Association of Physical Activity and Bone Mineral Density in Adults with Depressive Symptoms

Abstract

Introduction

Depression affects a significant proportion of adults in the United States. Studies exploring the association between depression and bone mineral density (BMD) have shown mixed results. Moreover, the relationship between BMD and physical activity (PA) in individuals with depressive symptoms is unknown. In this paper, we evaluated the association of depressive symptoms and PA with BMD, as well as difference in BMD among females with depressive symptoms before and after menopause.

Methods

Data from the 2011–2018 National Health and Nutrition Examination Survey were used. Multivariable linear regression was used to explore the relationship between BMD and exposure variables.

Results

The study included 9,238 participants, of whom 766 had depressive symptoms. The presence and severity of depressive symptoms were significantly associated with lower BMD (aCoef.=−0.0200 for depressive symptoms, −0.0017 for depressive symptom severity; p<0.001). Vigorous PA intensity was positively correlated with BMD, with and without controlling for depressive symptoms (aCoef.=0.0006; CI=[0.0003, 0.0008]; p<0.001). Additionally, high levels of vigorous PA showed a significant positive relationship with BMD (aCoef.=0.0141; CI=[0.0078, 0.0205]; p<0.001). Postmenopausal status was significantly associated with lower BMD. No significant interaction effects were observed between depressive symptoms and PA or menopausal status on BMD.

Discussion

Our study demonstrated the an association between depressive symptoms and low BMD, as well as a positive association between high-intensity vigorous PA and BMD. Future studies should aim to replicate our findings and evaluate the underlying mechanisms.

Keywords

depression - dual-energy x-ray absorptiometry - NHANES - bone mineral density - physical activity

Publication History

Received: 20 August 2024

Accepted: 23 June 2025

Article published online:
23 July 2025

• References

• 1 Kessler R, Berglund P, Delmer O. et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62: 593-602
• 2 Kleschevnikov AM, Belichenko PV, Salehi A. et al. Discoveries in Down syndrome: Moving basic science to clinical care. Progress. Brain Res 2012; 197: 199-221
• 3 van Dalfsen JH, Markus CR. The influence of sleep on human hypothalamic–pituitary–adrenal (HPA) axis reactivity: A systematic review. Sleep Med Rev 2018; 39: 187-194
• 4 Cizza G, Ravn P, Chrousos GP. et al. Depression: A major, unrecognized risk factor for osteoporosis?. Trends Endocrinol Metab 2001; 12: 198-203
• 5 Sözen T, Özışık L, Başaran NÇ. An overview and management of osteoporosis. Eur J Rheumatol 2017; 4: 46
• 6 Rachner TD, Khosla S, Hofbauer LC. Osteoporosis: Now and the future. Lancet 2011; 377: 1276-1287
• 7 Lorentzon M, Johansson H, Harvey NC. et al. Osteoporosis and fractures in women: The burden of disease. Climacteric 2022; 25: 4-10
• 8 Wu Q, Magnus JH, Liu J. et al. Depression and low bone mineral density: A meta-analysis of epidemiologic studies. Osteoporos Int 2009; 20: 1309-1320
• 9 Yirmiya R, Bab I. Major depression is a risk factor for low bone mineral density: A meta-analysis. Biol Psychiatry 2009; 66: 423-432
• 10 Mercurio M, de Filippis R, Spina G. et al. The use of antidepressants is linked to bone loss: A systematic review and metanalysis. Orthop Rev 2022; 14: 38564
• 11 Reginster JY, Deroisy R, Paul I. et al. Depressive vulnerability is not an independent risk factor for osteoporosis in postmenopausal women. Maturitas 1999; 33: 133-137
• 12 Whooley MA, Cauley JA, Zmuda JM. et al. Depressive symptoms and bone mineral density in older men. J Geriatr Psychiatry Neurol 2004; 17: 88-92
• 13 Oh SM, Kim HC, Ahn SV. et al. Association between depression and bone mineral density in community-dwelling older men and women in Korea. Maturitas 2012; 71: 142-146
• 14 Mussolino ME, Jonas BS, Looker AC. Depression and bone mineral density in young adults: Results from NHANES III. Psychosom Med 2004; 66: 533-537
• 15 Rizzoli R, Bianchi ML, Garabédian M. et al. Maximizing bone mineral mass gain during growth for the prevention of fractures in the adolescents and the elderly. Bone 2010; 46: 294-305
• 16 Edwards MH, Jameson K, Denison H. et al. Clinical risk factors, bone density and fall history in the prediction of incident fracture among men and women. Bone 2013; 52: 541-547
• 17 Ahlborg HG, Johnell O, Turner CH. et al. Bone loss and bone size after menopause. N Engl J Med 2003; 349: 327-334
• 18 Tella SH, Gallagher JC. Prevention and treatment of postmenopausal osteoporosis. J Steroid Biochem Mol Biol 2014; 142: 155-170
• 19 Karlsson MK, Rosengren BE. Exercise and peak bone mass. Curr Osteoporos Rep 2020; 18: 285-290
• 20 Lorentzon M, Mellström D, Ohlsson C. Association of amount of physical activity with cortical bone size and trabecular volumetric BMD in young adult men: the GOOD study. J Bone Miner Res 2005; 20: 1936-1943
• 21 Johansson J, Nordström A, Nordström P. Objectively measured physical activity is associated with parameters of bone in 70-year-old men and women. Bone 2015; 81: 72-79
• 22 Need AG, Wishart JM, Scopacasa F. et al. Effect of physical activity on femoral bone density in men. BMJ 1995; 310: 1501-1502
• 23 Costantini L, Pasquarella C, Odone A. et al. Screening for depression in primary care with Patient Health Questionnaire-9 (PHQ-9): A systematic review. J Affect Disord 2021; 279: 473-483
• 24 Martin A, Rief W, Klaiberg A. et al. Validity of the Brief Patient Health Questionnaire Mood Scale (PHQ-9) in the general population. Gen Hosp Psychiatry 2006; 28: 71-77
• 25 CDC. Body composition procedures manual. 2022 https://wwwn.cdc.gov/nchs/data/nhanes/2017-2018/manuals/Body_Composition_Procedures_Manual_2018.pdf
• 26 Jain RK, Vokes T. BMDs derived from total body DXA are strongly correlated with dedicated hip and spine BMD and are associated with prior fractures in NHANES. J Clin Densitom 2022; 25: 349-356
• 27 Wu Q, Magnus JH, Liu J. et al. Depression and low bone mineral density: A meta-analysis of epidemiologic studies. Osteoporos Int 2009; 20: 1309-1320
• 28 Yirmiya R, Bab I. Major depression is a risk factor for low bone mineral density: A meta-analysis. Biol Psychiatry 2009; 66: 423-432
• 29 Stubbs B, Brefka S, Dallmeier D. et al. Depression and reduced bone mineral density at the hip and lumbar spine: A comparative meta-analysis of studies in adults 60 years and older. Psychosom Med 2016; 78: 492-500
• 30 Ozsoy S, Eşel E, Turan MT. et al. Depresyonlu hastalarda kemik mineral yoğunluğunda değişiklik var mi? [Is there any alteration in bone mineral density in patients with depression?]. Turk Psikiyatri Derg 2005; 16: 77-82
• 31 Laudisio A, Marzetti E, Cocchi A. et al. Association of depressive symptoms with bone mineral density in older men: A population-based study. Int J Geriatr Psychiatry 2008; 23: 1119-1126
• 32 Venken K, Callewaert F, Boonen S. et al. Sex hormones, their receptors and bone health. Osteoporos Int 2008; 19: 1517-1525
• 33 Dean E, Söderlund A. What is the role of lifestyle behaviour change associated with non-communicable disease risk in managing musculoskeletal health conditions with special reference to chronic pain?. BMC Musculoskelet Disord 2015; 16: 87
• 34 Yirmiya R, Bab I. Major depression is a risk factor for low bone mineral density: A meta-analysis. Biol Psychiatry 2009; 66: 423-432
• 35 Spangler L, Scholes D, Brunner RL. et al. Depressive symptoms, bone loss, and fractures in postmenopausal women. J Gen Intern Med 2008; 23: 567-574
• 36 Yazici KM, Akinci A, Sütçü A. et al. Bone mineral density in premenopausal women with major depressive disorder. Psychiatry Res 2003; 117: 271-275
• 37 Cauley JA. Estrogen and bone health in men and women. Steroids 2015; 99: 11-15
• 38 Ng JS, Chin KY. Potential mechanisms linking psychological stress to bone health. Int J Med Sci 2021; 18: 604-614
• 39 Bielemann RM, Ramires VV, Wehrmeister FC. et al. Is vigorous-intensity physical activity required for improving bone mass in adolescence? Findings from a Brazilian birth cohort. Osteoporos Int 2019; 30: 1307-1315
• 40 Marin-Puyalto J, Mäestu J, Gómez-Cabello A. et al. Frequency and duration of vigorous physical activity bouts are associated with adolescent boys’ bone mineral status: A cross-sectional study. Bone 2019; 120: 141-147
• 41 Chastin SF, Mandrichenko O, Helbostadt JL. et al. Associations between objectively-measured sedentary behaviour and physical activity with bone mineral density in adults and older adults, the NHANES study. Bone 2014; 64: 254-262
• 42 Hackney AC, Lane AR. Exercise and the regulation of endocrine hormones. Prog Mol Biol Transl Sci 2015; 135: 293-311
• 43 Guadalupe-Grau A, Fuentes T, Guerra B. et al. Exercise and bone mass in adults. Sports Med 2009; 39: 439-468
• 44 Behringer M, Gruetzner S, McCourt M. et al. Effects of weight-bearing activities on bone mineral content and density in children and adolescents: A meta-analysis. J Bone Miner Res 2014; 29: 467-478
• 45 Zernicke R, MacKay C, Lorincz C. Mechanisms of bone remodeling during weight-bearing exercise. Appl Physiol Nutr Metab 2006; 31: 655-660
• 46 Bonjour JP, Chevalley T, Rizzoli R. et al. Gene-environment interactions in the skeletal response to nutrition and exercise during growth. Med Sport Sci 2007; 51: 64-80
• 47 Mata J, Thompson RJ, Jaeggi SM. et al. Walk on the bright side: Physical activity and affect in major depressive disorder. J Abnorm Psychol 2012; 121: 297-308