A combination of parental engagement and after-school programs for elementary school children may be a useful platform for delivering bone-strengthening habits that can prevent osteoporosis in adulthood and show improvement in bone and physical activity in the short term, according to research findings published in BMC Pediatrics.

Healthy habits formed in childhood have the potential to prevent or mitigate chronic disease in adulthood. The 2-year Beat Osteoporosis — Nourish and Exercise Skeletons project (BONES; ClinicalTrials.gov Identifier: NCT00065247) was developed to evaluate whether elementary school children who participated in an after-school-based, multifaceted behavior-change health intervention had improved bone quality and muscular strength and engaged in more bone-strengthening behaviors.

The BONES intervention included bone-strengthening physical activity (85 min/wk), daily calcium-rich snacks (380 mg/d), and educational materials (2 d/wk), along with parental education. The children participated in the intervention for 2 years. Of a total of 83 Massachusetts and Rhode Island after-school programs that included children aged between 6 and 9 years (n=1434), 25 programs with 469 participants were randomly assigned to the BONES intervention, 33 programs with 611 participants to the BONES + Parent (B+P) intervention, and 25 with 254 participants to the control group. Primary study outcomes were bone quality (defined as a composite of factors) and muscular strength. Secondary outcomes included knowledge and practice of bone-strengthening behaviors, body composition (body mass index [BMI] and percentage body fat), and physical activity level (metabolic equivalent time [MET] and weight-bearing factor [WBF] scores).

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Data on bone quality were collected from 46% of the girls and 35% of the boys who participated in the study. Compared with control participants, participants in the B+P group showed an increase in bone stiffness (a reduction of 2.1 units/year vs increase of 0.6 units/year; P =.05). When the findings for the BONES and B+P groups were combined, bone stiffness was still increased compared with that of the control group, though, not significantly (P =.06; an increase of 0.3 units/year vs a reduction of 2.1 units/year). When data from boys and girls were considered separately, the boys in all groups showed a negative rate of change in bone stiffness while the girls in both intervention groups showed a positive rate of change. Overall, in the pooled comparison, participants who were girls showed a significant rate of improvement in bone stiffness over time (increase in 2.1 units/year; P <.01). Increases in vertical jump and grip strength, as well as rates of change in BMI scores, were not significantly different among groups.  

Although all groups significantly increased their ability to identify foods rich in calcium as well as their knowledge of bone-strengthening activities, changes in the intervention groups were not significantly higher than in the control group. No change was seen in calcium intake or preference for calcium-rich foods. When results were pooled by sex, compared with control participants, those in the B+P group had statistically significant MET and WBF score increases (P <.01). Although participants in the BONES group also showed MET and WBF score increases, they were not significantly different from the increases seen in control participants (P <.10).

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Study investigators concluded, “The intensity and duration of the program that is needed to significantly [effect] bone and behavior (diet and physical activity) changes in both boys and girls is still unknown and is likely greater than was anticipated in the BONES Project. Future research should consider cost-effectiveness when delivering programs with the capability for broad reach.”


Economos CD, Hennessy E, Chui K, et al. Beat osteoporosis — nourish and exercise skeletons (BONES): a group randomized controlled trial in children. BMC Pediatr. 2020;20(1):83.

This article originally appeared on Rheumatology Advisor