. When available, seek advice from exercise professionals who have training on osteoporosis for exercise selection, intensity and progression, and activity modification, especially after recent fracture or if there is high risk of fracture. When not available, refer to Osteoporosis Canada resources.§ | Good practice statement |
| 2. Nutrition¶ | |
| 2.1. For people who meet the recommended dietary allowance for calcium with a variety of calcium-rich foods, we suggest no supplementation to prevent fractures. Remark: Health Canada’s recommended dietary allowance for calcium is 1000 mg/d (males aged 51–70 yr) and 1200 mg/d (females > 50 yr and males > 70 yr). | Conditional recommendation; moderate-to-high-certainty evidence |
| 2.2. We suggest following Health Canada’s recommendation on vitamin D for bone health. Remark: Health Canada’s recommended dietary allowance for vitamin D is 600 IU/d (age 51–70 yr) and 800 IU/d (age > 70 yr) for males and females. Given that it is difficult to achieve this level of intake, as few foods contain vitamin D, Health Canada recommends adults older than 50 yr take a vitamin D supplement of 400 IU daily, in addition to consuming vitamin D–rich foods, to achieve the recommended dietary allowance. For people at risk of vitamin D deficiency, additional supplemental vitamin D should be provided.** | Conditional recommendation; high-certainty evidence |
| 2.3. For people who follow Canada’s Food Guide (food-guide.canada.ca), we suggest no supplementation of protein, vitamin K or magnesium to prevent fractures. | Conditional recommendation; low-certainty evidence (protein, vitamin K), very low-certainty evidence (magnesium) |
| 2.4. For people initiating pharmacotherapy, it is good practice to individualize intake of calcium and vitamin D. Although participants in most pharmacotherapy trials received a minimum of 400 IU/d of vitamin D and up to 1000 mg/d of calcium supplements, food sources or supplementation should be individualized according to risk factors for insufficiency.** | Good practice statement |
Note: CAROC = Canadian Association of Radiologists and Osteoporosis Canada tool, FRAX = Fracture Risk Assessment Tool.
↵* Integrated approach is shown in Figure 1.
↵† See Table 1 for definitions.
↵‡ See Appendix 1, Supplementary Table 1 (available at www.cmaj.ca/lookup/doi/10.1503/cmaj.221647/tab-related-content) for key points on exercise and definitions.
↵§ See osteoporosis.ca/exercise/
↵¶ See Appendix 1, Supplementary Table 2, for key points on nutrition.
↵** See Appendix 1, Supplementary Table 4 for risk factors for vitamin D insufficiency.